Anxiety Disorders

Telehealth can be effective for delivering cognitive-behavioral therapy for insomnia (CBT-I) – and is not inferior to in-person treatment, new research suggests.

Results from a study of 60 adults with insomnia disorder showed no significant between-group difference at 3-month follow-up between those assigned to receive in-person CBT-I and those assigned to telehealth CBT-I in regard to change in score on the Insomnia Severity Index (ISI).

In addition, both groups showed significant change compared with a wait-list group, indicating that telehealth was not inferior to the in-person mode of delivery, the investigators note.

Telehealth ‘explosion’

Although CBT-I is the recommended intervention for insomnia, “widespread implementation of CBT-I is limited by the lack of clinicians who are trained in this treatment,” the investigators note. There is a “need for strategies to increase access, particularly for patients in areas with few health care providers.”

Telehealth is a promising technology for providing treatment, without the necessity of having the patient and the practitioner in the same place. There has been an “explosion” in its use because of restrictions necessitated by the COVID-19 pandemic. However, the “rapid deployment of telehealth interventions did not allow time to assess this approach in a controlled manner,” so it is possible that this type of communication might reduce treatment efficacy, the investigators note.

Previous research suggests that telehealth psychotherapeutic treatments in general are not inferior to in-person treatments. One study showed that CBT-I delivered via telehealth was noninferior to in-person delivery. However, that study did not include a control group.

“I have been doing telehealth clinical work for about 10 years – so way before the pandemic pushed everything virtual,” Dr. Gehrman said. “But when I would talk about my telehealth work to other providers, I would frequently get asked whether the advantages of telehealth (greater access to care, reduced travel costs) came at a price of lower efficacy.”

Dr. Gehrman said he suspected that telehealth treatment was just as effective and wanted to formally test this impression to see whether he was correct.

The investigators randomly assigned 60 adults (mean age, 32.72 years; mean ISI score, 17.0; 65% women) with insomnia disorder to in-person CBT-I (n = 20), telehealth-delivered CBT-I (n = 21), or to a wait-list control group (n = 19). For the study, insomnia disorder was determined on the basis of DSM-5 criteria.

Most participants had completed college or postgraduate school (43% and 37%, respectively) and did not have many comorbidities.

The primary outcome was change on the ISI. Other assessments included measures of depression, anxiety, work and social adjustment, fatigue, and medical outcomes. Participants also completed a home unattended sleep study using a portable monitor to screen participants for obstructive sleep apnea.

Both types of CBT-I were delivered over 6 to 8 weekly sessions, with 2-week and 3-month post-treatment follow-ups.

An a priori margin of -3.0 points was used in the noninferiority analysis, and all analyses were conducted using mixed-effects models, the authors explain.
 

Necessary evil?

In the primary noninferiority analyses, the mean change in ISI score from baseline to 3-month follow-up was -7.8 points for in-person CBT-I, -7.5 points for telehealth, and -1.6 for wait list.

The difference between the CBT-I groups was not statistically significant (t 28 = -0.98, P = .33).

“The lower confidence limit of this between-group difference in the mean ISI changes was greater than the a priori margin of -3.0 points, indicating that telehealth treatment was not inferior to in-person treatment,” the investigators write.

Although there were significant improvements on most secondary outcome measures related to mood/anxiety and daytime functioning, the investigators found no group differences.

The findings suggest that the benefits of telehealth, including increased access and reduced travel time, “do not come with a cost of reduced efficacy,” the researchers write.

The study was conducted prior to the COVID-19 pandemic, the investigators note. However, the results “underscore that the use of telehealth during the pandemic is not a ‘necessary evil,’ but rather a means of providing high quality care while reducing risks of exposure,” they write.
 

Benefits, fidelity maintained

Commenting on the study, J. Todd Arnedt, PhD, professor of psychiatry and neurology and co-director of the Sleep and Circadian Research Laboratory, Michigan Medicine, University of Michigan, Ann Arbor, said it is “one of the first studies to clearly demonstrate that the benefits and fidelity of CBT for insomnia, which is most commonly delivered in-person, can be maintained with telehealth delivery.”

Dr. Arnedt is also director of the Behavioral Sleep Medicine Program and was not involved in the study. He said the findings “support the use of this modality by providers to expand access to this highly effective but underutilized insomnia treatment.”

Additionally, telehealth delivery of CBT-I “offers a safe and effective alternative to in-person care for improving insomnia and associated daytime consequences and has the potential to reduce health care disparities by increasing availability to underserved communities,” Dr. Arnedt said.

However, the investigators point out that the utility of this approach for underserved communities needs further investigation. A study limitation was that the participants were “generally healthy and well educated.”

In addition, further research is needed to see whether the findings can be generalized to individuals who have “more complicated health or socioeconomic difficulties,” they write.

The study was funded by a grant from the American Sleep Medicine Foundation and the Doris Duke Charitable Foundation Clinical Scientist Development Award. Dr. Gehrman has received research funding from Merck, is a consultant to WW, and serves on the scientific advisory board of Eight Sleep. The other authors’ disclosures are listed in the original article. Dr. Arnedt reports no relevant financial relationships but notes that he was the principal investigator of a similar study run in parallel to this one that was also funded by the American Academy of Sleep Medicine Foundation at the same time.

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

Telehealth can be effective for delivering cognitive-behavioral therapy for insomnia (CBT-I) – and is not inferior to in-person treatment, new research suggests.

Results from a study of 60 adults with insomnia disorder showed no significant between-group difference at 3-month follow-up between those assigned to receive in-person CBT-I and those assigned to telehealth CBT-I in regard to change in score on the Insomnia Severity Index (ISI).

In addition, both groups showed significant change compared with a wait-list group, indicating that telehealth was not inferior to the in-person mode of delivery, the investigators note.

Telehealth ‘explosion’

Although CBT-I is the recommended intervention for insomnia, “widespread implementation of CBT-I is limited by the lack of clinicians who are trained in this treatment,” the investigators note. There is a “need for strategies to increase access, particularly for patients in areas with few health care providers.”

Telehealth is a promising technology for providing treatment, without the necessity of having the patient and the practitioner in the same place. There has been an “explosion” in its use because of restrictions necessitated by the COVID-19 pandemic. However, the “rapid deployment of telehealth interventions did not allow time to assess this approach in a controlled manner,” so it is possible that this type of communication might reduce treatment efficacy, the investigators note.

Previous research suggests that telehealth psychotherapeutic treatments in general are not inferior to in-person treatments. One study showed that CBT-I delivered via telehealth was noninferior to in-person delivery. However, that study did not include a control group.

“I have been doing telehealth clinical work for about 10 years – so way before the pandemic pushed everything virtual,” Dr. Gehrman said. “But when I would talk about my telehealth work to other providers, I would frequently get asked whether the advantages of telehealth (greater access to care, reduced travel costs) came at a price of lower efficacy.”

Dr. Gehrman said he suspected that telehealth treatment was just as effective and wanted to formally test this impression to see whether he was correct.

The investigators randomly assigned 60 adults (mean age, 32.72 years; mean ISI score, 17.0; 65% women) with insomnia disorder to in-person CBT-I (n = 20), telehealth-delivered CBT-I (n = 21), or to a wait-list control group (n = 19). For the study, insomnia disorder was determined on the basis of DSM-5 criteria.

Most participants had completed college or postgraduate school (43% and 37%, respectively) and did not have many comorbidities.

The primary outcome was change on the ISI. Other assessments included measures of depression, anxiety, work and social adjustment, fatigue, and medical outcomes. Participants also completed a home unattended sleep study using a portable monitor to screen participants for obstructive sleep apnea.

Both types of CBT-I were delivered over 6 to 8 weekly sessions, with 2-week and 3-month post-treatment follow-ups.

An a priori margin of -3.0 points was used in the noninferiority analysis, and all analyses were conducted using mixed-effects models, the authors explain.
 

Necessary evil?

In the primary noninferiority analyses, the mean change in ISI score from baseline to 3-month follow-up was -7.8 points for in-person CBT-I, -7.5 points for telehealth, and -1.6 for wait list.

The difference between the CBT-I groups was not statistically significant (t 28 = -0.98, P = .33).

“The lower confidence limit of this between-group difference in the mean ISI changes was greater than the a priori margin of -3.0 points, indicating that telehealth treatment was not inferior to in-person treatment,” the investigators write.

Although there were significant improvements on most secondary outcome measures related to mood/anxiety and daytime functioning, the investigators found no group differences.

The findings suggest that the benefits of telehealth, including increased access and reduced travel time, “do not come with a cost of reduced efficacy,” the researchers write.

The study was conducted prior to the COVID-19 pandemic, the investigators note. However, the results “underscore that the use of telehealth during the pandemic is not a ‘necessary evil,’ but rather a means of providing high quality care while reducing risks of exposure,” they write.
 

Benefits, fidelity maintained

Commenting on the study, J. Todd Arnedt, PhD, professor of psychiatry and neurology and co-director of the Sleep and Circadian Research Laboratory, Michigan Medicine, University of Michigan, Ann Arbor, said it is “one of the first studies to clearly demonstrate that the benefits and fidelity of CBT for insomnia, which is most commonly delivered in-person, can be maintained with telehealth delivery.”

Dr. Arnedt is also director of the Behavioral Sleep Medicine Program and was not involved in the study. He said the findings “support the use of this modality by providers to expand access to this highly effective but underutilized insomnia treatment.”

Additionally, telehealth delivery of CBT-I “offers a safe and effective alternative to in-person care for improving insomnia and associated daytime consequences and has the potential to reduce health care disparities by increasing availability to underserved communities,” Dr. Arnedt said.

However, the investigators point out that the utility of this approach for underserved communities needs further investigation. A study limitation was that the participants were “generally healthy and well educated.”

In addition, further research is needed to see whether the findings can be generalized to individuals who have “more complicated health or socioeconomic difficulties,” they write.

The study was funded by a grant from the American Sleep Medicine Foundation and the Doris Duke Charitable Foundation Clinical Scientist Development Award. Dr. Gehrman has received research funding from Merck, is a consultant to WW, and serves on the scientific advisory board of Eight Sleep. The other authors’ disclosures are listed in the original article. Dr. Arnedt reports no relevant financial relationships but notes that he was the principal investigator of a similar study run in parallel to this one that was also funded by the American Academy of Sleep Medicine Foundation at the same time.

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

Telehealth can be effective for delivering cognitive-behavioral therapy for insomnia (CBT-I) – and is not inferior to in-person treatment, new research suggests.

Results from a study of 60 adults with insomnia disorder showed no significant between-group difference at 3-month follow-up between those assigned to receive in-person CBT-I and those assigned to telehealth CBT-I in regard to change in score on the Insomnia Severity Index (ISI).

In addition, both groups showed significant change compared with a wait-list group, indicating that telehealth was not inferior to the in-person mode of delivery, the investigators note.

Telehealth ‘explosion’

Although CBT-I is the recommended intervention for insomnia, “widespread implementation of CBT-I is limited by the lack of clinicians who are trained in this treatment,” the investigators note. There is a “need for strategies to increase access, particularly for patients in areas with few health care providers.”

Telehealth is a promising technology for providing treatment, without the necessity of having the patient and the practitioner in the same place. There has been an “explosion” in its use because of restrictions necessitated by the COVID-19 pandemic. However, the “rapid deployment of telehealth interventions did not allow time to assess this approach in a controlled manner,” so it is possible that this type of communication might reduce treatment efficacy, the investigators note.

Previous research suggests that telehealth psychotherapeutic treatments in general are not inferior to in-person treatments. One study showed that CBT-I delivered via telehealth was noninferior to in-person delivery. However, that study did not include a control group.

“I have been doing telehealth clinical work for about 10 years – so way before the pandemic pushed everything virtual,” Dr. Gehrman said. “But when I would talk about my telehealth work to other providers, I would frequently get asked whether the advantages of telehealth (greater access to care, reduced travel costs) came at a price of lower efficacy.”

Dr. Gehrman said he suspected that telehealth treatment was just as effective and wanted to formally test this impression to see whether he was correct.

The investigators randomly assigned 60 adults (mean age, 32.72 years; mean ISI score, 17.0; 65% women) with insomnia disorder to in-person CBT-I (n = 20), telehealth-delivered CBT-I (n = 21), or to a wait-list control group (n = 19). For the study, insomnia disorder was determined on the basis of DSM-5 criteria.

Most participants had completed college or postgraduate school (43% and 37%, respectively) and did not have many comorbidities.

The primary outcome was change on the ISI. Other assessments included measures of depression, anxiety, work and social adjustment, fatigue, and medical outcomes. Participants also completed a home unattended sleep study using a portable monitor to screen participants for obstructive sleep apnea.

Both types of CBT-I were delivered over 6 to 8 weekly sessions, with 2-week and 3-month post-treatment follow-ups.

An a priori margin of -3.0 points was used in the noninferiority analysis, and all analyses were conducted using mixed-effects models, the authors explain.
 

Necessary evil?

In the primary noninferiority analyses, the mean change in ISI score from baseline to 3-month follow-up was -7.8 points for in-person CBT-I, -7.5 points for telehealth, and -1.6 for wait list.

The difference between the CBT-I groups was not statistically significant (t 28 = -0.98, P = .33).

“The lower confidence limit of this between-group difference in the mean ISI changes was greater than the a priori margin of -3.0 points, indicating that telehealth treatment was not inferior to in-person treatment,” the investigators write.

Although there were significant improvements on most secondary outcome measures related to mood/anxiety and daytime functioning, the investigators found no group differences.

The findings suggest that the benefits of telehealth, including increased access and reduced travel time, “do not come with a cost of reduced efficacy,” the researchers write.

The study was conducted prior to the COVID-19 pandemic, the investigators note. However, the results “underscore that the use of telehealth during the pandemic is not a ‘necessary evil,’ but rather a means of providing high quality care while reducing risks of exposure,” they write.
 

Benefits, fidelity maintained

Commenting on the study, J. Todd Arnedt, PhD, professor of psychiatry and neurology and co-director of the Sleep and Circadian Research Laboratory, Michigan Medicine, University of Michigan, Ann Arbor, said it is “one of the first studies to clearly demonstrate that the benefits and fidelity of CBT for insomnia, which is most commonly delivered in-person, can be maintained with telehealth delivery.”

Dr. Arnedt is also director of the Behavioral Sleep Medicine Program and was not involved in the study. He said the findings “support the use of this modality by providers to expand access to this highly effective but underutilized insomnia treatment.”

Additionally, telehealth delivery of CBT-I “offers a safe and effective alternative to in-person care for improving insomnia and associated daytime consequences and has the potential to reduce health care disparities by increasing availability to underserved communities,” Dr. Arnedt said.

However, the investigators point out that the utility of this approach for underserved communities needs further investigation. A study limitation was that the participants were “generally healthy and well educated.”

In addition, further research is needed to see whether the findings can be generalized to individuals who have “more complicated health or socioeconomic difficulties,” they write.

The study was funded by a grant from the American Sleep Medicine Foundation and the Doris Duke Charitable Foundation Clinical Scientist Development Award. Dr. Gehrman has received research funding from Merck, is a consultant to WW, and serves on the scientific advisory board of Eight Sleep. The other authors’ disclosures are listed in the original article. Dr. Arnedt reports no relevant financial relationships but notes that he was the principal investigator of a similar study run in parallel to this one that was also funded by the American Academy of Sleep Medicine Foundation at the same time.

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

Back-to-school jitters are heightened this year, as children head back to the risk of COVID transmission in class, but one upside to the return of in-person school may be better mental health for students.

Courtesy Dr. Matt Hawrilenko

New research shows that virtual schooling, which dominated in many districts last year, was associated with worse mental health outcomes for students – especially older ones – and youth from Black, Hispanic, or lower-income families were hit hardest because they experienced the most closures.

“Schools with lower funding may have had more difficulty meeting guidelines for safe reopening, including updates to ventilation systems and finding the physical space to create safe distancing between children,” explained lead author Matt Hawrilenko, PhD, of the department of psychiatry and behavioral sciences at the University of Washington, Seattle, in an interview.

“In the context of complex school reopening decisions that balance competing risks and benefits, these findings suggest that allocating funding to support safe in-person instruction may reduce mental health inequities associated with race/ethnicity and income,” he and his coauthors noted in the study, published in JAMA Network Open. “Ensuring that all students have access to additional educational and mental health resources must be an important public health priority, met with appropriate funding and work force augmentation, during and beyond the COVID-19 pandemic.”

The study used a cross-sectional population-based survey of 2,324 parents of school-age children in the United States. It was administered in English and Spanish via web and telephone between Dec. 2 and Dec. 21, 2020, and used the parent-report version of the Strengths and Difficulties Questionnaire (SDQ) to assess mental health difficulties of one child per family in four domains: emotional problems, peer problems, conduct, and hyperactivity. Parents were also asked about what kind of schooling their child had received in the last year (remote, in-person, or hybrid) and about demographic information such as child age, gender, household income, parent race and ethnicity, and parent education.

The results showed that, during the 2020 school year, 58.0% of children attended school remotely, 24% attended fully in person, and 18.0% attended in a hybrid format. “Fully remote schooling was strongly patterned along lines of parent race and ethnicity as well as income,” the authors noted. “Parents of 336 children attending school in person (65.8%) but of 597 children attending school fully remotely (44.5%) were White, whereas all other racial/ethnic groups had larger proportions of children attending school fully remotely (P < .001).”

In terms of mental health, the findings showed that older children who attended school remotely had more difficulties, compared with those who attended in-person – but among younger children, remote learning was comparable or slightly better for mental health.

Specifically, “a child aged 17 years attending school remotely would be expected to have a total difficulty score 2.4 points higher than a child of the same age attending school in person, corresponding to a small effect size in favor of in-person schooling,” the authors wrote. “Conversely, a child aged 4 years attending school remotely would be expected to have a total difficulty score 0.5 points lower than a child of the same age attending school in person, corresponding to a very small effect size in favor of remote schooling.”

Age of child proves critical

“Our best estimate is that remote schooling was associated with no difference in mental health difficulties at age 6, and with slightly more difficulties with each year of age after that, with differences most clearly apparent for high school–aged kids,” explained Dr. Hawrilenko, adding the finding suggests that school reopenings should prioritize older children.

However, “what kids are doing at home matters,” he added. “In the youngest age group, the biggest work kids are doing in school and childcare settings is social and emotional development. … Finding opportunities for regular, safe social interactions with peers – perhaps during outdoor playdates – can help them build those skills.”

He emphasized with the anticipated starts and stutters of the new school year there is an important role that doctors can play.

“First, they can help families assess their own risk profile, and whether it makes sense for their children to attend school in person or remotely [to the extent that is an option]. Second, they can help families think through how school closures might impact their child specifically. For those kids who wind up with long chunks of remote schooling, scheduling in regular interactions with other kids in safe ways could make a big difference. Another driver of child anxiety might be learning loss, and this is a good place to reinforce that not every mental health problem needs a mental health solution.

“A lot of kids might be rightfully anxious about having fallen behind over the pandemic. These kids are preparing to transition to college or to the workforce and may be feeling increasingly behind while approaching these moments of transition. Pointing families toward the resources to help them navigate these issues could go a long way to helping quell child anxiety.”

Research helps fill vacuum

Elizabeth A. Stuart, PhD, who was not involved in the study, said in an interview that this research is particularly valuable because there have been very few data on this topic, especially on a large-scale national sample.

Courtesy Dr. Elizabeth A. Stuart

“Sadly, many of the results are not surprising,” said Dr. Stuart, a statistician and professor of mental health at Johns Hopkins University, Baltimore. “Data have shown significant mental health challenges for adults during the pandemic, and it is not surprising that children and youth would experience that as well, especially for those whose daily routines and structures changed dramatically and who were not able to be interacting in-person with teachers, staff, and classmates. This is an important reminder that schools provide not just academic instruction for students, but that the social interactions and other services (such as behavioral health supports, meals, and connections with other social services) students might receive in school are crucial.

“It has been heartening to see a stronger commitment to getting students safely back into school this fall across the country, and that the Centers for Disease Control and Prevention highlighted the benefits of in-person schooling in their COVID-19–related guidance for schools.”

Dr. Stuart added that, as students return to classes, it will be important for schools to tackle ongoing mental health challenges.

“Some students may be struggling in obvious ways; for others it may be harder to identify. It will also be important to continue to monitor children’s and youth mental health … as returning to in-person school may bring its own challenges. For some individuals and communities, the mental health impacts of the pandemic may last even after the physical health risks resolve.”

Dr. Hawrilenko agreed.

“From a policy perspective, I am quite frankly terrified about how these inequities – in particular, learning loss – might play out long after school closures are a distant memory,” he said. “It is critical to provide schools the resources not just to minimize risk when reopening, but additional funding for workforce augmentation – both for mental health staffing and for additional educational support – to help students navigate the months and years over which they transition back into the classroom.”

Dr. Hawrilenko and Dr. Stuart had no disclosures.

Back-to-school jitters are heightened this year, as children head back to the risk of COVID transmission in class, but one upside to the return of in-person school may be better mental health for students.

Courtesy Dr. Matt Hawrilenko

New research shows that virtual schooling, which dominated in many districts last year, was associated with worse mental health outcomes for students – especially older ones – and youth from Black, Hispanic, or lower-income families were hit hardest because they experienced the most closures.

“Schools with lower funding may have had more difficulty meeting guidelines for safe reopening, including updates to ventilation systems and finding the physical space to create safe distancing between children,” explained lead author Matt Hawrilenko, PhD, of the department of psychiatry and behavioral sciences at the University of Washington, Seattle, in an interview.

“In the context of complex school reopening decisions that balance competing risks and benefits, these findings suggest that allocating funding to support safe in-person instruction may reduce mental health inequities associated with race/ethnicity and income,” he and his coauthors noted in the study, published in JAMA Network Open. “Ensuring that all students have access to additional educational and mental health resources must be an important public health priority, met with appropriate funding and work force augmentation, during and beyond the COVID-19 pandemic.”

The study used a cross-sectional population-based survey of 2,324 parents of school-age children in the United States. It was administered in English and Spanish via web and telephone between Dec. 2 and Dec. 21, 2020, and used the parent-report version of the Strengths and Difficulties Questionnaire (SDQ) to assess mental health difficulties of one child per family in four domains: emotional problems, peer problems, conduct, and hyperactivity. Parents were also asked about what kind of schooling their child had received in the last year (remote, in-person, or hybrid) and about demographic information such as child age, gender, household income, parent race and ethnicity, and parent education.

The results showed that, during the 2020 school year, 58.0% of children attended school remotely, 24% attended fully in person, and 18.0% attended in a hybrid format. “Fully remote schooling was strongly patterned along lines of parent race and ethnicity as well as income,” the authors noted. “Parents of 336 children attending school in person (65.8%) but of 597 children attending school fully remotely (44.5%) were White, whereas all other racial/ethnic groups had larger proportions of children attending school fully remotely (P < .001).”

In terms of mental health, the findings showed that older children who attended school remotely had more difficulties, compared with those who attended in-person – but among younger children, remote learning was comparable or slightly better for mental health.

Specifically, “a child aged 17 years attending school remotely would be expected to have a total difficulty score 2.4 points higher than a child of the same age attending school in person, corresponding to a small effect size in favor of in-person schooling,” the authors wrote. “Conversely, a child aged 4 years attending school remotely would be expected to have a total difficulty score 0.5 points lower than a child of the same age attending school in person, corresponding to a very small effect size in favor of remote schooling.”

Age of child proves critical

“Our best estimate is that remote schooling was associated with no difference in mental health difficulties at age 6, and with slightly more difficulties with each year of age after that, with differences most clearly apparent for high school–aged kids,” explained Dr. Hawrilenko, adding the finding suggests that school reopenings should prioritize older children.

However, “what kids are doing at home matters,” he added. “In the youngest age group, the biggest work kids are doing in school and childcare settings is social and emotional development. … Finding opportunities for regular, safe social interactions with peers – perhaps during outdoor playdates – can help them build those skills.”

He emphasized with the anticipated starts and stutters of the new school year there is an important role that doctors can play.

“First, they can help families assess their own risk profile, and whether it makes sense for their children to attend school in person or remotely [to the extent that is an option]. Second, they can help families think through how school closures might impact their child specifically. For those kids who wind up with long chunks of remote schooling, scheduling in regular interactions with other kids in safe ways could make a big difference. Another driver of child anxiety might be learning loss, and this is a good place to reinforce that not every mental health problem needs a mental health solution.

“A lot of kids might be rightfully anxious about having fallen behind over the pandemic. These kids are preparing to transition to college or to the workforce and may be feeling increasingly behind while approaching these moments of transition. Pointing families toward the resources to help them navigate these issues could go a long way to helping quell child anxiety.”

Research helps fill vacuum

Elizabeth A. Stuart, PhD, who was not involved in the study, said in an interview that this research is particularly valuable because there have been very few data on this topic, especially on a large-scale national sample.

Courtesy Dr. Elizabeth A. Stuart

“Sadly, many of the results are not surprising,” said Dr. Stuart, a statistician and professor of mental health at Johns Hopkins University, Baltimore. “Data have shown significant mental health challenges for adults during the pandemic, and it is not surprising that children and youth would experience that as well, especially for those whose daily routines and structures changed dramatically and who were not able to be interacting in-person with teachers, staff, and classmates. This is an important reminder that schools provide not just academic instruction for students, but that the social interactions and other services (such as behavioral health supports, meals, and connections with other social services) students might receive in school are crucial.

“It has been heartening to see a stronger commitment to getting students safely back into school this fall across the country, and that the Centers for Disease Control and Prevention highlighted the benefits of in-person schooling in their COVID-19–related guidance for schools.”

Dr. Stuart added that, as students return to classes, it will be important for schools to tackle ongoing mental health challenges.

“Some students may be struggling in obvious ways; for others it may be harder to identify. It will also be important to continue to monitor children’s and youth mental health … as returning to in-person school may bring its own challenges. For some individuals and communities, the mental health impacts of the pandemic may last even after the physical health risks resolve.”

Dr. Hawrilenko agreed.

“From a policy perspective, I am quite frankly terrified about how these inequities – in particular, learning loss – might play out long after school closures are a distant memory,” he said. “It is critical to provide schools the resources not just to minimize risk when reopening, but additional funding for workforce augmentation – both for mental health staffing and for additional educational support – to help students navigate the months and years over which they transition back into the classroom.”

Dr. Hawrilenko and Dr. Stuart had no disclosures.

Back-to-school jitters are heightened this year, as children head back to the risk of COVID transmission in class, but one upside to the return of in-person school may be better mental health for students.

Courtesy Dr. Matt Hawrilenko

New research shows that virtual schooling, which dominated in many districts last year, was associated with worse mental health outcomes for students – especially older ones – and youth from Black, Hispanic, or lower-income families were hit hardest because they experienced the most closures.

“Schools with lower funding may have had more difficulty meeting guidelines for safe reopening, including updates to ventilation systems and finding the physical space to create safe distancing between children,” explained lead author Matt Hawrilenko, PhD, of the department of psychiatry and behavioral sciences at the University of Washington, Seattle, in an interview.

“In the context of complex school reopening decisions that balance competing risks and benefits, these findings suggest that allocating funding to support safe in-person instruction may reduce mental health inequities associated with race/ethnicity and income,” he and his coauthors noted in the study, published in JAMA Network Open. “Ensuring that all students have access to additional educational and mental health resources must be an important public health priority, met with appropriate funding and work force augmentation, during and beyond the COVID-19 pandemic.”

The study used a cross-sectional population-based survey of 2,324 parents of school-age children in the United States. It was administered in English and Spanish via web and telephone between Dec. 2 and Dec. 21, 2020, and used the parent-report version of the Strengths and Difficulties Questionnaire (SDQ) to assess mental health difficulties of one child per family in four domains: emotional problems, peer problems, conduct, and hyperactivity. Parents were also asked about what kind of schooling their child had received in the last year (remote, in-person, or hybrid) and about demographic information such as child age, gender, household income, parent race and ethnicity, and parent education.

The results showed that, during the 2020 school year, 58.0% of children attended school remotely, 24% attended fully in person, and 18.0% attended in a hybrid format. “Fully remote schooling was strongly patterned along lines of parent race and ethnicity as well as income,” the authors noted. “Parents of 336 children attending school in person (65.8%) but of 597 children attending school fully remotely (44.5%) were White, whereas all other racial/ethnic groups had larger proportions of children attending school fully remotely (P < .001).”

In terms of mental health, the findings showed that older children who attended school remotely had more difficulties, compared with those who attended in-person – but among younger children, remote learning was comparable or slightly better for mental health.

Specifically, “a child aged 17 years attending school remotely would be expected to have a total difficulty score 2.4 points higher than a child of the same age attending school in person, corresponding to a small effect size in favor of in-person schooling,” the authors wrote. “Conversely, a child aged 4 years attending school remotely would be expected to have a total difficulty score 0.5 points lower than a child of the same age attending school in person, corresponding to a very small effect size in favor of remote schooling.”

Age of child proves critical

“Our best estimate is that remote schooling was associated with no difference in mental health difficulties at age 6, and with slightly more difficulties with each year of age after that, with differences most clearly apparent for high school–aged kids,” explained Dr. Hawrilenko, adding the finding suggests that school reopenings should prioritize older children.

However, “what kids are doing at home matters,” he added. “In the youngest age group, the biggest work kids are doing in school and childcare settings is social and emotional development. … Finding opportunities for regular, safe social interactions with peers – perhaps during outdoor playdates – can help them build those skills.”

He emphasized with the anticipated starts and stutters of the new school year there is an important role that doctors can play.

“First, they can help families assess their own risk profile, and whether it makes sense for their children to attend school in person or remotely [to the extent that is an option]. Second, they can help families think through how school closures might impact their child specifically. For those kids who wind up with long chunks of remote schooling, scheduling in regular interactions with other kids in safe ways could make a big difference. Another driver of child anxiety might be learning loss, and this is a good place to reinforce that not every mental health problem needs a mental health solution.

“A lot of kids might be rightfully anxious about having fallen behind over the pandemic. These kids are preparing to transition to college or to the workforce and may be feeling increasingly behind while approaching these moments of transition. Pointing families toward the resources to help them navigate these issues could go a long way to helping quell child anxiety.”

Research helps fill vacuum

Elizabeth A. Stuart, PhD, who was not involved in the study, said in an interview that this research is particularly valuable because there have been very few data on this topic, especially on a large-scale national sample.

Courtesy Dr. Elizabeth A. Stuart

“Sadly, many of the results are not surprising,” said Dr. Stuart, a statistician and professor of mental health at Johns Hopkins University, Baltimore. “Data have shown significant mental health challenges for adults during the pandemic, and it is not surprising that children and youth would experience that as well, especially for those whose daily routines and structures changed dramatically and who were not able to be interacting in-person with teachers, staff, and classmates. This is an important reminder that schools provide not just academic instruction for students, but that the social interactions and other services (such as behavioral health supports, meals, and connections with other social services) students might receive in school are crucial.

“It has been heartening to see a stronger commitment to getting students safely back into school this fall across the country, and that the Centers for Disease Control and Prevention highlighted the benefits of in-person schooling in their COVID-19–related guidance for schools.”

Dr. Stuart added that, as students return to classes, it will be important for schools to tackle ongoing mental health challenges.

“Some students may be struggling in obvious ways; for others it may be harder to identify. It will also be important to continue to monitor children’s and youth mental health … as returning to in-person school may bring its own challenges. For some individuals and communities, the mental health impacts of the pandemic may last even after the physical health risks resolve.”

Dr. Hawrilenko agreed.

“From a policy perspective, I am quite frankly terrified about how these inequities – in particular, learning loss – might play out long after school closures are a distant memory,” he said. “It is critical to provide schools the resources not just to minimize risk when reopening, but additional funding for workforce augmentation – both for mental health staffing and for additional educational support – to help students navigate the months and years over which they transition back into the classroom.”

Dr. Hawrilenko and Dr. Stuart had no disclosures.

After a steep decline in the first months of the COVID-19 pandemic, youth with suicidal thoughts and behaviors visiting an emergency department (ED) resurged with an overrepresentation among girls and children without a prior psychiatric history, according to a cross-sectional study conducted at Kaiser Permanente Northern California.

JochenSchoenfeld/Thinkstock

The latest findings, published in JAMA Psychiatry, are highly consistent with Centers for Disease Control and Prevention data published a few months earlier in the Morbidity and Mortality Weekly Report that looked at these trends among young people aged 12-25 before and during the pandemic. In addition, the new data suggest that prevention efforts might be particularly helpful for these young people and their families.

“As suicide-related encounters have made up more ED volume during the pandemic, increasing ED-based interventions, staff trained in addressing emergency mental health needs, and aftercare resources may also be valuable in addressing the needs of this population,” wrote Kathryn K. Erickson-Ridout, MD, PhD, first author of the more recent study and an adjunct investigator with the Kaiser Permanente Division of Research, Oakland, Calif.

“While these results suggest many of our youth are coping well through the pandemic, we need to be vigilant as health care workers,” she said in an interview.

Dr. Ridout and associates evaluated suicide-related ED visits among children aged 5-17 years presenting to EDs in the Kaiser Permanente Northern California system. Four periods in 2020 were compared with the same four periods in 2019.

In the first period, March through May 2020, the incidence rate ratio (IRR) of suicide-related ED visits among children and adolescents fell more than 40% (IRR, 0.53; P < .001) relative to the same months in 2019. This is consistent with a broader decline in other types of ED visits during the beginning of the COVID-19 pandemic.

In the periods of June through August and September to Dec. 15, suicide-related ED visits increased, reaching prepandemic levels overall but with differences between genders. In girls, an increase in the first period reached significance (IRR, 1.19; P = .04) and then climbed even higher in the second (hazard ratio, 1.22; P < .001).
 

Youth present with no prior psychiatric history

Among boys, the increase relative to 2019 in the first period was modest and nonsignificant (IRR, 1.05; P = .26) In the second period, suicide-related ED visits fell and the difference relative to the same period in 2019 reached statistical significance (IRR, 0.81; P = .02).

Other characteristics of suicide-related ED visits during the pandemic were also different from those observed in 2019. One was an increase in visits from youth with no prior history of mental health or suicide-related outpatient visits.

“This finding may suggest that a youth’s first presentation to the ED for suicidal thoughts and behaviors differed during the pandemic, compared to prior to the pandemic,” Dr. Erickson-Ridout explained. “Mental health comorbidities first diagnosed at the ED encounter may suggest an increased complexity at first presentation.”

These data are remarkably similar to ED visits for suicide attempts that were reported by the CDC several months earlier. The CDC data were drawn from the National Syndromic Surveillance Program, which captures data from 71% of the EDs in the United States.

Measured from March 29 to April 25, 2020, ED visits for a suicide attempt declined by more than 25% in both girls and boys, but by early May, those visits were already starting to return to prepandemic levels, particularly among girls, according to the CDC report. When evaluated from July 26 through Aug. 22, 2020, the mean weekly ED visits for suspected suicide attempts had increased 26.2% among girls but only 10.8% among boys, compared with the same period in 2019.

‘More severe distress’ found among girls

In the most recent period evaluated, starting Feb. 21, 2021, and extending to March 20, there was a 50.6% increase among girls in the mean number of weekly ED visits for suspected suicide attempts, compared with the same period in 2019. For boys, the increase was 3.7%.

Higher rates of suicide attempts among girls have been reported by others independent of the COVID-19 pandemic, but the CDC investigators led by Ellen Yard, PhD, a researcher in the CDC’s National Center for Environmental Health, Chamblee, Ga., reported that others have also found greater suicide ideation and attempts by girls during the pandemic. This new report “suggests more severe distress among young females than has been identified in previous reports during the pandemic.”

Neither study was designed to isolate the reason or reasons for an increase in suicide-related ED visits overall or among girls specifically, but Dr. Yard and her coinvestigators speculated that social distancing and isolation during the COVID-19 pandemic might be affecting girls more.

The faster increase in suicide attempts among girls compared with boys “speaks to the importance of upstream prevention to prevent this group from becoming suicidal in the first place as well as improving suicide care both during and after ED visits,” said Dr. Yard, who was interviewed about this research.

For clinicians, she recommended “scaling up adoption of evidence-based best practice.” She cited two such resources from the National Action Alliance for Suicide Prevention (NAASP). One resource is the Best Practices in Care Transitions for Individuals with Suicide Risk: Inpatient Care to Outpatient Care; the other is called Recommended Standard Care. Both are available online for free from the NAASP.

Dr. Erickson-Ridout and Dr. Yard reported no potential conflicts of interest.

After a steep decline in the first months of the COVID-19 pandemic, youth with suicidal thoughts and behaviors visiting an emergency department (ED) resurged with an overrepresentation among girls and children without a prior psychiatric history, according to a cross-sectional study conducted at Kaiser Permanente Northern California.

JochenSchoenfeld/Thinkstock

The latest findings, published in JAMA Psychiatry, are highly consistent with Centers for Disease Control and Prevention data published a few months earlier in the Morbidity and Mortality Weekly Report that looked at these trends among young people aged 12-25 before and during the pandemic. In addition, the new data suggest that prevention efforts might be particularly helpful for these young people and their families.

“As suicide-related encounters have made up more ED volume during the pandemic, increasing ED-based interventions, staff trained in addressing emergency mental health needs, and aftercare resources may also be valuable in addressing the needs of this population,” wrote Kathryn K. Erickson-Ridout, MD, PhD, first author of the more recent study and an adjunct investigator with the Kaiser Permanente Division of Research, Oakland, Calif.

“While these results suggest many of our youth are coping well through the pandemic, we need to be vigilant as health care workers,” she said in an interview.

Dr. Ridout and associates evaluated suicide-related ED visits among children aged 5-17 years presenting to EDs in the Kaiser Permanente Northern California system. Four periods in 2020 were compared with the same four periods in 2019.

In the first period, March through May 2020, the incidence rate ratio (IRR) of suicide-related ED visits among children and adolescents fell more than 40% (IRR, 0.53; P < .001) relative to the same months in 2019. This is consistent with a broader decline in other types of ED visits during the beginning of the COVID-19 pandemic.

In the periods of June through August and September to Dec. 15, suicide-related ED visits increased, reaching prepandemic levels overall but with differences between genders. In girls, an increase in the first period reached significance (IRR, 1.19; P = .04) and then climbed even higher in the second (hazard ratio, 1.22; P < .001).
 

Youth present with no prior psychiatric history

Among boys, the increase relative to 2019 in the first period was modest and nonsignificant (IRR, 1.05; P = .26) In the second period, suicide-related ED visits fell and the difference relative to the same period in 2019 reached statistical significance (IRR, 0.81; P = .02).

Other characteristics of suicide-related ED visits during the pandemic were also different from those observed in 2019. One was an increase in visits from youth with no prior history of mental health or suicide-related outpatient visits.

“This finding may suggest that a youth’s first presentation to the ED for suicidal thoughts and behaviors differed during the pandemic, compared to prior to the pandemic,” Dr. Erickson-Ridout explained. “Mental health comorbidities first diagnosed at the ED encounter may suggest an increased complexity at first presentation.”

These data are remarkably similar to ED visits for suicide attempts that were reported by the CDC several months earlier. The CDC data were drawn from the National Syndromic Surveillance Program, which captures data from 71% of the EDs in the United States.

Measured from March 29 to April 25, 2020, ED visits for a suicide attempt declined by more than 25% in both girls and boys, but by early May, those visits were already starting to return to prepandemic levels, particularly among girls, according to the CDC report. When evaluated from July 26 through Aug. 22, 2020, the mean weekly ED visits for suspected suicide attempts had increased 26.2% among girls but only 10.8% among boys, compared with the same period in 2019.

‘More severe distress’ found among girls

In the most recent period evaluated, starting Feb. 21, 2021, and extending to March 20, there was a 50.6% increase among girls in the mean number of weekly ED visits for suspected suicide attempts, compared with the same period in 2019. For boys, the increase was 3.7%.

Higher rates of suicide attempts among girls have been reported by others independent of the COVID-19 pandemic, but the CDC investigators led by Ellen Yard, PhD, a researcher in the CDC’s National Center for Environmental Health, Chamblee, Ga., reported that others have also found greater suicide ideation and attempts by girls during the pandemic. This new report “suggests more severe distress among young females than has been identified in previous reports during the pandemic.”

Neither study was designed to isolate the reason or reasons for an increase in suicide-related ED visits overall or among girls specifically, but Dr. Yard and her coinvestigators speculated that social distancing and isolation during the COVID-19 pandemic might be affecting girls more.

The faster increase in suicide attempts among girls compared with boys “speaks to the importance of upstream prevention to prevent this group from becoming suicidal in the first place as well as improving suicide care both during and after ED visits,” said Dr. Yard, who was interviewed about this research.

For clinicians, she recommended “scaling up adoption of evidence-based best practice.” She cited two such resources from the National Action Alliance for Suicide Prevention (NAASP). One resource is the Best Practices in Care Transitions for Individuals with Suicide Risk: Inpatient Care to Outpatient Care; the other is called Recommended Standard Care. Both are available online for free from the NAASP.

Dr. Erickson-Ridout and Dr. Yard reported no potential conflicts of interest.

After a steep decline in the first months of the COVID-19 pandemic, youth with suicidal thoughts and behaviors visiting an emergency department (ED) resurged with an overrepresentation among girls and children without a prior psychiatric history, according to a cross-sectional study conducted at Kaiser Permanente Northern California.

JochenSchoenfeld/Thinkstock

The latest findings, published in JAMA Psychiatry, are highly consistent with Centers for Disease Control and Prevention data published a few months earlier in the Morbidity and Mortality Weekly Report that looked at these trends among young people aged 12-25 before and during the pandemic. In addition, the new data suggest that prevention efforts might be particularly helpful for these young people and their families.

“As suicide-related encounters have made up more ED volume during the pandemic, increasing ED-based interventions, staff trained in addressing emergency mental health needs, and aftercare resources may also be valuable in addressing the needs of this population,” wrote Kathryn K. Erickson-Ridout, MD, PhD, first author of the more recent study and an adjunct investigator with the Kaiser Permanente Division of Research, Oakland, Calif.

“While these results suggest many of our youth are coping well through the pandemic, we need to be vigilant as health care workers,” she said in an interview.

Dr. Ridout and associates evaluated suicide-related ED visits among children aged 5-17 years presenting to EDs in the Kaiser Permanente Northern California system. Four periods in 2020 were compared with the same four periods in 2019.

In the first period, March through May 2020, the incidence rate ratio (IRR) of suicide-related ED visits among children and adolescents fell more than 40% (IRR, 0.53; P < .001) relative to the same months in 2019. This is consistent with a broader decline in other types of ED visits during the beginning of the COVID-19 pandemic.

In the periods of June through August and September to Dec. 15, suicide-related ED visits increased, reaching prepandemic levels overall but with differences between genders. In girls, an increase in the first period reached significance (IRR, 1.19; P = .04) and then climbed even higher in the second (hazard ratio, 1.22; P < .001).
 

Youth present with no prior psychiatric history

Among boys, the increase relative to 2019 in the first period was modest and nonsignificant (IRR, 1.05; P = .26) In the second period, suicide-related ED visits fell and the difference relative to the same period in 2019 reached statistical significance (IRR, 0.81; P = .02).

Other characteristics of suicide-related ED visits during the pandemic were also different from those observed in 2019. One was an increase in visits from youth with no prior history of mental health or suicide-related outpatient visits.

“This finding may suggest that a youth’s first presentation to the ED for suicidal thoughts and behaviors differed during the pandemic, compared to prior to the pandemic,” Dr. Erickson-Ridout explained. “Mental health comorbidities first diagnosed at the ED encounter may suggest an increased complexity at first presentation.”

These data are remarkably similar to ED visits for suicide attempts that were reported by the CDC several months earlier. The CDC data were drawn from the National Syndromic Surveillance Program, which captures data from 71% of the EDs in the United States.

Measured from March 29 to April 25, 2020, ED visits for a suicide attempt declined by more than 25% in both girls and boys, but by early May, those visits were already starting to return to prepandemic levels, particularly among girls, according to the CDC report. When evaluated from July 26 through Aug. 22, 2020, the mean weekly ED visits for suspected suicide attempts had increased 26.2% among girls but only 10.8% among boys, compared with the same period in 2019.

‘More severe distress’ found among girls

In the most recent period evaluated, starting Feb. 21, 2021, and extending to March 20, there was a 50.6% increase among girls in the mean number of weekly ED visits for suspected suicide attempts, compared with the same period in 2019. For boys, the increase was 3.7%.

Higher rates of suicide attempts among girls have been reported by others independent of the COVID-19 pandemic, but the CDC investigators led by Ellen Yard, PhD, a researcher in the CDC’s National Center for Environmental Health, Chamblee, Ga., reported that others have also found greater suicide ideation and attempts by girls during the pandemic. This new report “suggests more severe distress among young females than has been identified in previous reports during the pandemic.”

Neither study was designed to isolate the reason or reasons for an increase in suicide-related ED visits overall or among girls specifically, but Dr. Yard and her coinvestigators speculated that social distancing and isolation during the COVID-19 pandemic might be affecting girls more.

The faster increase in suicide attempts among girls compared with boys “speaks to the importance of upstream prevention to prevent this group from becoming suicidal in the first place as well as improving suicide care both during and after ED visits,” said Dr. Yard, who was interviewed about this research.

For clinicians, she recommended “scaling up adoption of evidence-based best practice.” She cited two such resources from the National Action Alliance for Suicide Prevention (NAASP). One resource is the Best Practices in Care Transitions for Individuals with Suicide Risk: Inpatient Care to Outpatient Care; the other is called Recommended Standard Care. Both are available online for free from the NAASP.

Dr. Erickson-Ridout and Dr. Yard reported no potential conflicts of interest.

The scope and magnitude of the Sept. 11, 2001, attacks on the World Trade Center and the Pentagon were unprecedented in U.S. history. It was arguably the most serious trauma to beset Americans on U.S. soil. The 20th anniversary of 9/11 will take place during another crisis, not only in American history but also in world history – the COVID-19 pandemic.

Photo by Mario Tama/Getty Images

“As different as these two events are, there are obvious points of comparison,” Jonathan DePierro, PhD, assistant professor of psychiatry, Icahn School of Medicine at Mount Sinai, New York, said in an interview. “Both were unprecedented life-threatening situations, presenting threats to individuals’ lives and profoundly traumatizing not only society as a whole but also first responders.”

Dr. DePierro, who is also the clinical director of the Center for Stress, Resilience, and Personal Growth at Mount Sinai, thinks there are many lessons to be learned from the mental health response to 9/11 that can inform our understanding of and response to the mental health needs of today’s first responders in the COVID-19 crisis, particularly health care professionals.

“Every one of our hospitals became a ‘ground zero’ early during the pandemic, and we see the numbers rising again and hospitals again overwhelmed, so our institutions need to design interventions to meet the needs of our health care professionals,” he said.
 

Placing trauma within a new framework

According to Priscilla Dass-Brailsford, EdD, MPH, professor of psychology, department of psychiatry, Georgetown University, Washington, Sept. 11, 2001, “placed trauma within a new framework.”

“Prior to 9/11, crisis protocols and how to manage stress in the aftermath of violent events were uncommon,” Dr. Dass-Brailsford, a clinical psychologist with expertise in trauma who also chairs a clinical psychology program for the Chicago School of Professional Psychology, said in an interview.

As a first responder, she was involved in early interventions for survivors of 9/11. On Sept. 11, 2001, she had just resigned her position as coordinator of the community crisis response team – the first of its kind in the United States – through the Victims of Violence Program in Cambridge, in Cambridge, Mass.

The program responded to communities in which there were high rates of drive-by shootings and similar acts of violence. Because of her crisis experience, Dr. Dass-Brailsford was asked to conduct debriefings in Boston in the area where the 9/11 terrorists had stayed prior to boarding the planes that were used in the terrorist attacks. She subsequently went to New York City to conduct similar psychological debriefings with affected communities.

“What we’ve learned is that we had no crisis protocol on how to manage the stress in the aftermath of such a violent event, no standard operating procedures. There were very few people trained in crisis and trauma response at that time. Partially spurred by 9/11, trauma training programs became more prolific,” she said. Dr. Dass-Brailsford developed a trauma certification program at Lesley University in Cambridge, Mass., where she began to teach after 9/11. “I saw the importance of having clinicians trained to respond in a crisis, because responding to a crisis is very different from conducting regular mental health interventions.”
 

Short- and long-term interventions

Dr. DePierro said that Mount Sinai has a 20-year history of responding to the physical and mental health needs of 9/11 responders.

“We saw a number of first responders experiencing clinical depression, anxiety, a lot of worry, symptoms of posttraumatic stress disorder, and an increase in alcohol and/or substance use,” he recounted. In some, these responses were immediate; in others, the onset of symptoms was more gradual. Some responders had acute reactions that lasted for several months to a year, whereas for others, the reactions were prolonged, and they remained “chronically distressed long after the immediate exposure to the event,” he said.

Recent studies have shown that, during the COVID-19 pandemic, health care professionals and many essential workers have experienced similar symptoms, Dr. DePierro noted.

Mental health care professionals who provided interventions for workers involved in recovery and cleanup at the World Trade Center have highlighted the need for long-term monitoring of people on the front lines during the COVID-19 pandemic – especially health care workers, other essential personnel (for example, delivery, postal, and grocery store workers) and surviving family members. “Health monitoring and treatment efforts for 9/11 survivors and responders were put into place soon after the attacks and continue to this day,” using funding provided through the James Zadroga Act, Dr. DePierro said.

“Without similarly unified health registry and treatment services, many individuals – especially from underserved groups – will likely experience chronic mental health consequences and will be unable to access high-quality health care services,” he stated.
 

‘Psychological first aid’

“Although many people who go through a crisis – whether as a result of terrorism, such as 9/11, or a medical crisis, such as the current pandemic, or a natural disaster, such as Hurricane Katrina – experience PTSD, it’s important to note that not everyone who goes through a crisis and is traumatized will go on to develop PTSD,” Dr. Dass-Brailsford emphasized.

“To me, 9/11 placed psychological first aid on the map. Even if you are not a clinician, you can be trained to provide psychological first aid by becoming familiar with people’s reactions to trauma and how you can support them through it,” she continued.

For example, if a coworker is agitated or “seems to be having a meltdown, you can be there by offering support and getting them the appropriate help.” Research has suggested that having social support before and after a traumatic event can be helpful in determining vulnerability to the development of PTSD and in modulating the impact of the trauma.

Psychological first aid is helpful as an interim measure. “If you see a coworker holding their head in their hands all day and staring at the screen, identifying whether the person might be having a dissociative episode is critical. Providing some support is important, but if more intensive professional support is needed, determining that and making a referral becomes key,” Dr. Dass-Brailsford stated.

Dr. DePierro added: “One of the most important messages that I want health care workers to know from my years of working with 9/11 survivors is that feeling distressed after a traumatic event is very common, but with effective care, one doesn’t necessarily need to be in treatment for years.”

Danielle Ofri, MD, PhD, clinical professor, department of medicine, New York University, agreed. “It is important to continue keeping tabs on each other and remaining sensitive to the collateral struggles of our colleagues. Some have children who are struggling in school, others have parents who have lost a job. Continuing to check in on others and offer support is critical going forward,” she said in an interview.
 

Cohesiveness and volunteerism

One of the most powerful antidotes to long-term traumatization is a sense of community cohesiveness. This was the case following 9/11, and it is the case during the COVID-19 pandemic, according to Dr. Ofri, an internist at Bellevue Hospital in New York.

“There was an enormous mobilization. Bellevue is a city hospital with a level 1 trauma center, and we expected to be swamped, so the whole hospital shifted into gear,” said Dr. Ofri. “What would have been terrifying seemed tolerable because we felt that we were in it together. We discharged the inpatients to make beds available. Within hours, we had converted clinics into emergency departments and ICUs. We worked seamlessly, and the crisis brought us together ... but then, of course, no patients showed up.”

She described her relationship with her colleagues as “feeling almost like a family, especially during the pandemic, when so many others were in lockdown and feeling isolated and useless.”

She and her colleagues saw each other daily. Although the content of their tasks and responsibilities changed and people were redeployed to other areas, “our workday didn’t really change. It would have been overwhelming if we hadn’t had our daily meetings to regroup and assess where we were. Each day, everything we had learned or implemented the day before – treatment protocols, testing protocols, our understanding of how the virus was communicated – would change and need to be reevaluated. Those morning meetings were critical to staying centered. It felt as though we were building a plane and flying it at the same time, which felt both scary and heady. Luckily, it took place within the fraternity of a committed and caring group.”

Dr. Ofri recounted that, after 9/11, as well as during the pandemic, “professionals kept jumping in from the sidelines to volunteer. Within hours of the collapse of the towers, the ED had filled with staff. People came out of retirement and out from vacation and out of the woodwork. It was very heartening.”

Even more inspiring, “all the departmental barriers seemed to break down. People were willing to step out of their ordinary roles and check their egos at the door. Seasoned physicians were willing to function as medical interns.”

This generosity of time and spirit “helped keep us going,” she said.

Dr. DePierro agreed. “One of the things I’ve seen on medical floors is that COVID actually brought some units together, increasing their cohesion and mutual support and increasing the bonds between people.” These intensified bonds “increased the resilience of everyone involved.”
 

Commitment to the community

Dr. Ofri recalls families gathering at the hospital after 9/11, watching posters of missing people going up all over the hospital as well as on mailboxes and lampposts. Because the center for missing people was located right next door to Bellevue, there were long lines of families coming in to register. The chief medical office was there, and a huge tent was built to accommodate the families. The tent took up the entire block. “We felt a lot of ownership, because families were coming here,” she said.

The street remained closed even as the days, weeks, and years stretched on, and the tent remained. It was used as a reflection area for families. During the pandemic, that area was used for refrigerated trucks that served as temporary morgues.

“Both logistically and emotionally, we had a feeling during the pandemic of, ‘We’ve been here before, we’ll do it again and be there for the community,’ ” Dr. Ofri said.

She noted that the sense of commitment to the community carried her and fellow clinicians through the toughest parts of 9/11 and of the COVID-19 pandemic.

“People look to the medical system as a lodestar. ‘Where’s my family member? What should I do? Should I be tested? Vaccinated?’ We were there to be a steady presence for the community physically, psychologically, emotionally, and medically, which helped center us as well,” Dr. Ofri said. “If we didn’t have that, we might have all given in to existential panic.”

She added: “Although we had to work twice as hard, often amid great personal risk, we had the good fortune of having a sense of purpose, something to contribute, plus the community of colleagues we cared about and trusted with our lives.”
 

Crisis and personal growth

Dr. DePierro said that participants who went through 9/11 have been coming to Mount Sinai’s World Trade Center Health Program for care for nearly two decades. “Many are doing quite well, despite the emotional trauma and the dust and toxin exposure, which has given us a window into what makes people resilient.”

Social and community support are key factors in resilience. Another is recognizing opportunities for personal or professional growth during the crisis, according to Dr. DePierro.

During the pandemic, hospital staff were redeployed to departments where they didn’t typically work. They worked with new colleagues and used skills in patient care that they hadn’t needed for years or even decades. “Although this was stressful and distressing, quite a number said they came through with more medical knowledge than before and that they had forged relationships in the trenches that have been lasting and have become important to them,” he reported.

He noted that, during both crises, for first responders and health care practitioners, religious or spiritual faith was a source of resilience. “During the peak of the pandemic, chaplains provided an exorbitant amount of staff support as clinicians turned to the chaplain to help make sense of what they were going through and connect to something greater than themselves.” Similarly, during 9/11, police and fire department chaplains “played a huge role in supporting the first responders,” Dr. DePierro said.

He said that Mount Sinai holds resilience workshops “where we focus on these topics and teach health care workers how to build resilience in their lives, heal day-to-day stressors, and even grow from the experience.”

Dr. Ofri, who is the founder and editor-in-chief of the Bellevue Literary Review, added that the arts played an important role in bolstering resilience and providing a creative outlet for clinicians after 9/11 and again during the pandemic.

The publication is celebrating its twentieth anniversary – its first issue went to press in September 2001. The cover contained an acknowledgment of 9/11.

Dr. Ofri said that a gala event had been planned for Oct. 7, 2001, to celebrate the inaugural issue of the publication. She assumed no one would show up, given that the United States had invaded Afghanistan only hours earlier. To her surprise, over a hundred people attended, “which made me realize the role of the arts during trauma. People were seeking to come together and hear poetry, fiction, and creative nonfiction.”

Dr. Ofri has been “impressed by the amount of incredible creative writing of all sorts that has been submitted [to the publication] during the pandemic, an unexpected flowering of the arts.”
 

Unique challenges, unique opportunities

All three experts pointed to several noteworthy differences between the experiences of first responders following 9/11 and those of today’s health care professionals during the pandemic.

“What happened on Sept. 11 was one discrete event, and although it obviously led to years of recovering body parts and cleaning up Ground Zero, and on a national level it led to a war, it nevertheless was a single event,” Dr. DePierro observed. By contrast, the COVID-19 pandemic is ongoing, and for health care practitioners, “it’s by no means over. Again and again, they are being thrown back into battle, dealing with fatigue, weariness, and loss of life.”

Moreover, “it is my understanding that immediately following 9/11, there was a general coming together in our country, but it’s obvious that today, there’s a great deal of fractiousness, contention, disagreement, and disunity in our country when it comes to COVID-19,” Dr. DePierro continued.

“This takes a great toll, particularly on health care workers who are dealing with COVID-19 on a daily basis and experience a disconnect between what they see on their floors and ICUs of the hospital, experiencing loss of life they’ve likely never encountered in their careers, and what people are saying when they downplay the seriousness of COVID-19,” he said.

Dr. Ofri agreed. “The fragmentation of our country and the failure of leadership at the highest level to provide even the basics, such as PPE [personal protective equipment] for health care professionals, left us baffled, profoundly hurt, and angry.”

A positive difference between the COVID-19 pandemic and the aftermath of 9/11 is the development of sophisticated technology that allows interventions for traumatized individuals – both health care professionals and the general public – through telehealth, Dr. DePierro pointed out.

“I would say that these resources and technologies are a silver lining and should continue to be expanded on,” he said. “Now, busy health care workers can access all manner of supportive services, including teletherapy, right from home or between shifts.”

Another “silver lining” is that the pandemic has shone a spotlight on an issue that predated the pandemic – the mental health of health care professionals. Opening a discussion about this has reduced stigma and hopefully has paved the way for improved treatments and for providing resources.

Dr. Dass-Brailsford added that “it is important, going forward, for all of us to be trauma informed, to know how trauma and trauma-related stress unfolds in both other people and yourself, and to know what coping skills can be used to avoid crises from developing – a task that extends across all types of disasters.”

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

The scope and magnitude of the Sept. 11, 2001, attacks on the World Trade Center and the Pentagon were unprecedented in U.S. history. It was arguably the most serious trauma to beset Americans on U.S. soil. The 20th anniversary of 9/11 will take place during another crisis, not only in American history but also in world history – the COVID-19 pandemic.

Photo by Mario Tama/Getty Images

“As different as these two events are, there are obvious points of comparison,” Jonathan DePierro, PhD, assistant professor of psychiatry, Icahn School of Medicine at Mount Sinai, New York, said in an interview. “Both were unprecedented life-threatening situations, presenting threats to individuals’ lives and profoundly traumatizing not only society as a whole but also first responders.”

Dr. DePierro, who is also the clinical director of the Center for Stress, Resilience, and Personal Growth at Mount Sinai, thinks there are many lessons to be learned from the mental health response to 9/11 that can inform our understanding of and response to the mental health needs of today’s first responders in the COVID-19 crisis, particularly health care professionals.

“Every one of our hospitals became a ‘ground zero’ early during the pandemic, and we see the numbers rising again and hospitals again overwhelmed, so our institutions need to design interventions to meet the needs of our health care professionals,” he said.
 

Placing trauma within a new framework

According to Priscilla Dass-Brailsford, EdD, MPH, professor of psychology, department of psychiatry, Georgetown University, Washington, Sept. 11, 2001, “placed trauma within a new framework.”

“Prior to 9/11, crisis protocols and how to manage stress in the aftermath of violent events were uncommon,” Dr. Dass-Brailsford, a clinical psychologist with expertise in trauma who also chairs a clinical psychology program for the Chicago School of Professional Psychology, said in an interview.

As a first responder, she was involved in early interventions for survivors of 9/11. On Sept. 11, 2001, she had just resigned her position as coordinator of the community crisis response team – the first of its kind in the United States – through the Victims of Violence Program in Cambridge, in Cambridge, Mass.

The program responded to communities in which there were high rates of drive-by shootings and similar acts of violence. Because of her crisis experience, Dr. Dass-Brailsford was asked to conduct debriefings in Boston in the area where the 9/11 terrorists had stayed prior to boarding the planes that were used in the terrorist attacks. She subsequently went to New York City to conduct similar psychological debriefings with affected communities.

“What we’ve learned is that we had no crisis protocol on how to manage the stress in the aftermath of such a violent event, no standard operating procedures. There were very few people trained in crisis and trauma response at that time. Partially spurred by 9/11, trauma training programs became more prolific,” she said. Dr. Dass-Brailsford developed a trauma certification program at Lesley University in Cambridge, Mass., where she began to teach after 9/11. “I saw the importance of having clinicians trained to respond in a crisis, because responding to a crisis is very different from conducting regular mental health interventions.”
 

Short- and long-term interventions

Dr. DePierro said that Mount Sinai has a 20-year history of responding to the physical and mental health needs of 9/11 responders.

“We saw a number of first responders experiencing clinical depression, anxiety, a lot of worry, symptoms of posttraumatic stress disorder, and an increase in alcohol and/or substance use,” he recounted. In some, these responses were immediate; in others, the onset of symptoms was more gradual. Some responders had acute reactions that lasted for several months to a year, whereas for others, the reactions were prolonged, and they remained “chronically distressed long after the immediate exposure to the event,” he said.

Recent studies have shown that, during the COVID-19 pandemic, health care professionals and many essential workers have experienced similar symptoms, Dr. DePierro noted.

Mental health care professionals who provided interventions for workers involved in recovery and cleanup at the World Trade Center have highlighted the need for long-term monitoring of people on the front lines during the COVID-19 pandemic – especially health care workers, other essential personnel (for example, delivery, postal, and grocery store workers) and surviving family members. “Health monitoring and treatment efforts for 9/11 survivors and responders were put into place soon after the attacks and continue to this day,” using funding provided through the James Zadroga Act, Dr. DePierro said.

“Without similarly unified health registry and treatment services, many individuals – especially from underserved groups – will likely experience chronic mental health consequences and will be unable to access high-quality health care services,” he stated.
 

‘Psychological first aid’

“Although many people who go through a crisis – whether as a result of terrorism, such as 9/11, or a medical crisis, such as the current pandemic, or a natural disaster, such as Hurricane Katrina – experience PTSD, it’s important to note that not everyone who goes through a crisis and is traumatized will go on to develop PTSD,” Dr. Dass-Brailsford emphasized.

“To me, 9/11 placed psychological first aid on the map. Even if you are not a clinician, you can be trained to provide psychological first aid by becoming familiar with people’s reactions to trauma and how you can support them through it,” she continued.

For example, if a coworker is agitated or “seems to be having a meltdown, you can be there by offering support and getting them the appropriate help.” Research has suggested that having social support before and after a traumatic event can be helpful in determining vulnerability to the development of PTSD and in modulating the impact of the trauma.

Psychological first aid is helpful as an interim measure. “If you see a coworker holding their head in their hands all day and staring at the screen, identifying whether the person might be having a dissociative episode is critical. Providing some support is important, but if more intensive professional support is needed, determining that and making a referral becomes key,” Dr. Dass-Brailsford stated.

Dr. DePierro added: “One of the most important messages that I want health care workers to know from my years of working with 9/11 survivors is that feeling distressed after a traumatic event is very common, but with effective care, one doesn’t necessarily need to be in treatment for years.”

Danielle Ofri, MD, PhD, clinical professor, department of medicine, New York University, agreed. “It is important to continue keeping tabs on each other and remaining sensitive to the collateral struggles of our colleagues. Some have children who are struggling in school, others have parents who have lost a job. Continuing to check in on others and offer support is critical going forward,” she said in an interview.
 

Cohesiveness and volunteerism

One of the most powerful antidotes to long-term traumatization is a sense of community cohesiveness. This was the case following 9/11, and it is the case during the COVID-19 pandemic, according to Dr. Ofri, an internist at Bellevue Hospital in New York.

“There was an enormous mobilization. Bellevue is a city hospital with a level 1 trauma center, and we expected to be swamped, so the whole hospital shifted into gear,” said Dr. Ofri. “What would have been terrifying seemed tolerable because we felt that we were in it together. We discharged the inpatients to make beds available. Within hours, we had converted clinics into emergency departments and ICUs. We worked seamlessly, and the crisis brought us together ... but then, of course, no patients showed up.”

She described her relationship with her colleagues as “feeling almost like a family, especially during the pandemic, when so many others were in lockdown and feeling isolated and useless.”

She and her colleagues saw each other daily. Although the content of their tasks and responsibilities changed and people were redeployed to other areas, “our workday didn’t really change. It would have been overwhelming if we hadn’t had our daily meetings to regroup and assess where we were. Each day, everything we had learned or implemented the day before – treatment protocols, testing protocols, our understanding of how the virus was communicated – would change and need to be reevaluated. Those morning meetings were critical to staying centered. It felt as though we were building a plane and flying it at the same time, which felt both scary and heady. Luckily, it took place within the fraternity of a committed and caring group.”

Dr. Ofri recounted that, after 9/11, as well as during the pandemic, “professionals kept jumping in from the sidelines to volunteer. Within hours of the collapse of the towers, the ED had filled with staff. People came out of retirement and out from vacation and out of the woodwork. It was very heartening.”

Even more inspiring, “all the departmental barriers seemed to break down. People were willing to step out of their ordinary roles and check their egos at the door. Seasoned physicians were willing to function as medical interns.”

This generosity of time and spirit “helped keep us going,” she said.

Dr. DePierro agreed. “One of the things I’ve seen on medical floors is that COVID actually brought some units together, increasing their cohesion and mutual support and increasing the bonds between people.” These intensified bonds “increased the resilience of everyone involved.”
 

Commitment to the community

Dr. Ofri recalls families gathering at the hospital after 9/11, watching posters of missing people going up all over the hospital as well as on mailboxes and lampposts. Because the center for missing people was located right next door to Bellevue, there were long lines of families coming in to register. The chief medical office was there, and a huge tent was built to accommodate the families. The tent took up the entire block. “We felt a lot of ownership, because families were coming here,” she said.

The street remained closed even as the days, weeks, and years stretched on, and the tent remained. It was used as a reflection area for families. During the pandemic, that area was used for refrigerated trucks that served as temporary morgues.

“Both logistically and emotionally, we had a feeling during the pandemic of, ‘We’ve been here before, we’ll do it again and be there for the community,’ ” Dr. Ofri said.

She noted that the sense of commitment to the community carried her and fellow clinicians through the toughest parts of 9/11 and of the COVID-19 pandemic.

“People look to the medical system as a lodestar. ‘Where’s my family member? What should I do? Should I be tested? Vaccinated?’ We were there to be a steady presence for the community physically, psychologically, emotionally, and medically, which helped center us as well,” Dr. Ofri said. “If we didn’t have that, we might have all given in to existential panic.”

She added: “Although we had to work twice as hard, often amid great personal risk, we had the good fortune of having a sense of purpose, something to contribute, plus the community of colleagues we cared about and trusted with our lives.”
 

Crisis and personal growth

Dr. DePierro said that participants who went through 9/11 have been coming to Mount Sinai’s World Trade Center Health Program for care for nearly two decades. “Many are doing quite well, despite the emotional trauma and the dust and toxin exposure, which has given us a window into what makes people resilient.”

Social and community support are key factors in resilience. Another is recognizing opportunities for personal or professional growth during the crisis, according to Dr. DePierro.

During the pandemic, hospital staff were redeployed to departments where they didn’t typically work. They worked with new colleagues and used skills in patient care that they hadn’t needed for years or even decades. “Although this was stressful and distressing, quite a number said they came through with more medical knowledge than before and that they had forged relationships in the trenches that have been lasting and have become important to them,” he reported.

He noted that, during both crises, for first responders and health care practitioners, religious or spiritual faith was a source of resilience. “During the peak of the pandemic, chaplains provided an exorbitant amount of staff support as clinicians turned to the chaplain to help make sense of what they were going through and connect to something greater than themselves.” Similarly, during 9/11, police and fire department chaplains “played a huge role in supporting the first responders,” Dr. DePierro said.

He said that Mount Sinai holds resilience workshops “where we focus on these topics and teach health care workers how to build resilience in their lives, heal day-to-day stressors, and even grow from the experience.”

Dr. Ofri, who is the founder and editor-in-chief of the Bellevue Literary Review, added that the arts played an important role in bolstering resilience and providing a creative outlet for clinicians after 9/11 and again during the pandemic.

The publication is celebrating its twentieth anniversary – its first issue went to press in September 2001. The cover contained an acknowledgment of 9/11.

Dr. Ofri said that a gala event had been planned for Oct. 7, 2001, to celebrate the inaugural issue of the publication. She assumed no one would show up, given that the United States had invaded Afghanistan only hours earlier. To her surprise, over a hundred people attended, “which made me realize the role of the arts during trauma. People were seeking to come together and hear poetry, fiction, and creative nonfiction.”

Dr. Ofri has been “impressed by the amount of incredible creative writing of all sorts that has been submitted [to the publication] during the pandemic, an unexpected flowering of the arts.”
 

Unique challenges, unique opportunities

All three experts pointed to several noteworthy differences between the experiences of first responders following 9/11 and those of today’s health care professionals during the pandemic.

“What happened on Sept. 11 was one discrete event, and although it obviously led to years of recovering body parts and cleaning up Ground Zero, and on a national level it led to a war, it nevertheless was a single event,” Dr. DePierro observed. By contrast, the COVID-19 pandemic is ongoing, and for health care practitioners, “it’s by no means over. Again and again, they are being thrown back into battle, dealing with fatigue, weariness, and loss of life.”

Moreover, “it is my understanding that immediately following 9/11, there was a general coming together in our country, but it’s obvious that today, there’s a great deal of fractiousness, contention, disagreement, and disunity in our country when it comes to COVID-19,” Dr. DePierro continued.

“This takes a great toll, particularly on health care workers who are dealing with COVID-19 on a daily basis and experience a disconnect between what they see on their floors and ICUs of the hospital, experiencing loss of life they’ve likely never encountered in their careers, and what people are saying when they downplay the seriousness of COVID-19,” he said.

Dr. Ofri agreed. “The fragmentation of our country and the failure of leadership at the highest level to provide even the basics, such as PPE [personal protective equipment] for health care professionals, left us baffled, profoundly hurt, and angry.”

A positive difference between the COVID-19 pandemic and the aftermath of 9/11 is the development of sophisticated technology that allows interventions for traumatized individuals – both health care professionals and the general public – through telehealth, Dr. DePierro pointed out.

“I would say that these resources and technologies are a silver lining and should continue to be expanded on,” he said. “Now, busy health care workers can access all manner of supportive services, including teletherapy, right from home or between shifts.”

Another “silver lining” is that the pandemic has shone a spotlight on an issue that predated the pandemic – the mental health of health care professionals. Opening a discussion about this has reduced stigma and hopefully has paved the way for improved treatments and for providing resources.

Dr. Dass-Brailsford added that “it is important, going forward, for all of us to be trauma informed, to know how trauma and trauma-related stress unfolds in both other people and yourself, and to know what coping skills can be used to avoid crises from developing – a task that extends across all types of disasters.”

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

The scope and magnitude of the Sept. 11, 2001, attacks on the World Trade Center and the Pentagon were unprecedented in U.S. history. It was arguably the most serious trauma to beset Americans on U.S. soil. The 20th anniversary of 9/11 will take place during another crisis, not only in American history but also in world history – the COVID-19 pandemic.

Photo by Mario Tama/Getty Images

“As different as these two events are, there are obvious points of comparison,” Jonathan DePierro, PhD, assistant professor of psychiatry, Icahn School of Medicine at Mount Sinai, New York, said in an interview. “Both were unprecedented life-threatening situations, presenting threats to individuals’ lives and profoundly traumatizing not only society as a whole but also first responders.”

Dr. DePierro, who is also the clinical director of the Center for Stress, Resilience, and Personal Growth at Mount Sinai, thinks there are many lessons to be learned from the mental health response to 9/11 that can inform our understanding of and response to the mental health needs of today’s first responders in the COVID-19 crisis, particularly health care professionals.

“Every one of our hospitals became a ‘ground zero’ early during the pandemic, and we see the numbers rising again and hospitals again overwhelmed, so our institutions need to design interventions to meet the needs of our health care professionals,” he said.
 

Placing trauma within a new framework

According to Priscilla Dass-Brailsford, EdD, MPH, professor of psychology, department of psychiatry, Georgetown University, Washington, Sept. 11, 2001, “placed trauma within a new framework.”

“Prior to 9/11, crisis protocols and how to manage stress in the aftermath of violent events were uncommon,” Dr. Dass-Brailsford, a clinical psychologist with expertise in trauma who also chairs a clinical psychology program for the Chicago School of Professional Psychology, said in an interview.

As a first responder, she was involved in early interventions for survivors of 9/11. On Sept. 11, 2001, she had just resigned her position as coordinator of the community crisis response team – the first of its kind in the United States – through the Victims of Violence Program in Cambridge, in Cambridge, Mass.

The program responded to communities in which there were high rates of drive-by shootings and similar acts of violence. Because of her crisis experience, Dr. Dass-Brailsford was asked to conduct debriefings in Boston in the area where the 9/11 terrorists had stayed prior to boarding the planes that were used in the terrorist attacks. She subsequently went to New York City to conduct similar psychological debriefings with affected communities.

“What we’ve learned is that we had no crisis protocol on how to manage the stress in the aftermath of such a violent event, no standard operating procedures. There were very few people trained in crisis and trauma response at that time. Partially spurred by 9/11, trauma training programs became more prolific,” she said. Dr. Dass-Brailsford developed a trauma certification program at Lesley University in Cambridge, Mass., where she began to teach after 9/11. “I saw the importance of having clinicians trained to respond in a crisis, because responding to a crisis is very different from conducting regular mental health interventions.”
 

Short- and long-term interventions

Dr. DePierro said that Mount Sinai has a 20-year history of responding to the physical and mental health needs of 9/11 responders.

“We saw a number of first responders experiencing clinical depression, anxiety, a lot of worry, symptoms of posttraumatic stress disorder, and an increase in alcohol and/or substance use,” he recounted. In some, these responses were immediate; in others, the onset of symptoms was more gradual. Some responders had acute reactions that lasted for several months to a year, whereas for others, the reactions were prolonged, and they remained “chronically distressed long after the immediate exposure to the event,” he said.

Recent studies have shown that, during the COVID-19 pandemic, health care professionals and many essential workers have experienced similar symptoms, Dr. DePierro noted.

Mental health care professionals who provided interventions for workers involved in recovery and cleanup at the World Trade Center have highlighted the need for long-term monitoring of people on the front lines during the COVID-19 pandemic – especially health care workers, other essential personnel (for example, delivery, postal, and grocery store workers) and surviving family members. “Health monitoring and treatment efforts for 9/11 survivors and responders were put into place soon after the attacks and continue to this day,” using funding provided through the James Zadroga Act, Dr. DePierro said.

“Without similarly unified health registry and treatment services, many individuals – especially from underserved groups – will likely experience chronic mental health consequences and will be unable to access high-quality health care services,” he stated.
 

‘Psychological first aid’

“Although many people who go through a crisis – whether as a result of terrorism, such as 9/11, or a medical crisis, such as the current pandemic, or a natural disaster, such as Hurricane Katrina – experience PTSD, it’s important to note that not everyone who goes through a crisis and is traumatized will go on to develop PTSD,” Dr. Dass-Brailsford emphasized.

“To me, 9/11 placed psychological first aid on the map. Even if you are not a clinician, you can be trained to provide psychological first aid by becoming familiar with people’s reactions to trauma and how you can support them through it,” she continued.

For example, if a coworker is agitated or “seems to be having a meltdown, you can be there by offering support and getting them the appropriate help.” Research has suggested that having social support before and after a traumatic event can be helpful in determining vulnerability to the development of PTSD and in modulating the impact of the trauma.

Psychological first aid is helpful as an interim measure. “If you see a coworker holding their head in their hands all day and staring at the screen, identifying whether the person might be having a dissociative episode is critical. Providing some support is important, but if more intensive professional support is needed, determining that and making a referral becomes key,” Dr. Dass-Brailsford stated.

Dr. DePierro added: “One of the most important messages that I want health care workers to know from my years of working with 9/11 survivors is that feeling distressed after a traumatic event is very common, but with effective care, one doesn’t necessarily need to be in treatment for years.”

Danielle Ofri, MD, PhD, clinical professor, department of medicine, New York University, agreed. “It is important to continue keeping tabs on each other and remaining sensitive to the collateral struggles of our colleagues. Some have children who are struggling in school, others have parents who have lost a job. Continuing to check in on others and offer support is critical going forward,” she said in an interview.
 

Cohesiveness and volunteerism

One of the most powerful antidotes to long-term traumatization is a sense of community cohesiveness. This was the case following 9/11, and it is the case during the COVID-19 pandemic, according to Dr. Ofri, an internist at Bellevue Hospital in New York.

“There was an enormous mobilization. Bellevue is a city hospital with a level 1 trauma center, and we expected to be swamped, so the whole hospital shifted into gear,” said Dr. Ofri. “What would have been terrifying seemed tolerable because we felt that we were in it together. We discharged the inpatients to make beds available. Within hours, we had converted clinics into emergency departments and ICUs. We worked seamlessly, and the crisis brought us together ... but then, of course, no patients showed up.”

She described her relationship with her colleagues as “feeling almost like a family, especially during the pandemic, when so many others were in lockdown and feeling isolated and useless.”

She and her colleagues saw each other daily. Although the content of their tasks and responsibilities changed and people were redeployed to other areas, “our workday didn’t really change. It would have been overwhelming if we hadn’t had our daily meetings to regroup and assess where we were. Each day, everything we had learned or implemented the day before – treatment protocols, testing protocols, our understanding of how the virus was communicated – would change and need to be reevaluated. Those morning meetings were critical to staying centered. It felt as though we were building a plane and flying it at the same time, which felt both scary and heady. Luckily, it took place within the fraternity of a committed and caring group.”

Dr. Ofri recounted that, after 9/11, as well as during the pandemic, “professionals kept jumping in from the sidelines to volunteer. Within hours of the collapse of the towers, the ED had filled with staff. People came out of retirement and out from vacation and out of the woodwork. It was very heartening.”

Even more inspiring, “all the departmental barriers seemed to break down. People were willing to step out of their ordinary roles and check their egos at the door. Seasoned physicians were willing to function as medical interns.”

This generosity of time and spirit “helped keep us going,” she said.

Dr. DePierro agreed. “One of the things I’ve seen on medical floors is that COVID actually brought some units together, increasing their cohesion and mutual support and increasing the bonds between people.” These intensified bonds “increased the resilience of everyone involved.”
 

Commitment to the community

Dr. Ofri recalls families gathering at the hospital after 9/11, watching posters of missing people going up all over the hospital as well as on mailboxes and lampposts. Because the center for missing people was located right next door to Bellevue, there were long lines of families coming in to register. The chief medical office was there, and a huge tent was built to accommodate the families. The tent took up the entire block. “We felt a lot of ownership, because families were coming here,” she said.

The street remained closed even as the days, weeks, and years stretched on, and the tent remained. It was used as a reflection area for families. During the pandemic, that area was used for refrigerated trucks that served as temporary morgues.

“Both logistically and emotionally, we had a feeling during the pandemic of, ‘We’ve been here before, we’ll do it again and be there for the community,’ ” Dr. Ofri said.

She noted that the sense of commitment to the community carried her and fellow clinicians through the toughest parts of 9/11 and of the COVID-19 pandemic.

“People look to the medical system as a lodestar. ‘Where’s my family member? What should I do? Should I be tested? Vaccinated?’ We were there to be a steady presence for the community physically, psychologically, emotionally, and medically, which helped center us as well,” Dr. Ofri said. “If we didn’t have that, we might have all given in to existential panic.”

She added: “Although we had to work twice as hard, often amid great personal risk, we had the good fortune of having a sense of purpose, something to contribute, plus the community of colleagues we cared about and trusted with our lives.”
 

Crisis and personal growth

Dr. DePierro said that participants who went through 9/11 have been coming to Mount Sinai’s World Trade Center Health Program for care for nearly two decades. “Many are doing quite well, despite the emotional trauma and the dust and toxin exposure, which has given us a window into what makes people resilient.”

Social and community support are key factors in resilience. Another is recognizing opportunities for personal or professional growth during the crisis, according to Dr. DePierro.

During the pandemic, hospital staff were redeployed to departments where they didn’t typically work. They worked with new colleagues and used skills in patient care that they hadn’t needed for years or even decades. “Although this was stressful and distressing, quite a number said they came through with more medical knowledge than before and that they had forged relationships in the trenches that have been lasting and have become important to them,” he reported.

He noted that, during both crises, for first responders and health care practitioners, religious or spiritual faith was a source of resilience. “During the peak of the pandemic, chaplains provided an exorbitant amount of staff support as clinicians turned to the chaplain to help make sense of what they were going through and connect to something greater than themselves.” Similarly, during 9/11, police and fire department chaplains “played a huge role in supporting the first responders,” Dr. DePierro said.

He said that Mount Sinai holds resilience workshops “where we focus on these topics and teach health care workers how to build resilience in their lives, heal day-to-day stressors, and even grow from the experience.”

Dr. Ofri, who is the founder and editor-in-chief of the Bellevue Literary Review, added that the arts played an important role in bolstering resilience and providing a creative outlet for clinicians after 9/11 and again during the pandemic.

The publication is celebrating its twentieth anniversary – its first issue went to press in September 2001. The cover contained an acknowledgment of 9/11.

Dr. Ofri said that a gala event had been planned for Oct. 7, 2001, to celebrate the inaugural issue of the publication. She assumed no one would show up, given that the United States had invaded Afghanistan only hours earlier. To her surprise, over a hundred people attended, “which made me realize the role of the arts during trauma. People were seeking to come together and hear poetry, fiction, and creative nonfiction.”

Dr. Ofri has been “impressed by the amount of incredible creative writing of all sorts that has been submitted [to the publication] during the pandemic, an unexpected flowering of the arts.”
 

Unique challenges, unique opportunities

All three experts pointed to several noteworthy differences between the experiences of first responders following 9/11 and those of today’s health care professionals during the pandemic.

“What happened on Sept. 11 was one discrete event, and although it obviously led to years of recovering body parts and cleaning up Ground Zero, and on a national level it led to a war, it nevertheless was a single event,” Dr. DePierro observed. By contrast, the COVID-19 pandemic is ongoing, and for health care practitioners, “it’s by no means over. Again and again, they are being thrown back into battle, dealing with fatigue, weariness, and loss of life.”

Moreover, “it is my understanding that immediately following 9/11, there was a general coming together in our country, but it’s obvious that today, there’s a great deal of fractiousness, contention, disagreement, and disunity in our country when it comes to COVID-19,” Dr. DePierro continued.

“This takes a great toll, particularly on health care workers who are dealing with COVID-19 on a daily basis and experience a disconnect between what they see on their floors and ICUs of the hospital, experiencing loss of life they’ve likely never encountered in their careers, and what people are saying when they downplay the seriousness of COVID-19,” he said.

Dr. Ofri agreed. “The fragmentation of our country and the failure of leadership at the highest level to provide even the basics, such as PPE [personal protective equipment] for health care professionals, left us baffled, profoundly hurt, and angry.”

A positive difference between the COVID-19 pandemic and the aftermath of 9/11 is the development of sophisticated technology that allows interventions for traumatized individuals – both health care professionals and the general public – through telehealth, Dr. DePierro pointed out.

“I would say that these resources and technologies are a silver lining and should continue to be expanded on,” he said. “Now, busy health care workers can access all manner of supportive services, including teletherapy, right from home or between shifts.”

Another “silver lining” is that the pandemic has shone a spotlight on an issue that predated the pandemic – the mental health of health care professionals. Opening a discussion about this has reduced stigma and hopefully has paved the way for improved treatments and for providing resources.

Dr. Dass-Brailsford added that “it is important, going forward, for all of us to be trauma informed, to know how trauma and trauma-related stress unfolds in both other people and yourself, and to know what coping skills can be used to avoid crises from developing – a task that extends across all types of disasters.”

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

Equine therapy, which involves interactions with horses in a controlled environment, reduces fear and other symptoms of posttraumatic stress disorder, new research suggests.

Man O&#039;War Project

Results from a study of about 60 military veterans who underwent weekly sessions of horse-assisted therapy showed “marked reductions” in clinician-rated and self-reported symptoms of PTSD and depression up to 3 months post treatment.

“What we’re doing here with horses is helping people overcome something very specific to PTSD,” coinvestigator Yuval Neria, PhD, professor of clinical medical psychology and director of the PTSD treatment and research program, Columbia University Medical Center, New York, said in an interview.

“It offers the opportunity to overcome fear, to facilitate self-efficacy, to facilitate trust in yourself, to understand your feelings, and perhaps to change them over time, he said.

In addition, veterans loved the experience, Dr. Neria reported. He noted that many patients with PTSD have trouble with traditional treatments and are eager to try something “creative and new.”

The findings were published online Aug. 31, 2021, in the Journal of Clinical Psychiatry.
 

Building bonds

PTSD affects an estimated 10%-30% of U.S. military personnel. These rates are higher than in the general population because veterans may experience increased trauma through combat, injury, and sexual assault, the investigators noted.

Previous research has suggested that horse-human interactions can build bonds that foster behavioral changes. These powerful animals provide instantaneous feedback, allowing patients to develop emotional awareness.

“Horses are very sensitive to whatever we communicate with them, whether it’s fear or anger or stress,” said Dr. Neria.

Equine-assisted therapy is increasingly being used for various mental and physical conditions. Launching an open-label study to examine this type of treatment for PTSD “was an opportunity to look at something very, very different,” Dr. Neria said.

“This is not psychotherapy, it’s not medication, and it’s not neural stimulation,” he added.

The study included 63 veterans with PTSD (mean age, 50 years; 37% women). Of these, 47 were receiving psychotherapy alone, pharmacotherapy alone, or both. In addition, 48 had at least one comorbid disorder. All were divided into 16 groups of three to five participants each.

The program consisted of eight 90-minute weekly sessions conducted at a large equestrian center. Sessions were coled by a mental health professional and an equine specialist who guided participants in horse communication and behavior.

Early sessions focused on acquainting patients with the horses, grooming exercises, and learning “leading,” which involved directing a horse with a rope or wand. During subsequent sessions, patients became more comfortable with managing the horses in individual and teamwork exercises.

The horses were specifically chosen for their temperament and had no history of aggression. A horse wrangler attended sessions to further ensure safety.
 

Few dropouts

The study included four assessment points: pretreatment, midpoint, post treatment, and 3-month follow-up.

All 63 participants completed baseline assessments. Only five patients (7.9%) discontinued the program.

“We didn’t see dropouts at the rate we usually see in evidence-based therapies for PTSD, which is remarkable and suggests that people really loved it,” said Dr. Neria.

Man O&#039;War Project

The primary outcome was the Clinician-Administered PTSD Scale–5 (CAPS-5), a structured interview that evaluates intrusive memories, social avoidance, and other symptoms based on DSM-5 criteria.

In the intent-to-treat analysis, mean CAPS-5 scores decreased from 38.6 at baseline to 26.9 post treatment. In addition, 29 (46.0%) and 23 (36.5%) participants scored below the PTSD diagnostic threshold of 25 at posttreatment and follow-up, respectively.

Notably, 50.8% of the study population had a clinically significant change, defined as 30% or greater decrease in CAPS-5 score, at post treatment; 54.0% had a significant change at follow-up.

Mean scores on the self-reported 20-item PTSD Checklist for DSM-5 questionnaire decreased from 50.7 at baseline to 34.6 at study termination.

Depression symptoms, measured by the clinician-rated Hamilton Depression Rating Scale and the self-reported Beck Depression Inventory–II, also improved.
 

Structural, functional change

The results did not differ by age, gender, or type of trauma. Dr. Neria noted that many women in the study had suffered sexual abuse or assault, suggesting that the intervention might be appropriate for PTSD outside the military.

“I’m very keen on moving this along into a civilian population,” he said.

The study did not examine potential mechanisms of action. The benefits may come from something inherent in the equine interactions, the human group process, or just being in the beautiful setting where the treatment took place, the investigators noted.

However, Dr. Neria thinks there is another potential explanation – real changes in the brain.

Neuroimaging of a subsample of 20 participants before and after the intervention showed a significant increase in caudate functional connectivity and a reduction in gray matter density of the thalamus and the caudate.

“We see a big change both structurally and functionally,” with the results pointing to an impact on the reward network of the brain, said Dr. Neria.

“This suggests that pleasure was perhaps the main mechanism of action,” which corresponds with patient reports of really enjoying the experience, he added.

Dr. Neria noted that equine therapy is different from bonding with a loyal dog. Interacting with a large and powerful animal may give veterans a sense of accomplishment and self-worth, which can be tremendously therapeutic.
 

Next step in therapy?

Commenting on the research, retired Col. Elspeth Cameron Ritchie, MD, chair of psychiatry, MedStar Washington Hospital Center, Washington, called equine therapy “innovative” in PTSD.

“I see this as the next step in finding acceptable therapies that people like to do,” she said.

Some patients have an aversion to talk therapy because it makes them relive their trauma; and many dislike the side effects of medications, which can include erectile dysfunction, said Dr. Ritchie, who was not involved with the research.

“So something like this that they can enjoy, have a sense of mastery, can bond with an animal, I think is wonderful,” she said.

Dr. Ritchie noted that working with animals offers “a kind of biofeedback” that may calm anxieties, help maintain control, and “is very nonjudgmental.”

However, she pointed out that equine therapy is not new. For example, horses have been used previously to treat patients with a variety of disabilities, including autism.

Dr. Ritchie thought it was “very wise” that study participants just learned to control the horses and didn’t actually ride them, because that could be a frightening experience.

Nonetheless, she noted equine therapy “is not going to be accessible for everybody.”

In addition, Dr. Ritchie was surprised that the investigators didn’t mention more of the quite extensive research that has been conducted on dog therapy in patients with PTSD.

Dr. Neria and Ritchie disclosed no relevant financial relationships.

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

Equine therapy, which involves interactions with horses in a controlled environment, reduces fear and other symptoms of posttraumatic stress disorder, new research suggests.

Man O&#039;War Project

Results from a study of about 60 military veterans who underwent weekly sessions of horse-assisted therapy showed “marked reductions” in clinician-rated and self-reported symptoms of PTSD and depression up to 3 months post treatment.

“What we’re doing here with horses is helping people overcome something very specific to PTSD,” coinvestigator Yuval Neria, PhD, professor of clinical medical psychology and director of the PTSD treatment and research program, Columbia University Medical Center, New York, said in an interview.

“It offers the opportunity to overcome fear, to facilitate self-efficacy, to facilitate trust in yourself, to understand your feelings, and perhaps to change them over time, he said.

In addition, veterans loved the experience, Dr. Neria reported. He noted that many patients with PTSD have trouble with traditional treatments and are eager to try something “creative and new.”

The findings were published online Aug. 31, 2021, in the Journal of Clinical Psychiatry.
 

Building bonds

PTSD affects an estimated 10%-30% of U.S. military personnel. These rates are higher than in the general population because veterans may experience increased trauma through combat, injury, and sexual assault, the investigators noted.

Previous research has suggested that horse-human interactions can build bonds that foster behavioral changes. These powerful animals provide instantaneous feedback, allowing patients to develop emotional awareness.

“Horses are very sensitive to whatever we communicate with them, whether it’s fear or anger or stress,” said Dr. Neria.

Equine-assisted therapy is increasingly being used for various mental and physical conditions. Launching an open-label study to examine this type of treatment for PTSD “was an opportunity to look at something very, very different,” Dr. Neria said.

“This is not psychotherapy, it’s not medication, and it’s not neural stimulation,” he added.

The study included 63 veterans with PTSD (mean age, 50 years; 37% women). Of these, 47 were receiving psychotherapy alone, pharmacotherapy alone, or both. In addition, 48 had at least one comorbid disorder. All were divided into 16 groups of three to five participants each.

The program consisted of eight 90-minute weekly sessions conducted at a large equestrian center. Sessions were coled by a mental health professional and an equine specialist who guided participants in horse communication and behavior.

Early sessions focused on acquainting patients with the horses, grooming exercises, and learning “leading,” which involved directing a horse with a rope or wand. During subsequent sessions, patients became more comfortable with managing the horses in individual and teamwork exercises.

The horses were specifically chosen for their temperament and had no history of aggression. A horse wrangler attended sessions to further ensure safety.
 

Few dropouts

The study included four assessment points: pretreatment, midpoint, post treatment, and 3-month follow-up.

All 63 participants completed baseline assessments. Only five patients (7.9%) discontinued the program.

“We didn’t see dropouts at the rate we usually see in evidence-based therapies for PTSD, which is remarkable and suggests that people really loved it,” said Dr. Neria.

Man O&#039;War Project

The primary outcome was the Clinician-Administered PTSD Scale–5 (CAPS-5), a structured interview that evaluates intrusive memories, social avoidance, and other symptoms based on DSM-5 criteria.

In the intent-to-treat analysis, mean CAPS-5 scores decreased from 38.6 at baseline to 26.9 post treatment. In addition, 29 (46.0%) and 23 (36.5%) participants scored below the PTSD diagnostic threshold of 25 at posttreatment and follow-up, respectively.

Notably, 50.8% of the study population had a clinically significant change, defined as 30% or greater decrease in CAPS-5 score, at post treatment; 54.0% had a significant change at follow-up.

Mean scores on the self-reported 20-item PTSD Checklist for DSM-5 questionnaire decreased from 50.7 at baseline to 34.6 at study termination.

Depression symptoms, measured by the clinician-rated Hamilton Depression Rating Scale and the self-reported Beck Depression Inventory–II, also improved.
 

Structural, functional change

The results did not differ by age, gender, or type of trauma. Dr. Neria noted that many women in the study had suffered sexual abuse or assault, suggesting that the intervention might be appropriate for PTSD outside the military.

“I’m very keen on moving this along into a civilian population,” he said.

The study did not examine potential mechanisms of action. The benefits may come from something inherent in the equine interactions, the human group process, or just being in the beautiful setting where the treatment took place, the investigators noted.

However, Dr. Neria thinks there is another potential explanation – real changes in the brain.

Neuroimaging of a subsample of 20 participants before and after the intervention showed a significant increase in caudate functional connectivity and a reduction in gray matter density of the thalamus and the caudate.

“We see a big change both structurally and functionally,” with the results pointing to an impact on the reward network of the brain, said Dr. Neria.

“This suggests that pleasure was perhaps the main mechanism of action,” which corresponds with patient reports of really enjoying the experience, he added.

Dr. Neria noted that equine therapy is different from bonding with a loyal dog. Interacting with a large and powerful animal may give veterans a sense of accomplishment and self-worth, which can be tremendously therapeutic.
 

Next step in therapy?

Commenting on the research, retired Col. Elspeth Cameron Ritchie, MD, chair of psychiatry, MedStar Washington Hospital Center, Washington, called equine therapy “innovative” in PTSD.

“I see this as the next step in finding acceptable therapies that people like to do,” she said.

Some patients have an aversion to talk therapy because it makes them relive their trauma; and many dislike the side effects of medications, which can include erectile dysfunction, said Dr. Ritchie, who was not involved with the research.

“So something like this that they can enjoy, have a sense of mastery, can bond with an animal, I think is wonderful,” she said.

Dr. Ritchie noted that working with animals offers “a kind of biofeedback” that may calm anxieties, help maintain control, and “is very nonjudgmental.”

However, she pointed out that equine therapy is not new. For example, horses have been used previously to treat patients with a variety of disabilities, including autism.

Dr. Ritchie thought it was “very wise” that study participants just learned to control the horses and didn’t actually ride them, because that could be a frightening experience.

Nonetheless, she noted equine therapy “is not going to be accessible for everybody.”

In addition, Dr. Ritchie was surprised that the investigators didn’t mention more of the quite extensive research that has been conducted on dog therapy in patients with PTSD.

Dr. Neria and Ritchie disclosed no relevant financial relationships.

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

Equine therapy, which involves interactions with horses in a controlled environment, reduces fear and other symptoms of posttraumatic stress disorder, new research suggests.

Man O&#039;War Project

Results from a study of about 60 military veterans who underwent weekly sessions of horse-assisted therapy showed “marked reductions” in clinician-rated and self-reported symptoms of PTSD and depression up to 3 months post treatment.

“What we’re doing here with horses is helping people overcome something very specific to PTSD,” coinvestigator Yuval Neria, PhD, professor of clinical medical psychology and director of the PTSD treatment and research program, Columbia University Medical Center, New York, said in an interview.

“It offers the opportunity to overcome fear, to facilitate self-efficacy, to facilitate trust in yourself, to understand your feelings, and perhaps to change them over time, he said.

In addition, veterans loved the experience, Dr. Neria reported. He noted that many patients with PTSD have trouble with traditional treatments and are eager to try something “creative and new.”

The findings were published online Aug. 31, 2021, in the Journal of Clinical Psychiatry.
 

Building bonds

PTSD affects an estimated 10%-30% of U.S. military personnel. These rates are higher than in the general population because veterans may experience increased trauma through combat, injury, and sexual assault, the investigators noted.

Previous research has suggested that horse-human interactions can build bonds that foster behavioral changes. These powerful animals provide instantaneous feedback, allowing patients to develop emotional awareness.

“Horses are very sensitive to whatever we communicate with them, whether it’s fear or anger or stress,” said Dr. Neria.

Equine-assisted therapy is increasingly being used for various mental and physical conditions. Launching an open-label study to examine this type of treatment for PTSD “was an opportunity to look at something very, very different,” Dr. Neria said.

“This is not psychotherapy, it’s not medication, and it’s not neural stimulation,” he added.

The study included 63 veterans with PTSD (mean age, 50 years; 37% women). Of these, 47 were receiving psychotherapy alone, pharmacotherapy alone, or both. In addition, 48 had at least one comorbid disorder. All were divided into 16 groups of three to five participants each.

The program consisted of eight 90-minute weekly sessions conducted at a large equestrian center. Sessions were coled by a mental health professional and an equine specialist who guided participants in horse communication and behavior.

Early sessions focused on acquainting patients with the horses, grooming exercises, and learning “leading,” which involved directing a horse with a rope or wand. During subsequent sessions, patients became more comfortable with managing the horses in individual and teamwork exercises.

The horses were specifically chosen for their temperament and had no history of aggression. A horse wrangler attended sessions to further ensure safety.
 

Few dropouts

The study included four assessment points: pretreatment, midpoint, post treatment, and 3-month follow-up.

All 63 participants completed baseline assessments. Only five patients (7.9%) discontinued the program.

“We didn’t see dropouts at the rate we usually see in evidence-based therapies for PTSD, which is remarkable and suggests that people really loved it,” said Dr. Neria.

Man O&#039;War Project

The primary outcome was the Clinician-Administered PTSD Scale–5 (CAPS-5), a structured interview that evaluates intrusive memories, social avoidance, and other symptoms based on DSM-5 criteria.

In the intent-to-treat analysis, mean CAPS-5 scores decreased from 38.6 at baseline to 26.9 post treatment. In addition, 29 (46.0%) and 23 (36.5%) participants scored below the PTSD diagnostic threshold of 25 at posttreatment and follow-up, respectively.

Notably, 50.8% of the study population had a clinically significant change, defined as 30% or greater decrease in CAPS-5 score, at post treatment; 54.0% had a significant change at follow-up.

Mean scores on the self-reported 20-item PTSD Checklist for DSM-5 questionnaire decreased from 50.7 at baseline to 34.6 at study termination.

Depression symptoms, measured by the clinician-rated Hamilton Depression Rating Scale and the self-reported Beck Depression Inventory–II, also improved.
 

Structural, functional change

The results did not differ by age, gender, or type of trauma. Dr. Neria noted that many women in the study had suffered sexual abuse or assault, suggesting that the intervention might be appropriate for PTSD outside the military.

“I’m very keen on moving this along into a civilian population,” he said.

The study did not examine potential mechanisms of action. The benefits may come from something inherent in the equine interactions, the human group process, or just being in the beautiful setting where the treatment took place, the investigators noted.

However, Dr. Neria thinks there is another potential explanation – real changes in the brain.

Neuroimaging of a subsample of 20 participants before and after the intervention showed a significant increase in caudate functional connectivity and a reduction in gray matter density of the thalamus and the caudate.

“We see a big change both structurally and functionally,” with the results pointing to an impact on the reward network of the brain, said Dr. Neria.

“This suggests that pleasure was perhaps the main mechanism of action,” which corresponds with patient reports of really enjoying the experience, he added.

Dr. Neria noted that equine therapy is different from bonding with a loyal dog. Interacting with a large and powerful animal may give veterans a sense of accomplishment and self-worth, which can be tremendously therapeutic.
 

Next step in therapy?

Commenting on the research, retired Col. Elspeth Cameron Ritchie, MD, chair of psychiatry, MedStar Washington Hospital Center, Washington, called equine therapy “innovative” in PTSD.

“I see this as the next step in finding acceptable therapies that people like to do,” she said.

Some patients have an aversion to talk therapy because it makes them relive their trauma; and many dislike the side effects of medications, which can include erectile dysfunction, said Dr. Ritchie, who was not involved with the research.

“So something like this that they can enjoy, have a sense of mastery, can bond with an animal, I think is wonderful,” she said.

Dr. Ritchie noted that working with animals offers “a kind of biofeedback” that may calm anxieties, help maintain control, and “is very nonjudgmental.”

However, she pointed out that equine therapy is not new. For example, horses have been used previously to treat patients with a variety of disabilities, including autism.

Dr. Ritchie thought it was “very wise” that study participants just learned to control the horses and didn’t actually ride them, because that could be a frightening experience.

Nonetheless, she noted equine therapy “is not going to be accessible for everybody.”

In addition, Dr. Ritchie was surprised that the investigators didn’t mention more of the quite extensive research that has been conducted on dog therapy in patients with PTSD.

Dr. Neria and Ritchie disclosed no relevant financial relationships.

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

The brain is inarguably the most complex and mysterious organ in the human body.

As the epicenter of intelligence, mastermind of movement, and song for our senses, the brain is more than a 3-lb organ encased in shell and fluid. Rather, it is the crown jewel that defines the self and, broadly, humanity.

©Thinkstock

For decades now, researchers have been exploring the potential for connecting our own astounding biological “computer” with actual physical mainframes. These so-called “brain-computer interfaces” (BCIs) are showing promise in treating an array of conditions, including paralysis, deafness, stroke, and even psychiatric disorders.

Among the big players in this area of research is billionaire entrepreneur Elon Musk, who in 2016 founded Neuralink. The company’s short-term mission is to develop a brain-to-machine interface to help people with neurologic conditions (for example, Parkinson’s disease). The long-term mission is to steer humanity into the era of “superhuman cognition.”

But first, some neuroscience 101.

Neurons are specialized cells that transmit and receive information. The basic structure of a neuron includes the dendrite, soma, and axon. The dendrite is the signal receiver. The soma is the cell body that is connected to the dendrites and serves as a structure to pass signals. The axon, also known as the nerve fiber, transmits the signal away from the soma.

Neurons communicate with each other at the synapse (for example, axon-dendrite connection). Neurons send information to each other through action potentials. An action potential may be defined as an electric impulse that transmits down the axon, causing the release of neurotransmitters, which may consequently either inhibit or excite the next neuron (leading to the initiation of another action potential).

So how will the company and other BCI companies tap into this evolutionarily ancient system to develop an implant that will obtain and decode information output from the brain?

The Neuralink implant is composed of three parts: The Link, neural threads, and the charger.

A robotic system, controlled by a neurosurgeon, will place an implant into the brain. The Link is the central component. It processes and transmits neural signals. The micron-scale neural threads are connected to the Link and other areas of the brain. The threads also contain electrodes, which are responsible for detecting neural signals. The charger ensures the battery is charged via wireless connection.

The invasive nature of this implant allows for precise readouts of electric outputs from the brain – unlike noninvasive devices, which are less sensitive and specific. Additionally, owing to its small size, engineers and neurosurgeons can implant the device in very specific brain regions as well as customize electrode distribution.

The Neuralink implant would be paired with an application via Bluetooth connection. The goal is to enable someone with the implant to control their device or computer by simply thinking. The application offers several exercises to help guide and train individuals on how to use the implant for its intended purpose. This technology would allow people with neurologic difficulties (for example, paralysis) to communicate more easily through text or speech synthesis, as well as partake in creative activities such as photography.

Existing text and speech synthesis technology are already underway. For example, Synchron, a BCI platform company, is investigating the use of Stentrode for people with severe paralysis. This neuroprosthesis was designed to help people associate thought with movement through Bluetooth technology (for example, texting, emailing, shopping, online banking). Preliminary results from a study in which the device was used for patients with amyotrophic lateral sclerosis showed improvements in functional independence via direct thinking.

Software intended to enable high-performance handwriting utilizing BCI technology is being developed by Francis R. Willett, PhD, at Stanford (Calif.) University. The technology has also shown promise.

“We’ve learned that the brain retains its ability to prescribe fine movements a full decade after the body has lost its ability to execute those movements,” says Dr. Willett, who recently reported on results from a BCI study of handwriting conversion in an individual with full-body paralysis. Through a recurrent neural networking decoding approach, the BrainGate study participant was able to type 90 characters per minute – with an impressive 94.1% raw accuracy – using thoughts alone.

Although not a fully implantable brain device, this percutaneous implant has also been studied of its capacity to restore arm function among individuals who suffered from chronic stroke. Preliminary results from the Cortimo trials, led by Mijail D. Serruya, MD, an assistant professor at Thomas Jefferson University, Philadelphia, have been positive. Researchers implanted microelectrode arrays to decode brain signals and power motor function in a participant who had experienced a stroke 2 years earlier. The participant was able to use a powered arm brace on their paralyzed arm.

Neuralink recently released a video demonstrating the use of the interface in a monkey named Pager as it played a game with a joystick. Company researchers inserted a 1024-Electrode neural recording and data transmission device called the N1 Link into the left and right motor cortices. Using the implant, neural activity was sent to a decoder algorithm. Throughout the process, the decoder algorithm was refined and calibrated. After a few minutes, Pager was able to control the cursor on the screen using his mind instead of the joystick.

Mr. Musk hopes to develop Neuralink further to change not only the way we treat neurological disorders but also the way we interact with ourselves and our environment. It’s a lofty goal to be sure, but one that doesn’t seem outside the realm of possibility in the near future.
 

Known unknowns: The ethical dilemmas

One major conundrum facing the future of BCI technology is that researchers don’t fully understand the science regarding how brain signaling, artificial intelligence (AI) software, and prostheses interact. Although offloading computations improves the predictive nature of AI algorithms, there are concerns of identity and personal agency.

How do we know that an action is truly the result of one’s own thinking or, rather, the outcome of AI software? In this context, the autocorrect function while typing can be incredibly useful when we’re in a pinch for time, when we’re using one hand to type, or because of ease. However, it’s also easy to create and send out unintended or inappropriate messages.

These algorithms are designed to learn from our behavior and anticipate our next move. However, a question arises as to whether we are the authors of our own thoughts or whether we are simply the device that delivers messages under the control of external forces.

“People may question whether new personality changes they experience are truly representative of themselves or whether they are now a product of the implant (e.g., ‘Is that really me?’; ‘Have I grown as a person, or is it the technology?’). This then raises questions about agency and who we are as people,” says Kerry Bowman, PhD, a clinical bioethicist and assistant professor at the Temerty Faculty of Medicine of the University of Toronto.

It’s important to have safeguards in place to ensure the privacy of our thoughts. In an age where data is currency, it’s crucial to establish boundaries to preserve our autonomy and prevent exploitation (for example, by private companies or hackers). Although Neuralink and BCIs generally are certainly pushing the boundaries of neural engineering in profound ways, it’s important to note the biological and ethical implications of this technology.

As Dr. Bowman points out, “throughout the entire human story, under the worst of human circumstances, such as captivity and torture, the one safe ground and place for all people has been the privacy of one’s own mind. No one could ever interfere, take away, or be aware of those thoughts. However, this technology challenges one’s own privacy – that this technology (and, by extension, a company) could be aware of those thoughts.”

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

The brain is inarguably the most complex and mysterious organ in the human body.

As the epicenter of intelligence, mastermind of movement, and song for our senses, the brain is more than a 3-lb organ encased in shell and fluid. Rather, it is the crown jewel that defines the self and, broadly, humanity.

©Thinkstock

For decades now, researchers have been exploring the potential for connecting our own astounding biological “computer” with actual physical mainframes. These so-called “brain-computer interfaces” (BCIs) are showing promise in treating an array of conditions, including paralysis, deafness, stroke, and even psychiatric disorders.

Among the big players in this area of research is billionaire entrepreneur Elon Musk, who in 2016 founded Neuralink. The company’s short-term mission is to develop a brain-to-machine interface to help people with neurologic conditions (for example, Parkinson’s disease). The long-term mission is to steer humanity into the era of “superhuman cognition.”

But first, some neuroscience 101.

Neurons are specialized cells that transmit and receive information. The basic structure of a neuron includes the dendrite, soma, and axon. The dendrite is the signal receiver. The soma is the cell body that is connected to the dendrites and serves as a structure to pass signals. The axon, also known as the nerve fiber, transmits the signal away from the soma.

Neurons communicate with each other at the synapse (for example, axon-dendrite connection). Neurons send information to each other through action potentials. An action potential may be defined as an electric impulse that transmits down the axon, causing the release of neurotransmitters, which may consequently either inhibit or excite the next neuron (leading to the initiation of another action potential).

So how will the company and other BCI companies tap into this evolutionarily ancient system to develop an implant that will obtain and decode information output from the brain?

The Neuralink implant is composed of three parts: The Link, neural threads, and the charger.

A robotic system, controlled by a neurosurgeon, will place an implant into the brain. The Link is the central component. It processes and transmits neural signals. The micron-scale neural threads are connected to the Link and other areas of the brain. The threads also contain electrodes, which are responsible for detecting neural signals. The charger ensures the battery is charged via wireless connection.

The invasive nature of this implant allows for precise readouts of electric outputs from the brain – unlike noninvasive devices, which are less sensitive and specific. Additionally, owing to its small size, engineers and neurosurgeons can implant the device in very specific brain regions as well as customize electrode distribution.

The Neuralink implant would be paired with an application via Bluetooth connection. The goal is to enable someone with the implant to control their device or computer by simply thinking. The application offers several exercises to help guide and train individuals on how to use the implant for its intended purpose. This technology would allow people with neurologic difficulties (for example, paralysis) to communicate more easily through text or speech synthesis, as well as partake in creative activities such as photography.

Existing text and speech synthesis technology are already underway. For example, Synchron, a BCI platform company, is investigating the use of Stentrode for people with severe paralysis. This neuroprosthesis was designed to help people associate thought with movement through Bluetooth technology (for example, texting, emailing, shopping, online banking). Preliminary results from a study in which the device was used for patients with amyotrophic lateral sclerosis showed improvements in functional independence via direct thinking.

Software intended to enable high-performance handwriting utilizing BCI technology is being developed by Francis R. Willett, PhD, at Stanford (Calif.) University. The technology has also shown promise.

“We’ve learned that the brain retains its ability to prescribe fine movements a full decade after the body has lost its ability to execute those movements,” says Dr. Willett, who recently reported on results from a BCI study of handwriting conversion in an individual with full-body paralysis. Through a recurrent neural networking decoding approach, the BrainGate study participant was able to type 90 characters per minute – with an impressive 94.1% raw accuracy – using thoughts alone.

Although not a fully implantable brain device, this percutaneous implant has also been studied of its capacity to restore arm function among individuals who suffered from chronic stroke. Preliminary results from the Cortimo trials, led by Mijail D. Serruya, MD, an assistant professor at Thomas Jefferson University, Philadelphia, have been positive. Researchers implanted microelectrode arrays to decode brain signals and power motor function in a participant who had experienced a stroke 2 years earlier. The participant was able to use a powered arm brace on their paralyzed arm.

Neuralink recently released a video demonstrating the use of the interface in a monkey named Pager as it played a game with a joystick. Company researchers inserted a 1024-Electrode neural recording and data transmission device called the N1 Link into the left and right motor cortices. Using the implant, neural activity was sent to a decoder algorithm. Throughout the process, the decoder algorithm was refined and calibrated. After a few minutes, Pager was able to control the cursor on the screen using his mind instead of the joystick.

Mr. Musk hopes to develop Neuralink further to change not only the way we treat neurological disorders but also the way we interact with ourselves and our environment. It’s a lofty goal to be sure, but one that doesn’t seem outside the realm of possibility in the near future.
 

Known unknowns: The ethical dilemmas

One major conundrum facing the future of BCI technology is that researchers don’t fully understand the science regarding how brain signaling, artificial intelligence (AI) software, and prostheses interact. Although offloading computations improves the predictive nature of AI algorithms, there are concerns of identity and personal agency.

How do we know that an action is truly the result of one’s own thinking or, rather, the outcome of AI software? In this context, the autocorrect function while typing can be incredibly useful when we’re in a pinch for time, when we’re using one hand to type, or because of ease. However, it’s also easy to create and send out unintended or inappropriate messages.

These algorithms are designed to learn from our behavior and anticipate our next move. However, a question arises as to whether we are the authors of our own thoughts or whether we are simply the device that delivers messages under the control of external forces.

“People may question whether new personality changes they experience are truly representative of themselves or whether they are now a product of the implant (e.g., ‘Is that really me?’; ‘Have I grown as a person, or is it the technology?’). This then raises questions about agency and who we are as people,” says Kerry Bowman, PhD, a clinical bioethicist and assistant professor at the Temerty Faculty of Medicine of the University of Toronto.

It’s important to have safeguards in place to ensure the privacy of our thoughts. In an age where data is currency, it’s crucial to establish boundaries to preserve our autonomy and prevent exploitation (for example, by private companies or hackers). Although Neuralink and BCIs generally are certainly pushing the boundaries of neural engineering in profound ways, it’s important to note the biological and ethical implications of this technology.

As Dr. Bowman points out, “throughout the entire human story, under the worst of human circumstances, such as captivity and torture, the one safe ground and place for all people has been the privacy of one’s own mind. No one could ever interfere, take away, or be aware of those thoughts. However, this technology challenges one’s own privacy – that this technology (and, by extension, a company) could be aware of those thoughts.”

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

The brain is inarguably the most complex and mysterious organ in the human body.

As the epicenter of intelligence, mastermind of movement, and song for our senses, the brain is more than a 3-lb organ encased in shell and fluid. Rather, it is the crown jewel that defines the self and, broadly, humanity.

©Thinkstock

For decades now, researchers have been exploring the potential for connecting our own astounding biological “computer” with actual physical mainframes. These so-called “brain-computer interfaces” (BCIs) are showing promise in treating an array of conditions, including paralysis, deafness, stroke, and even psychiatric disorders.

Among the big players in this area of research is billionaire entrepreneur Elon Musk, who in 2016 founded Neuralink. The company’s short-term mission is to develop a brain-to-machine interface to help people with neurologic conditions (for example, Parkinson’s disease). The long-term mission is to steer humanity into the era of “superhuman cognition.”

But first, some neuroscience 101.

Neurons are specialized cells that transmit and receive information. The basic structure of a neuron includes the dendrite, soma, and axon. The dendrite is the signal receiver. The soma is the cell body that is connected to the dendrites and serves as a structure to pass signals. The axon, also known as the nerve fiber, transmits the signal away from the soma.

Neurons communicate with each other at the synapse (for example, axon-dendrite connection). Neurons send information to each other through action potentials. An action potential may be defined as an electric impulse that transmits down the axon, causing the release of neurotransmitters, which may consequently either inhibit or excite the next neuron (leading to the initiation of another action potential).

So how will the company and other BCI companies tap into this evolutionarily ancient system to develop an implant that will obtain and decode information output from the brain?

The Neuralink implant is composed of three parts: The Link, neural threads, and the charger.

A robotic system, controlled by a neurosurgeon, will place an implant into the brain. The Link is the central component. It processes and transmits neural signals. The micron-scale neural threads are connected to the Link and other areas of the brain. The threads also contain electrodes, which are responsible for detecting neural signals. The charger ensures the battery is charged via wireless connection.

The invasive nature of this implant allows for precise readouts of electric outputs from the brain – unlike noninvasive devices, which are less sensitive and specific. Additionally, owing to its small size, engineers and neurosurgeons can implant the device in very specific brain regions as well as customize electrode distribution.

The Neuralink implant would be paired with an application via Bluetooth connection. The goal is to enable someone with the implant to control their device or computer by simply thinking. The application offers several exercises to help guide and train individuals on how to use the implant for its intended purpose. This technology would allow people with neurologic difficulties (for example, paralysis) to communicate more easily through text or speech synthesis, as well as partake in creative activities such as photography.

Existing text and speech synthesis technology are already underway. For example, Synchron, a BCI platform company, is investigating the use of Stentrode for people with severe paralysis. This neuroprosthesis was designed to help people associate thought with movement through Bluetooth technology (for example, texting, emailing, shopping, online banking). Preliminary results from a study in which the device was used for patients with amyotrophic lateral sclerosis showed improvements in functional independence via direct thinking.

Software intended to enable high-performance handwriting utilizing BCI technology is being developed by Francis R. Willett, PhD, at Stanford (Calif.) University. The technology has also shown promise.

“We’ve learned that the brain retains its ability to prescribe fine movements a full decade after the body has lost its ability to execute those movements,” says Dr. Willett, who recently reported on results from a BCI study of handwriting conversion in an individual with full-body paralysis. Through a recurrent neural networking decoding approach, the BrainGate study participant was able to type 90 characters per minute – with an impressive 94.1% raw accuracy – using thoughts alone.

Although not a fully implantable brain device, this percutaneous implant has also been studied of its capacity to restore arm function among individuals who suffered from chronic stroke. Preliminary results from the Cortimo trials, led by Mijail D. Serruya, MD, an assistant professor at Thomas Jefferson University, Philadelphia, have been positive. Researchers implanted microelectrode arrays to decode brain signals and power motor function in a participant who had experienced a stroke 2 years earlier. The participant was able to use a powered arm brace on their paralyzed arm.

Neuralink recently released a video demonstrating the use of the interface in a monkey named Pager as it played a game with a joystick. Company researchers inserted a 1024-Electrode neural recording and data transmission device called the N1 Link into the left and right motor cortices. Using the implant, neural activity was sent to a decoder algorithm. Throughout the process, the decoder algorithm was refined and calibrated. After a few minutes, Pager was able to control the cursor on the screen using his mind instead of the joystick.

Mr. Musk hopes to develop Neuralink further to change not only the way we treat neurological disorders but also the way we interact with ourselves and our environment. It’s a lofty goal to be sure, but one that doesn’t seem outside the realm of possibility in the near future.
 

Known unknowns: The ethical dilemmas

One major conundrum facing the future of BCI technology is that researchers don’t fully understand the science regarding how brain signaling, artificial intelligence (AI) software, and prostheses interact. Although offloading computations improves the predictive nature of AI algorithms, there are concerns of identity and personal agency.

How do we know that an action is truly the result of one’s own thinking or, rather, the outcome of AI software? In this context, the autocorrect function while typing can be incredibly useful when we’re in a pinch for time, when we’re using one hand to type, or because of ease. However, it’s also easy to create and send out unintended or inappropriate messages.

These algorithms are designed to learn from our behavior and anticipate our next move. However, a question arises as to whether we are the authors of our own thoughts or whether we are simply the device that delivers messages under the control of external forces.

“People may question whether new personality changes they experience are truly representative of themselves or whether they are now a product of the implant (e.g., ‘Is that really me?’; ‘Have I grown as a person, or is it the technology?’). This then raises questions about agency and who we are as people,” says Kerry Bowman, PhD, a clinical bioethicist and assistant professor at the Temerty Faculty of Medicine of the University of Toronto.

It’s important to have safeguards in place to ensure the privacy of our thoughts. In an age where data is currency, it’s crucial to establish boundaries to preserve our autonomy and prevent exploitation (for example, by private companies or hackers). Although Neuralink and BCIs generally are certainly pushing the boundaries of neural engineering in profound ways, it’s important to note the biological and ethical implications of this technology.

As Dr. Bowman points out, “throughout the entire human story, under the worst of human circumstances, such as captivity and torture, the one safe ground and place for all people has been the privacy of one’s own mind. No one could ever interfere, take away, or be aware of those thoughts. However, this technology challenges one’s own privacy – that this technology (and, by extension, a company) could be aware of those thoughts.”

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

Opioid overdose deaths were significantly higher during 2020, but occurrences were not homogeneous across nine states. Male deaths were higher than in the 2 previous years in two states, according to a new, granular examination of data collected by researchers at the Massachusetts General Hospital (Mass General), Boston.

The analysis also showed that synthetic opioids such as fentanyl played an outsized role in most of the states that were reviewed. Additional drugs of abuse found in decedents, such as cocaine and psychostimulants, were more prevalent in some states than in others.

The Centers for Disease Control and Prevention used provisional death data in its recent report. It found that opioid-related deaths substantially rose in 2020 and that synthetic opioids were a primary driver.

The current Mass General analysis provides a more timely and detailed dive, senior author Mohammad Jalali, PhD, who is a senior scientist at Mass General’s Institute for Technology Assessment, told this news organization.

The findings, which have not yet been peer reviewed, were published in MedRxiv.
 

Shifting sands of opioid use disorder

Dr. Jalali and colleagues used a decision analysis approach to study opioid data in the hopes of providing better tools for policymakers to analyze and project trends and also to be better prepared to address the shifting sands of opioid use disorder in the United States.

They attempted to collect data on confirmed opioid overdose deaths from all 50 states and Washington, D.C. to assess what might have changed during the COVID-19 pandemic. Only nine states provided enough data for the analysis, which has been submitted to a peer reviewed publication.

These states were Alaska, Connecticut, Indiana, Massachusetts, North Carolina, Rhode Island, Colorado, Utah, and Wyoming.

“Drug overdose data are collected and reported more slowly than COVID-19 data,” Dr. Jalali said in a press release. The data reflected a lag time of about 4 to 8 months in Massachusetts and North Carolina to more than a year in Maryland and Ohio, he noted.

The reporting lag “has clouded the understanding of the effects of the COVID-19 pandemic on opioid-related overdose deaths,” said Dr. Jalali.

Commenting on the findings, Brandon Marshall, PhD, associate professor of epidemiology at Brown University, Providence, R.I, said that “the overall pattern of what’s being reported here is not surprising,” given the national trends seen in the CDC data.

“This paper adds a deeper dive into some of the sociodemographic trends that we’re starting to observe in specific states,” Dr. Marshall said.

Also commenting for this news organization, Brian Fuehrlein, MD, PhD, director of the psychiatric emergency department at the VA Connecticut Healthcare System in West Haven, Connecticut, noted that the current study “highlights things that we are currently seeing at VA Connecticut.”
 

Decrease in heroin, rise in fentanyl

The investigators found a significant reduction in overdose deaths that involved heroin in Alaska, Connecticut, Indiana, Massachusetts, North Carolina, and Rhode Island. That was a new trend for Alaska, Indiana, and Rhode Island, although with only 3 years of data, it’s hard to say whether it will continue, Dr. Jalali noted.

The decrease in heroin involvement seemed to continue a trend previously observed in Colorado, Connecticut, Massachusetts, and North Carolina.

In Connecticut, heroin was involved in 36% of deaths in 2018, 30% in 2019, and 16% in 2020, according to the study.

“We have begun seeing more and more heroin-negative, fentanyl-positive drug screens,” said Dr. Fuehrlein, who is also associate professor of psychiatry at Yale University, New Haven, Conn.

“There is a shift from fentanyl being an adulterant to fentanyl being what is sold and used exclusively,” he added.

In 2020, 92% (n = 887) of deaths in Connecticut involved synthetic opioids, continuing a trend. In Alaska, however, synthetic opioids were involved in 60% (44) of deaths, which is a big jump from 23% (9) in 2018.

Synthetic opioids were involved in the largest percentage of overdoses in all of the states studied. The fewest deaths, 17 (49%), occurred in Wyoming.

Cocaine is also increasingly found in addition to other substances in decedents. In Alaska, about 14% of individuals who overdosed in 2020 also had cocaine in their system, which was a jump from 2% in the prior year.

In Colorado, 19% (94) of those who died also had taken cocaine, up from 13% in 2019. Cocaine was also frequently found in those who died in the northeast: 39% (467) of those who died in Massachusetts, 29% (280) in Connecticut, and 47% (109) in Rhode Island.

There was also an increase in psychostimulants found in those who had died in Massachusetts in 2020.
 

More male overdoses in 2020

Results also showed that, compared to 2019, significantly more men died from overdoses in 2020 in Colorado (61% vs. 70%, P = .017) and Indiana (62% vs. 70%, P = .026).

This finding was unexpected, said Dr. Marshall, who has observed the same phenomenon in Rhode Island. He is the scientific director of PreventOverdoseRI, Rhode Island’s drug overdose surveillance and information dashboard.

Dr. Marshall and his colleagues conducted a study that also found disproportionate increases in overdoses among men. The findings of that study will be published in September.

“We’re still trying to wrap our head around why that is,” he said. He added that a deeper dive into the Rhode Island data showed that the deaths were increased especially among middle-aged men who had been diagnosed with depression and anxiety.

The same patterns were not seen among women in either Dr. Jalali’s study or his own analysis of the Rhode Island data, said Dr. Marshall.

“That suggests the COVID-19 pandemic impacted men who are at risk for overdose in some particularly severe way,” he noted.

Dr. Fuehrlein said he believes a variety of factors have led to an increase in overdose deaths during the pandemic, including the fact that many patients who would normally seek help avoided care or dropped out of treatment because of COVID fears. In addition, other support systems, such as group therapy and Narcotics Anonymous, were unavailable.

The pandemic increased stress, which can lead to worsening substance use, said Dr. Fuehrlein. He also noted that regular opioid suppliers were often not available, which led some to buy from different dealers, “which can lead to overdose if the fentanyl content is different.”
 

Identifying at-risk individuals

Dr. Jalali and colleagues note that clinicians and policymakers could use the new study to help identify and treat at-risk individuals.

“Practitioners and policy makers can use our findings to help them anticipate which groups of people might be most affected by opioid overdose and which types of policy interventions might be most effective given each state’s unique situation,” said lead study author Gian-Gabriel P. Garcia, PhD, in a press release. At the time of the study, Dr. Garcia was a postdoctoral fellow at Mass General and Harvard Medical School. He is currently an assistant professor at Georgia Tech, Atlanta.

Dr. Marshall pointed out that Dr. Jalali’s study is also relevant for emergency departments.

ED clinicians “are and will be seeing patients coming in who have no idea they were exposed to an opioid, nevermind fentanyl,” he said. ED clinicians can discuss with patients various harm reduction techniques, including the use of naloxone as well as test strips that can detect fentanyl in the drug supply, he added.

“Given the increasing use of fentanyl, which is very dangerous in overdose, clinicians need to be well versed in a harm reduction/overdose prevention approach to patient care,” Dr. Fuehrlein agreed.

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

Opioid overdose deaths were significantly higher during 2020, but occurrences were not homogeneous across nine states. Male deaths were higher than in the 2 previous years in two states, according to a new, granular examination of data collected by researchers at the Massachusetts General Hospital (Mass General), Boston.

The analysis also showed that synthetic opioids such as fentanyl played an outsized role in most of the states that were reviewed. Additional drugs of abuse found in decedents, such as cocaine and psychostimulants, were more prevalent in some states than in others.

The Centers for Disease Control and Prevention used provisional death data in its recent report. It found that opioid-related deaths substantially rose in 2020 and that synthetic opioids were a primary driver.

The current Mass General analysis provides a more timely and detailed dive, senior author Mohammad Jalali, PhD, who is a senior scientist at Mass General’s Institute for Technology Assessment, told this news organization.

The findings, which have not yet been peer reviewed, were published in MedRxiv.
 

Shifting sands of opioid use disorder

Dr. Jalali and colleagues used a decision analysis approach to study opioid data in the hopes of providing better tools for policymakers to analyze and project trends and also to be better prepared to address the shifting sands of opioid use disorder in the United States.

They attempted to collect data on confirmed opioid overdose deaths from all 50 states and Washington, D.C. to assess what might have changed during the COVID-19 pandemic. Only nine states provided enough data for the analysis, which has been submitted to a peer reviewed publication.

These states were Alaska, Connecticut, Indiana, Massachusetts, North Carolina, Rhode Island, Colorado, Utah, and Wyoming.

“Drug overdose data are collected and reported more slowly than COVID-19 data,” Dr. Jalali said in a press release. The data reflected a lag time of about 4 to 8 months in Massachusetts and North Carolina to more than a year in Maryland and Ohio, he noted.

The reporting lag “has clouded the understanding of the effects of the COVID-19 pandemic on opioid-related overdose deaths,” said Dr. Jalali.

Commenting on the findings, Brandon Marshall, PhD, associate professor of epidemiology at Brown University, Providence, R.I, said that “the overall pattern of what’s being reported here is not surprising,” given the national trends seen in the CDC data.

“This paper adds a deeper dive into some of the sociodemographic trends that we’re starting to observe in specific states,” Dr. Marshall said.

Also commenting for this news organization, Brian Fuehrlein, MD, PhD, director of the psychiatric emergency department at the VA Connecticut Healthcare System in West Haven, Connecticut, noted that the current study “highlights things that we are currently seeing at VA Connecticut.”
 

Decrease in heroin, rise in fentanyl

The investigators found a significant reduction in overdose deaths that involved heroin in Alaska, Connecticut, Indiana, Massachusetts, North Carolina, and Rhode Island. That was a new trend for Alaska, Indiana, and Rhode Island, although with only 3 years of data, it’s hard to say whether it will continue, Dr. Jalali noted.

The decrease in heroin involvement seemed to continue a trend previously observed in Colorado, Connecticut, Massachusetts, and North Carolina.

In Connecticut, heroin was involved in 36% of deaths in 2018, 30% in 2019, and 16% in 2020, according to the study.

“We have begun seeing more and more heroin-negative, fentanyl-positive drug screens,” said Dr. Fuehrlein, who is also associate professor of psychiatry at Yale University, New Haven, Conn.

“There is a shift from fentanyl being an adulterant to fentanyl being what is sold and used exclusively,” he added.

In 2020, 92% (n = 887) of deaths in Connecticut involved synthetic opioids, continuing a trend. In Alaska, however, synthetic opioids were involved in 60% (44) of deaths, which is a big jump from 23% (9) in 2018.

Synthetic opioids were involved in the largest percentage of overdoses in all of the states studied. The fewest deaths, 17 (49%), occurred in Wyoming.

Cocaine is also increasingly found in addition to other substances in decedents. In Alaska, about 14% of individuals who overdosed in 2020 also had cocaine in their system, which was a jump from 2% in the prior year.

In Colorado, 19% (94) of those who died also had taken cocaine, up from 13% in 2019. Cocaine was also frequently found in those who died in the northeast: 39% (467) of those who died in Massachusetts, 29% (280) in Connecticut, and 47% (109) in Rhode Island.

There was also an increase in psychostimulants found in those who had died in Massachusetts in 2020.
 

More male overdoses in 2020

Results also showed that, compared to 2019, significantly more men died from overdoses in 2020 in Colorado (61% vs. 70%, P = .017) and Indiana (62% vs. 70%, P = .026).

This finding was unexpected, said Dr. Marshall, who has observed the same phenomenon in Rhode Island. He is the scientific director of PreventOverdoseRI, Rhode Island’s drug overdose surveillance and information dashboard.

Dr. Marshall and his colleagues conducted a study that also found disproportionate increases in overdoses among men. The findings of that study will be published in September.

“We’re still trying to wrap our head around why that is,” he said. He added that a deeper dive into the Rhode Island data showed that the deaths were increased especially among middle-aged men who had been diagnosed with depression and anxiety.

The same patterns were not seen among women in either Dr. Jalali’s study or his own analysis of the Rhode Island data, said Dr. Marshall.

“That suggests the COVID-19 pandemic impacted men who are at risk for overdose in some particularly severe way,” he noted.

Dr. Fuehrlein said he believes a variety of factors have led to an increase in overdose deaths during the pandemic, including the fact that many patients who would normally seek help avoided care or dropped out of treatment because of COVID fears. In addition, other support systems, such as group therapy and Narcotics Anonymous, were unavailable.

The pandemic increased stress, which can lead to worsening substance use, said Dr. Fuehrlein. He also noted that regular opioid suppliers were often not available, which led some to buy from different dealers, “which can lead to overdose if the fentanyl content is different.”
 

Identifying at-risk individuals

Dr. Jalali and colleagues note that clinicians and policymakers could use the new study to help identify and treat at-risk individuals.

“Practitioners and policy makers can use our findings to help them anticipate which groups of people might be most affected by opioid overdose and which types of policy interventions might be most effective given each state’s unique situation,” said lead study author Gian-Gabriel P. Garcia, PhD, in a press release. At the time of the study, Dr. Garcia was a postdoctoral fellow at Mass General and Harvard Medical School. He is currently an assistant professor at Georgia Tech, Atlanta.

Dr. Marshall pointed out that Dr. Jalali’s study is also relevant for emergency departments.

ED clinicians “are and will be seeing patients coming in who have no idea they were exposed to an opioid, nevermind fentanyl,” he said. ED clinicians can discuss with patients various harm reduction techniques, including the use of naloxone as well as test strips that can detect fentanyl in the drug supply, he added.

“Given the increasing use of fentanyl, which is very dangerous in overdose, clinicians need to be well versed in a harm reduction/overdose prevention approach to patient care,” Dr. Fuehrlein agreed.

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

Opioid overdose deaths were significantly higher during 2020, but occurrences were not homogeneous across nine states. Male deaths were higher than in the 2 previous years in two states, according to a new, granular examination of data collected by researchers at the Massachusetts General Hospital (Mass General), Boston.

The analysis also showed that synthetic opioids such as fentanyl played an outsized role in most of the states that were reviewed. Additional drugs of abuse found in decedents, such as cocaine and psychostimulants, were more prevalent in some states than in others.

The Centers for Disease Control and Prevention used provisional death data in its recent report. It found that opioid-related deaths substantially rose in 2020 and that synthetic opioids were a primary driver.

The current Mass General analysis provides a more timely and detailed dive, senior author Mohammad Jalali, PhD, who is a senior scientist at Mass General’s Institute for Technology Assessment, told this news organization.

The findings, which have not yet been peer reviewed, were published in MedRxiv.
 

Shifting sands of opioid use disorder

Dr. Jalali and colleagues used a decision analysis approach to study opioid data in the hopes of providing better tools for policymakers to analyze and project trends and also to be better prepared to address the shifting sands of opioid use disorder in the United States.

They attempted to collect data on confirmed opioid overdose deaths from all 50 states and Washington, D.C. to assess what might have changed during the COVID-19 pandemic. Only nine states provided enough data for the analysis, which has been submitted to a peer reviewed publication.

These states were Alaska, Connecticut, Indiana, Massachusetts, North Carolina, Rhode Island, Colorado, Utah, and Wyoming.

“Drug overdose data are collected and reported more slowly than COVID-19 data,” Dr. Jalali said in a press release. The data reflected a lag time of about 4 to 8 months in Massachusetts and North Carolina to more than a year in Maryland and Ohio, he noted.

The reporting lag “has clouded the understanding of the effects of the COVID-19 pandemic on opioid-related overdose deaths,” said Dr. Jalali.

Commenting on the findings, Brandon Marshall, PhD, associate professor of epidemiology at Brown University, Providence, R.I, said that “the overall pattern of what’s being reported here is not surprising,” given the national trends seen in the CDC data.

“This paper adds a deeper dive into some of the sociodemographic trends that we’re starting to observe in specific states,” Dr. Marshall said.

Also commenting for this news organization, Brian Fuehrlein, MD, PhD, director of the psychiatric emergency department at the VA Connecticut Healthcare System in West Haven, Connecticut, noted that the current study “highlights things that we are currently seeing at VA Connecticut.”
 

Decrease in heroin, rise in fentanyl

The investigators found a significant reduction in overdose deaths that involved heroin in Alaska, Connecticut, Indiana, Massachusetts, North Carolina, and Rhode Island. That was a new trend for Alaska, Indiana, and Rhode Island, although with only 3 years of data, it’s hard to say whether it will continue, Dr. Jalali noted.

The decrease in heroin involvement seemed to continue a trend previously observed in Colorado, Connecticut, Massachusetts, and North Carolina.

In Connecticut, heroin was involved in 36% of deaths in 2018, 30% in 2019, and 16% in 2020, according to the study.

“We have begun seeing more and more heroin-negative, fentanyl-positive drug screens,” said Dr. Fuehrlein, who is also associate professor of psychiatry at Yale University, New Haven, Conn.

“There is a shift from fentanyl being an adulterant to fentanyl being what is sold and used exclusively,” he added.

In 2020, 92% (n = 887) of deaths in Connecticut involved synthetic opioids, continuing a trend. In Alaska, however, synthetic opioids were involved in 60% (44) of deaths, which is a big jump from 23% (9) in 2018.

Synthetic opioids were involved in the largest percentage of overdoses in all of the states studied. The fewest deaths, 17 (49%), occurred in Wyoming.

Cocaine is also increasingly found in addition to other substances in decedents. In Alaska, about 14% of individuals who overdosed in 2020 also had cocaine in their system, which was a jump from 2% in the prior year.

In Colorado, 19% (94) of those who died also had taken cocaine, up from 13% in 2019. Cocaine was also frequently found in those who died in the northeast: 39% (467) of those who died in Massachusetts, 29% (280) in Connecticut, and 47% (109) in Rhode Island.

There was also an increase in psychostimulants found in those who had died in Massachusetts in 2020.
 

More male overdoses in 2020

Results also showed that, compared to 2019, significantly more men died from overdoses in 2020 in Colorado (61% vs. 70%, P = .017) and Indiana (62% vs. 70%, P = .026).

This finding was unexpected, said Dr. Marshall, who has observed the same phenomenon in Rhode Island. He is the scientific director of PreventOverdoseRI, Rhode Island’s drug overdose surveillance and information dashboard.

Dr. Marshall and his colleagues conducted a study that also found disproportionate increases in overdoses among men. The findings of that study will be published in September.

“We’re still trying to wrap our head around why that is,” he said. He added that a deeper dive into the Rhode Island data showed that the deaths were increased especially among middle-aged men who had been diagnosed with depression and anxiety.

The same patterns were not seen among women in either Dr. Jalali’s study or his own analysis of the Rhode Island data, said Dr. Marshall.

“That suggests the COVID-19 pandemic impacted men who are at risk for overdose in some particularly severe way,” he noted.

Dr. Fuehrlein said he believes a variety of factors have led to an increase in overdose deaths during the pandemic, including the fact that many patients who would normally seek help avoided care or dropped out of treatment because of COVID fears. In addition, other support systems, such as group therapy and Narcotics Anonymous, were unavailable.

The pandemic increased stress, which can lead to worsening substance use, said Dr. Fuehrlein. He also noted that regular opioid suppliers were often not available, which led some to buy from different dealers, “which can lead to overdose if the fentanyl content is different.”
 

Identifying at-risk individuals

Dr. Jalali and colleagues note that clinicians and policymakers could use the new study to help identify and treat at-risk individuals.

“Practitioners and policy makers can use our findings to help them anticipate which groups of people might be most affected by opioid overdose and which types of policy interventions might be most effective given each state’s unique situation,” said lead study author Gian-Gabriel P. Garcia, PhD, in a press release. At the time of the study, Dr. Garcia was a postdoctoral fellow at Mass General and Harvard Medical School. He is currently an assistant professor at Georgia Tech, Atlanta.

Dr. Marshall pointed out that Dr. Jalali’s study is also relevant for emergency departments.

ED clinicians “are and will be seeing patients coming in who have no idea they were exposed to an opioid, nevermind fentanyl,” he said. ED clinicians can discuss with patients various harm reduction techniques, including the use of naloxone as well as test strips that can detect fentanyl in the drug supply, he added.

“Given the increasing use of fentanyl, which is very dangerous in overdose, clinicians need to be well versed in a harm reduction/overdose prevention approach to patient care,” Dr. Fuehrlein agreed.

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

Treatment of pediatric obsessive-compulsive disorder (OCD) has evolved in recent years, with more attention given to some of the neuropsychiatric underpinnings of the condition and how they can affect treatment response.

At the Focus on Neuropsychiatry 2021 meeting, Jeffrey Strawn, MD, outlined some of the neuropsychiatry affecting disease and potential mechanisms to help control obsessions and behaviors, and how they may fit with some therapeutic regimens.

Dr. Strawn discussed the psychological construct of cognitive control, which can provide patients an “out” from the cycle of obsession/fear/worry and compulsion/avoidance. In the face of distress, compulsion and avoidance lead to relief, which reinforces the obsession/fear/worry; this in turn leads to more distress.

“We have an escape door for this circuit” in the form of cognitive control, said Dr. Strawn, who is an associate professor of pediatrics at Cincinnati Children’s Hospital Medical Center.

Cognitive control is linked to insight, which can in turn increase adaptive behaviors that help the patient resist the compulsion. Patients won’t eliminate distress, but they can be helped to make it more tolerable. Therapists can then help them move toward goal-directed thoughts and behaviors. Cognitive control is associated with several neural networks, but Dr. Strawn focused on two: the frontoparietal network, associated with top-down regulation; and the cingular-opercular network. Both of these are engaged during cognitive control processes, and play a role inhibitory control and error monitoring.

Dr. Strawn discussed a recent study that explored the neurofunctional basis of treatment. It compared the effects of a stress management therapy and cognitive-behavioral therapy (CBT) in children and adults with OCD at 6 and 12 weeks. The study found similar symptom reductions in both adults and adolescents in both intervention groups.

Before initiating treatment, the researchers conducted functional MRI scans of participants while conducting an incentive flanker task, which reveals brain activity in response to cognitive control and reward processing.

A larger therapeutic response was found in the CBT group among patients who had a larger pretreatment activation within the right temporal lobe and rostral anterior cingulate cortex during cognitive control, as well as those with more activation within the medial prefrontal, orbitofrontal, lateral prefrontal, and amygdala regions during reward processing. On the other hand, within the stress management therapy group, treatment responses were better among those who had lower pretreatment activation among overlapping regions.

“There was a difference in terms of the neurofunctional predictors of treatment response. One of the key regions is the medial prefrontal cortex as well as the rostral anterior cingulate,” said Dr. Strawn, at the meeting presented by MedscapeLive. MedscapeLive and this news organization are owned by the same parent company.

On the neuropharmacology side, numerous medications have been approved for OCD. Dr. Strawn highlighted some studies to illustrate general OCD treatment concepts. That included the 2004 Pediatric OCD Treatment Study, which was one of the only trials to compare placebo with an SSRI, CBT, and the combination of SSRI and CBT. It showed the best results with combination therapy, and the difference appeared early in the treatment course.

That study had aggressive dosing, which led to some issues with sertraline tolerability. Dr. Strawn showed results of a study at his institution which showed that the drug levels of pediatric patients treated with sertraline depended on CYP2C19 metabolism, which affects overall exposure and peak dose concentration. In pediatric populations, some SSRIs clear more slowly and can have high peak concentrations. SSRIs have more side effects than serotonin and norepinephrine reuptake inhibitors in both anxiety disorders and OCD. A key difference between the two is that SSRI treatment is associated with greater frequency of activation, which is difficult to define, but includes restlessness and agitation and insomnia in the beginning stages of treatment.

SSRIs also lead to improvement early in the course of treatment, which was shown in a meta-analysis of nine trials. However, the same study showed that clomipramine is associated with a faster and greater magnitude of improvement, compared with SSRIs, even when the latter are dosed aggressively.

Clomipramine is a potent inhibitor of both serotonin and norepinephrine reuptake. It is recommended to monitor clomipramine levels in pediatric OCD patients, and Dr. Strawn suggested that monitoring should include both the parent drug and its primary metabolite, norclomipramine. At a given dose, there can be a great deal of variation in drug level. The clomipramine/norclomipramine ratio can provide information about the patient’s metabolic state, as well as drug adherence.

Dr. Strawn noted that peak levels occur around 1-3 hours after the dose, “and we really do want at least a 12-hour trough level.” EKGs should be performed at baseline and after any titration of clomipramine dose.

He also discussed pediatric OCD patients with OCD and tics. About one-third of Tourette syndrome patients experience OCD at some point. Tics often improve, whereas OCD more often persists. Tics that co-occur with OCD are associated with a lesser response to SSRI treatment, but not CBT treatment. Similarly, patients with hoarding tendencies are about one-third less likely to respond to SSRIs, CBT, or combination therapy.

Dr. Strawn discussed the concept of accommodation, in which family members cope with a patient’s behavior by altering routines to minimize distress and impairment. This may take the form of facilitating rituals, providing reassurance about a patient’s fears, acquiescing to demands, reducing the child’s day-to-day responsibilities, or helping the child complete tasks. Such actions are well intentioned, but they undermine cognitive control, negatively reinforce symptom engagement, and are associated with functional impairment. Reassurance is the most important behavior, occurring in more than half of patients, and it’s measurable. Parental involvement with rituals is also a concern. “This is associated with higher levels of child OCD severity, as well as parental psychopathology, and lower family cohesion. So oftentimes, there’s a real need to incorporate a family component for the therapeutic aspect of OCD treatment in children and adolescents,” said Dr. Strawn.

New developments in neurobiology and neuropsychology have changed the view of exposure. The old model emphasized the child’s fear rating as an index of corrective learning. The idea was that habituation would decrease anxiety and distress from future exposures. The new model revolves around inhibitory learning theory, which focuses on the variability of distress and aims to increase tolerance of distress. Another goal is to develop new, non-threat associations.

Finally, Dr. Strawn pointed out predictors of poor outcomes in pediatric OCD, including factors such as compulsion severity, oppositional behavior, frequent handwashing, functional impairment, lack of insight, externalizing symptoms, and possibly hoarding. Problematic family characteristics include higher levels of accommodation, parental anxiety, low family cohesion, and high levels of conflict. “The last three really represent a very concerning triad of family behaviors that may necessitate specific family work in order to facilitate the recovery of the pediatric patient,” Dr. Strawn said.

During the question-and-answer session after the talk, Dr. Strawn was asked whether there might be an inflammatory component to OCD, and whether pediatric autoimmune neuropsychiatric disorders associated with streptococcus (PANDAS) might be a prodromal condition. He noted that some studies have shown a relationship, but results have been mixed, with lots of heterogeneity within the studied populations. To be suspicious that a patient had OCD resulting from PANDAS would require a high threshold, including an acute onset of symptoms. “This is a situation also where I would tend to involve consultation with some other specialties, including neurology. And obviously there would be follow-up in terms of the general workup,” he said.

Dr. Strawn has received research funding from Allergan, Otsuka, and Myriad Genetics. He has consulted for Myriad Genetics, and is a speaker for CMEology and the Neuroscience Education Institute.

Treatment of pediatric obsessive-compulsive disorder (OCD) has evolved in recent years, with more attention given to some of the neuropsychiatric underpinnings of the condition and how they can affect treatment response.

At the Focus on Neuropsychiatry 2021 meeting, Jeffrey Strawn, MD, outlined some of the neuropsychiatry affecting disease and potential mechanisms to help control obsessions and behaviors, and how they may fit with some therapeutic regimens.

Dr. Strawn discussed the psychological construct of cognitive control, which can provide patients an “out” from the cycle of obsession/fear/worry and compulsion/avoidance. In the face of distress, compulsion and avoidance lead to relief, which reinforces the obsession/fear/worry; this in turn leads to more distress.

“We have an escape door for this circuit” in the form of cognitive control, said Dr. Strawn, who is an associate professor of pediatrics at Cincinnati Children’s Hospital Medical Center.

Cognitive control is linked to insight, which can in turn increase adaptive behaviors that help the patient resist the compulsion. Patients won’t eliminate distress, but they can be helped to make it more tolerable. Therapists can then help them move toward goal-directed thoughts and behaviors. Cognitive control is associated with several neural networks, but Dr. Strawn focused on two: the frontoparietal network, associated with top-down regulation; and the cingular-opercular network. Both of these are engaged during cognitive control processes, and play a role inhibitory control and error monitoring.

Dr. Strawn discussed a recent study that explored the neurofunctional basis of treatment. It compared the effects of a stress management therapy and cognitive-behavioral therapy (CBT) in children and adults with OCD at 6 and 12 weeks. The study found similar symptom reductions in both adults and adolescents in both intervention groups.

Before initiating treatment, the researchers conducted functional MRI scans of participants while conducting an incentive flanker task, which reveals brain activity in response to cognitive control and reward processing.

A larger therapeutic response was found in the CBT group among patients who had a larger pretreatment activation within the right temporal lobe and rostral anterior cingulate cortex during cognitive control, as well as those with more activation within the medial prefrontal, orbitofrontal, lateral prefrontal, and amygdala regions during reward processing. On the other hand, within the stress management therapy group, treatment responses were better among those who had lower pretreatment activation among overlapping regions.

“There was a difference in terms of the neurofunctional predictors of treatment response. One of the key regions is the medial prefrontal cortex as well as the rostral anterior cingulate,” said Dr. Strawn, at the meeting presented by MedscapeLive. MedscapeLive and this news organization are owned by the same parent company.

On the neuropharmacology side, numerous medications have been approved for OCD. Dr. Strawn highlighted some studies to illustrate general OCD treatment concepts. That included the 2004 Pediatric OCD Treatment Study, which was one of the only trials to compare placebo with an SSRI, CBT, and the combination of SSRI and CBT. It showed the best results with combination therapy, and the difference appeared early in the treatment course.

That study had aggressive dosing, which led to some issues with sertraline tolerability. Dr. Strawn showed results of a study at his institution which showed that the drug levels of pediatric patients treated with sertraline depended on CYP2C19 metabolism, which affects overall exposure and peak dose concentration. In pediatric populations, some SSRIs clear more slowly and can have high peak concentrations. SSRIs have more side effects than serotonin and norepinephrine reuptake inhibitors in both anxiety disorders and OCD. A key difference between the two is that SSRI treatment is associated with greater frequency of activation, which is difficult to define, but includes restlessness and agitation and insomnia in the beginning stages of treatment.

SSRIs also lead to improvement early in the course of treatment, which was shown in a meta-analysis of nine trials. However, the same study showed that clomipramine is associated with a faster and greater magnitude of improvement, compared with SSRIs, even when the latter are dosed aggressively.

Clomipramine is a potent inhibitor of both serotonin and norepinephrine reuptake. It is recommended to monitor clomipramine levels in pediatric OCD patients, and Dr. Strawn suggested that monitoring should include both the parent drug and its primary metabolite, norclomipramine. At a given dose, there can be a great deal of variation in drug level. The clomipramine/norclomipramine ratio can provide information about the patient’s metabolic state, as well as drug adherence.

Dr. Strawn noted that peak levels occur around 1-3 hours after the dose, “and we really do want at least a 12-hour trough level.” EKGs should be performed at baseline and after any titration of clomipramine dose.

He also discussed pediatric OCD patients with OCD and tics. About one-third of Tourette syndrome patients experience OCD at some point. Tics often improve, whereas OCD more often persists. Tics that co-occur with OCD are associated with a lesser response to SSRI treatment, but not CBT treatment. Similarly, patients with hoarding tendencies are about one-third less likely to respond to SSRIs, CBT, or combination therapy.

Dr. Strawn discussed the concept of accommodation, in which family members cope with a patient’s behavior by altering routines to minimize distress and impairment. This may take the form of facilitating rituals, providing reassurance about a patient’s fears, acquiescing to demands, reducing the child’s day-to-day responsibilities, or helping the child complete tasks. Such actions are well intentioned, but they undermine cognitive control, negatively reinforce symptom engagement, and are associated with functional impairment. Reassurance is the most important behavior, occurring in more than half of patients, and it’s measurable. Parental involvement with rituals is also a concern. “This is associated with higher levels of child OCD severity, as well as parental psychopathology, and lower family cohesion. So oftentimes, there’s a real need to incorporate a family component for the therapeutic aspect of OCD treatment in children and adolescents,” said Dr. Strawn.

New developments in neurobiology and neuropsychology have changed the view of exposure. The old model emphasized the child’s fear rating as an index of corrective learning. The idea was that habituation would decrease anxiety and distress from future exposures. The new model revolves around inhibitory learning theory, which focuses on the variability of distress and aims to increase tolerance of distress. Another goal is to develop new, non-threat associations.

Finally, Dr. Strawn pointed out predictors of poor outcomes in pediatric OCD, including factors such as compulsion severity, oppositional behavior, frequent handwashing, functional impairment, lack of insight, externalizing symptoms, and possibly hoarding. Problematic family characteristics include higher levels of accommodation, parental anxiety, low family cohesion, and high levels of conflict. “The last three really represent a very concerning triad of family behaviors that may necessitate specific family work in order to facilitate the recovery of the pediatric patient,” Dr. Strawn said.

During the question-and-answer session after the talk, Dr. Strawn was asked whether there might be an inflammatory component to OCD, and whether pediatric autoimmune neuropsychiatric disorders associated with streptococcus (PANDAS) might be a prodromal condition. He noted that some studies have shown a relationship, but results have been mixed, with lots of heterogeneity within the studied populations. To be suspicious that a patient had OCD resulting from PANDAS would require a high threshold, including an acute onset of symptoms. “This is a situation also where I would tend to involve consultation with some other specialties, including neurology. And obviously there would be follow-up in terms of the general workup,” he said.

Dr. Strawn has received research funding from Allergan, Otsuka, and Myriad Genetics. He has consulted for Myriad Genetics, and is a speaker for CMEology and the Neuroscience Education Institute.

Treatment of pediatric obsessive-compulsive disorder (OCD) has evolved in recent years, with more attention given to some of the neuropsychiatric underpinnings of the condition and how they can affect treatment response.

At the Focus on Neuropsychiatry 2021 meeting, Jeffrey Strawn, MD, outlined some of the neuropsychiatry affecting disease and potential mechanisms to help control obsessions and behaviors, and how they may fit with some therapeutic regimens.

Dr. Strawn discussed the psychological construct of cognitive control, which can provide patients an “out” from the cycle of obsession/fear/worry and compulsion/avoidance. In the face of distress, compulsion and avoidance lead to relief, which reinforces the obsession/fear/worry; this in turn leads to more distress.

“We have an escape door for this circuit” in the form of cognitive control, said Dr. Strawn, who is an associate professor of pediatrics at Cincinnati Children’s Hospital Medical Center.

Cognitive control is linked to insight, which can in turn increase adaptive behaviors that help the patient resist the compulsion. Patients won’t eliminate distress, but they can be helped to make it more tolerable. Therapists can then help them move toward goal-directed thoughts and behaviors. Cognitive control is associated with several neural networks, but Dr. Strawn focused on two: the frontoparietal network, associated with top-down regulation; and the cingular-opercular network. Both of these are engaged during cognitive control processes, and play a role inhibitory control and error monitoring.

Dr. Strawn discussed a recent study that explored the neurofunctional basis of treatment. It compared the effects of a stress management therapy and cognitive-behavioral therapy (CBT) in children and adults with OCD at 6 and 12 weeks. The study found similar symptom reductions in both adults and adolescents in both intervention groups.

Before initiating treatment, the researchers conducted functional MRI scans of participants while conducting an incentive flanker task, which reveals brain activity in response to cognitive control and reward processing.

A larger therapeutic response was found in the CBT group among patients who had a larger pretreatment activation within the right temporal lobe and rostral anterior cingulate cortex during cognitive control, as well as those with more activation within the medial prefrontal, orbitofrontal, lateral prefrontal, and amygdala regions during reward processing. On the other hand, within the stress management therapy group, treatment responses were better among those who had lower pretreatment activation among overlapping regions.

“There was a difference in terms of the neurofunctional predictors of treatment response. One of the key regions is the medial prefrontal cortex as well as the rostral anterior cingulate,” said Dr. Strawn, at the meeting presented by MedscapeLive. MedscapeLive and this news organization are owned by the same parent company.

On the neuropharmacology side, numerous medications have been approved for OCD. Dr. Strawn highlighted some studies to illustrate general OCD treatment concepts. That included the 2004 Pediatric OCD Treatment Study, which was one of the only trials to compare placebo with an SSRI, CBT, and the combination of SSRI and CBT. It showed the best results with combination therapy, and the difference appeared early in the treatment course.

That study had aggressive dosing, which led to some issues with sertraline tolerability. Dr. Strawn showed results of a study at his institution which showed that the drug levels of pediatric patients treated with sertraline depended on CYP2C19 metabolism, which affects overall exposure and peak dose concentration. In pediatric populations, some SSRIs clear more slowly and can have high peak concentrations. SSRIs have more side effects than serotonin and norepinephrine reuptake inhibitors in both anxiety disorders and OCD. A key difference between the two is that SSRI treatment is associated with greater frequency of activation, which is difficult to define, but includes restlessness and agitation and insomnia in the beginning stages of treatment.

SSRIs also lead to improvement early in the course of treatment, which was shown in a meta-analysis of nine trials. However, the same study showed that clomipramine is associated with a faster and greater magnitude of improvement, compared with SSRIs, even when the latter are dosed aggressively.

Clomipramine is a potent inhibitor of both serotonin and norepinephrine reuptake. It is recommended to monitor clomipramine levels in pediatric OCD patients, and Dr. Strawn suggested that monitoring should include both the parent drug and its primary metabolite, norclomipramine. At a given dose, there can be a great deal of variation in drug level. The clomipramine/norclomipramine ratio can provide information about the patient’s metabolic state, as well as drug adherence.

Dr. Strawn noted that peak levels occur around 1-3 hours after the dose, “and we really do want at least a 12-hour trough level.” EKGs should be performed at baseline and after any titration of clomipramine dose.

He also discussed pediatric OCD patients with OCD and tics. About one-third of Tourette syndrome patients experience OCD at some point. Tics often improve, whereas OCD more often persists. Tics that co-occur with OCD are associated with a lesser response to SSRI treatment, but not CBT treatment. Similarly, patients with hoarding tendencies are about one-third less likely to respond to SSRIs, CBT, or combination therapy.

Dr. Strawn discussed the concept of accommodation, in which family members cope with a patient’s behavior by altering routines to minimize distress and impairment. This may take the form of facilitating rituals, providing reassurance about a patient’s fears, acquiescing to demands, reducing the child’s day-to-day responsibilities, or helping the child complete tasks. Such actions are well intentioned, but they undermine cognitive control, negatively reinforce symptom engagement, and are associated with functional impairment. Reassurance is the most important behavior, occurring in more than half of patients, and it’s measurable. Parental involvement with rituals is also a concern. “This is associated with higher levels of child OCD severity, as well as parental psychopathology, and lower family cohesion. So oftentimes, there’s a real need to incorporate a family component for the therapeutic aspect of OCD treatment in children and adolescents,” said Dr. Strawn.

New developments in neurobiology and neuropsychology have changed the view of exposure. The old model emphasized the child’s fear rating as an index of corrective learning. The idea was that habituation would decrease anxiety and distress from future exposures. The new model revolves around inhibitory learning theory, which focuses on the variability of distress and aims to increase tolerance of distress. Another goal is to develop new, non-threat associations.

Finally, Dr. Strawn pointed out predictors of poor outcomes in pediatric OCD, including factors such as compulsion severity, oppositional behavior, frequent handwashing, functional impairment, lack of insight, externalizing symptoms, and possibly hoarding. Problematic family characteristics include higher levels of accommodation, parental anxiety, low family cohesion, and high levels of conflict. “The last three really represent a very concerning triad of family behaviors that may necessitate specific family work in order to facilitate the recovery of the pediatric patient,” Dr. Strawn said.

During the question-and-answer session after the talk, Dr. Strawn was asked whether there might be an inflammatory component to OCD, and whether pediatric autoimmune neuropsychiatric disorders associated with streptococcus (PANDAS) might be a prodromal condition. He noted that some studies have shown a relationship, but results have been mixed, with lots of heterogeneity within the studied populations. To be suspicious that a patient had OCD resulting from PANDAS would require a high threshold, including an acute onset of symptoms. “This is a situation also where I would tend to involve consultation with some other specialties, including neurology. And obviously there would be follow-up in terms of the general workup,” he said.

Dr. Strawn has received research funding from Allergan, Otsuka, and Myriad Genetics. He has consulted for Myriad Genetics, and is a speaker for CMEology and the Neuroscience Education Institute.

Service members with posttraumatic stress disorder and other mental health conditions may eventually have expanded access to service dogs through legislation recently signed into law by President Joseph R. Biden.

supersizer/E+

The Puppies Assisting Wounded Servicemembers (PAWS) for Veterans Therapy Act (HR 1448) orders the Department of Veterans Affairs to begin a pilot program that over the course of 5 years will examine the utility and effectiveness of service dogs for improving the mental health of military veterans.

The legislation does not set a specific start date for the pilot program, but Rory Diamond, CEO of K9s for Warriors, a nonprofit organization based in Ponte Vedra, Fla., noted that K9s for Warriors and other organizations will be pushing the VA to start in 2022.

“We commend the White House for supporting this bill as a critical step in combating veteran suicide, and we’re confident in the path ahead for service dogs ultimately becoming a covered VA benefit to veterans with PTSD,” Mr. Diamond said in a statement provided to this news organization.

“For servicemembers relying on task-trained service dogs for PTSD, the HR 1448 is a giant leap towards supporting veterans and their service dogs in an equitable way,” Canine Companions, a national nonprofit organization that trains and provides service dogs, said in its own statement.

“It might mean the difference between having a veteran who won’t be here tomorrow and having one that will,” the group added.
 

Invisible wounds of war

In another statement, Bill McCabe, legislative affairs director at the Enlisted Association, said that “now, more than ever, veterans suffering from invisible wounds of war need access to trained service dogs, which have been scientifically proven to help alleviate symptoms of posttraumatic stress,” as well as traumatic brain injuries (TBIs) and military sexual trauma.

“We thank President Biden for recognizing veterans need every possible option when seeking mental health treatments, and look forward to working with the Department of Veterans Affairs to implement this important program,” Mr. McCabe said.

A recent VA report showed that in 2014, 40% of veterans had mental health conditions such as PTSD and substance use. An average of 20 veterans per day died by suicide that year.

Veterans with problems regarding mobility, hearing, and sight, as well as some mental health problems, have been eligible to have costs of veterinary care for service dogs paid by the VA, although the VA has not paid for the training of the animals.

The PAWS Act, which was bipartisan legislation introduced by U.S. Senators Thom Tillis (R-N.C.), Kyrsten Sinema (D-Ariz.), Kevin Cramer (R-N.D.), and Dianne Feinstein (D-Calif.), aims to expand eligibility to those with any mental health problems.

For at least a decade, various service dog and veterans’ organizations have pushed to have the VA expand the service dog benefit. This new law is a “first step,” said Mr. Diamond. “We had to kick open the door,” he said, adding that “the VA has essentially said no for almost 15 years.”

Mr. Diamond noted that there is “overwhelming” evidence showing that service dogs improve quality of life and reduce distress for veterans with PTSD and other diagnoses.
 

‘No excuse’

Results from a VA study showed that suicidal ideation was reduced in veterans who were paired with service dogs, compared with veterans paired with emotional support dogs. The study, which was made public in March, found no reduction in overall disability, according to a report by Military.com.

K9s for Warriors cites numerous other studies, published in peer-reviewed journals, that have shown that service dogs reduce PTSD symptoms, especially hypervigilance.

“There really is no excuse not to have the VA engaged in helping veterans suffering from posttraumatic stress who are extremely high risk of suicide to get a lifesaving service dog,” Mr. Diamond said.

His organization has paired 700 veterans suffering from TBI, PTSD, or military sexual trauma with a service dog. The organization provides a 3-week training program for the veteran and his or her dog.

Although about 200 of the graduates have been eligible to receive coverage from the VA for veterinary care for the dogs, it requires a lot of paperwork, and the criteria for who can be certified to receive that benefit are somewhat vague, Mr. Diamond noted.

Under current policy, the dog and veteran must have successfully completed a training program offered by an organization accredited by Assistance Dogs International or the International Guide Dog Federation. The VA does not pay for the training or the dog – which at K9s for Warriors costs about $25,000.

The new pilot program will enable eligible veterans to receive dog training instruction from accredited nonprofit service dog training organizations, and it will give them the opportunity to adopt a dog that they actively assisted in training.

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

Service members with posttraumatic stress disorder and other mental health conditions may eventually have expanded access to service dogs through legislation recently signed into law by President Joseph R. Biden.

supersizer/E+

The Puppies Assisting Wounded Servicemembers (PAWS) for Veterans Therapy Act (HR 1448) orders the Department of Veterans Affairs to begin a pilot program that over the course of 5 years will examine the utility and effectiveness of service dogs for improving the mental health of military veterans.

The legislation does not set a specific start date for the pilot program, but Rory Diamond, CEO of K9s for Warriors, a nonprofit organization based in Ponte Vedra, Fla., noted that K9s for Warriors and other organizations will be pushing the VA to start in 2022.

“We commend the White House for supporting this bill as a critical step in combating veteran suicide, and we’re confident in the path ahead for service dogs ultimately becoming a covered VA benefit to veterans with PTSD,” Mr. Diamond said in a statement provided to this news organization.

“For servicemembers relying on task-trained service dogs for PTSD, the HR 1448 is a giant leap towards supporting veterans and their service dogs in an equitable way,” Canine Companions, a national nonprofit organization that trains and provides service dogs, said in its own statement.

“It might mean the difference between having a veteran who won’t be here tomorrow and having one that will,” the group added.
 

Invisible wounds of war

In another statement, Bill McCabe, legislative affairs director at the Enlisted Association, said that “now, more than ever, veterans suffering from invisible wounds of war need access to trained service dogs, which have been scientifically proven to help alleviate symptoms of posttraumatic stress,” as well as traumatic brain injuries (TBIs) and military sexual trauma.

“We thank President Biden for recognizing veterans need every possible option when seeking mental health treatments, and look forward to working with the Department of Veterans Affairs to implement this important program,” Mr. McCabe said.

A recent VA report showed that in 2014, 40% of veterans had mental health conditions such as PTSD and substance use. An average of 20 veterans per day died by suicide that year.

Veterans with problems regarding mobility, hearing, and sight, as well as some mental health problems, have been eligible to have costs of veterinary care for service dogs paid by the VA, although the VA has not paid for the training of the animals.

The PAWS Act, which was bipartisan legislation introduced by U.S. Senators Thom Tillis (R-N.C.), Kyrsten Sinema (D-Ariz.), Kevin Cramer (R-N.D.), and Dianne Feinstein (D-Calif.), aims to expand eligibility to those with any mental health problems.

For at least a decade, various service dog and veterans’ organizations have pushed to have the VA expand the service dog benefit. This new law is a “first step,” said Mr. Diamond. “We had to kick open the door,” he said, adding that “the VA has essentially said no for almost 15 years.”

Mr. Diamond noted that there is “overwhelming” evidence showing that service dogs improve quality of life and reduce distress for veterans with PTSD and other diagnoses.
 

‘No excuse’

Results from a VA study showed that suicidal ideation was reduced in veterans who were paired with service dogs, compared with veterans paired with emotional support dogs. The study, which was made public in March, found no reduction in overall disability, according to a report by Military.com.

K9s for Warriors cites numerous other studies, published in peer-reviewed journals, that have shown that service dogs reduce PTSD symptoms, especially hypervigilance.

“There really is no excuse not to have the VA engaged in helping veterans suffering from posttraumatic stress who are extremely high risk of suicide to get a lifesaving service dog,” Mr. Diamond said.

His organization has paired 700 veterans suffering from TBI, PTSD, or military sexual trauma with a service dog. The organization provides a 3-week training program for the veteran and his or her dog.

Although about 200 of the graduates have been eligible to receive coverage from the VA for veterinary care for the dogs, it requires a lot of paperwork, and the criteria for who can be certified to receive that benefit are somewhat vague, Mr. Diamond noted.

Under current policy, the dog and veteran must have successfully completed a training program offered by an organization accredited by Assistance Dogs International or the International Guide Dog Federation. The VA does not pay for the training or the dog – which at K9s for Warriors costs about $25,000.

The new pilot program will enable eligible veterans to receive dog training instruction from accredited nonprofit service dog training organizations, and it will give them the opportunity to adopt a dog that they actively assisted in training.

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

Service members with posttraumatic stress disorder and other mental health conditions may eventually have expanded access to service dogs through legislation recently signed into law by President Joseph R. Biden.

supersizer/E+

The Puppies Assisting Wounded Servicemembers (PAWS) for Veterans Therapy Act (HR 1448) orders the Department of Veterans Affairs to begin a pilot program that over the course of 5 years will examine the utility and effectiveness of service dogs for improving the mental health of military veterans.

The legislation does not set a specific start date for the pilot program, but Rory Diamond, CEO of K9s for Warriors, a nonprofit organization based in Ponte Vedra, Fla., noted that K9s for Warriors and other organizations will be pushing the VA to start in 2022.

“We commend the White House for supporting this bill as a critical step in combating veteran suicide, and we’re confident in the path ahead for service dogs ultimately becoming a covered VA benefit to veterans with PTSD,” Mr. Diamond said in a statement provided to this news organization.

“For servicemembers relying on task-trained service dogs for PTSD, the HR 1448 is a giant leap towards supporting veterans and their service dogs in an equitable way,” Canine Companions, a national nonprofit organization that trains and provides service dogs, said in its own statement.

“It might mean the difference between having a veteran who won’t be here tomorrow and having one that will,” the group added.
 

Invisible wounds of war

In another statement, Bill McCabe, legislative affairs director at the Enlisted Association, said that “now, more than ever, veterans suffering from invisible wounds of war need access to trained service dogs, which have been scientifically proven to help alleviate symptoms of posttraumatic stress,” as well as traumatic brain injuries (TBIs) and military sexual trauma.

“We thank President Biden for recognizing veterans need every possible option when seeking mental health treatments, and look forward to working with the Department of Veterans Affairs to implement this important program,” Mr. McCabe said.

A recent VA report showed that in 2014, 40% of veterans had mental health conditions such as PTSD and substance use. An average of 20 veterans per day died by suicide that year.

Veterans with problems regarding mobility, hearing, and sight, as well as some mental health problems, have been eligible to have costs of veterinary care for service dogs paid by the VA, although the VA has not paid for the training of the animals.

The PAWS Act, which was bipartisan legislation introduced by U.S. Senators Thom Tillis (R-N.C.), Kyrsten Sinema (D-Ariz.), Kevin Cramer (R-N.D.), and Dianne Feinstein (D-Calif.), aims to expand eligibility to those with any mental health problems.

For at least a decade, various service dog and veterans’ organizations have pushed to have the VA expand the service dog benefit. This new law is a “first step,” said Mr. Diamond. “We had to kick open the door,” he said, adding that “the VA has essentially said no for almost 15 years.”

Mr. Diamond noted that there is “overwhelming” evidence showing that service dogs improve quality of life and reduce distress for veterans with PTSD and other diagnoses.
 

‘No excuse’

Results from a VA study showed that suicidal ideation was reduced in veterans who were paired with service dogs, compared with veterans paired with emotional support dogs. The study, which was made public in March, found no reduction in overall disability, according to a report by Military.com.

K9s for Warriors cites numerous other studies, published in peer-reviewed journals, that have shown that service dogs reduce PTSD symptoms, especially hypervigilance.

“There really is no excuse not to have the VA engaged in helping veterans suffering from posttraumatic stress who are extremely high risk of suicide to get a lifesaving service dog,” Mr. Diamond said.

His organization has paired 700 veterans suffering from TBI, PTSD, or military sexual trauma with a service dog. The organization provides a 3-week training program for the veteran and his or her dog.

Although about 200 of the graduates have been eligible to receive coverage from the VA for veterinary care for the dogs, it requires a lot of paperwork, and the criteria for who can be certified to receive that benefit are somewhat vague, Mr. Diamond noted.

Under current policy, the dog and veteran must have successfully completed a training program offered by an organization accredited by Assistance Dogs International or the International Guide Dog Federation. The VA does not pay for the training or the dog – which at K9s for Warriors costs about $25,000.

The new pilot program will enable eligible veterans to receive dog training instruction from accredited nonprofit service dog training organizations, and it will give them the opportunity to adopt a dog that they actively assisted in training.

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

This story is a collaboration between KHN and “Science Friday.” 

Rafiah Maxie has been a licensed clinical social worker in the Chicago area for a decade. Throughout that time, she’d viewed suicide as a problem most prevalent among middle-aged white men.

Until May 27, 2020.

That day, Maxie’s 19-year-old son, Jamal Clay – who loved playing the trumpet and participating in theater, who would help her unload groceries from the car and raise funds for the March of the Dimes – killed himself in their garage.

“Now I cannot blink without seeing my son hanging,” said Maxie, who is Black.

Clay’s death, along with the suicides of more than 100 other Black residents in Illinois last year, has led locals to call for new prevention efforts focused on Black communities. In 2020, during the pandemic’s first year, suicides among White residents decreased compared with previous years, while they increased among Black residents, according to state data.

But this is not a local problem. Nor is it limited to the pandemic.

Interviews with a dozen suicide researchers, data collected from states across the country, and a review of decades of research revealed that suicide is a growing crisis for communities of color – one that plagued them well before the pandemic and has only been exacerbated since.

Overall suicide rates in the U.S. decreased in 2019 and 2020. National and local studies attribute the trend to a drop among White Americans, who make up the majority of suicide deaths. Meanwhile, rates for Black, Hispanic, and Asian Americans – though lower than those of their white peers – continued to climb in many states. (Suicide rates have been consistently high for Native Americans.)

“COVID created more transparency regarding what we already knew was happening,” said Sonyia Richardson, a licensed clinical social worker who focuses on serving people of color, and assistant professor at the University of North Carolina–Charlotte, where she researches suicide. When you put the suicide rates of all communities in one bucket, “that bucket says it’s getting better and what we’re doing is working,” she said. “But that’s not the case for communities of color.”
 

Losing generations

Although the suicide rate is highest among middle-aged White men, young people of color are emerging as particularly at risk.

Research shows Black kids younger than 13 die by suicide at nearly twice the rate of White kids and, over time, their suicide rates have grown even as rates have decreased for White children. Among teenagers and young adults, suicide deaths have increased more than 45% for Black Americans and about 40% for Asian Americans in the 7 years ending in 2019. Other concerning trends in suicide attempts date to the ’90s.

“We’re losing generations,” said Sean Joe, a national expert on Black suicide and a professor at Washington University in St. Louis. “We have to pay attention now because if you’re out of the first decade of life and think life is not worth pursuing, that’s a signal to say something is going really wrong.”

These statistics also refute traditional ideas that suicide doesn’t happen in certain ethnic or minority populations because they’re “protected” and “resilient” or the “model minority,” said Kiara Alvarez, a researcher and psychologist at Massachusetts General Hospital who focuses on suicide among Hispanic and immigrant populations.

Although these groups may have had low suicide rates historically, that’s changing, she said.

Paul Chin lost his 17-year-old brother, Chris, to suicide in 2009. A poem Chris wrote in high school about his heritage has left Chin, 8 years his senior, wondering if his brother struggled to feel accepted in the U.S., despite being born and raised in New York.

Growing up, Asian Americans weren’t represented in lessons at school or in pop culture, said Chin, now 37. Even in clinical research on suicide as well as other health topics, kids like Chris are underrepresented, with less than 1% of federal research funding focused on Asian Americans.

It wasn’t until the pandemic, and the concurrent rise in hate crimes against Asian Americans, that Chin saw national attention on the community’s mental health. He hopes the interest is not short-lived.

Suicide is the leading cause of death for Asian Americans ages 15 to 24, yet “that doesn’t get enough attention,” Chin said. “It’s important to continue to share these stories.”

Kathy Williams, who is Black, has been on a similar mission since her 15-year-old son, Torian Graves, died by suicide in 1996. People didn’t talk about suicide in the Black community then, she said. So she started raising the topic at her church in Durham, N.C., and in local schools. She wanted Black families to know the warning signs and society at large to recognize the seriousness of the problem.

The pandemic may have highlighted this, Williams said, but “it has always happened. Always.”
 

Pandemic sheds light on the triggers

Pinpointing the root causes of rising suicide within communities of color has proved difficult. How much stems from mental illness? How much from socioeconomic changes like job losses or social isolation? Now, COVID-19 may offer some clues.

Recent decades have been marked by growing economic instability, a widening racial wealth gap, and more public attention on police killings of unarmed Black and Brown people, said Michael Lindsey, executive director of the New York University McSilver Institute for Poverty Policy and Research.

With social media, youths face racism on more fronts than their parents did, said Leslie Adams, assistant professor in the department of mental health at Johns Hopkins Bloomberg School of Public Health.

Each of these factors has been shown to affect suicide risk. For example, experiencing racism and sexism together is linked to a threefold increase in suicidal thoughts for Asian American women, said Brian Keum, assistant professor at UCLA, based on preliminary research findings.

COVID-19 intensified these hardships among communities of color, with disproportionate numbers of lost loved ones, lost jobs, and lost housing. The murder of George Floyd prompted widespread racial unrest, and Asian Americans saw an increase in hate crimes.

At the same time, studies in Connecticut and Maryland found that suicide rates rose within these populations and dropped for their White counterparts.

“It’s not just a problem within the person, but societal issues that need to be addressed,” said Shari Jager-Hyman, assistant professor of psychiatry at the University of Pennsylvania.
 

Lessons from Texas

In Texas, COVID-19 hit Hispanics especially hard. As of July 2021, they accounted for 45% of all COVID-19 deaths and disproportionately lost jobs. Individuals living in the U.S. without authorization were generally not eligible for unemployment benefits or federal stimulus checks.

During this time, suicide deaths among Hispanic Texans climbed from 847 deaths in 2019 to 962 deaths in 2020, according to preliminary state data. Suicide deaths rose for Black Texans and residents classified as “other” races or ethnicities, but decreased for White Texans.

The numbers didn’t surprise Marc Mendiola. The 20-year-old grew up in a majority-Hispanic community on the south side of San Antonio. Even before the pandemic, he often heard classmates say they were suicidal. Many faced dire finances at home, sometimes living without electricity, food, or water. Those who sought mental health treatment often found services prohibitively expensive or inaccessible because they weren’t offered in Spanish.

“These are conditions the community has always been in,” Mendiola said. “But with the pandemic, it’s even worse.”

Four years ago, Mendiola and his classmates at South San High School began advocating for mental health services. In late 2019, just months before COVID-19 struck, their vision became reality. Six community agencies partnered to offer free services to students and their families across three school districts.

Richard Davidson, chief operating officer of Family Service, one of the groups in the collaborative, said the number of students discussing economic stressors has been on the rise since April 2020. More than 90% of the students who received services in the first half of 2021 were Hispanic, and nearly 10% reported thoughts of suicide or self-harm, program data show. None died by suicide.

Many students are so worried about what’s for dinner the next day that they’re not able to see a future beyond that, Davidson said. That’s when suicide can feel like a viable option.

“One of the things we do is help them see … that despite this situation now, you can create a vision for your future,” Davidson said.
 

A good future

Researchers say the promise of a good future is often overlooked in suicide prevention, perhaps because achieving it is so challenging. It requires economic and social growth and breaking systemic barriers.

Tevis Simon works to address all those fronts. As a child in West Baltimore, Simon, who is Black, faced poverty and trauma. As an adult, she attempted suicide three times. But now she shares her story with youths across the city to inspire them to overcome challenges. She also talks to politicians, law enforcement agencies, and public policy officials about their responsibilities.

“We can’t not talk about race,” said Simon, 43. “We can’t not talk about systematic oppression. We cannot not talk about these conditions that affect our mental well-being and our feeling and desire to live.”

For Jamal Clay in Illinois, the systemic barriers started early. Before his suicide last year, he had tried to harm himself when he was 12 and the victim of bullies. At that time, he was hospitalized for a few days and told to follow up with outpatient therapy, said his mother, Maxie.

But it was difficult to find therapists who accepted Medicaid, she said. When Maxie finally found one, there was a 60-day wait. Other therapists canceled appointments, she said.

“So we worked on our own,” Maxie said, relying on church and community. Her son seemed to improve. “We thought we closed that chapter in our lives.”

But when the pandemic hit, everything got worse, she said. Clay came home from college and worked at an Amazon warehouse. On drives to and from work, he was frequently pulled over by police. He stopped wearing hats so officers would consider him less intimidating, Maxie said.

“He felt uncomfortable being out in the street,” she said.

Maxie is still trying to make sense of what happened the day Clay died. But she’s found meaning in starting a nonprofit called Soul Survivors of Chicago. Through the organization, she provides education, scholarships and shoes – including Jamal’s old ones – to those impacted by violence, suicide, and trauma.

“My son won’t be able to have a first interview in [those] shoes. He won’t be able to have a nice jump shot or go to church or even meet his wife,” Maxie said.

But she hopes his shoes will carry someone else to a good future.

[Editor’s note: For the purposes of this story, “people of color” or “communities of color” refers to any racial or ethnic populations whose members do not identify as White, including those who are multiracial. Hispanics can be of any race or combination of races.]

KHN senior correspondent JoNel Aleccia contributed to this report. KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

This story is a collaboration between KHN and “Science Friday.” 

Rafiah Maxie has been a licensed clinical social worker in the Chicago area for a decade. Throughout that time, she’d viewed suicide as a problem most prevalent among middle-aged white men.

Until May 27, 2020.

That day, Maxie’s 19-year-old son, Jamal Clay – who loved playing the trumpet and participating in theater, who would help her unload groceries from the car and raise funds for the March of the Dimes – killed himself in their garage.

“Now I cannot blink without seeing my son hanging,” said Maxie, who is Black.

Clay’s death, along with the suicides of more than 100 other Black residents in Illinois last year, has led locals to call for new prevention efforts focused on Black communities. In 2020, during the pandemic’s first year, suicides among White residents decreased compared with previous years, while they increased among Black residents, according to state data.

But this is not a local problem. Nor is it limited to the pandemic.

Interviews with a dozen suicide researchers, data collected from states across the country, and a review of decades of research revealed that suicide is a growing crisis for communities of color – one that plagued them well before the pandemic and has only been exacerbated since.

Overall suicide rates in the U.S. decreased in 2019 and 2020. National and local studies attribute the trend to a drop among White Americans, who make up the majority of suicide deaths. Meanwhile, rates for Black, Hispanic, and Asian Americans – though lower than those of their white peers – continued to climb in many states. (Suicide rates have been consistently high for Native Americans.)

“COVID created more transparency regarding what we already knew was happening,” said Sonyia Richardson, a licensed clinical social worker who focuses on serving people of color, and assistant professor at the University of North Carolina–Charlotte, where she researches suicide. When you put the suicide rates of all communities in one bucket, “that bucket says it’s getting better and what we’re doing is working,” she said. “But that’s not the case for communities of color.”
 

Losing generations

Although the suicide rate is highest among middle-aged White men, young people of color are emerging as particularly at risk.

Research shows Black kids younger than 13 die by suicide at nearly twice the rate of White kids and, over time, their suicide rates have grown even as rates have decreased for White children. Among teenagers and young adults, suicide deaths have increased more than 45% for Black Americans and about 40% for Asian Americans in the 7 years ending in 2019. Other concerning trends in suicide attempts date to the ’90s.

“We’re losing generations,” said Sean Joe, a national expert on Black suicide and a professor at Washington University in St. Louis. “We have to pay attention now because if you’re out of the first decade of life and think life is not worth pursuing, that’s a signal to say something is going really wrong.”

These statistics also refute traditional ideas that suicide doesn’t happen in certain ethnic or minority populations because they’re “protected” and “resilient” or the “model minority,” said Kiara Alvarez, a researcher and psychologist at Massachusetts General Hospital who focuses on suicide among Hispanic and immigrant populations.

Although these groups may have had low suicide rates historically, that’s changing, she said.

Paul Chin lost his 17-year-old brother, Chris, to suicide in 2009. A poem Chris wrote in high school about his heritage has left Chin, 8 years his senior, wondering if his brother struggled to feel accepted in the U.S., despite being born and raised in New York.

Growing up, Asian Americans weren’t represented in lessons at school or in pop culture, said Chin, now 37. Even in clinical research on suicide as well as other health topics, kids like Chris are underrepresented, with less than 1% of federal research funding focused on Asian Americans.

It wasn’t until the pandemic, and the concurrent rise in hate crimes against Asian Americans, that Chin saw national attention on the community’s mental health. He hopes the interest is not short-lived.

Suicide is the leading cause of death for Asian Americans ages 15 to 24, yet “that doesn’t get enough attention,” Chin said. “It’s important to continue to share these stories.”

Kathy Williams, who is Black, has been on a similar mission since her 15-year-old son, Torian Graves, died by suicide in 1996. People didn’t talk about suicide in the Black community then, she said. So she started raising the topic at her church in Durham, N.C., and in local schools. She wanted Black families to know the warning signs and society at large to recognize the seriousness of the problem.

The pandemic may have highlighted this, Williams said, but “it has always happened. Always.”
 

Pandemic sheds light on the triggers

Pinpointing the root causes of rising suicide within communities of color has proved difficult. How much stems from mental illness? How much from socioeconomic changes like job losses or social isolation? Now, COVID-19 may offer some clues.

Recent decades have been marked by growing economic instability, a widening racial wealth gap, and more public attention on police killings of unarmed Black and Brown people, said Michael Lindsey, executive director of the New York University McSilver Institute for Poverty Policy and Research.

With social media, youths face racism on more fronts than their parents did, said Leslie Adams, assistant professor in the department of mental health at Johns Hopkins Bloomberg School of Public Health.

Each of these factors has been shown to affect suicide risk. For example, experiencing racism and sexism together is linked to a threefold increase in suicidal thoughts for Asian American women, said Brian Keum, assistant professor at UCLA, based on preliminary research findings.

COVID-19 intensified these hardships among communities of color, with disproportionate numbers of lost loved ones, lost jobs, and lost housing. The murder of George Floyd prompted widespread racial unrest, and Asian Americans saw an increase in hate crimes.

At the same time, studies in Connecticut and Maryland found that suicide rates rose within these populations and dropped for their White counterparts.

“It’s not just a problem within the person, but societal issues that need to be addressed,” said Shari Jager-Hyman, assistant professor of psychiatry at the University of Pennsylvania.
 

Lessons from Texas

In Texas, COVID-19 hit Hispanics especially hard. As of July 2021, they accounted for 45% of all COVID-19 deaths and disproportionately lost jobs. Individuals living in the U.S. without authorization were generally not eligible for unemployment benefits or federal stimulus checks.

During this time, suicide deaths among Hispanic Texans climbed from 847 deaths in 2019 to 962 deaths in 2020, according to preliminary state data. Suicide deaths rose for Black Texans and residents classified as “other” races or ethnicities, but decreased for White Texans.

The numbers didn’t surprise Marc Mendiola. The 20-year-old grew up in a majority-Hispanic community on the south side of San Antonio. Even before the pandemic, he often heard classmates say they were suicidal. Many faced dire finances at home, sometimes living without electricity, food, or water. Those who sought mental health treatment often found services prohibitively expensive or inaccessible because they weren’t offered in Spanish.

“These are conditions the community has always been in,” Mendiola said. “But with the pandemic, it’s even worse.”

Four years ago, Mendiola and his classmates at South San High School began advocating for mental health services. In late 2019, just months before COVID-19 struck, their vision became reality. Six community agencies partnered to offer free services to students and their families across three school districts.

Richard Davidson, chief operating officer of Family Service, one of the groups in the collaborative, said the number of students discussing economic stressors has been on the rise since April 2020. More than 90% of the students who received services in the first half of 2021 were Hispanic, and nearly 10% reported thoughts of suicide or self-harm, program data show. None died by suicide.

Many students are so worried about what’s for dinner the next day that they’re not able to see a future beyond that, Davidson said. That’s when suicide can feel like a viable option.

“One of the things we do is help them see … that despite this situation now, you can create a vision for your future,” Davidson said.
 

A good future

Researchers say the promise of a good future is often overlooked in suicide prevention, perhaps because achieving it is so challenging. It requires economic and social growth and breaking systemic barriers.

Tevis Simon works to address all those fronts. As a child in West Baltimore, Simon, who is Black, faced poverty and trauma. As an adult, she attempted suicide three times. But now she shares her story with youths across the city to inspire them to overcome challenges. She also talks to politicians, law enforcement agencies, and public policy officials about their responsibilities.

“We can’t not talk about race,” said Simon, 43. “We can’t not talk about systematic oppression. We cannot not talk about these conditions that affect our mental well-being and our feeling and desire to live.”

For Jamal Clay in Illinois, the systemic barriers started early. Before his suicide last year, he had tried to harm himself when he was 12 and the victim of bullies. At that time, he was hospitalized for a few days and told to follow up with outpatient therapy, said his mother, Maxie.

But it was difficult to find therapists who accepted Medicaid, she said. When Maxie finally found one, there was a 60-day wait. Other therapists canceled appointments, she said.

“So we worked on our own,” Maxie said, relying on church and community. Her son seemed to improve. “We thought we closed that chapter in our lives.”

But when the pandemic hit, everything got worse, she said. Clay came home from college and worked at an Amazon warehouse. On drives to and from work, he was frequently pulled over by police. He stopped wearing hats so officers would consider him less intimidating, Maxie said.

“He felt uncomfortable being out in the street,” she said.

Maxie is still trying to make sense of what happened the day Clay died. But she’s found meaning in starting a nonprofit called Soul Survivors of Chicago. Through the organization, she provides education, scholarships and shoes – including Jamal’s old ones – to those impacted by violence, suicide, and trauma.

“My son won’t be able to have a first interview in [those] shoes. He won’t be able to have a nice jump shot or go to church or even meet his wife,” Maxie said.

But she hopes his shoes will carry someone else to a good future.

[Editor’s note: For the purposes of this story, “people of color” or “communities of color” refers to any racial or ethnic populations whose members do not identify as White, including those who are multiracial. Hispanics can be of any race or combination of races.]

KHN senior correspondent JoNel Aleccia contributed to this report. KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

This story is a collaboration between KHN and “Science Friday.” 

Rafiah Maxie has been a licensed clinical social worker in the Chicago area for a decade. Throughout that time, she’d viewed suicide as a problem most prevalent among middle-aged white men.

Until May 27, 2020.

That day, Maxie’s 19-year-old son, Jamal Clay – who loved playing the trumpet and participating in theater, who would help her unload groceries from the car and raise funds for the March of the Dimes – killed himself in their garage.

“Now I cannot blink without seeing my son hanging,” said Maxie, who is Black.

Clay’s death, along with the suicides of more than 100 other Black residents in Illinois last year, has led locals to call for new prevention efforts focused on Black communities. In 2020, during the pandemic’s first year, suicides among White residents decreased compared with previous years, while they increased among Black residents, according to state data.

But this is not a local problem. Nor is it limited to the pandemic.

Interviews with a dozen suicide researchers, data collected from states across the country, and a review of decades of research revealed that suicide is a growing crisis for communities of color – one that plagued them well before the pandemic and has only been exacerbated since.

Overall suicide rates in the U.S. decreased in 2019 and 2020. National and local studies attribute the trend to a drop among White Americans, who make up the majority of suicide deaths. Meanwhile, rates for Black, Hispanic, and Asian Americans – though lower than those of their white peers – continued to climb in many states. (Suicide rates have been consistently high for Native Americans.)

“COVID created more transparency regarding what we already knew was happening,” said Sonyia Richardson, a licensed clinical social worker who focuses on serving people of color, and assistant professor at the University of North Carolina–Charlotte, where she researches suicide. When you put the suicide rates of all communities in one bucket, “that bucket says it’s getting better and what we’re doing is working,” she said. “But that’s not the case for communities of color.”
 

Losing generations

Although the suicide rate is highest among middle-aged White men, young people of color are emerging as particularly at risk.

Research shows Black kids younger than 13 die by suicide at nearly twice the rate of White kids and, over time, their suicide rates have grown even as rates have decreased for White children. Among teenagers and young adults, suicide deaths have increased more than 45% for Black Americans and about 40% for Asian Americans in the 7 years ending in 2019. Other concerning trends in suicide attempts date to the ’90s.

“We’re losing generations,” said Sean Joe, a national expert on Black suicide and a professor at Washington University in St. Louis. “We have to pay attention now because if you’re out of the first decade of life and think life is not worth pursuing, that’s a signal to say something is going really wrong.”

These statistics also refute traditional ideas that suicide doesn’t happen in certain ethnic or minority populations because they’re “protected” and “resilient” or the “model minority,” said Kiara Alvarez, a researcher and psychologist at Massachusetts General Hospital who focuses on suicide among Hispanic and immigrant populations.

Although these groups may have had low suicide rates historically, that’s changing, she said.

Paul Chin lost his 17-year-old brother, Chris, to suicide in 2009. A poem Chris wrote in high school about his heritage has left Chin, 8 years his senior, wondering if his brother struggled to feel accepted in the U.S., despite being born and raised in New York.

Growing up, Asian Americans weren’t represented in lessons at school or in pop culture, said Chin, now 37. Even in clinical research on suicide as well as other health topics, kids like Chris are underrepresented, with less than 1% of federal research funding focused on Asian Americans.

It wasn’t until the pandemic, and the concurrent rise in hate crimes against Asian Americans, that Chin saw national attention on the community’s mental health. He hopes the interest is not short-lived.

Suicide is the leading cause of death for Asian Americans ages 15 to 24, yet “that doesn’t get enough attention,” Chin said. “It’s important to continue to share these stories.”

Kathy Williams, who is Black, has been on a similar mission since her 15-year-old son, Torian Graves, died by suicide in 1996. People didn’t talk about suicide in the Black community then, she said. So she started raising the topic at her church in Durham, N.C., and in local schools. She wanted Black families to know the warning signs and society at large to recognize the seriousness of the problem.

The pandemic may have highlighted this, Williams said, but “it has always happened. Always.”
 

Pandemic sheds light on the triggers

Pinpointing the root causes of rising suicide within communities of color has proved difficult. How much stems from mental illness? How much from socioeconomic changes like job losses or social isolation? Now, COVID-19 may offer some clues.

Recent decades have been marked by growing economic instability, a widening racial wealth gap, and more public attention on police killings of unarmed Black and Brown people, said Michael Lindsey, executive director of the New York University McSilver Institute for Poverty Policy and Research.

With social media, youths face racism on more fronts than their parents did, said Leslie Adams, assistant professor in the department of mental health at Johns Hopkins Bloomberg School of Public Health.

Each of these factors has been shown to affect suicide risk. For example, experiencing racism and sexism together is linked to a threefold increase in suicidal thoughts for Asian American women, said Brian Keum, assistant professor at UCLA, based on preliminary research findings.

COVID-19 intensified these hardships among communities of color, with disproportionate numbers of lost loved ones, lost jobs, and lost housing. The murder of George Floyd prompted widespread racial unrest, and Asian Americans saw an increase in hate crimes.

At the same time, studies in Connecticut and Maryland found that suicide rates rose within these populations and dropped for their White counterparts.

“It’s not just a problem within the person, but societal issues that need to be addressed,” said Shari Jager-Hyman, assistant professor of psychiatry at the University of Pennsylvania.
 

Lessons from Texas

In Texas, COVID-19 hit Hispanics especially hard. As of July 2021, they accounted for 45% of all COVID-19 deaths and disproportionately lost jobs. Individuals living in the U.S. without authorization were generally not eligible for unemployment benefits or federal stimulus checks.

During this time, suicide deaths among Hispanic Texans climbed from 847 deaths in 2019 to 962 deaths in 2020, according to preliminary state data. Suicide deaths rose for Black Texans and residents classified as “other” races or ethnicities, but decreased for White Texans.

The numbers didn’t surprise Marc Mendiola. The 20-year-old grew up in a majority-Hispanic community on the south side of San Antonio. Even before the pandemic, he often heard classmates say they were suicidal. Many faced dire finances at home, sometimes living without electricity, food, or water. Those who sought mental health treatment often found services prohibitively expensive or inaccessible because they weren’t offered in Spanish.

“These are conditions the community has always been in,” Mendiola said. “But with the pandemic, it’s even worse.”

Four years ago, Mendiola and his classmates at South San High School began advocating for mental health services. In late 2019, just months before COVID-19 struck, their vision became reality. Six community agencies partnered to offer free services to students and their families across three school districts.

Richard Davidson, chief operating officer of Family Service, one of the groups in the collaborative, said the number of students discussing economic stressors has been on the rise since April 2020. More than 90% of the students who received services in the first half of 2021 were Hispanic, and nearly 10% reported thoughts of suicide or self-harm, program data show. None died by suicide.

Many students are so worried about what’s for dinner the next day that they’re not able to see a future beyond that, Davidson said. That’s when suicide can feel like a viable option.

“One of the things we do is help them see … that despite this situation now, you can create a vision for your future,” Davidson said.
 

A good future

Researchers say the promise of a good future is often overlooked in suicide prevention, perhaps because achieving it is so challenging. It requires economic and social growth and breaking systemic barriers.

Tevis Simon works to address all those fronts. As a child in West Baltimore, Simon, who is Black, faced poverty and trauma. As an adult, she attempted suicide three times. But now she shares her story with youths across the city to inspire them to overcome challenges. She also talks to politicians, law enforcement agencies, and public policy officials about their responsibilities.

“We can’t not talk about race,” said Simon, 43. “We can’t not talk about systematic oppression. We cannot not talk about these conditions that affect our mental well-being and our feeling and desire to live.”

For Jamal Clay in Illinois, the systemic barriers started early. Before his suicide last year, he had tried to harm himself when he was 12 and the victim of bullies. At that time, he was hospitalized for a few days and told to follow up with outpatient therapy, said his mother, Maxie.

But it was difficult to find therapists who accepted Medicaid, she said. When Maxie finally found one, there was a 60-day wait. Other therapists canceled appointments, she said.

“So we worked on our own,” Maxie said, relying on church and community. Her son seemed to improve. “We thought we closed that chapter in our lives.”

But when the pandemic hit, everything got worse, she said. Clay came home from college and worked at an Amazon warehouse. On drives to and from work, he was frequently pulled over by police. He stopped wearing hats so officers would consider him less intimidating, Maxie said.

“He felt uncomfortable being out in the street,” she said.

Maxie is still trying to make sense of what happened the day Clay died. But she’s found meaning in starting a nonprofit called Soul Survivors of Chicago. Through the organization, she provides education, scholarships and shoes – including Jamal’s old ones – to those impacted by violence, suicide, and trauma.

“My son won’t be able to have a first interview in [those] shoes. He won’t be able to have a nice jump shot or go to church or even meet his wife,” Maxie said.

But she hopes his shoes will carry someone else to a good future.

[Editor’s note: For the purposes of this story, “people of color” or “communities of color” refers to any racial or ethnic populations whose members do not identify as White, including those who are multiracial. Hispanics can be of any race or combination of races.]

KHN senior correspondent JoNel Aleccia contributed to this report. KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.