User login
FDA approves first pill for postpartum depression
a condition that affects an estimated one in seven mothers in the United States.
The pill, zuranolone (Zurzuvae), is a neuroactive steroid that acts on GABAA receptors in the brain responsible for regulating mood, arousal, behavior, and cognition, according to Biogen, which, along with Sage Therapeutics, developed the product. The recommended dose for Zurzuvae is 50 mg taken once daily for 14 days, in the evening with a fatty meal, according to the FDA.
Postpartum depression often goes undiagnosed and untreated. Many mothers are hesitant to reveal their symptoms to family and clinicians, fearing they’ll be judged on their parenting. A 2017 study found that suicide accounted for roughly 5% of perinatal deaths among women in Canada, with most of those deaths occurring in the first 3 months in the year after giving birth.
“Postpartum depression is a serious and potentially life-threatening condition in which women experience sadness, guilt, worthlessness – even, in severe cases, thoughts of harming themselves or their child. And, because postpartum depression can disrupt the maternal-infant bond, it can also have consequences for the child’s physical and emotional development,” Tiffany R. Farchione, MD, director of the division of psychiatry at the FDA’s Center for Drug Evaluation and Research, said in a statement about the approval. “Having access to an oral medication will be a beneficial option for many of these women coping with extreme, and sometimes life-threatening, feelings.”
The other approved therapy for postpartum depression is the intravenous agent brexanolone (Zulresso; Sage). But the product requires prolonged infusions in hospital settings and costs $34,000.
FDA approval of Zurzuvae was based in part on data reported in a 2023 study in the American Journal of Psychiatry, which showed that the drug led to significantly greater improvement in depressive symptoms at 15 days compared with the placebo group. Improvements were observed on day 3, the earliest assessment, and were sustained at all subsequent visits during the treatment and follow-up period (through day 42).
Patients with anxiety who received the active drug experienced improvement in related symptoms compared with the patients who received a placebo.
The most common adverse events reported in the trial were somnolence and headaches. Weight gain, sexual dysfunction, withdrawal symptoms, and increased suicidal ideation or behavior were not observed.
The packaging for Zurzuvae will include a boxed warning noting that the drug can affect a user’s ability to drive and perform other potentially hazardous activities, possibly without their knowledge of the impairment, the FDA said. As a result, people who use Zurzuvae should not drive or operate heavy machinery for at least 12 hours after taking the pill.
A version of this article first appeared on Medscape.com.
a condition that affects an estimated one in seven mothers in the United States.
The pill, zuranolone (Zurzuvae), is a neuroactive steroid that acts on GABAA receptors in the brain responsible for regulating mood, arousal, behavior, and cognition, according to Biogen, which, along with Sage Therapeutics, developed the product. The recommended dose for Zurzuvae is 50 mg taken once daily for 14 days, in the evening with a fatty meal, according to the FDA.
Postpartum depression often goes undiagnosed and untreated. Many mothers are hesitant to reveal their symptoms to family and clinicians, fearing they’ll be judged on their parenting. A 2017 study found that suicide accounted for roughly 5% of perinatal deaths among women in Canada, with most of those deaths occurring in the first 3 months in the year after giving birth.
“Postpartum depression is a serious and potentially life-threatening condition in which women experience sadness, guilt, worthlessness – even, in severe cases, thoughts of harming themselves or their child. And, because postpartum depression can disrupt the maternal-infant bond, it can also have consequences for the child’s physical and emotional development,” Tiffany R. Farchione, MD, director of the division of psychiatry at the FDA’s Center for Drug Evaluation and Research, said in a statement about the approval. “Having access to an oral medication will be a beneficial option for many of these women coping with extreme, and sometimes life-threatening, feelings.”
The other approved therapy for postpartum depression is the intravenous agent brexanolone (Zulresso; Sage). But the product requires prolonged infusions in hospital settings and costs $34,000.
FDA approval of Zurzuvae was based in part on data reported in a 2023 study in the American Journal of Psychiatry, which showed that the drug led to significantly greater improvement in depressive symptoms at 15 days compared with the placebo group. Improvements were observed on day 3, the earliest assessment, and were sustained at all subsequent visits during the treatment and follow-up period (through day 42).
Patients with anxiety who received the active drug experienced improvement in related symptoms compared with the patients who received a placebo.
The most common adverse events reported in the trial were somnolence and headaches. Weight gain, sexual dysfunction, withdrawal symptoms, and increased suicidal ideation or behavior were not observed.
The packaging for Zurzuvae will include a boxed warning noting that the drug can affect a user’s ability to drive and perform other potentially hazardous activities, possibly without their knowledge of the impairment, the FDA said. As a result, people who use Zurzuvae should not drive or operate heavy machinery for at least 12 hours after taking the pill.
A version of this article first appeared on Medscape.com.
a condition that affects an estimated one in seven mothers in the United States.
The pill, zuranolone (Zurzuvae), is a neuroactive steroid that acts on GABAA receptors in the brain responsible for regulating mood, arousal, behavior, and cognition, according to Biogen, which, along with Sage Therapeutics, developed the product. The recommended dose for Zurzuvae is 50 mg taken once daily for 14 days, in the evening with a fatty meal, according to the FDA.
Postpartum depression often goes undiagnosed and untreated. Many mothers are hesitant to reveal their symptoms to family and clinicians, fearing they’ll be judged on their parenting. A 2017 study found that suicide accounted for roughly 5% of perinatal deaths among women in Canada, with most of those deaths occurring in the first 3 months in the year after giving birth.
“Postpartum depression is a serious and potentially life-threatening condition in which women experience sadness, guilt, worthlessness – even, in severe cases, thoughts of harming themselves or their child. And, because postpartum depression can disrupt the maternal-infant bond, it can also have consequences for the child’s physical and emotional development,” Tiffany R. Farchione, MD, director of the division of psychiatry at the FDA’s Center for Drug Evaluation and Research, said in a statement about the approval. “Having access to an oral medication will be a beneficial option for many of these women coping with extreme, and sometimes life-threatening, feelings.”
The other approved therapy for postpartum depression is the intravenous agent brexanolone (Zulresso; Sage). But the product requires prolonged infusions in hospital settings and costs $34,000.
FDA approval of Zurzuvae was based in part on data reported in a 2023 study in the American Journal of Psychiatry, which showed that the drug led to significantly greater improvement in depressive symptoms at 15 days compared with the placebo group. Improvements were observed on day 3, the earliest assessment, and were sustained at all subsequent visits during the treatment and follow-up period (through day 42).
Patients with anxiety who received the active drug experienced improvement in related symptoms compared with the patients who received a placebo.
The most common adverse events reported in the trial were somnolence and headaches. Weight gain, sexual dysfunction, withdrawal symptoms, and increased suicidal ideation or behavior were not observed.
The packaging for Zurzuvae will include a boxed warning noting that the drug can affect a user’s ability to drive and perform other potentially hazardous activities, possibly without their knowledge of the impairment, the FDA said. As a result, people who use Zurzuvae should not drive or operate heavy machinery for at least 12 hours after taking the pill.
A version of this article first appeared on Medscape.com.
Depression at any stage of life tied to increased dementia risk
Adults with depression have more than double the risk of developing dementia and the risk persists regardless of when in life depression is diagnosed, a large population-based study shows.
That the association between depression and dementia persisted even among individuals first diagnosed with depression in early or mid-life provides “strong evidence that depression is not only an early symptom of dementia, but also that depression increases dementia risk,” study investigator Holly Elser, MD, PhD, epidemiologist and resident physician, University of Pennsylvania, Philadelphia, told this news organization.
The study was published online in JAMA Neurology.
Double the risk
Several prior studies that have examined the relationship between depression and dementia over the life course have consistently shown depression later in life is associated with subsequent dementia.
“Late-life depression is generally thought to be an early symptom of dementia or a reaction to subclinical cognitive decline,” said Dr. Elser.
The investigators wanted to examine whether the association between depression and dementia persists even when depression is diagnosed earlier in life, which may suggest it increases the risk of dementia.
“To my knowledge, ours is the largest study on this topic to date, leveraging routinely and prospectively collected data from more than 1.4 million Danish citizens followed from 1977 to 2018,” Dr. Elser noted.
The cohort included 246,499 individuals diagnosed with depression and 1,190,302 individuals without depression.
In both groups, the median age was 50 years and 65% were women. Roughly two-thirds (68%) of those diagnosed with depression were diagnosed before age 60 years.
In Cox proportional hazards regression models, the overall hazard of dementia was more than doubled in those diagnosed with depression (hazard ratio [HR] 2.41). The risk of dementia with depression was more pronounced for men (HR, 2.98) than in women (HR, 2.21).
This association persisted even when the time elapsed from depression diagnosis was between 20 and 39 years (HR, 1.79) and whether depression was diagnosed in early life (18-44 years: HR, 3.08), mid-life (45-59 years: HR, 2.95), or late life (≥ 60 years: HR, 2.31).
It remains unclear whether effective treatment of depression modifies the risk of dementia, as the current study explored the role of antidepressants in a “very limited fashion,” Dr. Elser said.
Specifically, the researchers considered whether an individual was treated with an antidepressant within 6 months of the initial depression diagnosis and found no evidence of a difference in dementia risk between the treated and untreated groups.
“Research that explores implications of the timing and duration of treatment with antidepressants for dementia, treatment with cognitive behavioral therapy, and is able to evaluate the effectiveness of those treatments will be extremely important,” Dr. Elser said.
‘An assault on the brain’
Reached for comment, John Showalter, MD, chief product officer at Linus Health, said one of the most “intriguing” findings of the study is that a depression diagnosis earlier in adulthood conferred a greater risk of developing vascular dementia (HR, 3.28) than did dementia due to Alzheimer’s disease (HR, 1.73).
“The difference in risk for subtypes of dementia is a meaningful addition to our understanding of depression’s connection to dementia,” said Dr. Showalter, who was not involved in the study.
Also weighing in, Shaheen Lakhan, MD, PhD, a neurologist and researcher in Boston, said the findings from this “far-reaching investigation leave little room for doubt – depression unleashes a devastating storm within the brain, wreaking havoc on the lives of those ensnared by its grip.
“This massive, multi-decade, and high-data quality registry study adds another brick to the growing edifice of evidence attesting to the profound connection between psychiatric health and the very essence of brain health,” said Dr. Lakhan, who was not involved in the study.
“In a resounding declaration, this research underscores that psychiatric health should be perceived as an integral component of overall health – a paradigm shift that challenges long-standing misconceptions and stigmas surrounding mental disorders. Depression, once marginalized, now claims its rightful place on the pedestal of health concerns that must be addressed with unwavering resolve,” said Dr. Lakhan.
He noted that depression is “not just a mental battle, it’s a profound assault on the very fabric of the brain, leaving lives in turmoil and hearts in search of hope. No longer shrouded in silence, depression demands society’s attention.”
The study had no specific funding. Dr. Elser, Dr. Showalter, and Dr. Lakhan have reported no relevant financial relationships.
A version of this article appeared on Medscape.com.
Adults with depression have more than double the risk of developing dementia and the risk persists regardless of when in life depression is diagnosed, a large population-based study shows.
That the association between depression and dementia persisted even among individuals first diagnosed with depression in early or mid-life provides “strong evidence that depression is not only an early symptom of dementia, but also that depression increases dementia risk,” study investigator Holly Elser, MD, PhD, epidemiologist and resident physician, University of Pennsylvania, Philadelphia, told this news organization.
The study was published online in JAMA Neurology.
Double the risk
Several prior studies that have examined the relationship between depression and dementia over the life course have consistently shown depression later in life is associated with subsequent dementia.
“Late-life depression is generally thought to be an early symptom of dementia or a reaction to subclinical cognitive decline,” said Dr. Elser.
The investigators wanted to examine whether the association between depression and dementia persists even when depression is diagnosed earlier in life, which may suggest it increases the risk of dementia.
“To my knowledge, ours is the largest study on this topic to date, leveraging routinely and prospectively collected data from more than 1.4 million Danish citizens followed from 1977 to 2018,” Dr. Elser noted.
The cohort included 246,499 individuals diagnosed with depression and 1,190,302 individuals without depression.
In both groups, the median age was 50 years and 65% were women. Roughly two-thirds (68%) of those diagnosed with depression were diagnosed before age 60 years.
In Cox proportional hazards regression models, the overall hazard of dementia was more than doubled in those diagnosed with depression (hazard ratio [HR] 2.41). The risk of dementia with depression was more pronounced for men (HR, 2.98) than in women (HR, 2.21).
This association persisted even when the time elapsed from depression diagnosis was between 20 and 39 years (HR, 1.79) and whether depression was diagnosed in early life (18-44 years: HR, 3.08), mid-life (45-59 years: HR, 2.95), or late life (≥ 60 years: HR, 2.31).
It remains unclear whether effective treatment of depression modifies the risk of dementia, as the current study explored the role of antidepressants in a “very limited fashion,” Dr. Elser said.
Specifically, the researchers considered whether an individual was treated with an antidepressant within 6 months of the initial depression diagnosis and found no evidence of a difference in dementia risk between the treated and untreated groups.
“Research that explores implications of the timing and duration of treatment with antidepressants for dementia, treatment with cognitive behavioral therapy, and is able to evaluate the effectiveness of those treatments will be extremely important,” Dr. Elser said.
‘An assault on the brain’
Reached for comment, John Showalter, MD, chief product officer at Linus Health, said one of the most “intriguing” findings of the study is that a depression diagnosis earlier in adulthood conferred a greater risk of developing vascular dementia (HR, 3.28) than did dementia due to Alzheimer’s disease (HR, 1.73).
“The difference in risk for subtypes of dementia is a meaningful addition to our understanding of depression’s connection to dementia,” said Dr. Showalter, who was not involved in the study.
Also weighing in, Shaheen Lakhan, MD, PhD, a neurologist and researcher in Boston, said the findings from this “far-reaching investigation leave little room for doubt – depression unleashes a devastating storm within the brain, wreaking havoc on the lives of those ensnared by its grip.
“This massive, multi-decade, and high-data quality registry study adds another brick to the growing edifice of evidence attesting to the profound connection between psychiatric health and the very essence of brain health,” said Dr. Lakhan, who was not involved in the study.
“In a resounding declaration, this research underscores that psychiatric health should be perceived as an integral component of overall health – a paradigm shift that challenges long-standing misconceptions and stigmas surrounding mental disorders. Depression, once marginalized, now claims its rightful place on the pedestal of health concerns that must be addressed with unwavering resolve,” said Dr. Lakhan.
He noted that depression is “not just a mental battle, it’s a profound assault on the very fabric of the brain, leaving lives in turmoil and hearts in search of hope. No longer shrouded in silence, depression demands society’s attention.”
The study had no specific funding. Dr. Elser, Dr. Showalter, and Dr. Lakhan have reported no relevant financial relationships.
A version of this article appeared on Medscape.com.
Adults with depression have more than double the risk of developing dementia and the risk persists regardless of when in life depression is diagnosed, a large population-based study shows.
That the association between depression and dementia persisted even among individuals first diagnosed with depression in early or mid-life provides “strong evidence that depression is not only an early symptom of dementia, but also that depression increases dementia risk,” study investigator Holly Elser, MD, PhD, epidemiologist and resident physician, University of Pennsylvania, Philadelphia, told this news organization.
The study was published online in JAMA Neurology.
Double the risk
Several prior studies that have examined the relationship between depression and dementia over the life course have consistently shown depression later in life is associated with subsequent dementia.
“Late-life depression is generally thought to be an early symptom of dementia or a reaction to subclinical cognitive decline,” said Dr. Elser.
The investigators wanted to examine whether the association between depression and dementia persists even when depression is diagnosed earlier in life, which may suggest it increases the risk of dementia.
“To my knowledge, ours is the largest study on this topic to date, leveraging routinely and prospectively collected data from more than 1.4 million Danish citizens followed from 1977 to 2018,” Dr. Elser noted.
The cohort included 246,499 individuals diagnosed with depression and 1,190,302 individuals without depression.
In both groups, the median age was 50 years and 65% were women. Roughly two-thirds (68%) of those diagnosed with depression were diagnosed before age 60 years.
In Cox proportional hazards regression models, the overall hazard of dementia was more than doubled in those diagnosed with depression (hazard ratio [HR] 2.41). The risk of dementia with depression was more pronounced for men (HR, 2.98) than in women (HR, 2.21).
This association persisted even when the time elapsed from depression diagnosis was between 20 and 39 years (HR, 1.79) and whether depression was diagnosed in early life (18-44 years: HR, 3.08), mid-life (45-59 years: HR, 2.95), or late life (≥ 60 years: HR, 2.31).
It remains unclear whether effective treatment of depression modifies the risk of dementia, as the current study explored the role of antidepressants in a “very limited fashion,” Dr. Elser said.
Specifically, the researchers considered whether an individual was treated with an antidepressant within 6 months of the initial depression diagnosis and found no evidence of a difference in dementia risk between the treated and untreated groups.
“Research that explores implications of the timing and duration of treatment with antidepressants for dementia, treatment with cognitive behavioral therapy, and is able to evaluate the effectiveness of those treatments will be extremely important,” Dr. Elser said.
‘An assault on the brain’
Reached for comment, John Showalter, MD, chief product officer at Linus Health, said one of the most “intriguing” findings of the study is that a depression diagnosis earlier in adulthood conferred a greater risk of developing vascular dementia (HR, 3.28) than did dementia due to Alzheimer’s disease (HR, 1.73).
“The difference in risk for subtypes of dementia is a meaningful addition to our understanding of depression’s connection to dementia,” said Dr. Showalter, who was not involved in the study.
Also weighing in, Shaheen Lakhan, MD, PhD, a neurologist and researcher in Boston, said the findings from this “far-reaching investigation leave little room for doubt – depression unleashes a devastating storm within the brain, wreaking havoc on the lives of those ensnared by its grip.
“This massive, multi-decade, and high-data quality registry study adds another brick to the growing edifice of evidence attesting to the profound connection between psychiatric health and the very essence of brain health,” said Dr. Lakhan, who was not involved in the study.
“In a resounding declaration, this research underscores that psychiatric health should be perceived as an integral component of overall health – a paradigm shift that challenges long-standing misconceptions and stigmas surrounding mental disorders. Depression, once marginalized, now claims its rightful place on the pedestal of health concerns that must be addressed with unwavering resolve,” said Dr. Lakhan.
He noted that depression is “not just a mental battle, it’s a profound assault on the very fabric of the brain, leaving lives in turmoil and hearts in search of hope. No longer shrouded in silence, depression demands society’s attention.”
The study had no specific funding. Dr. Elser, Dr. Showalter, and Dr. Lakhan have reported no relevant financial relationships.
A version of this article appeared on Medscape.com.
Prescribing lifestyle changes: When medicine isn’t enough
In psychiatry, patients come to us with their list of symptoms, often a diagnosis they’ve made themselves, and the expectation that they will be given medication to fix their problem. Their diagnoses are often right on target – people often know if they are depressed or anxious, and Doctor Google may provide useful information.
Sometimes they want a specific medication, one they saw in a TV ad, or one that helped them in the past or has helped someone they know. As psychiatrists have focused more on their strengths as psychopharmacologists and less on psychotherapy, it gets easy for both the patient and the doctor to look to medication, cocktails, and titration as the only thing we do.
“My medicine stopped working,” is a line I commonly hear. Often the patient is on a complicated regimen that has been serving them well, and it seems unlikely that the five psychotropic medications they are taking have suddenly “stopped working.” An obvious exception is the SSRI “poop out” that can occur 6-12 months or more after beginning treatment. In addition, it’s important to make sure patients are taking their medications as prescribed, and that the generic formulations have not changed.
But as rates of mental illness increase, some of it spurred on by difficult times,
This is not to devalue our medications, but to help the patient see symptoms as having multiple factors and give them some means to intervene, in addition to medications. At the beginning of therapy, it is important to “prescribe” lifestyle changes that will facilitate the best possible outcomes.
Nonpharmaceutical prescriptions
Early in my career, people with alcohol use problems were told they needed to be substance free before they were candidates for antidepressants. While we no longer do that, it is still important to emphasize abstinence from addictive substances, and to recommend specific treatment when necessary.
Patients are often reluctant to see their use of alcohol, marijuana (it’s medical! It’s part of wellness!), or their pain medications as part of the problem, and this can be difficult. There have been times, after multiple medications have failed to help their symptoms, when I have said, “If you don’t get treatment for this problem, I am not going to be able to help you feel better” and that has been motivating for the patient.
There are other “prescriptions” to write. Regular sleep is essential for people with mood disorders, and this can be difficult for many patients, especially those who do shift work, or who have regular disruptions to their sleep from noise, pets, and children. Exercise is wonderful for the cardiovascular system, calms anxiety, and maintains strength, endurance, mobility, and quality of life as people age. But it can be a hard sell to people in a mental health crisis.
Nature is healing, and sunshine helps with maintaining circadian rhythms. For those who don’t exercise, I often “prescribe” 20 to 30 minutes a day of walking, preferably outside, during daylight hours, in a park or natural setting. For people with anxiety, it is important to check their caffeine consumption and to suggest ways to moderate it – moving to decaffeinated beverages or titrating down by mixing decaf with caffeinated.
Meditation is something that many people find helpful. For anxious people, it can be very difficult, and I will prescribe a specific instructional video course that I like on the well-being app InsightTimer – Sarah Blondin’s Learn How to Meditate in Seven Days. The sessions are approximately 10 minutes long, and that seems like the right amount of time for a beginner.
When people are very ill and don’t want to go into the hospital, I talk with them about things that happen in the hospital that are helpful, things they can try to mimic at home. In the hospital, patients don’t go to work, they don’t spend hours a day on the computer, and they are given a pass from dealing with the routine stresses of daily life.
I ask them to take time off work, to avoid as much stress as possible, to spend time with loved ones who give them comfort, and to avoid the people who leave them feeling drained or distressed. I ask them to engage in activities they find healing, to eat well, exercise, and avoid social media. In the hospital, I emphasize, they wake patients up in the morning, ask them to get out of bed and engage in therapeutic activities. They are fed and kept from intoxicants.
When it comes to nutrition, we know so little about how food affects mental health. I feel like it can’t hurt to ask people to avoid fast foods, soft drinks, and processed foods, and so I do.
And what about compliance? Of course, not everyone complies; not everyone is interested in making changes and these can be hard changes. I’ve recently started to recommend the book Atomic Habits by James Clear. Sometimes a bit of motivational interviewing can also be helpful in getting people to look at slowly moving toward making changes.
In prescribing lifestyle changes, it is important to offer most of these changes as suggestions, not as things we insist on, or that will leave the patient feeling ashamed if he doesn’t follow through. They should be discussed early in treatment so that patients don’t feel blamed for their illness or relapses. As with all the things we prescribe, some of these behavior changes help some of the people some of the time. Suggesting them, however, makes the strong statement that treating psychiatric disorders can be about more than passively swallowing a pill.
Dr. Miller is a coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice and is an assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, Baltimore. She disclosed no relevant conflicts of interest.
In psychiatry, patients come to us with their list of symptoms, often a diagnosis they’ve made themselves, and the expectation that they will be given medication to fix their problem. Their diagnoses are often right on target – people often know if they are depressed or anxious, and Doctor Google may provide useful information.
Sometimes they want a specific medication, one they saw in a TV ad, or one that helped them in the past or has helped someone they know. As psychiatrists have focused more on their strengths as psychopharmacologists and less on psychotherapy, it gets easy for both the patient and the doctor to look to medication, cocktails, and titration as the only thing we do.
“My medicine stopped working,” is a line I commonly hear. Often the patient is on a complicated regimen that has been serving them well, and it seems unlikely that the five psychotropic medications they are taking have suddenly “stopped working.” An obvious exception is the SSRI “poop out” that can occur 6-12 months or more after beginning treatment. In addition, it’s important to make sure patients are taking their medications as prescribed, and that the generic formulations have not changed.
But as rates of mental illness increase, some of it spurred on by difficult times,
This is not to devalue our medications, but to help the patient see symptoms as having multiple factors and give them some means to intervene, in addition to medications. At the beginning of therapy, it is important to “prescribe” lifestyle changes that will facilitate the best possible outcomes.
Nonpharmaceutical prescriptions
Early in my career, people with alcohol use problems were told they needed to be substance free before they were candidates for antidepressants. While we no longer do that, it is still important to emphasize abstinence from addictive substances, and to recommend specific treatment when necessary.
Patients are often reluctant to see their use of alcohol, marijuana (it’s medical! It’s part of wellness!), or their pain medications as part of the problem, and this can be difficult. There have been times, after multiple medications have failed to help their symptoms, when I have said, “If you don’t get treatment for this problem, I am not going to be able to help you feel better” and that has been motivating for the patient.
There are other “prescriptions” to write. Regular sleep is essential for people with mood disorders, and this can be difficult for many patients, especially those who do shift work, or who have regular disruptions to their sleep from noise, pets, and children. Exercise is wonderful for the cardiovascular system, calms anxiety, and maintains strength, endurance, mobility, and quality of life as people age. But it can be a hard sell to people in a mental health crisis.
Nature is healing, and sunshine helps with maintaining circadian rhythms. For those who don’t exercise, I often “prescribe” 20 to 30 minutes a day of walking, preferably outside, during daylight hours, in a park or natural setting. For people with anxiety, it is important to check their caffeine consumption and to suggest ways to moderate it – moving to decaffeinated beverages or titrating down by mixing decaf with caffeinated.
Meditation is something that many people find helpful. For anxious people, it can be very difficult, and I will prescribe a specific instructional video course that I like on the well-being app InsightTimer – Sarah Blondin’s Learn How to Meditate in Seven Days. The sessions are approximately 10 minutes long, and that seems like the right amount of time for a beginner.
When people are very ill and don’t want to go into the hospital, I talk with them about things that happen in the hospital that are helpful, things they can try to mimic at home. In the hospital, patients don’t go to work, they don’t spend hours a day on the computer, and they are given a pass from dealing with the routine stresses of daily life.
I ask them to take time off work, to avoid as much stress as possible, to spend time with loved ones who give them comfort, and to avoid the people who leave them feeling drained or distressed. I ask them to engage in activities they find healing, to eat well, exercise, and avoid social media. In the hospital, I emphasize, they wake patients up in the morning, ask them to get out of bed and engage in therapeutic activities. They are fed and kept from intoxicants.
When it comes to nutrition, we know so little about how food affects mental health. I feel like it can’t hurt to ask people to avoid fast foods, soft drinks, and processed foods, and so I do.
And what about compliance? Of course, not everyone complies; not everyone is interested in making changes and these can be hard changes. I’ve recently started to recommend the book Atomic Habits by James Clear. Sometimes a bit of motivational interviewing can also be helpful in getting people to look at slowly moving toward making changes.
In prescribing lifestyle changes, it is important to offer most of these changes as suggestions, not as things we insist on, or that will leave the patient feeling ashamed if he doesn’t follow through. They should be discussed early in treatment so that patients don’t feel blamed for their illness or relapses. As with all the things we prescribe, some of these behavior changes help some of the people some of the time. Suggesting them, however, makes the strong statement that treating psychiatric disorders can be about more than passively swallowing a pill.
Dr. Miller is a coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice and is an assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, Baltimore. She disclosed no relevant conflicts of interest.
In psychiatry, patients come to us with their list of symptoms, often a diagnosis they’ve made themselves, and the expectation that they will be given medication to fix their problem. Their diagnoses are often right on target – people often know if they are depressed or anxious, and Doctor Google may provide useful information.
Sometimes they want a specific medication, one they saw in a TV ad, or one that helped them in the past or has helped someone they know. As psychiatrists have focused more on their strengths as psychopharmacologists and less on psychotherapy, it gets easy for both the patient and the doctor to look to medication, cocktails, and titration as the only thing we do.
“My medicine stopped working,” is a line I commonly hear. Often the patient is on a complicated regimen that has been serving them well, and it seems unlikely that the five psychotropic medications they are taking have suddenly “stopped working.” An obvious exception is the SSRI “poop out” that can occur 6-12 months or more after beginning treatment. In addition, it’s important to make sure patients are taking their medications as prescribed, and that the generic formulations have not changed.
But as rates of mental illness increase, some of it spurred on by difficult times,
This is not to devalue our medications, but to help the patient see symptoms as having multiple factors and give them some means to intervene, in addition to medications. At the beginning of therapy, it is important to “prescribe” lifestyle changes that will facilitate the best possible outcomes.
Nonpharmaceutical prescriptions
Early in my career, people with alcohol use problems were told they needed to be substance free before they were candidates for antidepressants. While we no longer do that, it is still important to emphasize abstinence from addictive substances, and to recommend specific treatment when necessary.
Patients are often reluctant to see their use of alcohol, marijuana (it’s medical! It’s part of wellness!), or their pain medications as part of the problem, and this can be difficult. There have been times, after multiple medications have failed to help their symptoms, when I have said, “If you don’t get treatment for this problem, I am not going to be able to help you feel better” and that has been motivating for the patient.
There are other “prescriptions” to write. Regular sleep is essential for people with mood disorders, and this can be difficult for many patients, especially those who do shift work, or who have regular disruptions to their sleep from noise, pets, and children. Exercise is wonderful for the cardiovascular system, calms anxiety, and maintains strength, endurance, mobility, and quality of life as people age. But it can be a hard sell to people in a mental health crisis.
Nature is healing, and sunshine helps with maintaining circadian rhythms. For those who don’t exercise, I often “prescribe” 20 to 30 minutes a day of walking, preferably outside, during daylight hours, in a park or natural setting. For people with anxiety, it is important to check their caffeine consumption and to suggest ways to moderate it – moving to decaffeinated beverages or titrating down by mixing decaf with caffeinated.
Meditation is something that many people find helpful. For anxious people, it can be very difficult, and I will prescribe a specific instructional video course that I like on the well-being app InsightTimer – Sarah Blondin’s Learn How to Meditate in Seven Days. The sessions are approximately 10 minutes long, and that seems like the right amount of time for a beginner.
When people are very ill and don’t want to go into the hospital, I talk with them about things that happen in the hospital that are helpful, things they can try to mimic at home. In the hospital, patients don’t go to work, they don’t spend hours a day on the computer, and they are given a pass from dealing with the routine stresses of daily life.
I ask them to take time off work, to avoid as much stress as possible, to spend time with loved ones who give them comfort, and to avoid the people who leave them feeling drained or distressed. I ask them to engage in activities they find healing, to eat well, exercise, and avoid social media. In the hospital, I emphasize, they wake patients up in the morning, ask them to get out of bed and engage in therapeutic activities. They are fed and kept from intoxicants.
When it comes to nutrition, we know so little about how food affects mental health. I feel like it can’t hurt to ask people to avoid fast foods, soft drinks, and processed foods, and so I do.
And what about compliance? Of course, not everyone complies; not everyone is interested in making changes and these can be hard changes. I’ve recently started to recommend the book Atomic Habits by James Clear. Sometimes a bit of motivational interviewing can also be helpful in getting people to look at slowly moving toward making changes.
In prescribing lifestyle changes, it is important to offer most of these changes as suggestions, not as things we insist on, or that will leave the patient feeling ashamed if he doesn’t follow through. They should be discussed early in treatment so that patients don’t feel blamed for their illness or relapses. As with all the things we prescribe, some of these behavior changes help some of the people some of the time. Suggesting them, however, makes the strong statement that treating psychiatric disorders can be about more than passively swallowing a pill.
Dr. Miller is a coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice and is an assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, Baltimore. She disclosed no relevant conflicts of interest.
Burnout among surgeons: Lessons for psychiatrists
Burnout is an occupational phenomenon and a syndrome resulting from unsuccessfully managed chronic workplace stress. The characteristic features of burnout include feelings of exhaustion, cynicism, and reduced professional efficacy.1 A career in surgery is associated with demanding and unpredictable work hours in a high-stress environment.2-8 Research indicates that surgeons are at an elevated risk for developing burnout and mental health problems that can compromise patient care. A survey of the fellows of the American College of Surgeons found that 40% of surgeons experience burnout, 30% experience symptoms of depression, and 28% have a mental quality of life (QOL) score greater than one-half an SD below the population norm.9,10 Surgeon burnout was also found to compromise the delivery of medical care.9,10
To prevent serious harm to surgeons and patients, it is critical to understand the causative factors of burnout among surgeons and how they can be addressed. We conducted this systematic review to identify factors linked to burnout across surgical specialties and to suggest ways to mitigate these risk factors.
Methods
To identify studies of burnout among surgeons, we conducted an electronic search of Ovid MEDLINE, Ovid PsycInfo, SCOPUS, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials. The headings and keywords used are listed in Supplemental Table 1. Studies met the inclusion criteria if they evaluated residents or attendings, used a tool to measure burnout, and examined any surgical specialty. Studies were excluded if they were published before 2010; were conducted outside the United States; were review articles, commentaries, or abstracts without full text articles; evaluated medical school students; were published in a language other than English; did not use a tool to measure burnout; or examined a nonsurgical specialty. Our analysis was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)11 and is outlined in the Supplemental Figure.
Results
Surgical specialties and burnout
We identified 56 studies2-10,12-58 that focused on specific surgical specialties in relation to burnout. Supplemental Table 22-10,12-58 lists these studies and the surgical specialties they evaluated.
Work/life balance factors
Fifteen studies
Work hours
Fifteen studies2,7,14,20,21,30,34,41,42,44-46,50,52,56 examined work hours and burnout. Of these, 142,7,14,20,21,30,34,42,44-46,50,52,56 found a correlation between increased work hours and burnout, while only 1 study41 found no correlation between these factors.
Medical errors
Six studies2,14,18,43,49,52 discussed the role of burnout in medical errors. Of these, 52,14,43,49,52 reported a correlation between burnout and medical errors, while 1 study18 found no link between burnout and medical errors. The medical errors were self-reported.14,49 They included actions that resulted in patient harm, sample collection error, and errors in medication orders and laboratory test orders.2
Continue to: Institutional and organizational factors
Institutional and organizational factors
Eighteen studies3,13,14,18,20,22,23,29,30,36-38,44,45,47,54,56,57 examined how different organizational factors play a role in burnout. Four studies3,13,20,37 discussed administrative/bureaucratic work, 420,45,54,57 mentioned electronic medical documentation, 222,30 covered duty hour regulations, 318,45,57 discussed mistreatment of physicians, and 613,18,23,44,47,56 described the importance of workplace support in addressing burnout.
Physical and mental health factors
Eighteen studies6,7,14,15,17,20,26,27,29,34,43,44,48,52,54,57-59 discussed aspects of physical and mental health linked to burnout. Among these, 334,43,59 discussed the importance of physical health and focused on how improving physical health can reduce stress and burnout. Three studies6,17,58 noted the prevalence of suicidal ideation in both residents and attendings experiencing prolonged burnout. Five studies26,29,43,44,48 described the systematic barriers that inhibit physicians from getting professional help. Two studies7,27 reported marital status as a factor for burnout; participants who were single reported higher levels of depression and suicidal ideation. Five studies6,14,15,54,57 outlined how depression is associated with burnout.
Strategies to mitigate burnout
Fifteen studies
Take-home points
Research that focused on work/life balance and burnout found excessive time commitment to work is a major factor associated with poor work/life balance. Residents who worked >80 hours a week had a significantly higher burnout rate.56 One study found that 70% of residents reported not getting enough sleep, 30% reported not having enough energy for relationships, and 39% reported that they were not eating or exercising due to time constraints.4 A high correlation was found between the number of hours worked per week and rates of burnout, emotional exhaustion, and depersonalization. Emotional exhaustion and depersonalization are aspects of burnout measured by the Maslach Burnout Inventory (MBI).24 The excessive time commitment to work not only contributes to burnout but also prevents physicians from getting professional help. In 1 study, both residents (56%) and attendings (24%) reported that 1 of the biggest barriers to getting help for their burnout symptoms was the inability to take time off.34 Research indicates that the hours worked per week and work/home conflicts were independently associated with burnout and career satisfaction.15 A decrease of weekly work hours may give physicians time to meet their responsibilities at work and home, allowing for a decrease in burnout and an increase in career satisfaction.
Increased work hours have also been found to be correlated with medical errors. One study found that those who worked 60 hours per week were significantly less likely to report any major medical errors in the previous 3 months compared with those who worked 80 hours per week.9 The risk for the number of medical errors has been reported as being 2-fold if surgeons are unable to combat the burnout.49 On the other hand, a positive and supportive environment with easy access to resources to combat burnout and burnout prevention programs can reduce the frequency of medical errors, which also can reduce the risk of malpractice, thus further reducing stress and burnout.43
Continue to: In response to resident complaints...
In response to resident complaints about long duty hours, a new rule has been implemented that states residents cannot work >16 hours per shift.30 This rule has been found to increase quality of life and prevent burnout.30
The amount of time spent on electronic medical records and documentation has been a major complaint from doctors and was identified as a factor contributing to burnout.45 It can act as a time drain that impedes the physician from providing optimal patient care and cause additional stress. This suggests the need for organizations to find solutions to minimize this strain.
A concerning issue reported as an institutional factor and associated with burnout is mistreatment through discrimination, harassment, and physical or verbal abuse. A recent study found 45% of general and vascular surgeons reported being mistreated in some fashion.57 The strategies reported as helpful for institutions to combat mistreatment include resilience training, improved mentorship, and implicit bias training.57
Burnout has been positively correlated with anxiety and depression.6 A recent study reported that 13% of orthopedic surgery residents screened positive for depression.44 Higher levels of burnout and depersonalization have been found to be closely associated with increased rates of suicidal ideation.17 In a study of vascular surgeons, 8% were found to report suicidal ideation, and this increased to 15% among vascular surgeons who had higher levels of depersonalization and emotional exhaustion,58 both of which are associated with burnout. In another study, surgery residents and fellows were found to have lower levels of personal achievement and higher levels of depersonalization, depressive symptoms, alcohol abuse, and suicidal ideation compared to attending physicians and the general population.54 These findings spell out the association between burnout and depressive symptoms among surgeons and emphasize the need for institutions to create a culture that supports the mental health needs of their physicians. Without access to supportive resources, residents resort to alternative methods that may be detrimental in the long run. In a recent study, 17% of residents admitted to using alcohol, including binge drinking, to cope with their stress.4
Burnout and depression are linked to physical health risks such as cardiovascular disease, diabetes, substance abuse, and male infertility.6 Exercise has been shown to be beneficial for stress reduction, which can lead to changes in metabolism, inflammation, coagulation, and autonomic function.6 One study of surgeons found aerobic exercise and strength training were associated with lower rates of burnout and a higher quality of life.59
Continue to: The amount of burnout physicians...
The amount of burnout physicians experience can be determined by how they respond to adversities. Adaptive behaviors such as socializing, mindfulness, volunteering, and exercising have been found to be protective against burnout.6,37,54 Resilience training and maintaining low stress at work can decrease burnout.37 These findings highlight the need for physicians to be trained in the appropriate ways to combat their burnout symptoms.
Unfortunately, seeking help by health care professionals to improve mental health has been stigmatized, causing physicians to not seek help and instead resort to other ways to cope with their distress.26,34 While some of these coping methods may be positive, others—such as substance abuse or stress eating—can be maladaptive, leading to a poor quality of life, and in some cases, suicide.54 It is vital that effective mental health services become more accessible and for health care professionals to become aware of their maladaptive behaviors.34
Institutions finding ways to ease the path for their physicians to seek professional help to combat burnout may mitigate its negative impact. One strategy is to embed access to mental health services within regular wellness checks. Institutions can use wellness checks to provide resources to physicians who need it. These interventions have been found to be effective because they give physicians a safe space to seek help and become aware of any factors that could lead to burnout.18 Apart from these direct attempts to combat burnout, program-sponsored social events would also promote social connectedness with colleagues and contribute to a sense of well-being that could help decrease levels of burnout and depression.13 Mentorship has been shown to play a crucial role in decreasing burnout among residents. One study that examined the role of mentorship reported that 55% of residents felt supported, and of these, 96% felt mentorship was critical to their success.18 The role of institutions in helping to improve the well-being of surgeons is highlighted by the finding that increasing workplace support results in psychological resilience that can mitigate burnout at its roots.29
Bottom Line
Surgeons are at risk for burnout, which can impact their mental health and reduce their professional efficacy. Both institutions and surgeons themselves can take action to prevent burnout and treat burnout early when it occurs.
Related Resources
- Pahal P, Lippmann S. Building a better work/life balance. Current Psychiatry. 2021;20(8):e1-e2. doi:10.12788/cp.0158
- Gibson R, Hategan A. Physician burnout vs depression: recognize the signs. Current Psychiatry. 2019;18(10):41-42.
1. World Health Organization. International Statistical Classification of Diseases and Related Health Problems (ICD). 11th ed. World Health Organization; 2019.
2. Coombs DM, Lanni MA, Fosnot J, et al. Professional burnout in United States plastic surgery residents: is it a legitimate concern? Aesthet Surg J. 2020;40(7):802-810.
3. Klimo P Jr, DeCuypere M, Ragel BT, et al. Career satisfaction and burnout among U.S. neurosurgeons: a feasibility and pilot study. World Neurosurg. 2013;80(5):e59-e68.
4. Ha GQ, Go JT, Murayama KM, et al. Identifying sources of stress across years of general surgery residency. Hawaii J Health Soc Welf. 2020;79(3):75-81.
5. Khalafallah AM, Lam S, Gami A, et al. A national survey on the impact of the COVID-19 pandemic upon burnout and career satisfaction among neurosurgery residents. J Clin Neurosci. 2020;80:137-142.
6. Al-Humadi SM, Cáceda R, Bronson B, et al. Orthopaedic surgeon mental health during the COVID-19 pandemic. Geriatric Orthop Surg Rehabil. 2021;12:21514593211035230.
7. Larson DP, Carlson ML, Lohse CM, et al. Prevalence of and associations with distress and professional burnout among otolaryngologists: part I, trainees. Otolaryngol Head Neck Surg. 2021;164(5):1019-1029.
8. Streu R, Hawley S, Gay A, et al. Satisfaction with career choice among U.S. plastic surgeons: results from a national survey. Plast Reconstr Surg. 2010;126(2):636-642.
9. Shanafelt TD, Balch CM, Bechamps GJ, et al. Burnout and career satisfaction among American surgeons. Ann Surg. 2009;250(3):463-471.
10. Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6):995-1000.
11. Moher D, Liberati A, Tetzlaff J, et al; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg. 2010;8(5):336-341.
12. Yesantharao P, Lee E, Kraenzlin F, et al. Surgical block time satisfaction: a multi-institutional experience across twelve surgical disciplines. Perioperative Care Operating Room Manage. 2020;21:100128.
13. Nituica C, Bota OA, Blebea J. Specialty differences in resident resilience and burnout - a national survey. Am J Surg. 2021;222(2):319-328.
14. Balch CM, Shanafelt TD, Dyrbye L, et al. Surgeon distress as calibrated by hours worked and nights on call. J Am Coll Surg. 2010;211(5):609-619.
15. Dyrbye LN, Shanafelt TD, Balch CM, Satele D, Sloan J, Freischlag J. Relationship between work-home conflicts and burnout among American surgeons: a comparison by sex. Arch Surg. 2011;146(2):211-217.
16. Mahoney ST, Irish W, Strassle PD, et al. Practice characteristics and job satisfaction of private practice and academic surgeons. JAMA Surg. 2021;156(3):247-254.
17. Shanafelt TD, Balch CM, Dyrbye L, et al. Special report: suicidal ideation among American surgeons. Arch Surg. 2011;146(1):54-62.
18. Chow OS, Sudarshan M, Maxfield MW, et al. National survey of burnout and distress among cardiothoracic surgery trainees. Ann Thorac Surg. 2021;111(6):2066-2071.
19. Lam C, Kim Y, Cruz M, et al. Burnout and resiliency in Mohs surgeons: a survey study. Int J Womens Dermatol. 2021;7(3):319-322.
20. Carlson ML, Larson DP, O’Brien EK, et al. Prevalence of and associations with distress and professional burnout among otolaryngologists: part II, attending physicians. Otolaryngol Head Neck Surg. 2021;164(5):1030-1039.
21. Nida AM, Googe BJ, Lewis AF, et al. Resident fatigue in otolaryngology residents: a Web based survey. Am J Otolaryngol. 2016;37(3):210-216.
22. Antiel RM, Reed DA, Van Arendonk KJ, et al. Effects of duty hour restrictions on core competencies, education, quality of life, and burnout among general surgery interns. JAMA Surg. 2013;148(5):448-455.
23. Appelbaum NP, Lee N, Amendola M, et al. Surgical resident burnout and job satisfaction: the role of workplace climate and perceived support. J Surg Res. 2019;234:20-25.
24. Elmore LC, Jeffe DB, Jin L, et al. National survey of burnout among US general surgery residents. J Am Coll Surg. 2016;223(3):440-451.
25. Garcia DI, Pannuccio A, Gallegos J, et al. Resident-driven wellness initiatives improve resident wellness and perception of work environment. J Surg Res. 2021;258:8-16.
26. Hochberg MS, Berman RS, Kalet AL, et al. The stress of residency: recognizing the signs of depression and suicide in you and your fellow residents. Am J Surg. 2013;205(2):141-146.
27. Kurbatov V, Shaughnessy M, Baratta V, et al. Application of advanced bioinformatics to understand and predict burnout among surgical trainees. J Surg Educ. 2020;77(3):499-507.
28. Leach PK, Nygaard RM, Chipman JG, et al. Impostor phenomenon and burnout in general surgeons and general surgery residents. J Surg Educ. 2019;76(1):99-106.
29. Lebares CC, Greenberg AL, Ascher NL, et al. Exploration of individual and system-level well-being initiatives at an academic surgical residency program: a mixed-methods study. JAMA Netw Open. 2021;4(1):e2032676.
30. Lindeman BM, Sacks BC, Hirose K, et al. Multifaceted longitudinal study of surgical resident education, quality of life, and patient care before and after July 2011. J Surg Educ. 2013;70(6):769-776.
31. Rasmussen JM, Najarian MM, Ties JS, et al. Career satisfaction, gender bias, and work-life balance: a contemporary assessment of general surgeons. J Surg Educ. 2021;78(1):119-125.
32. Smeds MR, Janko MR, Allen S, et al. Burnout and its relationship with perceived stress, self-efficacy, depression, social support, and programmatic factors in general surgery residents. Am J Surg. 2020;219(6):907-912.
33. Wetzel CM, George A, Hanna GB, et al. Stress management training for surgeons--a randomized, controlled, intervention study. Ann Surg. 2011;253(3):488-494.
34. Williford ML, Scarlet S, Meyers MO, et al. Multiple-institution comparison of resident and faculty perceptions of burnout and depression during surgical training. JAMA Surg. 2018;153(8):705-711.
35. Zubair MH, Hussain LR, Williams KN, et al. Work-related quality of life of US general surgery residents: is it really so bad? J Surg Educ. 2017;74(6):e138-e146.
36. Song Y, Swendiman RA, Shannon AB, et al. Can we coach resilience? An evaluation of professional resilience coaching as a well-being initiative for surgical interns. J Surg Educ. 2020;77(6):1481-1489.
37. Morrell NT, Sears ED, Desai MJ, et al. A survey of burnout among members of the American Society for Surgery of the Hand. J Hand Surg Am. 2020;45(7):573-581.e516.
38. Khalafallah AM, Lam S, Gami A, et al. Burnout and career satisfaction among attending neurosurgeons during the COVID-19 pandemic. Clin Neurol Neurosurg. 2020;198:106193.
39. McAbee JH, Ragel BT, McCartney S, et al. Factors associated with career satisfaction and burnout among US neurosurgeons: results of a nationwide survey. J Neurosurg. 2015;123(1):161-173.
40. Shakir HJ, McPheeters MJ, Shallwani H, et al. The prevalence of burnout among US neurosurgery residents. Neurosurgery. 2018;83(3):582-590.
41. Govardhan LM, Pinelli V, Schnatz PF. Burnout, depression and job satisfaction in obstetrics and gynecology residents. Conn Med. 2012;76(7):389-395.
42. Driesman AS, Strauss EJ, Konda SR, et al. Factors associated with orthopaedic resident burnout: a pilot study. J Am Acad Orthop Surg. 2020;28(21):900-906.
43. Lichstein PM, He JK, Estok D, et al. What is the prevalence of burnout, depression, and substance use among orthopaedic surgery residents and what are the risk factors? A collaborative orthopaedic educational research group survey study. Clin Orthop Relat Res. 2020;478(8):1709-1718.
44. Somerson JS, Patton A, Ahmed AA, et al. Burnout among United States orthopaedic surgery residents. J Surg Educ. 2020;77(4):961-968.
45. Verret CI, Nguyen J, Verret C, et al. How do areas of work life drive burnout in orthopaedic attending surgeons, fellows, and residents? Clin Orthop Relat Res. 2021;479(2):251-262.
46. Sarosi A, Coakley BA, Berman L, et al. A cross-sectional analysis of compassion fatigue, burnout, and compassion satisfaction in pediatric surgeons in the U.S. J Pediatr Surg. 2021;56(8):1276-1284.
47. Crowe CS, Lopez J, Morrison SD, et al. The effects of the COVID-19 pandemic on resident education and wellness: a national survey of plastic surgery residents. Plast Reconstr Surg. 2021;148(3):462e-474e.
48. Qureshi HA, Rawlani R, Mioton LM, et al. Burnout phenomenon in U.S. plastic surgeons: risk factors and impact on quality of life. Plast Reconstr Surg. 2015;135(2):619-626.
49. Streu R, Hansen J, Abrahamse P, et al. Professional burnout among US plastic surgeons: results of a national survey. Ann Plast Surg. 2014;72(3):346-350.
50. Zhang JQ, Riba L, Magrini L, ET AL. Assessing burnout and professional fulfillment in breast surgery: results from a national survey of the American Society of Breast Surgeons. Ann Surg Oncol. 2019;26(10):3089-3098.
51. Balch CM, Shanafelt TD, Sloan J, et al. Burnout and career satisfaction among surgical oncologists compared with other surgical specialties. Ann Surg Oncol. 2011;18(1):16-25.
52. Wu D, Gross B, Rittenhouse K, et al. A preliminary analysis of compassion fatigue in a surgeon population: are female surgeons at heightened risk? Am Surg. 2017;83(11):1302-1307.
53. Cheng JW, Wagner H, Hernandez BC, et al. Stressors and coping mechanisms related to burnout within urology. Urology. 2020;139:27-36.
54. Koo K, Javier-DesLoges JF, Fang R, ET AL. Professional burnout, career choice regret, and unmet needs for well-being among urology residents. Urology. 2021;157:57-63.
55. Janko MR, Smeds MR. Burnout, depression, perceived stress, and self-efficacy in vascular surgery trainees. J Vasc Surg. 2019;69(4):1233-1242.
56. Coleman DM, Money SR, Meltzer AJ, et al. Vascular surgeon wellness and burnout: a report from the Society for Vascular Surgery Wellness Task Force. J Vasc Surg. 2021;73(6):1841-1850.e3.
57. Barrack RL, Miller LS, Sotile WM, et al. Effect of duty hour standards on burnout among orthopaedic surgery residents. Clin Orthop Relat Res. 2006;449:134-137.
58. Chia MC, Hu YY, Li RD, et al. Prevalence and risk factors for burnout in U.S. vascular surgery trainees. J Vasc Surg. 2022;75(1):308-315.e4.
59. Shanafelt TD, Oreskovich MR, Dyrbye LN, et al. Avoiding burnout: the personal health habits and wellness practices of US surgeons. Ann Surg. 2012;255(4):625-633.
Burnout is an occupational phenomenon and a syndrome resulting from unsuccessfully managed chronic workplace stress. The characteristic features of burnout include feelings of exhaustion, cynicism, and reduced professional efficacy.1 A career in surgery is associated with demanding and unpredictable work hours in a high-stress environment.2-8 Research indicates that surgeons are at an elevated risk for developing burnout and mental health problems that can compromise patient care. A survey of the fellows of the American College of Surgeons found that 40% of surgeons experience burnout, 30% experience symptoms of depression, and 28% have a mental quality of life (QOL) score greater than one-half an SD below the population norm.9,10 Surgeon burnout was also found to compromise the delivery of medical care.9,10
To prevent serious harm to surgeons and patients, it is critical to understand the causative factors of burnout among surgeons and how they can be addressed. We conducted this systematic review to identify factors linked to burnout across surgical specialties and to suggest ways to mitigate these risk factors.
Methods
To identify studies of burnout among surgeons, we conducted an electronic search of Ovid MEDLINE, Ovid PsycInfo, SCOPUS, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials. The headings and keywords used are listed in Supplemental Table 1. Studies met the inclusion criteria if they evaluated residents or attendings, used a tool to measure burnout, and examined any surgical specialty. Studies were excluded if they were published before 2010; were conducted outside the United States; were review articles, commentaries, or abstracts without full text articles; evaluated medical school students; were published in a language other than English; did not use a tool to measure burnout; or examined a nonsurgical specialty. Our analysis was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)11 and is outlined in the Supplemental Figure.
Results
Surgical specialties and burnout
We identified 56 studies2-10,12-58 that focused on specific surgical specialties in relation to burnout. Supplemental Table 22-10,12-58 lists these studies and the surgical specialties they evaluated.
Work/life balance factors
Fifteen studies
Work hours
Fifteen studies2,7,14,20,21,30,34,41,42,44-46,50,52,56 examined work hours and burnout. Of these, 142,7,14,20,21,30,34,42,44-46,50,52,56 found a correlation between increased work hours and burnout, while only 1 study41 found no correlation between these factors.
Medical errors
Six studies2,14,18,43,49,52 discussed the role of burnout in medical errors. Of these, 52,14,43,49,52 reported a correlation between burnout and medical errors, while 1 study18 found no link between burnout and medical errors. The medical errors were self-reported.14,49 They included actions that resulted in patient harm, sample collection error, and errors in medication orders and laboratory test orders.2
Continue to: Institutional and organizational factors
Institutional and organizational factors
Eighteen studies3,13,14,18,20,22,23,29,30,36-38,44,45,47,54,56,57 examined how different organizational factors play a role in burnout. Four studies3,13,20,37 discussed administrative/bureaucratic work, 420,45,54,57 mentioned electronic medical documentation, 222,30 covered duty hour regulations, 318,45,57 discussed mistreatment of physicians, and 613,18,23,44,47,56 described the importance of workplace support in addressing burnout.
Physical and mental health factors
Eighteen studies6,7,14,15,17,20,26,27,29,34,43,44,48,52,54,57-59 discussed aspects of physical and mental health linked to burnout. Among these, 334,43,59 discussed the importance of physical health and focused on how improving physical health can reduce stress and burnout. Three studies6,17,58 noted the prevalence of suicidal ideation in both residents and attendings experiencing prolonged burnout. Five studies26,29,43,44,48 described the systematic barriers that inhibit physicians from getting professional help. Two studies7,27 reported marital status as a factor for burnout; participants who were single reported higher levels of depression and suicidal ideation. Five studies6,14,15,54,57 outlined how depression is associated with burnout.
Strategies to mitigate burnout
Fifteen studies
Take-home points
Research that focused on work/life balance and burnout found excessive time commitment to work is a major factor associated with poor work/life balance. Residents who worked >80 hours a week had a significantly higher burnout rate.56 One study found that 70% of residents reported not getting enough sleep, 30% reported not having enough energy for relationships, and 39% reported that they were not eating or exercising due to time constraints.4 A high correlation was found between the number of hours worked per week and rates of burnout, emotional exhaustion, and depersonalization. Emotional exhaustion and depersonalization are aspects of burnout measured by the Maslach Burnout Inventory (MBI).24 The excessive time commitment to work not only contributes to burnout but also prevents physicians from getting professional help. In 1 study, both residents (56%) and attendings (24%) reported that 1 of the biggest barriers to getting help for their burnout symptoms was the inability to take time off.34 Research indicates that the hours worked per week and work/home conflicts were independently associated with burnout and career satisfaction.15 A decrease of weekly work hours may give physicians time to meet their responsibilities at work and home, allowing for a decrease in burnout and an increase in career satisfaction.
Increased work hours have also been found to be correlated with medical errors. One study found that those who worked 60 hours per week were significantly less likely to report any major medical errors in the previous 3 months compared with those who worked 80 hours per week.9 The risk for the number of medical errors has been reported as being 2-fold if surgeons are unable to combat the burnout.49 On the other hand, a positive and supportive environment with easy access to resources to combat burnout and burnout prevention programs can reduce the frequency of medical errors, which also can reduce the risk of malpractice, thus further reducing stress and burnout.43
Continue to: In response to resident complaints...
In response to resident complaints about long duty hours, a new rule has been implemented that states residents cannot work >16 hours per shift.30 This rule has been found to increase quality of life and prevent burnout.30
The amount of time spent on electronic medical records and documentation has been a major complaint from doctors and was identified as a factor contributing to burnout.45 It can act as a time drain that impedes the physician from providing optimal patient care and cause additional stress. This suggests the need for organizations to find solutions to minimize this strain.
A concerning issue reported as an institutional factor and associated with burnout is mistreatment through discrimination, harassment, and physical or verbal abuse. A recent study found 45% of general and vascular surgeons reported being mistreated in some fashion.57 The strategies reported as helpful for institutions to combat mistreatment include resilience training, improved mentorship, and implicit bias training.57
Burnout has been positively correlated with anxiety and depression.6 A recent study reported that 13% of orthopedic surgery residents screened positive for depression.44 Higher levels of burnout and depersonalization have been found to be closely associated with increased rates of suicidal ideation.17 In a study of vascular surgeons, 8% were found to report suicidal ideation, and this increased to 15% among vascular surgeons who had higher levels of depersonalization and emotional exhaustion,58 both of which are associated with burnout. In another study, surgery residents and fellows were found to have lower levels of personal achievement and higher levels of depersonalization, depressive symptoms, alcohol abuse, and suicidal ideation compared to attending physicians and the general population.54 These findings spell out the association between burnout and depressive symptoms among surgeons and emphasize the need for institutions to create a culture that supports the mental health needs of their physicians. Without access to supportive resources, residents resort to alternative methods that may be detrimental in the long run. In a recent study, 17% of residents admitted to using alcohol, including binge drinking, to cope with their stress.4
Burnout and depression are linked to physical health risks such as cardiovascular disease, diabetes, substance abuse, and male infertility.6 Exercise has been shown to be beneficial for stress reduction, which can lead to changes in metabolism, inflammation, coagulation, and autonomic function.6 One study of surgeons found aerobic exercise and strength training were associated with lower rates of burnout and a higher quality of life.59
Continue to: The amount of burnout physicians...
The amount of burnout physicians experience can be determined by how they respond to adversities. Adaptive behaviors such as socializing, mindfulness, volunteering, and exercising have been found to be protective against burnout.6,37,54 Resilience training and maintaining low stress at work can decrease burnout.37 These findings highlight the need for physicians to be trained in the appropriate ways to combat their burnout symptoms.
Unfortunately, seeking help by health care professionals to improve mental health has been stigmatized, causing physicians to not seek help and instead resort to other ways to cope with their distress.26,34 While some of these coping methods may be positive, others—such as substance abuse or stress eating—can be maladaptive, leading to a poor quality of life, and in some cases, suicide.54 It is vital that effective mental health services become more accessible and for health care professionals to become aware of their maladaptive behaviors.34
Institutions finding ways to ease the path for their physicians to seek professional help to combat burnout may mitigate its negative impact. One strategy is to embed access to mental health services within regular wellness checks. Institutions can use wellness checks to provide resources to physicians who need it. These interventions have been found to be effective because they give physicians a safe space to seek help and become aware of any factors that could lead to burnout.18 Apart from these direct attempts to combat burnout, program-sponsored social events would also promote social connectedness with colleagues and contribute to a sense of well-being that could help decrease levels of burnout and depression.13 Mentorship has been shown to play a crucial role in decreasing burnout among residents. One study that examined the role of mentorship reported that 55% of residents felt supported, and of these, 96% felt mentorship was critical to their success.18 The role of institutions in helping to improve the well-being of surgeons is highlighted by the finding that increasing workplace support results in psychological resilience that can mitigate burnout at its roots.29
Bottom Line
Surgeons are at risk for burnout, which can impact their mental health and reduce their professional efficacy. Both institutions and surgeons themselves can take action to prevent burnout and treat burnout early when it occurs.
Related Resources
- Pahal P, Lippmann S. Building a better work/life balance. Current Psychiatry. 2021;20(8):e1-e2. doi:10.12788/cp.0158
- Gibson R, Hategan A. Physician burnout vs depression: recognize the signs. Current Psychiatry. 2019;18(10):41-42.
Burnout is an occupational phenomenon and a syndrome resulting from unsuccessfully managed chronic workplace stress. The characteristic features of burnout include feelings of exhaustion, cynicism, and reduced professional efficacy.1 A career in surgery is associated with demanding and unpredictable work hours in a high-stress environment.2-8 Research indicates that surgeons are at an elevated risk for developing burnout and mental health problems that can compromise patient care. A survey of the fellows of the American College of Surgeons found that 40% of surgeons experience burnout, 30% experience symptoms of depression, and 28% have a mental quality of life (QOL) score greater than one-half an SD below the population norm.9,10 Surgeon burnout was also found to compromise the delivery of medical care.9,10
To prevent serious harm to surgeons and patients, it is critical to understand the causative factors of burnout among surgeons and how they can be addressed. We conducted this systematic review to identify factors linked to burnout across surgical specialties and to suggest ways to mitigate these risk factors.
Methods
To identify studies of burnout among surgeons, we conducted an electronic search of Ovid MEDLINE, Ovid PsycInfo, SCOPUS, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials. The headings and keywords used are listed in Supplemental Table 1. Studies met the inclusion criteria if they evaluated residents or attendings, used a tool to measure burnout, and examined any surgical specialty. Studies were excluded if they were published before 2010; were conducted outside the United States; were review articles, commentaries, or abstracts without full text articles; evaluated medical school students; were published in a language other than English; did not use a tool to measure burnout; or examined a nonsurgical specialty. Our analysis was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)11 and is outlined in the Supplemental Figure.
Results
Surgical specialties and burnout
We identified 56 studies2-10,12-58 that focused on specific surgical specialties in relation to burnout. Supplemental Table 22-10,12-58 lists these studies and the surgical specialties they evaluated.
Work/life balance factors
Fifteen studies
Work hours
Fifteen studies2,7,14,20,21,30,34,41,42,44-46,50,52,56 examined work hours and burnout. Of these, 142,7,14,20,21,30,34,42,44-46,50,52,56 found a correlation between increased work hours and burnout, while only 1 study41 found no correlation between these factors.
Medical errors
Six studies2,14,18,43,49,52 discussed the role of burnout in medical errors. Of these, 52,14,43,49,52 reported a correlation between burnout and medical errors, while 1 study18 found no link between burnout and medical errors. The medical errors were self-reported.14,49 They included actions that resulted in patient harm, sample collection error, and errors in medication orders and laboratory test orders.2
Continue to: Institutional and organizational factors
Institutional and organizational factors
Eighteen studies3,13,14,18,20,22,23,29,30,36-38,44,45,47,54,56,57 examined how different organizational factors play a role in burnout. Four studies3,13,20,37 discussed administrative/bureaucratic work, 420,45,54,57 mentioned electronic medical documentation, 222,30 covered duty hour regulations, 318,45,57 discussed mistreatment of physicians, and 613,18,23,44,47,56 described the importance of workplace support in addressing burnout.
Physical and mental health factors
Eighteen studies6,7,14,15,17,20,26,27,29,34,43,44,48,52,54,57-59 discussed aspects of physical and mental health linked to burnout. Among these, 334,43,59 discussed the importance of physical health and focused on how improving physical health can reduce stress and burnout. Three studies6,17,58 noted the prevalence of suicidal ideation in both residents and attendings experiencing prolonged burnout. Five studies26,29,43,44,48 described the systematic barriers that inhibit physicians from getting professional help. Two studies7,27 reported marital status as a factor for burnout; participants who were single reported higher levels of depression and suicidal ideation. Five studies6,14,15,54,57 outlined how depression is associated with burnout.
Strategies to mitigate burnout
Fifteen studies
Take-home points
Research that focused on work/life balance and burnout found excessive time commitment to work is a major factor associated with poor work/life balance. Residents who worked >80 hours a week had a significantly higher burnout rate.56 One study found that 70% of residents reported not getting enough sleep, 30% reported not having enough energy for relationships, and 39% reported that they were not eating or exercising due to time constraints.4 A high correlation was found between the number of hours worked per week and rates of burnout, emotional exhaustion, and depersonalization. Emotional exhaustion and depersonalization are aspects of burnout measured by the Maslach Burnout Inventory (MBI).24 The excessive time commitment to work not only contributes to burnout but also prevents physicians from getting professional help. In 1 study, both residents (56%) and attendings (24%) reported that 1 of the biggest barriers to getting help for their burnout symptoms was the inability to take time off.34 Research indicates that the hours worked per week and work/home conflicts were independently associated with burnout and career satisfaction.15 A decrease of weekly work hours may give physicians time to meet their responsibilities at work and home, allowing for a decrease in burnout and an increase in career satisfaction.
Increased work hours have also been found to be correlated with medical errors. One study found that those who worked 60 hours per week were significantly less likely to report any major medical errors in the previous 3 months compared with those who worked 80 hours per week.9 The risk for the number of medical errors has been reported as being 2-fold if surgeons are unable to combat the burnout.49 On the other hand, a positive and supportive environment with easy access to resources to combat burnout and burnout prevention programs can reduce the frequency of medical errors, which also can reduce the risk of malpractice, thus further reducing stress and burnout.43
Continue to: In response to resident complaints...
In response to resident complaints about long duty hours, a new rule has been implemented that states residents cannot work >16 hours per shift.30 This rule has been found to increase quality of life and prevent burnout.30
The amount of time spent on electronic medical records and documentation has been a major complaint from doctors and was identified as a factor contributing to burnout.45 It can act as a time drain that impedes the physician from providing optimal patient care and cause additional stress. This suggests the need for organizations to find solutions to minimize this strain.
A concerning issue reported as an institutional factor and associated with burnout is mistreatment through discrimination, harassment, and physical or verbal abuse. A recent study found 45% of general and vascular surgeons reported being mistreated in some fashion.57 The strategies reported as helpful for institutions to combat mistreatment include resilience training, improved mentorship, and implicit bias training.57
Burnout has been positively correlated with anxiety and depression.6 A recent study reported that 13% of orthopedic surgery residents screened positive for depression.44 Higher levels of burnout and depersonalization have been found to be closely associated with increased rates of suicidal ideation.17 In a study of vascular surgeons, 8% were found to report suicidal ideation, and this increased to 15% among vascular surgeons who had higher levels of depersonalization and emotional exhaustion,58 both of which are associated with burnout. In another study, surgery residents and fellows were found to have lower levels of personal achievement and higher levels of depersonalization, depressive symptoms, alcohol abuse, and suicidal ideation compared to attending physicians and the general population.54 These findings spell out the association between burnout and depressive symptoms among surgeons and emphasize the need for institutions to create a culture that supports the mental health needs of their physicians. Without access to supportive resources, residents resort to alternative methods that may be detrimental in the long run. In a recent study, 17% of residents admitted to using alcohol, including binge drinking, to cope with their stress.4
Burnout and depression are linked to physical health risks such as cardiovascular disease, diabetes, substance abuse, and male infertility.6 Exercise has been shown to be beneficial for stress reduction, which can lead to changes in metabolism, inflammation, coagulation, and autonomic function.6 One study of surgeons found aerobic exercise and strength training were associated with lower rates of burnout and a higher quality of life.59
Continue to: The amount of burnout physicians...
The amount of burnout physicians experience can be determined by how they respond to adversities. Adaptive behaviors such as socializing, mindfulness, volunteering, and exercising have been found to be protective against burnout.6,37,54 Resilience training and maintaining low stress at work can decrease burnout.37 These findings highlight the need for physicians to be trained in the appropriate ways to combat their burnout symptoms.
Unfortunately, seeking help by health care professionals to improve mental health has been stigmatized, causing physicians to not seek help and instead resort to other ways to cope with their distress.26,34 While some of these coping methods may be positive, others—such as substance abuse or stress eating—can be maladaptive, leading to a poor quality of life, and in some cases, suicide.54 It is vital that effective mental health services become more accessible and for health care professionals to become aware of their maladaptive behaviors.34
Institutions finding ways to ease the path for their physicians to seek professional help to combat burnout may mitigate its negative impact. One strategy is to embed access to mental health services within regular wellness checks. Institutions can use wellness checks to provide resources to physicians who need it. These interventions have been found to be effective because they give physicians a safe space to seek help and become aware of any factors that could lead to burnout.18 Apart from these direct attempts to combat burnout, program-sponsored social events would also promote social connectedness with colleagues and contribute to a sense of well-being that could help decrease levels of burnout and depression.13 Mentorship has been shown to play a crucial role in decreasing burnout among residents. One study that examined the role of mentorship reported that 55% of residents felt supported, and of these, 96% felt mentorship was critical to their success.18 The role of institutions in helping to improve the well-being of surgeons is highlighted by the finding that increasing workplace support results in psychological resilience that can mitigate burnout at its roots.29
Bottom Line
Surgeons are at risk for burnout, which can impact their mental health and reduce their professional efficacy. Both institutions and surgeons themselves can take action to prevent burnout and treat burnout early when it occurs.
Related Resources
- Pahal P, Lippmann S. Building a better work/life balance. Current Psychiatry. 2021;20(8):e1-e2. doi:10.12788/cp.0158
- Gibson R, Hategan A. Physician burnout vs depression: recognize the signs. Current Psychiatry. 2019;18(10):41-42.
1. World Health Organization. International Statistical Classification of Diseases and Related Health Problems (ICD). 11th ed. World Health Organization; 2019.
2. Coombs DM, Lanni MA, Fosnot J, et al. Professional burnout in United States plastic surgery residents: is it a legitimate concern? Aesthet Surg J. 2020;40(7):802-810.
3. Klimo P Jr, DeCuypere M, Ragel BT, et al. Career satisfaction and burnout among U.S. neurosurgeons: a feasibility and pilot study. World Neurosurg. 2013;80(5):e59-e68.
4. Ha GQ, Go JT, Murayama KM, et al. Identifying sources of stress across years of general surgery residency. Hawaii J Health Soc Welf. 2020;79(3):75-81.
5. Khalafallah AM, Lam S, Gami A, et al. A national survey on the impact of the COVID-19 pandemic upon burnout and career satisfaction among neurosurgery residents. J Clin Neurosci. 2020;80:137-142.
6. Al-Humadi SM, Cáceda R, Bronson B, et al. Orthopaedic surgeon mental health during the COVID-19 pandemic. Geriatric Orthop Surg Rehabil. 2021;12:21514593211035230.
7. Larson DP, Carlson ML, Lohse CM, et al. Prevalence of and associations with distress and professional burnout among otolaryngologists: part I, trainees. Otolaryngol Head Neck Surg. 2021;164(5):1019-1029.
8. Streu R, Hawley S, Gay A, et al. Satisfaction with career choice among U.S. plastic surgeons: results from a national survey. Plast Reconstr Surg. 2010;126(2):636-642.
9. Shanafelt TD, Balch CM, Bechamps GJ, et al. Burnout and career satisfaction among American surgeons. Ann Surg. 2009;250(3):463-471.
10. Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6):995-1000.
11. Moher D, Liberati A, Tetzlaff J, et al; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg. 2010;8(5):336-341.
12. Yesantharao P, Lee E, Kraenzlin F, et al. Surgical block time satisfaction: a multi-institutional experience across twelve surgical disciplines. Perioperative Care Operating Room Manage. 2020;21:100128.
13. Nituica C, Bota OA, Blebea J. Specialty differences in resident resilience and burnout - a national survey. Am J Surg. 2021;222(2):319-328.
14. Balch CM, Shanafelt TD, Dyrbye L, et al. Surgeon distress as calibrated by hours worked and nights on call. J Am Coll Surg. 2010;211(5):609-619.
15. Dyrbye LN, Shanafelt TD, Balch CM, Satele D, Sloan J, Freischlag J. Relationship between work-home conflicts and burnout among American surgeons: a comparison by sex. Arch Surg. 2011;146(2):211-217.
16. Mahoney ST, Irish W, Strassle PD, et al. Practice characteristics and job satisfaction of private practice and academic surgeons. JAMA Surg. 2021;156(3):247-254.
17. Shanafelt TD, Balch CM, Dyrbye L, et al. Special report: suicidal ideation among American surgeons. Arch Surg. 2011;146(1):54-62.
18. Chow OS, Sudarshan M, Maxfield MW, et al. National survey of burnout and distress among cardiothoracic surgery trainees. Ann Thorac Surg. 2021;111(6):2066-2071.
19. Lam C, Kim Y, Cruz M, et al. Burnout and resiliency in Mohs surgeons: a survey study. Int J Womens Dermatol. 2021;7(3):319-322.
20. Carlson ML, Larson DP, O’Brien EK, et al. Prevalence of and associations with distress and professional burnout among otolaryngologists: part II, attending physicians. Otolaryngol Head Neck Surg. 2021;164(5):1030-1039.
21. Nida AM, Googe BJ, Lewis AF, et al. Resident fatigue in otolaryngology residents: a Web based survey. Am J Otolaryngol. 2016;37(3):210-216.
22. Antiel RM, Reed DA, Van Arendonk KJ, et al. Effects of duty hour restrictions on core competencies, education, quality of life, and burnout among general surgery interns. JAMA Surg. 2013;148(5):448-455.
23. Appelbaum NP, Lee N, Amendola M, et al. Surgical resident burnout and job satisfaction: the role of workplace climate and perceived support. J Surg Res. 2019;234:20-25.
24. Elmore LC, Jeffe DB, Jin L, et al. National survey of burnout among US general surgery residents. J Am Coll Surg. 2016;223(3):440-451.
25. Garcia DI, Pannuccio A, Gallegos J, et al. Resident-driven wellness initiatives improve resident wellness and perception of work environment. J Surg Res. 2021;258:8-16.
26. Hochberg MS, Berman RS, Kalet AL, et al. The stress of residency: recognizing the signs of depression and suicide in you and your fellow residents. Am J Surg. 2013;205(2):141-146.
27. Kurbatov V, Shaughnessy M, Baratta V, et al. Application of advanced bioinformatics to understand and predict burnout among surgical trainees. J Surg Educ. 2020;77(3):499-507.
28. Leach PK, Nygaard RM, Chipman JG, et al. Impostor phenomenon and burnout in general surgeons and general surgery residents. J Surg Educ. 2019;76(1):99-106.
29. Lebares CC, Greenberg AL, Ascher NL, et al. Exploration of individual and system-level well-being initiatives at an academic surgical residency program: a mixed-methods study. JAMA Netw Open. 2021;4(1):e2032676.
30. Lindeman BM, Sacks BC, Hirose K, et al. Multifaceted longitudinal study of surgical resident education, quality of life, and patient care before and after July 2011. J Surg Educ. 2013;70(6):769-776.
31. Rasmussen JM, Najarian MM, Ties JS, et al. Career satisfaction, gender bias, and work-life balance: a contemporary assessment of general surgeons. J Surg Educ. 2021;78(1):119-125.
32. Smeds MR, Janko MR, Allen S, et al. Burnout and its relationship with perceived stress, self-efficacy, depression, social support, and programmatic factors in general surgery residents. Am J Surg. 2020;219(6):907-912.
33. Wetzel CM, George A, Hanna GB, et al. Stress management training for surgeons--a randomized, controlled, intervention study. Ann Surg. 2011;253(3):488-494.
34. Williford ML, Scarlet S, Meyers MO, et al. Multiple-institution comparison of resident and faculty perceptions of burnout and depression during surgical training. JAMA Surg. 2018;153(8):705-711.
35. Zubair MH, Hussain LR, Williams KN, et al. Work-related quality of life of US general surgery residents: is it really so bad? J Surg Educ. 2017;74(6):e138-e146.
36. Song Y, Swendiman RA, Shannon AB, et al. Can we coach resilience? An evaluation of professional resilience coaching as a well-being initiative for surgical interns. J Surg Educ. 2020;77(6):1481-1489.
37. Morrell NT, Sears ED, Desai MJ, et al. A survey of burnout among members of the American Society for Surgery of the Hand. J Hand Surg Am. 2020;45(7):573-581.e516.
38. Khalafallah AM, Lam S, Gami A, et al. Burnout and career satisfaction among attending neurosurgeons during the COVID-19 pandemic. Clin Neurol Neurosurg. 2020;198:106193.
39. McAbee JH, Ragel BT, McCartney S, et al. Factors associated with career satisfaction and burnout among US neurosurgeons: results of a nationwide survey. J Neurosurg. 2015;123(1):161-173.
40. Shakir HJ, McPheeters MJ, Shallwani H, et al. The prevalence of burnout among US neurosurgery residents. Neurosurgery. 2018;83(3):582-590.
41. Govardhan LM, Pinelli V, Schnatz PF. Burnout, depression and job satisfaction in obstetrics and gynecology residents. Conn Med. 2012;76(7):389-395.
42. Driesman AS, Strauss EJ, Konda SR, et al. Factors associated with orthopaedic resident burnout: a pilot study. J Am Acad Orthop Surg. 2020;28(21):900-906.
43. Lichstein PM, He JK, Estok D, et al. What is the prevalence of burnout, depression, and substance use among orthopaedic surgery residents and what are the risk factors? A collaborative orthopaedic educational research group survey study. Clin Orthop Relat Res. 2020;478(8):1709-1718.
44. Somerson JS, Patton A, Ahmed AA, et al. Burnout among United States orthopaedic surgery residents. J Surg Educ. 2020;77(4):961-968.
45. Verret CI, Nguyen J, Verret C, et al. How do areas of work life drive burnout in orthopaedic attending surgeons, fellows, and residents? Clin Orthop Relat Res. 2021;479(2):251-262.
46. Sarosi A, Coakley BA, Berman L, et al. A cross-sectional analysis of compassion fatigue, burnout, and compassion satisfaction in pediatric surgeons in the U.S. J Pediatr Surg. 2021;56(8):1276-1284.
47. Crowe CS, Lopez J, Morrison SD, et al. The effects of the COVID-19 pandemic on resident education and wellness: a national survey of plastic surgery residents. Plast Reconstr Surg. 2021;148(3):462e-474e.
48. Qureshi HA, Rawlani R, Mioton LM, et al. Burnout phenomenon in U.S. plastic surgeons: risk factors and impact on quality of life. Plast Reconstr Surg. 2015;135(2):619-626.
49. Streu R, Hansen J, Abrahamse P, et al. Professional burnout among US plastic surgeons: results of a national survey. Ann Plast Surg. 2014;72(3):346-350.
50. Zhang JQ, Riba L, Magrini L, ET AL. Assessing burnout and professional fulfillment in breast surgery: results from a national survey of the American Society of Breast Surgeons. Ann Surg Oncol. 2019;26(10):3089-3098.
51. Balch CM, Shanafelt TD, Sloan J, et al. Burnout and career satisfaction among surgical oncologists compared with other surgical specialties. Ann Surg Oncol. 2011;18(1):16-25.
52. Wu D, Gross B, Rittenhouse K, et al. A preliminary analysis of compassion fatigue in a surgeon population: are female surgeons at heightened risk? Am Surg. 2017;83(11):1302-1307.
53. Cheng JW, Wagner H, Hernandez BC, et al. Stressors and coping mechanisms related to burnout within urology. Urology. 2020;139:27-36.
54. Koo K, Javier-DesLoges JF, Fang R, ET AL. Professional burnout, career choice regret, and unmet needs for well-being among urology residents. Urology. 2021;157:57-63.
55. Janko MR, Smeds MR. Burnout, depression, perceived stress, and self-efficacy in vascular surgery trainees. J Vasc Surg. 2019;69(4):1233-1242.
56. Coleman DM, Money SR, Meltzer AJ, et al. Vascular surgeon wellness and burnout: a report from the Society for Vascular Surgery Wellness Task Force. J Vasc Surg. 2021;73(6):1841-1850.e3.
57. Barrack RL, Miller LS, Sotile WM, et al. Effect of duty hour standards on burnout among orthopaedic surgery residents. Clin Orthop Relat Res. 2006;449:134-137.
58. Chia MC, Hu YY, Li RD, et al. Prevalence and risk factors for burnout in U.S. vascular surgery trainees. J Vasc Surg. 2022;75(1):308-315.e4.
59. Shanafelt TD, Oreskovich MR, Dyrbye LN, et al. Avoiding burnout: the personal health habits and wellness practices of US surgeons. Ann Surg. 2012;255(4):625-633.
1. World Health Organization. International Statistical Classification of Diseases and Related Health Problems (ICD). 11th ed. World Health Organization; 2019.
2. Coombs DM, Lanni MA, Fosnot J, et al. Professional burnout in United States plastic surgery residents: is it a legitimate concern? Aesthet Surg J. 2020;40(7):802-810.
3. Klimo P Jr, DeCuypere M, Ragel BT, et al. Career satisfaction and burnout among U.S. neurosurgeons: a feasibility and pilot study. World Neurosurg. 2013;80(5):e59-e68.
4. Ha GQ, Go JT, Murayama KM, et al. Identifying sources of stress across years of general surgery residency. Hawaii J Health Soc Welf. 2020;79(3):75-81.
5. Khalafallah AM, Lam S, Gami A, et al. A national survey on the impact of the COVID-19 pandemic upon burnout and career satisfaction among neurosurgery residents. J Clin Neurosci. 2020;80:137-142.
6. Al-Humadi SM, Cáceda R, Bronson B, et al. Orthopaedic surgeon mental health during the COVID-19 pandemic. Geriatric Orthop Surg Rehabil. 2021;12:21514593211035230.
7. Larson DP, Carlson ML, Lohse CM, et al. Prevalence of and associations with distress and professional burnout among otolaryngologists: part I, trainees. Otolaryngol Head Neck Surg. 2021;164(5):1019-1029.
8. Streu R, Hawley S, Gay A, et al. Satisfaction with career choice among U.S. plastic surgeons: results from a national survey. Plast Reconstr Surg. 2010;126(2):636-642.
9. Shanafelt TD, Balch CM, Bechamps GJ, et al. Burnout and career satisfaction among American surgeons. Ann Surg. 2009;250(3):463-471.
10. Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6):995-1000.
11. Moher D, Liberati A, Tetzlaff J, et al; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg. 2010;8(5):336-341.
12. Yesantharao P, Lee E, Kraenzlin F, et al. Surgical block time satisfaction: a multi-institutional experience across twelve surgical disciplines. Perioperative Care Operating Room Manage. 2020;21:100128.
13. Nituica C, Bota OA, Blebea J. Specialty differences in resident resilience and burnout - a national survey. Am J Surg. 2021;222(2):319-328.
14. Balch CM, Shanafelt TD, Dyrbye L, et al. Surgeon distress as calibrated by hours worked and nights on call. J Am Coll Surg. 2010;211(5):609-619.
15. Dyrbye LN, Shanafelt TD, Balch CM, Satele D, Sloan J, Freischlag J. Relationship between work-home conflicts and burnout among American surgeons: a comparison by sex. Arch Surg. 2011;146(2):211-217.
16. Mahoney ST, Irish W, Strassle PD, et al. Practice characteristics and job satisfaction of private practice and academic surgeons. JAMA Surg. 2021;156(3):247-254.
17. Shanafelt TD, Balch CM, Dyrbye L, et al. Special report: suicidal ideation among American surgeons. Arch Surg. 2011;146(1):54-62.
18. Chow OS, Sudarshan M, Maxfield MW, et al. National survey of burnout and distress among cardiothoracic surgery trainees. Ann Thorac Surg. 2021;111(6):2066-2071.
19. Lam C, Kim Y, Cruz M, et al. Burnout and resiliency in Mohs surgeons: a survey study. Int J Womens Dermatol. 2021;7(3):319-322.
20. Carlson ML, Larson DP, O’Brien EK, et al. Prevalence of and associations with distress and professional burnout among otolaryngologists: part II, attending physicians. Otolaryngol Head Neck Surg. 2021;164(5):1030-1039.
21. Nida AM, Googe BJ, Lewis AF, et al. Resident fatigue in otolaryngology residents: a Web based survey. Am J Otolaryngol. 2016;37(3):210-216.
22. Antiel RM, Reed DA, Van Arendonk KJ, et al. Effects of duty hour restrictions on core competencies, education, quality of life, and burnout among general surgery interns. JAMA Surg. 2013;148(5):448-455.
23. Appelbaum NP, Lee N, Amendola M, et al. Surgical resident burnout and job satisfaction: the role of workplace climate and perceived support. J Surg Res. 2019;234:20-25.
24. Elmore LC, Jeffe DB, Jin L, et al. National survey of burnout among US general surgery residents. J Am Coll Surg. 2016;223(3):440-451.
25. Garcia DI, Pannuccio A, Gallegos J, et al. Resident-driven wellness initiatives improve resident wellness and perception of work environment. J Surg Res. 2021;258:8-16.
26. Hochberg MS, Berman RS, Kalet AL, et al. The stress of residency: recognizing the signs of depression and suicide in you and your fellow residents. Am J Surg. 2013;205(2):141-146.
27. Kurbatov V, Shaughnessy M, Baratta V, et al. Application of advanced bioinformatics to understand and predict burnout among surgical trainees. J Surg Educ. 2020;77(3):499-507.
28. Leach PK, Nygaard RM, Chipman JG, et al. Impostor phenomenon and burnout in general surgeons and general surgery residents. J Surg Educ. 2019;76(1):99-106.
29. Lebares CC, Greenberg AL, Ascher NL, et al. Exploration of individual and system-level well-being initiatives at an academic surgical residency program: a mixed-methods study. JAMA Netw Open. 2021;4(1):e2032676.
30. Lindeman BM, Sacks BC, Hirose K, et al. Multifaceted longitudinal study of surgical resident education, quality of life, and patient care before and after July 2011. J Surg Educ. 2013;70(6):769-776.
31. Rasmussen JM, Najarian MM, Ties JS, et al. Career satisfaction, gender bias, and work-life balance: a contemporary assessment of general surgeons. J Surg Educ. 2021;78(1):119-125.
32. Smeds MR, Janko MR, Allen S, et al. Burnout and its relationship with perceived stress, self-efficacy, depression, social support, and programmatic factors in general surgery residents. Am J Surg. 2020;219(6):907-912.
33. Wetzel CM, George A, Hanna GB, et al. Stress management training for surgeons--a randomized, controlled, intervention study. Ann Surg. 2011;253(3):488-494.
34. Williford ML, Scarlet S, Meyers MO, et al. Multiple-institution comparison of resident and faculty perceptions of burnout and depression during surgical training. JAMA Surg. 2018;153(8):705-711.
35. Zubair MH, Hussain LR, Williams KN, et al. Work-related quality of life of US general surgery residents: is it really so bad? J Surg Educ. 2017;74(6):e138-e146.
36. Song Y, Swendiman RA, Shannon AB, et al. Can we coach resilience? An evaluation of professional resilience coaching as a well-being initiative for surgical interns. J Surg Educ. 2020;77(6):1481-1489.
37. Morrell NT, Sears ED, Desai MJ, et al. A survey of burnout among members of the American Society for Surgery of the Hand. J Hand Surg Am. 2020;45(7):573-581.e516.
38. Khalafallah AM, Lam S, Gami A, et al. Burnout and career satisfaction among attending neurosurgeons during the COVID-19 pandemic. Clin Neurol Neurosurg. 2020;198:106193.
39. McAbee JH, Ragel BT, McCartney S, et al. Factors associated with career satisfaction and burnout among US neurosurgeons: results of a nationwide survey. J Neurosurg. 2015;123(1):161-173.
40. Shakir HJ, McPheeters MJ, Shallwani H, et al. The prevalence of burnout among US neurosurgery residents. Neurosurgery. 2018;83(3):582-590.
41. Govardhan LM, Pinelli V, Schnatz PF. Burnout, depression and job satisfaction in obstetrics and gynecology residents. Conn Med. 2012;76(7):389-395.
42. Driesman AS, Strauss EJ, Konda SR, et al. Factors associated with orthopaedic resident burnout: a pilot study. J Am Acad Orthop Surg. 2020;28(21):900-906.
43. Lichstein PM, He JK, Estok D, et al. What is the prevalence of burnout, depression, and substance use among orthopaedic surgery residents and what are the risk factors? A collaborative orthopaedic educational research group survey study. Clin Orthop Relat Res. 2020;478(8):1709-1718.
44. Somerson JS, Patton A, Ahmed AA, et al. Burnout among United States orthopaedic surgery residents. J Surg Educ. 2020;77(4):961-968.
45. Verret CI, Nguyen J, Verret C, et al. How do areas of work life drive burnout in orthopaedic attending surgeons, fellows, and residents? Clin Orthop Relat Res. 2021;479(2):251-262.
46. Sarosi A, Coakley BA, Berman L, et al. A cross-sectional analysis of compassion fatigue, burnout, and compassion satisfaction in pediatric surgeons in the U.S. J Pediatr Surg. 2021;56(8):1276-1284.
47. Crowe CS, Lopez J, Morrison SD, et al. The effects of the COVID-19 pandemic on resident education and wellness: a national survey of plastic surgery residents. Plast Reconstr Surg. 2021;148(3):462e-474e.
48. Qureshi HA, Rawlani R, Mioton LM, et al. Burnout phenomenon in U.S. plastic surgeons: risk factors and impact on quality of life. Plast Reconstr Surg. 2015;135(2):619-626.
49. Streu R, Hansen J, Abrahamse P, et al. Professional burnout among US plastic surgeons: results of a national survey. Ann Plast Surg. 2014;72(3):346-350.
50. Zhang JQ, Riba L, Magrini L, ET AL. Assessing burnout and professional fulfillment in breast surgery: results from a national survey of the American Society of Breast Surgeons. Ann Surg Oncol. 2019;26(10):3089-3098.
51. Balch CM, Shanafelt TD, Sloan J, et al. Burnout and career satisfaction among surgical oncologists compared with other surgical specialties. Ann Surg Oncol. 2011;18(1):16-25.
52. Wu D, Gross B, Rittenhouse K, et al. A preliminary analysis of compassion fatigue in a surgeon population: are female surgeons at heightened risk? Am Surg. 2017;83(11):1302-1307.
53. Cheng JW, Wagner H, Hernandez BC, et al. Stressors and coping mechanisms related to burnout within urology. Urology. 2020;139:27-36.
54. Koo K, Javier-DesLoges JF, Fang R, ET AL. Professional burnout, career choice regret, and unmet needs for well-being among urology residents. Urology. 2021;157:57-63.
55. Janko MR, Smeds MR. Burnout, depression, perceived stress, and self-efficacy in vascular surgery trainees. J Vasc Surg. 2019;69(4):1233-1242.
56. Coleman DM, Money SR, Meltzer AJ, et al. Vascular surgeon wellness and burnout: a report from the Society for Vascular Surgery Wellness Task Force. J Vasc Surg. 2021;73(6):1841-1850.e3.
57. Barrack RL, Miller LS, Sotile WM, et al. Effect of duty hour standards on burnout among orthopaedic surgery residents. Clin Orthop Relat Res. 2006;449:134-137.
58. Chia MC, Hu YY, Li RD, et al. Prevalence and risk factors for burnout in U.S. vascular surgery trainees. J Vasc Surg. 2022;75(1):308-315.e4.
59. Shanafelt TD, Oreskovich MR, Dyrbye LN, et al. Avoiding burnout: the personal health habits and wellness practices of US surgeons. Ann Surg. 2012;255(4):625-633.
Fast-acting postpartum depression drug is effective
The Food and Drug Administration is considering approving a postpartum depression medication that can start working rapidly – in as little as 3 days. Promising results for the drug, zuranolone, were published recently in The American Journal of Psychiatry.
Approximately 17% of women are affected by postpartum depression (PPD) during pregnancy or after birth, study authors noted. The condition often results in reduced breastfeeding, poor maternal-infant bonding, and hindering behavioral, emotional and brain development of the baby. Severe PPD can lead to suicide of the mother, which accounts for 20% of all postpartum deaths, they wrote.
The study included 196 people who had given birth in the past year, and were between the ages of 18 and 45 years old. Participants had major depression that began in the 3rd trimester of pregnancy or during the first 4 weeks of the postpartum period. Among participants, 22% were Black and 38% were Hispanic.
The average time it took for symptoms to significantly decline was 9 days. Most people who saw improvements had them continue for the entire 45-day follow-up period. The most common side effects were drowsiness, dizziness, and sleepiness.
Currently, PPD treatment includes taking antidepressants, which can take up to 12 weeks to work.
Researchers noted that the limitations of the study were that it only included women with severe PPD, and that women with a history of bipolar or psychotic disorders were excluded. Women in the study were not allowed to breastfeed, so the effect of zuranolone on lactation is unknown, they wrote.
A February news release from drugmaker Biogen indicated the FDA may decide whether to approve the medicine by Aug. 5.
A version of this article first appeared on WebMD.com.
The Food and Drug Administration is considering approving a postpartum depression medication that can start working rapidly – in as little as 3 days. Promising results for the drug, zuranolone, were published recently in The American Journal of Psychiatry.
Approximately 17% of women are affected by postpartum depression (PPD) during pregnancy or after birth, study authors noted. The condition often results in reduced breastfeeding, poor maternal-infant bonding, and hindering behavioral, emotional and brain development of the baby. Severe PPD can lead to suicide of the mother, which accounts for 20% of all postpartum deaths, they wrote.
The study included 196 people who had given birth in the past year, and were between the ages of 18 and 45 years old. Participants had major depression that began in the 3rd trimester of pregnancy or during the first 4 weeks of the postpartum period. Among participants, 22% were Black and 38% were Hispanic.
The average time it took for symptoms to significantly decline was 9 days. Most people who saw improvements had them continue for the entire 45-day follow-up period. The most common side effects were drowsiness, dizziness, and sleepiness.
Currently, PPD treatment includes taking antidepressants, which can take up to 12 weeks to work.
Researchers noted that the limitations of the study were that it only included women with severe PPD, and that women with a history of bipolar or psychotic disorders were excluded. Women in the study were not allowed to breastfeed, so the effect of zuranolone on lactation is unknown, they wrote.
A February news release from drugmaker Biogen indicated the FDA may decide whether to approve the medicine by Aug. 5.
A version of this article first appeared on WebMD.com.
The Food and Drug Administration is considering approving a postpartum depression medication that can start working rapidly – in as little as 3 days. Promising results for the drug, zuranolone, were published recently in The American Journal of Psychiatry.
Approximately 17% of women are affected by postpartum depression (PPD) during pregnancy or after birth, study authors noted. The condition often results in reduced breastfeeding, poor maternal-infant bonding, and hindering behavioral, emotional and brain development of the baby. Severe PPD can lead to suicide of the mother, which accounts for 20% of all postpartum deaths, they wrote.
The study included 196 people who had given birth in the past year, and were between the ages of 18 and 45 years old. Participants had major depression that began in the 3rd trimester of pregnancy or during the first 4 weeks of the postpartum period. Among participants, 22% were Black and 38% were Hispanic.
The average time it took for symptoms to significantly decline was 9 days. Most people who saw improvements had them continue for the entire 45-day follow-up period. The most common side effects were drowsiness, dizziness, and sleepiness.
Currently, PPD treatment includes taking antidepressants, which can take up to 12 weeks to work.
Researchers noted that the limitations of the study were that it only included women with severe PPD, and that women with a history of bipolar or psychotic disorders were excluded. Women in the study were not allowed to breastfeed, so the effect of zuranolone on lactation is unknown, they wrote.
A February news release from drugmaker Biogen indicated the FDA may decide whether to approve the medicine by Aug. 5.
A version of this article first appeared on WebMD.com.
FROM THE AMERICAN JOURNAL OF PSYCHIATRY
Subcutaneous ketamine for TRD practical, safe, and highly effective
“In this severely treatment-resistant population, of which 24% had failed to respond to treatment with electroconvulsive therapy, adequately dosed racemic ketamine produced benefits that were large, being both clinically and statistically superior to midazolam,” report the researchers, led by Colleen Loo, MD, MBBS, with Black Dog Institute, University of New South Wales, Sydney.
The study was published online in the British Journal of Psychiatry.
Individualized dosing
“Previously, most studies of racemic ketamine [administered] it by intravenous infusion over half an hour to several hours, which is a much more medically complex and expensive procedure,” Dr. Loo said in an interview.
The fact that subcutaneously administered ketamine was “highly effective” given by this practical and feasible route is a “major contribution to the field,” said Dr. Loo.
The Ketamine for Adult Depression trial assessed the acute efficacy and safety of a 4-week course of twice-weekly subcutaneous injections of racemic ketamine or midazolam (active control) in 174 adults with TRD.
Initially, the trial tested a fixed dose of 0.5 mg/kg ketamine vs. 0.025 mg/kg midazolam (cohort 1; 68 patients). Dosing was subsequently revised, after the data safety monitoring board recommended flexible-dose ketamine (0.5-0.9 mg/kg) or midazolam (0.025-0.045 mg/kg) with response-guided dosing increments (cohort 2; 106 patients).
The primary outcome was remission defined as Montgomery-Åsberg Rating Scale for Depression (MADRS) score ≤ 10 at week 4.
On this outcome, in the fixed-dose cohort, there was no statistically significant difference in remission rates between ketamine and midazolam (6.3% and 8.8%; odds ratio, 1.34; 95% CI, 0.22-8.21; P = .76).
However, there was a significant difference in remission in the flexible-dose cohort, with remission rates 19.6% for ketamine vs. just 2% for midazolam (OR, 12.11; 95% CI, 2.12-69.17; P = .005).
“The study showed that individualized dose adjustment, based on clinical response, was very important in optimizing the benefit of ketamine,” said Dr. Loo.
“It meant that one, you are more likely to respond as you receive a higher dose if needed, and two, you don’t receive a higher dose than needed, given that side effects are also dose-related,” she said.
Results also favored flexible-dose ketamine over midazolam for the secondary outcomes of response (≥ 50% reduction in MADRS: 29% vs. 4%; P = .001) and remission defined by a less rigid definition (MADRS ≤ 12: 22% vs. 4%; P = .007).
The results also confirm that the antidepressant effects of ketamine are not sustained when treatment stops.
“The study included careful follow-up for 4 weeks after the end of treatment. This is an important contribution to the literature, as it shows that ongoing treatment beyond the 4 weeks will be necessary for most people to maintain the benefits of ketamine treatment if you respond to the treatment. This study provided clear evidence of this, for racemic ketamine,” said Dr. Loo.
Overall, ketamine was well-tolerated, with the well-established acute effects of ketamine observed in both cohorts. The acute effects resolved or returned to pretreatment levels within the 2-hour observation period. No one required medical intervention, and there was no evidence of cognitive impairment.
Rigorous research, compelling data
Reached for comment, Roger S. McIntyre, MD, professor of psychiatry and pharmacology, University of Toronto, and head of the mood disorders psychopharmacology unit, said the data are “compelling with respect to efficacy and safety of subcutaneous ketamine in adults with major depression.”
Dr. McIntyre said the data are “highly relevant” for several reasons. “First, it is the most rigorous study conducted to date with subcutaneous administration of ketamine for adults living with treatment-resistant depression.”
Second, it “demonstrates the efficacy and safety of this route of delivery, which until now has not been studied with this level of rigor and which is a more scalable and accessible approach to administer ketamine to suitable candidates,” Dr. McIntyre said.
The study was funded by a competitive research grant from the Australian National Health and Medical Research Council. Dr. Loo has disclosed relationships with Douglas Pharmaceuticals and Janssen Cilag and is the medical director of neurostimulation and interventional psychiatry at Ramsay Health Care. Dr. McIntyre has received speaker/consultation fees from Lundbeck, Janssen, Alkermes, Neumora Therapeutics, Boehringer Ingelheim, Sage, Biogen, Mitsubishi Tanabe, Purdue, Pfizer, Otsuka, Takeda, Neurocrine, Sunovion, Bausch Health, Axsome, Novo Nordisk, Kris, Sanofi, Eisai, Intra-Cellular, NewBridge Pharmaceuticals, Viatris, AbbVie, and Atai Life Sciences. Dr. McIntyre is a CEO of Braxia Scientific Corp.
A version of this article first appeared on Medscape.com.
“In this severely treatment-resistant population, of which 24% had failed to respond to treatment with electroconvulsive therapy, adequately dosed racemic ketamine produced benefits that were large, being both clinically and statistically superior to midazolam,” report the researchers, led by Colleen Loo, MD, MBBS, with Black Dog Institute, University of New South Wales, Sydney.
The study was published online in the British Journal of Psychiatry.
Individualized dosing
“Previously, most studies of racemic ketamine [administered] it by intravenous infusion over half an hour to several hours, which is a much more medically complex and expensive procedure,” Dr. Loo said in an interview.
The fact that subcutaneously administered ketamine was “highly effective” given by this practical and feasible route is a “major contribution to the field,” said Dr. Loo.
The Ketamine for Adult Depression trial assessed the acute efficacy and safety of a 4-week course of twice-weekly subcutaneous injections of racemic ketamine or midazolam (active control) in 174 adults with TRD.
Initially, the trial tested a fixed dose of 0.5 mg/kg ketamine vs. 0.025 mg/kg midazolam (cohort 1; 68 patients). Dosing was subsequently revised, after the data safety monitoring board recommended flexible-dose ketamine (0.5-0.9 mg/kg) or midazolam (0.025-0.045 mg/kg) with response-guided dosing increments (cohort 2; 106 patients).
The primary outcome was remission defined as Montgomery-Åsberg Rating Scale for Depression (MADRS) score ≤ 10 at week 4.
On this outcome, in the fixed-dose cohort, there was no statistically significant difference in remission rates between ketamine and midazolam (6.3% and 8.8%; odds ratio, 1.34; 95% CI, 0.22-8.21; P = .76).
However, there was a significant difference in remission in the flexible-dose cohort, with remission rates 19.6% for ketamine vs. just 2% for midazolam (OR, 12.11; 95% CI, 2.12-69.17; P = .005).
“The study showed that individualized dose adjustment, based on clinical response, was very important in optimizing the benefit of ketamine,” said Dr. Loo.
“It meant that one, you are more likely to respond as you receive a higher dose if needed, and two, you don’t receive a higher dose than needed, given that side effects are also dose-related,” she said.
Results also favored flexible-dose ketamine over midazolam for the secondary outcomes of response (≥ 50% reduction in MADRS: 29% vs. 4%; P = .001) and remission defined by a less rigid definition (MADRS ≤ 12: 22% vs. 4%; P = .007).
The results also confirm that the antidepressant effects of ketamine are not sustained when treatment stops.
“The study included careful follow-up for 4 weeks after the end of treatment. This is an important contribution to the literature, as it shows that ongoing treatment beyond the 4 weeks will be necessary for most people to maintain the benefits of ketamine treatment if you respond to the treatment. This study provided clear evidence of this, for racemic ketamine,” said Dr. Loo.
Overall, ketamine was well-tolerated, with the well-established acute effects of ketamine observed in both cohorts. The acute effects resolved or returned to pretreatment levels within the 2-hour observation period. No one required medical intervention, and there was no evidence of cognitive impairment.
Rigorous research, compelling data
Reached for comment, Roger S. McIntyre, MD, professor of psychiatry and pharmacology, University of Toronto, and head of the mood disorders psychopharmacology unit, said the data are “compelling with respect to efficacy and safety of subcutaneous ketamine in adults with major depression.”
Dr. McIntyre said the data are “highly relevant” for several reasons. “First, it is the most rigorous study conducted to date with subcutaneous administration of ketamine for adults living with treatment-resistant depression.”
Second, it “demonstrates the efficacy and safety of this route of delivery, which until now has not been studied with this level of rigor and which is a more scalable and accessible approach to administer ketamine to suitable candidates,” Dr. McIntyre said.
The study was funded by a competitive research grant from the Australian National Health and Medical Research Council. Dr. Loo has disclosed relationships with Douglas Pharmaceuticals and Janssen Cilag and is the medical director of neurostimulation and interventional psychiatry at Ramsay Health Care. Dr. McIntyre has received speaker/consultation fees from Lundbeck, Janssen, Alkermes, Neumora Therapeutics, Boehringer Ingelheim, Sage, Biogen, Mitsubishi Tanabe, Purdue, Pfizer, Otsuka, Takeda, Neurocrine, Sunovion, Bausch Health, Axsome, Novo Nordisk, Kris, Sanofi, Eisai, Intra-Cellular, NewBridge Pharmaceuticals, Viatris, AbbVie, and Atai Life Sciences. Dr. McIntyre is a CEO of Braxia Scientific Corp.
A version of this article first appeared on Medscape.com.
“In this severely treatment-resistant population, of which 24% had failed to respond to treatment with electroconvulsive therapy, adequately dosed racemic ketamine produced benefits that were large, being both clinically and statistically superior to midazolam,” report the researchers, led by Colleen Loo, MD, MBBS, with Black Dog Institute, University of New South Wales, Sydney.
The study was published online in the British Journal of Psychiatry.
Individualized dosing
“Previously, most studies of racemic ketamine [administered] it by intravenous infusion over half an hour to several hours, which is a much more medically complex and expensive procedure,” Dr. Loo said in an interview.
The fact that subcutaneously administered ketamine was “highly effective” given by this practical and feasible route is a “major contribution to the field,” said Dr. Loo.
The Ketamine for Adult Depression trial assessed the acute efficacy and safety of a 4-week course of twice-weekly subcutaneous injections of racemic ketamine or midazolam (active control) in 174 adults with TRD.
Initially, the trial tested a fixed dose of 0.5 mg/kg ketamine vs. 0.025 mg/kg midazolam (cohort 1; 68 patients). Dosing was subsequently revised, after the data safety monitoring board recommended flexible-dose ketamine (0.5-0.9 mg/kg) or midazolam (0.025-0.045 mg/kg) with response-guided dosing increments (cohort 2; 106 patients).
The primary outcome was remission defined as Montgomery-Åsberg Rating Scale for Depression (MADRS) score ≤ 10 at week 4.
On this outcome, in the fixed-dose cohort, there was no statistically significant difference in remission rates between ketamine and midazolam (6.3% and 8.8%; odds ratio, 1.34; 95% CI, 0.22-8.21; P = .76).
However, there was a significant difference in remission in the flexible-dose cohort, with remission rates 19.6% for ketamine vs. just 2% for midazolam (OR, 12.11; 95% CI, 2.12-69.17; P = .005).
“The study showed that individualized dose adjustment, based on clinical response, was very important in optimizing the benefit of ketamine,” said Dr. Loo.
“It meant that one, you are more likely to respond as you receive a higher dose if needed, and two, you don’t receive a higher dose than needed, given that side effects are also dose-related,” she said.
Results also favored flexible-dose ketamine over midazolam for the secondary outcomes of response (≥ 50% reduction in MADRS: 29% vs. 4%; P = .001) and remission defined by a less rigid definition (MADRS ≤ 12: 22% vs. 4%; P = .007).
The results also confirm that the antidepressant effects of ketamine are not sustained when treatment stops.
“The study included careful follow-up for 4 weeks after the end of treatment. This is an important contribution to the literature, as it shows that ongoing treatment beyond the 4 weeks will be necessary for most people to maintain the benefits of ketamine treatment if you respond to the treatment. This study provided clear evidence of this, for racemic ketamine,” said Dr. Loo.
Overall, ketamine was well-tolerated, with the well-established acute effects of ketamine observed in both cohorts. The acute effects resolved or returned to pretreatment levels within the 2-hour observation period. No one required medical intervention, and there was no evidence of cognitive impairment.
Rigorous research, compelling data
Reached for comment, Roger S. McIntyre, MD, professor of psychiatry and pharmacology, University of Toronto, and head of the mood disorders psychopharmacology unit, said the data are “compelling with respect to efficacy and safety of subcutaneous ketamine in adults with major depression.”
Dr. McIntyre said the data are “highly relevant” for several reasons. “First, it is the most rigorous study conducted to date with subcutaneous administration of ketamine for adults living with treatment-resistant depression.”
Second, it “demonstrates the efficacy and safety of this route of delivery, which until now has not been studied with this level of rigor and which is a more scalable and accessible approach to administer ketamine to suitable candidates,” Dr. McIntyre said.
The study was funded by a competitive research grant from the Australian National Health and Medical Research Council. Dr. Loo has disclosed relationships with Douglas Pharmaceuticals and Janssen Cilag and is the medical director of neurostimulation and interventional psychiatry at Ramsay Health Care. Dr. McIntyre has received speaker/consultation fees from Lundbeck, Janssen, Alkermes, Neumora Therapeutics, Boehringer Ingelheim, Sage, Biogen, Mitsubishi Tanabe, Purdue, Pfizer, Otsuka, Takeda, Neurocrine, Sunovion, Bausch Health, Axsome, Novo Nordisk, Kris, Sanofi, Eisai, Intra-Cellular, NewBridge Pharmaceuticals, Viatris, AbbVie, and Atai Life Sciences. Dr. McIntyre is a CEO of Braxia Scientific Corp.
A version of this article first appeared on Medscape.com.
FROM THE BRITISH JOURNAL OF PSYCHIATRY
Novel talk therapy challenges CBT for treating anhedonic depression
While the trial was not adequately powered to test if augmented depression therapy (ADepT) is superior to CBT, “results nevertheless were encouraging,” lead author Barnaby Dunn, PhD, professor of clinical psychology, University of Exeter (England), said in an interview.
The trial showed that ADepT is feasible, acceptable, and “not worse than CBT,” also showing the “potential to be better than CBT in clinical outcomes,” Dr. Dunn said.
“By building positive mood, ADepT may help individuals stay well for longer in the future,” he noted.
The early results were published online in eClinicalMedicine.
Dual approach
“There are two sides to the depression coin – heightened negative mood and reduced positive mood. Classic CBT focuses mainly on repairing negative mood and pays less attention to building positive mood,” Dr. Dunn explained.
He said when he speaks to clients about what is key to recovery from depression, they often mention the importance of reconnecting to the positive.
“ADepT pays equal attention to building the positives as it does reducing the negatives, giving clients new skills to ‘act opposite’ to old ways of thinking and feeling that can stop them making the most of opportunities and being able to experience well-being,” Dr. Dunn said.
ADepT is an individual therapy delivered over 15 acute and 5 booster sessions, which is similar in “dose” to classic CBT, Dr. Dunn said.
The primary focus of ADepT is building well-being (capacity to experience pleasure, meaning, and social connection in life) and functional recovery, with depression conceptualized as patterns of thinking, feeling, and behaving that serve as barriers to achieving this goal.
Patients work with trained therapists to overcome barriers to being resilient (managing challenges to reduce negative affect) and thriving (taking opportunities to maximize positive affect).
A total of 82 adults with a moderate to severe current major depressive episode with features of anhedonia took part in the pilot trial. They were randomly allocated 1:1 to either 20 individual sessions of ADepT or CBT, delivered in the University of Exeter Accessing Evidence Based Psychological Therapies outpatient clinic.
Researcher-blinded assessments were completed at intake and after 6, 12, and 18 months. Coprimary outcomes were depression, measured via the Patient Health Questionnaire and well-being, gauged with the Warwick Edinburgh Mental Wellbeing Scale at 6 months.
Within-group analyses showed that both ADepT and CBT led to clinically meaningful improvements in depression, well-being, and all other secondary outcomes, including measures of anhedonia, Dr. Dunn said.
Between-group effects favored ADepT over CBT for depression and well-being. “For example, about 80% of clients no longer met diagnostic criteria for depression after ADepT, compared to around 56% of clients in CBT,” Dr. Dunn said.
“There were also numerically bigger gains in well-being and reductions in anhedonia in ADepT relative to CBT. A greater number of clients who recovered at the end of therapy stayed well over the longer term in ADepT relative to CBT,” he noted.
ADepT costs the same amount to deliver as CBT “but resulted in greater gains in quality of life, meaning it showed a high probability of being cost effective,” Dr. Dunn said.
ADepT has also been designed so that trained CBT therapists will be able to deliver it with minimal additional training.
“The next step,” said Dr. Dunn, “is a bigger definitive trial, which will formally test if ADepT is clinically superior to and better value for money than CBT when delivering ADepT in more routine care settings [U.K. NHS clinics rather than specialist university mood disorder center].”
The trial was funded by a Career Development Fellowship awarded to Dr. Dunn by the National Institute for Health and Care Research. Dr. Dunn has a book contract with Guilford Press to write the ADepT treatment manual and receives occasional payment or honoraria (including support for attending meetings) for delivering workshops and talks on ADepT.
A version of this article first appeared on Medscape.com.
While the trial was not adequately powered to test if augmented depression therapy (ADepT) is superior to CBT, “results nevertheless were encouraging,” lead author Barnaby Dunn, PhD, professor of clinical psychology, University of Exeter (England), said in an interview.
The trial showed that ADepT is feasible, acceptable, and “not worse than CBT,” also showing the “potential to be better than CBT in clinical outcomes,” Dr. Dunn said.
“By building positive mood, ADepT may help individuals stay well for longer in the future,” he noted.
The early results were published online in eClinicalMedicine.
Dual approach
“There are two sides to the depression coin – heightened negative mood and reduced positive mood. Classic CBT focuses mainly on repairing negative mood and pays less attention to building positive mood,” Dr. Dunn explained.
He said when he speaks to clients about what is key to recovery from depression, they often mention the importance of reconnecting to the positive.
“ADepT pays equal attention to building the positives as it does reducing the negatives, giving clients new skills to ‘act opposite’ to old ways of thinking and feeling that can stop them making the most of opportunities and being able to experience well-being,” Dr. Dunn said.
ADepT is an individual therapy delivered over 15 acute and 5 booster sessions, which is similar in “dose” to classic CBT, Dr. Dunn said.
The primary focus of ADepT is building well-being (capacity to experience pleasure, meaning, and social connection in life) and functional recovery, with depression conceptualized as patterns of thinking, feeling, and behaving that serve as barriers to achieving this goal.
Patients work with trained therapists to overcome barriers to being resilient (managing challenges to reduce negative affect) and thriving (taking opportunities to maximize positive affect).
A total of 82 adults with a moderate to severe current major depressive episode with features of anhedonia took part in the pilot trial. They were randomly allocated 1:1 to either 20 individual sessions of ADepT or CBT, delivered in the University of Exeter Accessing Evidence Based Psychological Therapies outpatient clinic.
Researcher-blinded assessments were completed at intake and after 6, 12, and 18 months. Coprimary outcomes were depression, measured via the Patient Health Questionnaire and well-being, gauged with the Warwick Edinburgh Mental Wellbeing Scale at 6 months.
Within-group analyses showed that both ADepT and CBT led to clinically meaningful improvements in depression, well-being, and all other secondary outcomes, including measures of anhedonia, Dr. Dunn said.
Between-group effects favored ADepT over CBT for depression and well-being. “For example, about 80% of clients no longer met diagnostic criteria for depression after ADepT, compared to around 56% of clients in CBT,” Dr. Dunn said.
“There were also numerically bigger gains in well-being and reductions in anhedonia in ADepT relative to CBT. A greater number of clients who recovered at the end of therapy stayed well over the longer term in ADepT relative to CBT,” he noted.
ADepT costs the same amount to deliver as CBT “but resulted in greater gains in quality of life, meaning it showed a high probability of being cost effective,” Dr. Dunn said.
ADepT has also been designed so that trained CBT therapists will be able to deliver it with minimal additional training.
“The next step,” said Dr. Dunn, “is a bigger definitive trial, which will formally test if ADepT is clinically superior to and better value for money than CBT when delivering ADepT in more routine care settings [U.K. NHS clinics rather than specialist university mood disorder center].”
The trial was funded by a Career Development Fellowship awarded to Dr. Dunn by the National Institute for Health and Care Research. Dr. Dunn has a book contract with Guilford Press to write the ADepT treatment manual and receives occasional payment or honoraria (including support for attending meetings) for delivering workshops and talks on ADepT.
A version of this article first appeared on Medscape.com.
While the trial was not adequately powered to test if augmented depression therapy (ADepT) is superior to CBT, “results nevertheless were encouraging,” lead author Barnaby Dunn, PhD, professor of clinical psychology, University of Exeter (England), said in an interview.
The trial showed that ADepT is feasible, acceptable, and “not worse than CBT,” also showing the “potential to be better than CBT in clinical outcomes,” Dr. Dunn said.
“By building positive mood, ADepT may help individuals stay well for longer in the future,” he noted.
The early results were published online in eClinicalMedicine.
Dual approach
“There are two sides to the depression coin – heightened negative mood and reduced positive mood. Classic CBT focuses mainly on repairing negative mood and pays less attention to building positive mood,” Dr. Dunn explained.
He said when he speaks to clients about what is key to recovery from depression, they often mention the importance of reconnecting to the positive.
“ADepT pays equal attention to building the positives as it does reducing the negatives, giving clients new skills to ‘act opposite’ to old ways of thinking and feeling that can stop them making the most of opportunities and being able to experience well-being,” Dr. Dunn said.
ADepT is an individual therapy delivered over 15 acute and 5 booster sessions, which is similar in “dose” to classic CBT, Dr. Dunn said.
The primary focus of ADepT is building well-being (capacity to experience pleasure, meaning, and social connection in life) and functional recovery, with depression conceptualized as patterns of thinking, feeling, and behaving that serve as barriers to achieving this goal.
Patients work with trained therapists to overcome barriers to being resilient (managing challenges to reduce negative affect) and thriving (taking opportunities to maximize positive affect).
A total of 82 adults with a moderate to severe current major depressive episode with features of anhedonia took part in the pilot trial. They were randomly allocated 1:1 to either 20 individual sessions of ADepT or CBT, delivered in the University of Exeter Accessing Evidence Based Psychological Therapies outpatient clinic.
Researcher-blinded assessments were completed at intake and after 6, 12, and 18 months. Coprimary outcomes were depression, measured via the Patient Health Questionnaire and well-being, gauged with the Warwick Edinburgh Mental Wellbeing Scale at 6 months.
Within-group analyses showed that both ADepT and CBT led to clinically meaningful improvements in depression, well-being, and all other secondary outcomes, including measures of anhedonia, Dr. Dunn said.
Between-group effects favored ADepT over CBT for depression and well-being. “For example, about 80% of clients no longer met diagnostic criteria for depression after ADepT, compared to around 56% of clients in CBT,” Dr. Dunn said.
“There were also numerically bigger gains in well-being and reductions in anhedonia in ADepT relative to CBT. A greater number of clients who recovered at the end of therapy stayed well over the longer term in ADepT relative to CBT,” he noted.
ADepT costs the same amount to deliver as CBT “but resulted in greater gains in quality of life, meaning it showed a high probability of being cost effective,” Dr. Dunn said.
ADepT has also been designed so that trained CBT therapists will be able to deliver it with minimal additional training.
“The next step,” said Dr. Dunn, “is a bigger definitive trial, which will formally test if ADepT is clinically superior to and better value for money than CBT when delivering ADepT in more routine care settings [U.K. NHS clinics rather than specialist university mood disorder center].”
The trial was funded by a Career Development Fellowship awarded to Dr. Dunn by the National Institute for Health and Care Research. Dr. Dunn has a book contract with Guilford Press to write the ADepT treatment manual and receives occasional payment or honoraria (including support for attending meetings) for delivering workshops and talks on ADepT.
A version of this article first appeared on Medscape.com.
FROM ECLINICALMEDICINE
Most Americans in favor of regulated therapeutic psychedelics
It is a surprisingly large percentage, said officials at the University of California, Berkeley, Center for the Science of Psychedelics, which conducted the online survey of 1,500 registered voters in early June.
“That is a stunning number,” said Michael Pollan, cofounder of the center, and author of “How to Change Your Mind,” a book that explored potential uses of psychedelics.
In a briefing with reporters, Mr. Pollan said that he believes the large support base, in part, reflects campaigns that have “been successful by highlighting the effectiveness of psychedelics as therapy for mental illness.”
However, the poll also showed that 61% of voters said that they do not perceive psychedelics as “good for society,” and 69% do not perceive them as “something for people like me.”
These negative sentiments “suggest a fragile kind of support – the kind of support where you’re only hearing one side of the story,” said Mr. Pollan.
Still, poll respondents supported other potential policy changes, including 56% in support of the U.S. Food and Drug Administration vetting and approving psychedelics so they could be available by prescription.
50% have tried psychedelics
Almost 80% said that it should be easier for researchers to study psychedelics, and just under one-half said that they backed removing criminal penalties for personal use and possession.
The poll results also show that almost half of respondents had heard about psychedelics recently, with 48% saying they had heard about the drugs’ use in treating mental illness.
Respondents who were most familiar with and positive about psychedelics tended to be White, male, aged 30-50 years, liberal, highly educated, living in a Western state, and have little to no religious or spiritual practice.
Overall, 52% of survey respondents said that they or someone close to them had used a psychedelic, with almost half of that use coming in the past 5 years. Some 40% said that the use had been more than a decade ago.
Almost three-quarters of psychedelic use was reported as recreational, but the second-biggest category was therapeutic use at 39%. About one-third of respondents said that they or someone close to them had microdosed.
Conservative voters had lower levels of awareness and first-degree connection use as well as the least amount of support for regulated therapeutic use, with only 45% saying they would back such a policy, compared with 80% of liberal voters and 66% of moderate voters.
Black individuals were the least likely to be familiar with psychedelics: Just 29% said that they had heard a little or a lot about the drugs, compared with 39% of Latinx individuals and 51% of White individuals. And just one-quarter reported first-degree use, compared with half of Latinx individuals and 56% of White individuals.
Who should be eligible?
When asked who should be eligible for treatment with psychedelics, 80% said that they were comfortable with its use for those with terminal illnesses. More than two-thirds expressed comfort with the drugs being used to help veterans and people with treatment-resistant depression and anxiety.
Less than one-half of respondents said that psychedelics should be available to everyone older than 21 years. And voters seemed to be less inclined to say psychedelics should be used to treat people with addiction, with just 45% indicating that they were very or somewhat comfortable with that use.
Mr. Pollan said that reflects perhaps some lack of knowledge or education.
“The story about addiction and psychedelics hasn’t gotten out,” he said. “I kind of get that intuitively the idea of using a drug to treat a drug doesn’t sound right to a lot of people. But in fact, there’s good evidence it works,” Mr. Pollan said.
Respondents said that doctors, nurses, and scientists were the most trusted source of information about psychedelics, whereas the FDA received lower confidence. Law enforcement was least trusted by liberals and most trusted by conservatives.
Mr. Pollan noted the reversal in attitudes, with Americans mostly now looking to the scientific and medical establishment for guidance on psychedelics.
“We went from a counterculture drug to something that is being taken seriously by scientists as a potential therapy,” he said.
The poll’s margin of error was ± 2.5%.
A version of this article first appeared on Medscape.com.
It is a surprisingly large percentage, said officials at the University of California, Berkeley, Center for the Science of Psychedelics, which conducted the online survey of 1,500 registered voters in early June.
“That is a stunning number,” said Michael Pollan, cofounder of the center, and author of “How to Change Your Mind,” a book that explored potential uses of psychedelics.
In a briefing with reporters, Mr. Pollan said that he believes the large support base, in part, reflects campaigns that have “been successful by highlighting the effectiveness of psychedelics as therapy for mental illness.”
However, the poll also showed that 61% of voters said that they do not perceive psychedelics as “good for society,” and 69% do not perceive them as “something for people like me.”
These negative sentiments “suggest a fragile kind of support – the kind of support where you’re only hearing one side of the story,” said Mr. Pollan.
Still, poll respondents supported other potential policy changes, including 56% in support of the U.S. Food and Drug Administration vetting and approving psychedelics so they could be available by prescription.
50% have tried psychedelics
Almost 80% said that it should be easier for researchers to study psychedelics, and just under one-half said that they backed removing criminal penalties for personal use and possession.
The poll results also show that almost half of respondents had heard about psychedelics recently, with 48% saying they had heard about the drugs’ use in treating mental illness.
Respondents who were most familiar with and positive about psychedelics tended to be White, male, aged 30-50 years, liberal, highly educated, living in a Western state, and have little to no religious or spiritual practice.
Overall, 52% of survey respondents said that they or someone close to them had used a psychedelic, with almost half of that use coming in the past 5 years. Some 40% said that the use had been more than a decade ago.
Almost three-quarters of psychedelic use was reported as recreational, but the second-biggest category was therapeutic use at 39%. About one-third of respondents said that they or someone close to them had microdosed.
Conservative voters had lower levels of awareness and first-degree connection use as well as the least amount of support for regulated therapeutic use, with only 45% saying they would back such a policy, compared with 80% of liberal voters and 66% of moderate voters.
Black individuals were the least likely to be familiar with psychedelics: Just 29% said that they had heard a little or a lot about the drugs, compared with 39% of Latinx individuals and 51% of White individuals. And just one-quarter reported first-degree use, compared with half of Latinx individuals and 56% of White individuals.
Who should be eligible?
When asked who should be eligible for treatment with psychedelics, 80% said that they were comfortable with its use for those with terminal illnesses. More than two-thirds expressed comfort with the drugs being used to help veterans and people with treatment-resistant depression and anxiety.
Less than one-half of respondents said that psychedelics should be available to everyone older than 21 years. And voters seemed to be less inclined to say psychedelics should be used to treat people with addiction, with just 45% indicating that they were very or somewhat comfortable with that use.
Mr. Pollan said that reflects perhaps some lack of knowledge or education.
“The story about addiction and psychedelics hasn’t gotten out,” he said. “I kind of get that intuitively the idea of using a drug to treat a drug doesn’t sound right to a lot of people. But in fact, there’s good evidence it works,” Mr. Pollan said.
Respondents said that doctors, nurses, and scientists were the most trusted source of information about psychedelics, whereas the FDA received lower confidence. Law enforcement was least trusted by liberals and most trusted by conservatives.
Mr. Pollan noted the reversal in attitudes, with Americans mostly now looking to the scientific and medical establishment for guidance on psychedelics.
“We went from a counterculture drug to something that is being taken seriously by scientists as a potential therapy,” he said.
The poll’s margin of error was ± 2.5%.
A version of this article first appeared on Medscape.com.
It is a surprisingly large percentage, said officials at the University of California, Berkeley, Center for the Science of Psychedelics, which conducted the online survey of 1,500 registered voters in early June.
“That is a stunning number,” said Michael Pollan, cofounder of the center, and author of “How to Change Your Mind,” a book that explored potential uses of psychedelics.
In a briefing with reporters, Mr. Pollan said that he believes the large support base, in part, reflects campaigns that have “been successful by highlighting the effectiveness of psychedelics as therapy for mental illness.”
However, the poll also showed that 61% of voters said that they do not perceive psychedelics as “good for society,” and 69% do not perceive them as “something for people like me.”
These negative sentiments “suggest a fragile kind of support – the kind of support where you’re only hearing one side of the story,” said Mr. Pollan.
Still, poll respondents supported other potential policy changes, including 56% in support of the U.S. Food and Drug Administration vetting and approving psychedelics so they could be available by prescription.
50% have tried psychedelics
Almost 80% said that it should be easier for researchers to study psychedelics, and just under one-half said that they backed removing criminal penalties for personal use and possession.
The poll results also show that almost half of respondents had heard about psychedelics recently, with 48% saying they had heard about the drugs’ use in treating mental illness.
Respondents who were most familiar with and positive about psychedelics tended to be White, male, aged 30-50 years, liberal, highly educated, living in a Western state, and have little to no religious or spiritual practice.
Overall, 52% of survey respondents said that they or someone close to them had used a psychedelic, with almost half of that use coming in the past 5 years. Some 40% said that the use had been more than a decade ago.
Almost three-quarters of psychedelic use was reported as recreational, but the second-biggest category was therapeutic use at 39%. About one-third of respondents said that they or someone close to them had microdosed.
Conservative voters had lower levels of awareness and first-degree connection use as well as the least amount of support for regulated therapeutic use, with only 45% saying they would back such a policy, compared with 80% of liberal voters and 66% of moderate voters.
Black individuals were the least likely to be familiar with psychedelics: Just 29% said that they had heard a little or a lot about the drugs, compared with 39% of Latinx individuals and 51% of White individuals. And just one-quarter reported first-degree use, compared with half of Latinx individuals and 56% of White individuals.
Who should be eligible?
When asked who should be eligible for treatment with psychedelics, 80% said that they were comfortable with its use for those with terminal illnesses. More than two-thirds expressed comfort with the drugs being used to help veterans and people with treatment-resistant depression and anxiety.
Less than one-half of respondents said that psychedelics should be available to everyone older than 21 years. And voters seemed to be less inclined to say psychedelics should be used to treat people with addiction, with just 45% indicating that they were very or somewhat comfortable with that use.
Mr. Pollan said that reflects perhaps some lack of knowledge or education.
“The story about addiction and psychedelics hasn’t gotten out,” he said. “I kind of get that intuitively the idea of using a drug to treat a drug doesn’t sound right to a lot of people. But in fact, there’s good evidence it works,” Mr. Pollan said.
Respondents said that doctors, nurses, and scientists were the most trusted source of information about psychedelics, whereas the FDA received lower confidence. Law enforcement was least trusted by liberals and most trusted by conservatives.
Mr. Pollan noted the reversal in attitudes, with Americans mostly now looking to the scientific and medical establishment for guidance on psychedelics.
“We went from a counterculture drug to something that is being taken seriously by scientists as a potential therapy,” he said.
The poll’s margin of error was ± 2.5%.
A version of this article first appeared on Medscape.com.
Clinical index predicts common postpartum mental health disorders
Developed by Canadian researchers, the easily implementable PMH CAREPLAN index “creates a framework for clinically actionable risk stratification that could assist patients and providers in determining an individual’s level of risk for common postpartum mental health disorders and direct them to appropriate intervention,” wrote a group led by Simone N. Vigod, MD, MSc, head of the department of psychiatry at Women’s College Hospital, Toronto, in the British Journal of Psychiatry.
After giving birth, women are especially vulnerable to major depression, anxiety, PTSD, and obsessive-compulsive disorder, which have a general postpartum prevalence of 7%-20%.
Common PMH disorders are to be distinguished from the more rare but severe PMH disorders such as postpartum psychosis and bipolar disorder, the researchers stressed.
“We know there are interventions that can prevent these disorders, but these seem to work best in people who are at high risk for developing the illnesses, “ Dr. Vigod said. “So, we wanted to be able to determine the level of risk that a person might actually experience them.”
In an ideal world, she continued, physicians might be able to say to a patient: “You have a 50% chance of developing postpartum depression and anxiety, so it may be worth investing your time and resources in a course of preventive psychotherapy.” Or: “You have a 90% chance of developing these disorders, so it might be worth going back on your medications even though you are breastfeeding.” Or: “You have only a 1% chance of developing them, so probably it’s not worthwhile to go back on your medication prophylactically.”
A need for a new assessment tool, akin to the Framingham Risk Score for 10-year cardiovascular events and the FRAX scoring system for 10-year fracture risk, was evident since previous indices based largely on patient self-reporting have had moderate predictive capacity, and have not been adopted in clinical practice, Dr. Vigod and associates noted.
Split-cohort design
Using population-based health administrative data and hospital birth records from Ontario during 2012-2015, Dr. Vigod’s group created and internally validated a predictive model for common PMH disorders in a cohort of 152,362 mothers. They then converted it to a risk index after validation in an additional cohort of 75,772 mothers. The women had delivered live infants during 2012-2014.
A common PMH disorder occurred in 13,608 mothers, while 214,526 were unaffected.
Independently associated PMH variables were many: prenatal care provider, mental health diagnosis history and medications during pregnancy, psychiatric hospital admissions or ED visits, conception type and complications, and apprehension of newborn by child services. Other factors were region of maternal origin, extremes of gestational age at birth, primary maternal language, lactation intention, maternal age, and number of prenatal visits.
Based on a broad span of scores from 0 to 39, 1-year common PMH disorder risk ranged from 1.5% to 40.5%, with an overall 1-year prevalence of 6%, consistent with previous studies. That included 11,262 (5%) mothers with an anxiety or related disorder, 3,392 (1.5%) with a depressive episode, and 1,046 (0.5%) with both. The best trade-off of sensitivity/specificity for risk appeared to be at a screening threshold score of 17 or above.
Risk drivers
PMH-affected mothers were slightly younger than unaffected women (mean age, 29.9 years vs. 30.6 years), more likely to be primiparous (45.2% vs. 42%), and less likely to be recent immigrants (16.7% vs. 27.2%).
They were also more likely to have previously experienced postpartum depression (4.4% vs. 1.4%), any depression (15.3% vs. 4.4%), and any anxiety disorder (13.8% vs. 4.3%).
As to lifestyle, smoking was more common in women with PMH (15.0% vs. 10.2%), as were the use of nonprescribed substances (3% vs. 1.4%) and intimate partner violence in pregnancy (2.7% vs. 1.5%).
In addition, the affected group experienced more pregnancy complications than their unaffected peers (16% vs. 13.9%), preterm birth (8.2% vs. 6.8%), and Apgar scores below 7 at 1 or 5 minutes (10.5% vs. 7.6%).
Low income did not appear to have an impact since just over 20% in either group fell into the lowest neighborhood income quintile.
Commenting on the index but not involved in developing it, LaTasha D. Nelson, MD, an associate professor or medicine and a maternal-fetal medicine specialist at Northwestern Medicine in Chicago, doubted the Canadian model would work as well in the more fragmented U.S. health care system, compared with Canada’s universal model with its large provincial health databases.
She also found the large number of variables and broad score range potentially problematic, especially if the risk threshold is set at less than half the maximum score at 17, at which some low-risk mothers might get screening and perhaps intervention. “Are we going to use up the resources we have for those who might not need help, or are we going to treat someone who really needs it?” she asked.
Another concern is the postpartum timing of assessment. At Dr. Nelson’s center, mothers are checked for mental health at two points during pregnancy and those with higher scores are triaged for further care.
Dr. Nelson was also puzzled by the score-lowering impact of prenatal care given by a nurse practitioner and “other” provider : –5 and –2, respectively, versus +3 for a midwife and +1 for a family doctor. “This may capture more relaxed, easy-going multiparous mothers who felt comfortable turning to an NP,” she said.
It may indeed reflect that the risk level of a person who sees those providers is overall lower, Dr. Vigod agreed. “This is one reason why we would want to see replication of these results in other jurisdictions and by other ways of diagnosis before putting it out into clinical practice.”
As to the score-lowering effect of not speaking English as the primary tongue, Dr. Nelson wondered, “is that because we’re taking better care of mothers who speak the main language and missing those who speak other languages? Are they not getting the same level of interrogation?”
It may be that individuals in these groups were less likely to access mental health care, Dr. Vigod agreed, or it might reflect the so-called healthy immigrant effect or culturally different levels of postpartum support. “It might mean that there are more people who benefit from community-level protective factors in these groups. We know that social support is an important protective factor.”
Despite her reservations about the index, Dr. Nelson said that increasing attention to the pre- and postnatal mental health of mothers is an important part of maternal care. “This is an issue that needs to be recognized.”
The next step, Dr. Vigod said, is to determine whether the index holds up in other populations. “Then, we would want to test it out to see if recommending interventions based on a certain level of risk improves outcomes. At what percentage risk would starting an antidepressant medication result in a reduced risk for postpartum depression or anxiety – 90%, 80%, 70%, or less?”
The study received funding from the Canadian Institutes of Health Research. Data were analyzed by ICES, an independent nonprofit research organization that holds population-based data. Dr. Vigod reported royalties from UpToDate for materials related to depression and pregnancy. Dr. Nelson disclosed no relevant competing interests.
Developed by Canadian researchers, the easily implementable PMH CAREPLAN index “creates a framework for clinically actionable risk stratification that could assist patients and providers in determining an individual’s level of risk for common postpartum mental health disorders and direct them to appropriate intervention,” wrote a group led by Simone N. Vigod, MD, MSc, head of the department of psychiatry at Women’s College Hospital, Toronto, in the British Journal of Psychiatry.
After giving birth, women are especially vulnerable to major depression, anxiety, PTSD, and obsessive-compulsive disorder, which have a general postpartum prevalence of 7%-20%.
Common PMH disorders are to be distinguished from the more rare but severe PMH disorders such as postpartum psychosis and bipolar disorder, the researchers stressed.
“We know there are interventions that can prevent these disorders, but these seem to work best in people who are at high risk for developing the illnesses, “ Dr. Vigod said. “So, we wanted to be able to determine the level of risk that a person might actually experience them.”
In an ideal world, she continued, physicians might be able to say to a patient: “You have a 50% chance of developing postpartum depression and anxiety, so it may be worth investing your time and resources in a course of preventive psychotherapy.” Or: “You have a 90% chance of developing these disorders, so it might be worth going back on your medications even though you are breastfeeding.” Or: “You have only a 1% chance of developing them, so probably it’s not worthwhile to go back on your medication prophylactically.”
A need for a new assessment tool, akin to the Framingham Risk Score for 10-year cardiovascular events and the FRAX scoring system for 10-year fracture risk, was evident since previous indices based largely on patient self-reporting have had moderate predictive capacity, and have not been adopted in clinical practice, Dr. Vigod and associates noted.
Split-cohort design
Using population-based health administrative data and hospital birth records from Ontario during 2012-2015, Dr. Vigod’s group created and internally validated a predictive model for common PMH disorders in a cohort of 152,362 mothers. They then converted it to a risk index after validation in an additional cohort of 75,772 mothers. The women had delivered live infants during 2012-2014.
A common PMH disorder occurred in 13,608 mothers, while 214,526 were unaffected.
Independently associated PMH variables were many: prenatal care provider, mental health diagnosis history and medications during pregnancy, psychiatric hospital admissions or ED visits, conception type and complications, and apprehension of newborn by child services. Other factors were region of maternal origin, extremes of gestational age at birth, primary maternal language, lactation intention, maternal age, and number of prenatal visits.
Based on a broad span of scores from 0 to 39, 1-year common PMH disorder risk ranged from 1.5% to 40.5%, with an overall 1-year prevalence of 6%, consistent with previous studies. That included 11,262 (5%) mothers with an anxiety or related disorder, 3,392 (1.5%) with a depressive episode, and 1,046 (0.5%) with both. The best trade-off of sensitivity/specificity for risk appeared to be at a screening threshold score of 17 or above.
Risk drivers
PMH-affected mothers were slightly younger than unaffected women (mean age, 29.9 years vs. 30.6 years), more likely to be primiparous (45.2% vs. 42%), and less likely to be recent immigrants (16.7% vs. 27.2%).
They were also more likely to have previously experienced postpartum depression (4.4% vs. 1.4%), any depression (15.3% vs. 4.4%), and any anxiety disorder (13.8% vs. 4.3%).
As to lifestyle, smoking was more common in women with PMH (15.0% vs. 10.2%), as were the use of nonprescribed substances (3% vs. 1.4%) and intimate partner violence in pregnancy (2.7% vs. 1.5%).
In addition, the affected group experienced more pregnancy complications than their unaffected peers (16% vs. 13.9%), preterm birth (8.2% vs. 6.8%), and Apgar scores below 7 at 1 or 5 minutes (10.5% vs. 7.6%).
Low income did not appear to have an impact since just over 20% in either group fell into the lowest neighborhood income quintile.
Commenting on the index but not involved in developing it, LaTasha D. Nelson, MD, an associate professor or medicine and a maternal-fetal medicine specialist at Northwestern Medicine in Chicago, doubted the Canadian model would work as well in the more fragmented U.S. health care system, compared with Canada’s universal model with its large provincial health databases.
She also found the large number of variables and broad score range potentially problematic, especially if the risk threshold is set at less than half the maximum score at 17, at which some low-risk mothers might get screening and perhaps intervention. “Are we going to use up the resources we have for those who might not need help, or are we going to treat someone who really needs it?” she asked.
Another concern is the postpartum timing of assessment. At Dr. Nelson’s center, mothers are checked for mental health at two points during pregnancy and those with higher scores are triaged for further care.
Dr. Nelson was also puzzled by the score-lowering impact of prenatal care given by a nurse practitioner and “other” provider : –5 and –2, respectively, versus +3 for a midwife and +1 for a family doctor. “This may capture more relaxed, easy-going multiparous mothers who felt comfortable turning to an NP,” she said.
It may indeed reflect that the risk level of a person who sees those providers is overall lower, Dr. Vigod agreed. “This is one reason why we would want to see replication of these results in other jurisdictions and by other ways of diagnosis before putting it out into clinical practice.”
As to the score-lowering effect of not speaking English as the primary tongue, Dr. Nelson wondered, “is that because we’re taking better care of mothers who speak the main language and missing those who speak other languages? Are they not getting the same level of interrogation?”
It may be that individuals in these groups were less likely to access mental health care, Dr. Vigod agreed, or it might reflect the so-called healthy immigrant effect or culturally different levels of postpartum support. “It might mean that there are more people who benefit from community-level protective factors in these groups. We know that social support is an important protective factor.”
Despite her reservations about the index, Dr. Nelson said that increasing attention to the pre- and postnatal mental health of mothers is an important part of maternal care. “This is an issue that needs to be recognized.”
The next step, Dr. Vigod said, is to determine whether the index holds up in other populations. “Then, we would want to test it out to see if recommending interventions based on a certain level of risk improves outcomes. At what percentage risk would starting an antidepressant medication result in a reduced risk for postpartum depression or anxiety – 90%, 80%, 70%, or less?”
The study received funding from the Canadian Institutes of Health Research. Data were analyzed by ICES, an independent nonprofit research organization that holds population-based data. Dr. Vigod reported royalties from UpToDate for materials related to depression and pregnancy. Dr. Nelson disclosed no relevant competing interests.
Developed by Canadian researchers, the easily implementable PMH CAREPLAN index “creates a framework for clinically actionable risk stratification that could assist patients and providers in determining an individual’s level of risk for common postpartum mental health disorders and direct them to appropriate intervention,” wrote a group led by Simone N. Vigod, MD, MSc, head of the department of psychiatry at Women’s College Hospital, Toronto, in the British Journal of Psychiatry.
After giving birth, women are especially vulnerable to major depression, anxiety, PTSD, and obsessive-compulsive disorder, which have a general postpartum prevalence of 7%-20%.
Common PMH disorders are to be distinguished from the more rare but severe PMH disorders such as postpartum psychosis and bipolar disorder, the researchers stressed.
“We know there are interventions that can prevent these disorders, but these seem to work best in people who are at high risk for developing the illnesses, “ Dr. Vigod said. “So, we wanted to be able to determine the level of risk that a person might actually experience them.”
In an ideal world, she continued, physicians might be able to say to a patient: “You have a 50% chance of developing postpartum depression and anxiety, so it may be worth investing your time and resources in a course of preventive psychotherapy.” Or: “You have a 90% chance of developing these disorders, so it might be worth going back on your medications even though you are breastfeeding.” Or: “You have only a 1% chance of developing them, so probably it’s not worthwhile to go back on your medication prophylactically.”
A need for a new assessment tool, akin to the Framingham Risk Score for 10-year cardiovascular events and the FRAX scoring system for 10-year fracture risk, was evident since previous indices based largely on patient self-reporting have had moderate predictive capacity, and have not been adopted in clinical practice, Dr. Vigod and associates noted.
Split-cohort design
Using population-based health administrative data and hospital birth records from Ontario during 2012-2015, Dr. Vigod’s group created and internally validated a predictive model for common PMH disorders in a cohort of 152,362 mothers. They then converted it to a risk index after validation in an additional cohort of 75,772 mothers. The women had delivered live infants during 2012-2014.
A common PMH disorder occurred in 13,608 mothers, while 214,526 were unaffected.
Independently associated PMH variables were many: prenatal care provider, mental health diagnosis history and medications during pregnancy, psychiatric hospital admissions or ED visits, conception type and complications, and apprehension of newborn by child services. Other factors were region of maternal origin, extremes of gestational age at birth, primary maternal language, lactation intention, maternal age, and number of prenatal visits.
Based on a broad span of scores from 0 to 39, 1-year common PMH disorder risk ranged from 1.5% to 40.5%, with an overall 1-year prevalence of 6%, consistent with previous studies. That included 11,262 (5%) mothers with an anxiety or related disorder, 3,392 (1.5%) with a depressive episode, and 1,046 (0.5%) with both. The best trade-off of sensitivity/specificity for risk appeared to be at a screening threshold score of 17 or above.
Risk drivers
PMH-affected mothers were slightly younger than unaffected women (mean age, 29.9 years vs. 30.6 years), more likely to be primiparous (45.2% vs. 42%), and less likely to be recent immigrants (16.7% vs. 27.2%).
They were also more likely to have previously experienced postpartum depression (4.4% vs. 1.4%), any depression (15.3% vs. 4.4%), and any anxiety disorder (13.8% vs. 4.3%).
As to lifestyle, smoking was more common in women with PMH (15.0% vs. 10.2%), as were the use of nonprescribed substances (3% vs. 1.4%) and intimate partner violence in pregnancy (2.7% vs. 1.5%).
In addition, the affected group experienced more pregnancy complications than their unaffected peers (16% vs. 13.9%), preterm birth (8.2% vs. 6.8%), and Apgar scores below 7 at 1 or 5 minutes (10.5% vs. 7.6%).
Low income did not appear to have an impact since just over 20% in either group fell into the lowest neighborhood income quintile.
Commenting on the index but not involved in developing it, LaTasha D. Nelson, MD, an associate professor or medicine and a maternal-fetal medicine specialist at Northwestern Medicine in Chicago, doubted the Canadian model would work as well in the more fragmented U.S. health care system, compared with Canada’s universal model with its large provincial health databases.
She also found the large number of variables and broad score range potentially problematic, especially if the risk threshold is set at less than half the maximum score at 17, at which some low-risk mothers might get screening and perhaps intervention. “Are we going to use up the resources we have for those who might not need help, or are we going to treat someone who really needs it?” she asked.
Another concern is the postpartum timing of assessment. At Dr. Nelson’s center, mothers are checked for mental health at two points during pregnancy and those with higher scores are triaged for further care.
Dr. Nelson was also puzzled by the score-lowering impact of prenatal care given by a nurse practitioner and “other” provider : –5 and –2, respectively, versus +3 for a midwife and +1 for a family doctor. “This may capture more relaxed, easy-going multiparous mothers who felt comfortable turning to an NP,” she said.
It may indeed reflect that the risk level of a person who sees those providers is overall lower, Dr. Vigod agreed. “This is one reason why we would want to see replication of these results in other jurisdictions and by other ways of diagnosis before putting it out into clinical practice.”
As to the score-lowering effect of not speaking English as the primary tongue, Dr. Nelson wondered, “is that because we’re taking better care of mothers who speak the main language and missing those who speak other languages? Are they not getting the same level of interrogation?”
It may be that individuals in these groups were less likely to access mental health care, Dr. Vigod agreed, or it might reflect the so-called healthy immigrant effect or culturally different levels of postpartum support. “It might mean that there are more people who benefit from community-level protective factors in these groups. We know that social support is an important protective factor.”
Despite her reservations about the index, Dr. Nelson said that increasing attention to the pre- and postnatal mental health of mothers is an important part of maternal care. “This is an issue that needs to be recognized.”
The next step, Dr. Vigod said, is to determine whether the index holds up in other populations. “Then, we would want to test it out to see if recommending interventions based on a certain level of risk improves outcomes. At what percentage risk would starting an antidepressant medication result in a reduced risk for postpartum depression or anxiety – 90%, 80%, 70%, or less?”
The study received funding from the Canadian Institutes of Health Research. Data were analyzed by ICES, an independent nonprofit research organization that holds population-based data. Dr. Vigod reported royalties from UpToDate for materials related to depression and pregnancy. Dr. Nelson disclosed no relevant competing interests.
FROM THE BRITISH JOURNAL OF PSYCHIATRY
Keep depression, anxiety screening top of mind in patients with psoriatic disease
DUBLIN – , warranting routine screening and having community contacts for mental health professional referrals, Elizabeth Wallace, MD, said at the annual meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis.
Dr. Wallace, of Cherry Hills Dermatology, Englewood, Colo., discussed the complex interactions between mental illness and psoriatic disease and the potential pitfalls of this comorbidity for these patients.
The topic of mental health is “consistently at the top of our patients’ minds, and certainly our minds too,” said session comoderator and GRAPPA president-elect Joseph F. Merola, MD, MMSc.
“In the U.S., around 17% of people with psoriasis have depression vs. 9% in those without psoriasis,” Dr. Wallace explained. “Psoriasis patients are twice as likely to have depression, compared to those without psoriasis, and psoriasis patients are 33% more likely to attempt suicide and 20% more likely to complete suicide, compared to those without psoriasis.” More severe psoriasis and younger age of onset are also associated with a greater likelihood of suicidality, she added.
Mediators of depression
“The inflammatory mechanisms driving PsD can drive depression and anxiety, and vice-versa,” she said. “There are often also genetic links, for example genetic variations in serotonin receptors, and psychological issues in psoriatic disease are predictably worsened by feelings of stigmatization, embarrassment, and social isolation.”
There are also efforts underway in clinics to “normalize” screening for anxiety and depression among this patient cohort, Dr. Wallace said. “We know that our psoriasis patients face social stigma from the visibility of their disease, and that stress can lead to flares of their condition,” she told the attendees. “We also know that patients who experience stigma also have an increased risk of depressive symptoms. We all know now that psoriasis has well-established pathways with upregulated proinflammatory cytokines.
“Increased cytokines stimulate indoleamine 2,3-dioxygenase, which converts tryptophan to kynurenine. Kynurenine is metabolized to quinolinic acid, which is neurotoxic.” She explained that because serotonin derives from tryptophan, decreases in tryptophan lead to reduced serotonin, and therefore increased risk of depression.
Interleukin-6 is known to be upregulated in depression and downregulated with the use of antidepressant medications, Dr. Wallace said. Mouse models in research have shown that deletion of the IL-6 gene produces antidepressant effects, and studies in humans have shown that IL-6, more than any other serum cytokine, is found at higher levels in humans with depression and psoriatic disease.
IL-17 is also implicated in psoriatic disease and mental health problems, Dr. Wallace said. “With stress, you get upregulation of the Tc17 cells, which produce IL-17,” she explained. “IL-17, along with other inflammatory markers, can actually make the blood-brain barrier more permeable, and when you get more permeability to the blood-brain barrier, you get these cytokines that can cross from the periphery and into the brain.
“With this crossing into the brain, you get further activation of more Th17 [cells] and that, on neurons, leads to increased potassium production, which is directly neurotoxic, so you get neuron destruction.”
Talking about depression
“So, what can we share with our patients?” Dr. Wallace asked. “We can discuss with them that psoriatic patients in general are more likely to be depressed or to have higher rates of suicide. The literature consistently shows that patients whose psoriasis is successfully treated experience reduced depression, and we can provide an understandable review of systemic medications, with warnings on depression and/or suicidality.”
Dr. Wallace advised to screen for depression with the Patient Health Questionnaire-2 (PHQ-2), a validated, two-item tool that asks, “Over the past 2 weeks, how often have you been bothered by having little interest or pleasure in doing things?” and “Over the past 2 weeks, how often have you been bothered by feeling down, depressed, or hopeless?”
She presented a case study illustrative of the type of presentation she sees in her clinic. It involved a 32-year-old man with plaque psoriasis and a high degree of body surface affected. “It’s now July in Colorado, it’s getting warm, people want to wear their shorts and T-shirts, but he said he could no longer hide his psoriasis,” said Dr. Wallace. “Further, it’s in areas that he cannot hide, such as his scalp, his beard, and he also has nail disease. Often, these patients don’t want to shake hands with their bosses or their colleagues and that’s very embarrassing for them.”
Dr. Wallace explained that this patient had seen advertisements for biologic drugs and requested to commence a treatment course. “During the exam, and now that you are developing some rapport with him, you discover that he is feeling down, is embarrassed at work, and has started to avoid social situations.” This is illustrative of a patient who should be screened for mental health conditions, specifically using PHQ-2, she said.
“You can be the person at the front line to screen these patients for mental health conditions, and, specifically for depression, with PHQ-2,” she said. PHQ-2 scores range from 0 to 6, and a score of 3 or higher is considered a positive screen.
“This is where your relationship with another health provider who is most qualified to care for these patients and validate them for their mental health condition can be absolutely critical,” Dr. Wallace said.
Successful PsD treatment lessens the risk for mental health comorbidities, and this is also seen in psoriatic arthritis, Dr. Wallace pointed out. Patient education is critical regarding their increased risk for depression and potential suicidal ideation, she added.
“It’s our job as clinicians to provide patients with an understandable, easy-to-digest review of systemic medications and warnings on depression and suicidality so that they can be aware of these factors.”
Perspective from Dr. Merola
In an interview, Dr. Merola, a double board-certified dermatologist and rheumatologist at Brigham and Women’s Hospital, Boston, discussed the interactions between mental and physical illness.
“One of the things we are learning is that it’s very much a multifactorial issue, in that skin and joints contribute, in some obvious ways, to anxiety and depression, like the fact that somebody doesn’t feel good about their appearance, or they can’t complete daily activities,” he said. “Those are the more obvious ones. But there is data and evidence that there is a biology behind that as well – inflammatory cytokines that drive skin disease probably also have a direct impact on the CNS and probably also drive anxiety and depression.
“We know that disordered sleep contributes to anxiety – think about how we feel if we get a horrible night’s sleep ... it’s hard to pick apart: ‘Am I depressed, am I anxious because I am having too much coffee? Because I am fatigued?’ So, we get into these circles, but the point is, we have to break these cycles, and we have to do it in multiple places. Yes, we have to fix the skin and the joints, but we also have to have interventions and think about how to screen for anxiety and depression. We also have to think about identifying disordered sleep, and how we intervene there as well.”
These challenges require a collaborative approach among physicians. “We can help patients to build their team that gets them help for their skin, for their joints, for their anxiety or depression, their disordered sleep, for their nutritional disorders, their obesity, and so on. So, we are trying to pick apart and unpack those complexities,” he said.
In regard to the potential impacts of this holistic strategy on physician workloads, Dr. Merola acknowledged it is important to consider physician wellness. “There’s no question that we want to be doing the best we can for our colleagues, but we don’t want to overload our colleagues by saying, ‘By the way, not only should we be treating their skin and joints,’ which of course we should be doing, but ‘could you also manage their diabetes, their obesity, their disordered sleep, their anxiety, their depression, difficulties with insurance, getting access to treatments, etc.’
“This is where effective collaboration between physicians becomes important,” he stressed. “We can’t manage every single piece, but we can make sure our patients are informed, are aware, and assist them to get the help that they need.”
In the United States, there “is a real issue” with access to mental health care and greater awareness needs to be created around this issue, he added.
Dr. Wallace and Dr. Merola report no relevant financial relationships.
A version of this article first appeared on Medscape.com.
DUBLIN – , warranting routine screening and having community contacts for mental health professional referrals, Elizabeth Wallace, MD, said at the annual meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis.
Dr. Wallace, of Cherry Hills Dermatology, Englewood, Colo., discussed the complex interactions between mental illness and psoriatic disease and the potential pitfalls of this comorbidity for these patients.
The topic of mental health is “consistently at the top of our patients’ minds, and certainly our minds too,” said session comoderator and GRAPPA president-elect Joseph F. Merola, MD, MMSc.
“In the U.S., around 17% of people with psoriasis have depression vs. 9% in those without psoriasis,” Dr. Wallace explained. “Psoriasis patients are twice as likely to have depression, compared to those without psoriasis, and psoriasis patients are 33% more likely to attempt suicide and 20% more likely to complete suicide, compared to those without psoriasis.” More severe psoriasis and younger age of onset are also associated with a greater likelihood of suicidality, she added.
Mediators of depression
“The inflammatory mechanisms driving PsD can drive depression and anxiety, and vice-versa,” she said. “There are often also genetic links, for example genetic variations in serotonin receptors, and psychological issues in psoriatic disease are predictably worsened by feelings of stigmatization, embarrassment, and social isolation.”
There are also efforts underway in clinics to “normalize” screening for anxiety and depression among this patient cohort, Dr. Wallace said. “We know that our psoriasis patients face social stigma from the visibility of their disease, and that stress can lead to flares of their condition,” she told the attendees. “We also know that patients who experience stigma also have an increased risk of depressive symptoms. We all know now that psoriasis has well-established pathways with upregulated proinflammatory cytokines.
“Increased cytokines stimulate indoleamine 2,3-dioxygenase, which converts tryptophan to kynurenine. Kynurenine is metabolized to quinolinic acid, which is neurotoxic.” She explained that because serotonin derives from tryptophan, decreases in tryptophan lead to reduced serotonin, and therefore increased risk of depression.
Interleukin-6 is known to be upregulated in depression and downregulated with the use of antidepressant medications, Dr. Wallace said. Mouse models in research have shown that deletion of the IL-6 gene produces antidepressant effects, and studies in humans have shown that IL-6, more than any other serum cytokine, is found at higher levels in humans with depression and psoriatic disease.
IL-17 is also implicated in psoriatic disease and mental health problems, Dr. Wallace said. “With stress, you get upregulation of the Tc17 cells, which produce IL-17,” she explained. “IL-17, along with other inflammatory markers, can actually make the blood-brain barrier more permeable, and when you get more permeability to the blood-brain barrier, you get these cytokines that can cross from the periphery and into the brain.
“With this crossing into the brain, you get further activation of more Th17 [cells] and that, on neurons, leads to increased potassium production, which is directly neurotoxic, so you get neuron destruction.”
Talking about depression
“So, what can we share with our patients?” Dr. Wallace asked. “We can discuss with them that psoriatic patients in general are more likely to be depressed or to have higher rates of suicide. The literature consistently shows that patients whose psoriasis is successfully treated experience reduced depression, and we can provide an understandable review of systemic medications, with warnings on depression and/or suicidality.”
Dr. Wallace advised to screen for depression with the Patient Health Questionnaire-2 (PHQ-2), a validated, two-item tool that asks, “Over the past 2 weeks, how often have you been bothered by having little interest or pleasure in doing things?” and “Over the past 2 weeks, how often have you been bothered by feeling down, depressed, or hopeless?”
She presented a case study illustrative of the type of presentation she sees in her clinic. It involved a 32-year-old man with plaque psoriasis and a high degree of body surface affected. “It’s now July in Colorado, it’s getting warm, people want to wear their shorts and T-shirts, but he said he could no longer hide his psoriasis,” said Dr. Wallace. “Further, it’s in areas that he cannot hide, such as his scalp, his beard, and he also has nail disease. Often, these patients don’t want to shake hands with their bosses or their colleagues and that’s very embarrassing for them.”
Dr. Wallace explained that this patient had seen advertisements for biologic drugs and requested to commence a treatment course. “During the exam, and now that you are developing some rapport with him, you discover that he is feeling down, is embarrassed at work, and has started to avoid social situations.” This is illustrative of a patient who should be screened for mental health conditions, specifically using PHQ-2, she said.
“You can be the person at the front line to screen these patients for mental health conditions, and, specifically for depression, with PHQ-2,” she said. PHQ-2 scores range from 0 to 6, and a score of 3 or higher is considered a positive screen.
“This is where your relationship with another health provider who is most qualified to care for these patients and validate them for their mental health condition can be absolutely critical,” Dr. Wallace said.
Successful PsD treatment lessens the risk for mental health comorbidities, and this is also seen in psoriatic arthritis, Dr. Wallace pointed out. Patient education is critical regarding their increased risk for depression and potential suicidal ideation, she added.
“It’s our job as clinicians to provide patients with an understandable, easy-to-digest review of systemic medications and warnings on depression and suicidality so that they can be aware of these factors.”
Perspective from Dr. Merola
In an interview, Dr. Merola, a double board-certified dermatologist and rheumatologist at Brigham and Women’s Hospital, Boston, discussed the interactions between mental and physical illness.
“One of the things we are learning is that it’s very much a multifactorial issue, in that skin and joints contribute, in some obvious ways, to anxiety and depression, like the fact that somebody doesn’t feel good about their appearance, or they can’t complete daily activities,” he said. “Those are the more obvious ones. But there is data and evidence that there is a biology behind that as well – inflammatory cytokines that drive skin disease probably also have a direct impact on the CNS and probably also drive anxiety and depression.
“We know that disordered sleep contributes to anxiety – think about how we feel if we get a horrible night’s sleep ... it’s hard to pick apart: ‘Am I depressed, am I anxious because I am having too much coffee? Because I am fatigued?’ So, we get into these circles, but the point is, we have to break these cycles, and we have to do it in multiple places. Yes, we have to fix the skin and the joints, but we also have to have interventions and think about how to screen for anxiety and depression. We also have to think about identifying disordered sleep, and how we intervene there as well.”
These challenges require a collaborative approach among physicians. “We can help patients to build their team that gets them help for their skin, for their joints, for their anxiety or depression, their disordered sleep, for their nutritional disorders, their obesity, and so on. So, we are trying to pick apart and unpack those complexities,” he said.
In regard to the potential impacts of this holistic strategy on physician workloads, Dr. Merola acknowledged it is important to consider physician wellness. “There’s no question that we want to be doing the best we can for our colleagues, but we don’t want to overload our colleagues by saying, ‘By the way, not only should we be treating their skin and joints,’ which of course we should be doing, but ‘could you also manage their diabetes, their obesity, their disordered sleep, their anxiety, their depression, difficulties with insurance, getting access to treatments, etc.’
“This is where effective collaboration between physicians becomes important,” he stressed. “We can’t manage every single piece, but we can make sure our patients are informed, are aware, and assist them to get the help that they need.”
In the United States, there “is a real issue” with access to mental health care and greater awareness needs to be created around this issue, he added.
Dr. Wallace and Dr. Merola report no relevant financial relationships.
A version of this article first appeared on Medscape.com.
DUBLIN – , warranting routine screening and having community contacts for mental health professional referrals, Elizabeth Wallace, MD, said at the annual meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis.
Dr. Wallace, of Cherry Hills Dermatology, Englewood, Colo., discussed the complex interactions between mental illness and psoriatic disease and the potential pitfalls of this comorbidity for these patients.
The topic of mental health is “consistently at the top of our patients’ minds, and certainly our minds too,” said session comoderator and GRAPPA president-elect Joseph F. Merola, MD, MMSc.
“In the U.S., around 17% of people with psoriasis have depression vs. 9% in those without psoriasis,” Dr. Wallace explained. “Psoriasis patients are twice as likely to have depression, compared to those without psoriasis, and psoriasis patients are 33% more likely to attempt suicide and 20% more likely to complete suicide, compared to those without psoriasis.” More severe psoriasis and younger age of onset are also associated with a greater likelihood of suicidality, she added.
Mediators of depression
“The inflammatory mechanisms driving PsD can drive depression and anxiety, and vice-versa,” she said. “There are often also genetic links, for example genetic variations in serotonin receptors, and psychological issues in psoriatic disease are predictably worsened by feelings of stigmatization, embarrassment, and social isolation.”
There are also efforts underway in clinics to “normalize” screening for anxiety and depression among this patient cohort, Dr. Wallace said. “We know that our psoriasis patients face social stigma from the visibility of their disease, and that stress can lead to flares of their condition,” she told the attendees. “We also know that patients who experience stigma also have an increased risk of depressive symptoms. We all know now that psoriasis has well-established pathways with upregulated proinflammatory cytokines.
“Increased cytokines stimulate indoleamine 2,3-dioxygenase, which converts tryptophan to kynurenine. Kynurenine is metabolized to quinolinic acid, which is neurotoxic.” She explained that because serotonin derives from tryptophan, decreases in tryptophan lead to reduced serotonin, and therefore increased risk of depression.
Interleukin-6 is known to be upregulated in depression and downregulated with the use of antidepressant medications, Dr. Wallace said. Mouse models in research have shown that deletion of the IL-6 gene produces antidepressant effects, and studies in humans have shown that IL-6, more than any other serum cytokine, is found at higher levels in humans with depression and psoriatic disease.
IL-17 is also implicated in psoriatic disease and mental health problems, Dr. Wallace said. “With stress, you get upregulation of the Tc17 cells, which produce IL-17,” she explained. “IL-17, along with other inflammatory markers, can actually make the blood-brain barrier more permeable, and when you get more permeability to the blood-brain barrier, you get these cytokines that can cross from the periphery and into the brain.
“With this crossing into the brain, you get further activation of more Th17 [cells] and that, on neurons, leads to increased potassium production, which is directly neurotoxic, so you get neuron destruction.”
Talking about depression
“So, what can we share with our patients?” Dr. Wallace asked. “We can discuss with them that psoriatic patients in general are more likely to be depressed or to have higher rates of suicide. The literature consistently shows that patients whose psoriasis is successfully treated experience reduced depression, and we can provide an understandable review of systemic medications, with warnings on depression and/or suicidality.”
Dr. Wallace advised to screen for depression with the Patient Health Questionnaire-2 (PHQ-2), a validated, two-item tool that asks, “Over the past 2 weeks, how often have you been bothered by having little interest or pleasure in doing things?” and “Over the past 2 weeks, how often have you been bothered by feeling down, depressed, or hopeless?”
She presented a case study illustrative of the type of presentation she sees in her clinic. It involved a 32-year-old man with plaque psoriasis and a high degree of body surface affected. “It’s now July in Colorado, it’s getting warm, people want to wear their shorts and T-shirts, but he said he could no longer hide his psoriasis,” said Dr. Wallace. “Further, it’s in areas that he cannot hide, such as his scalp, his beard, and he also has nail disease. Often, these patients don’t want to shake hands with their bosses or their colleagues and that’s very embarrassing for them.”
Dr. Wallace explained that this patient had seen advertisements for biologic drugs and requested to commence a treatment course. “During the exam, and now that you are developing some rapport with him, you discover that he is feeling down, is embarrassed at work, and has started to avoid social situations.” This is illustrative of a patient who should be screened for mental health conditions, specifically using PHQ-2, she said.
“You can be the person at the front line to screen these patients for mental health conditions, and, specifically for depression, with PHQ-2,” she said. PHQ-2 scores range from 0 to 6, and a score of 3 or higher is considered a positive screen.
“This is where your relationship with another health provider who is most qualified to care for these patients and validate them for their mental health condition can be absolutely critical,” Dr. Wallace said.
Successful PsD treatment lessens the risk for mental health comorbidities, and this is also seen in psoriatic arthritis, Dr. Wallace pointed out. Patient education is critical regarding their increased risk for depression and potential suicidal ideation, she added.
“It’s our job as clinicians to provide patients with an understandable, easy-to-digest review of systemic medications and warnings on depression and suicidality so that they can be aware of these factors.”
Perspective from Dr. Merola
In an interview, Dr. Merola, a double board-certified dermatologist and rheumatologist at Brigham and Women’s Hospital, Boston, discussed the interactions between mental and physical illness.
“One of the things we are learning is that it’s very much a multifactorial issue, in that skin and joints contribute, in some obvious ways, to anxiety and depression, like the fact that somebody doesn’t feel good about their appearance, or they can’t complete daily activities,” he said. “Those are the more obvious ones. But there is data and evidence that there is a biology behind that as well – inflammatory cytokines that drive skin disease probably also have a direct impact on the CNS and probably also drive anxiety and depression.
“We know that disordered sleep contributes to anxiety – think about how we feel if we get a horrible night’s sleep ... it’s hard to pick apart: ‘Am I depressed, am I anxious because I am having too much coffee? Because I am fatigued?’ So, we get into these circles, but the point is, we have to break these cycles, and we have to do it in multiple places. Yes, we have to fix the skin and the joints, but we also have to have interventions and think about how to screen for anxiety and depression. We also have to think about identifying disordered sleep, and how we intervene there as well.”
These challenges require a collaborative approach among physicians. “We can help patients to build their team that gets them help for their skin, for their joints, for their anxiety or depression, their disordered sleep, for their nutritional disorders, their obesity, and so on. So, we are trying to pick apart and unpack those complexities,” he said.
In regard to the potential impacts of this holistic strategy on physician workloads, Dr. Merola acknowledged it is important to consider physician wellness. “There’s no question that we want to be doing the best we can for our colleagues, but we don’t want to overload our colleagues by saying, ‘By the way, not only should we be treating their skin and joints,’ which of course we should be doing, but ‘could you also manage their diabetes, their obesity, their disordered sleep, their anxiety, their depression, difficulties with insurance, getting access to treatments, etc.’
“This is where effective collaboration between physicians becomes important,” he stressed. “We can’t manage every single piece, but we can make sure our patients are informed, are aware, and assist them to get the help that they need.”
In the United States, there “is a real issue” with access to mental health care and greater awareness needs to be created around this issue, he added.
Dr. Wallace and Dr. Merola report no relevant financial relationships.
A version of this article first appeared on Medscape.com.
AT GRAPPA 2023