Depression

With suicide rates among young people rising in recent years, the American Academy of Pediatrics is now recommending adolescents 12 and up be screened for suicide risk as a part of regular preventive care.

The group recently added the recommendation on screening for suicide risk to its depression screening guidelines. Health care providers are urged to ask their young patients a set of questions to identify thoughts and plans for suicide, WDEF.com reported.

“Number one we need to screen for depression and the presence of depression, and those people will usually have a feeling of depressed mood, hopelessness, helplessness, and/or basically a lack of interest in pleasure or anticipation of happiness,” Timothy Fuller, DO, medical director of behavioral health and pediatrics for the American Academy of Pediatrics, told WDEF.

It’s a myth that talking about suicide makes it more likely a person will attempt suicide, he said.

“One of the biggest things you can do, as well, if you do have a child or teenager that has suicidality or that have depression with serious, significant suicide risk, is to just ask them how they’re doing every day,” Dr. Fuller said, according to WDEF.

The recommendation comes about 6 months after U.S. Surgeon General Vivek Murthy, MD, urged more attention be paid to youth mental health.

“Mental health challenges in children, adolescents, and young adults are real and widespread. Even before the pandemic, an alarming number of young people struggled with feelings of helplessness, depression, and thoughts of suicide – and rates have increased over the past decade,” Dr. Murthy said, according to a news release from the U.S. Department of Health & Human Services.

Between 2007 and 2018, suicide rates among people ages 10-24 in the United States went up by 57%, the department said. Estimates showed over 6,600 suicides among this age group in 2020, it said.

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

With suicide rates among young people rising in recent years, the American Academy of Pediatrics is now recommending adolescents 12 and up be screened for suicide risk as a part of regular preventive care.

The group recently added the recommendation on screening for suicide risk to its depression screening guidelines. Health care providers are urged to ask their young patients a set of questions to identify thoughts and plans for suicide, WDEF.com reported.

“Number one we need to screen for depression and the presence of depression, and those people will usually have a feeling of depressed mood, hopelessness, helplessness, and/or basically a lack of interest in pleasure or anticipation of happiness,” Timothy Fuller, DO, medical director of behavioral health and pediatrics for the American Academy of Pediatrics, told WDEF.

It’s a myth that talking about suicide makes it more likely a person will attempt suicide, he said.

“One of the biggest things you can do, as well, if you do have a child or teenager that has suicidality or that have depression with serious, significant suicide risk, is to just ask them how they’re doing every day,” Dr. Fuller said, according to WDEF.

The recommendation comes about 6 months after U.S. Surgeon General Vivek Murthy, MD, urged more attention be paid to youth mental health.

“Mental health challenges in children, adolescents, and young adults are real and widespread. Even before the pandemic, an alarming number of young people struggled with feelings of helplessness, depression, and thoughts of suicide – and rates have increased over the past decade,” Dr. Murthy said, according to a news release from the U.S. Department of Health & Human Services.

Between 2007 and 2018, suicide rates among people ages 10-24 in the United States went up by 57%, the department said. Estimates showed over 6,600 suicides among this age group in 2020, it said.

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

With suicide rates among young people rising in recent years, the American Academy of Pediatrics is now recommending adolescents 12 and up be screened for suicide risk as a part of regular preventive care.

The group recently added the recommendation on screening for suicide risk to its depression screening guidelines. Health care providers are urged to ask their young patients a set of questions to identify thoughts and plans for suicide, WDEF.com reported.

“Number one we need to screen for depression and the presence of depression, and those people will usually have a feeling of depressed mood, hopelessness, helplessness, and/or basically a lack of interest in pleasure or anticipation of happiness,” Timothy Fuller, DO, medical director of behavioral health and pediatrics for the American Academy of Pediatrics, told WDEF.

It’s a myth that talking about suicide makes it more likely a person will attempt suicide, he said.

“One of the biggest things you can do, as well, if you do have a child or teenager that has suicidality or that have depression with serious, significant suicide risk, is to just ask them how they’re doing every day,” Dr. Fuller said, according to WDEF.

The recommendation comes about 6 months after U.S. Surgeon General Vivek Murthy, MD, urged more attention be paid to youth mental health.

“Mental health challenges in children, adolescents, and young adults are real and widespread. Even before the pandemic, an alarming number of young people struggled with feelings of helplessness, depression, and thoughts of suicide – and rates have increased over the past decade,” Dr. Murthy said, according to a news release from the U.S. Department of Health & Human Services.

Between 2007 and 2018, suicide rates among people ages 10-24 in the United States went up by 57%, the department said. Estimates showed over 6,600 suicides among this age group in 2020, it said.

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

Physicians have screened new and expectant mothers for perinatal depression for years. But what about fathers?

A new systematic review and meta-analysis suggests it’s time for health care providers to ask both parents about any mental health symptoms before and after their baby is born.

“We are screening most mothers for signs of perinatal depression,” said Kara Smythe, MD, at the department of primary care and population health and Institute of Epidemiology and Health Care at the University College London, who is the lead author of the study. “But we aren’t always asking about the relationship between them and the person helping them care for this newborn. If we don’t consider the experience of new fathers, we’re doing a disservice to everyone.”

Without screening both parents, health care providers can miss important clues to why child and parents experience adverse health outcomes post birth.

The study, published in JAMA Network Open, found that for 3.18% of couples, both parents concurrently experienced depression before and following a birth. The mental illness was more common in the late postnatal period (3-12 months).

According to the Centers for Disease Control and Prevention, about 1 in 8 women experience symptoms of postpartum depression. Other sources indicate the incidence may be much higher. Findings from a mobile app using the Edinburgh Postnatal Depression Scale presented at the American Psychiatric Association’s annual meeting in 2019 indicated more than half of the 164,237 women who used the free app reported symptoms of depression for up to a year following the birth of their baby.
 

The findings

Dr. Smythe and her team reviewed previously published observational studies on the prevalence of perinatal depression or anxiety in couples from the Ovid and Web of Science between Jan. 1, 1990, and June 8, 2021.

They ultimately included 23 studies with data from 29,286 couples. They broke the data into subgroups of persons with antenatal depression, early postnatal depression (0-12 weeks), late postnatal depression (3-13 months), and perinatal anxiety.

About 1.7% (P < .001) of couples experienced antenatal depression, and about 2.4% (P < .001) experienced early postnatal depression. About 3.2% (P < .001) experienced late postnatal depression. The data on perinatal anxiety were insufficient, they write.

The vast majority of couples included in the samples were White, heterosexual, and highly educated with a middle to high socioeconomic background. The pregnancies were reportedly wanted, if not planned. The majority of the studies – 21 – included in the analysis were from countries other than the United States.

According to the study, evidence suggests that paternal depression can lead to increased symptoms of depression in mothers during pregnancy and the following 6 months. Men reported perinatal depression at similar rates as women, and Dr. Smythe said it’s becoming clear that men experience similar struggles as they transition into fatherhood.

J. J. Parker, MD, a pediatric and internal attending physician at Lurie Children’s Hospital of Chicago and Northwestern Medicine, said the findings solidify what he has observed from his own experience as a new father and resident.

“You’re at higher risk of having depression if your partner has depression, but it’s important to see that in the numbers,” Dr. Parker told this news organization. “I think from a clinician standpoint, this demonstrates that 3% of infants are living in households where both parents are depressed, and that has major implications for the development and health of those children.”

Dr. Smythe and her colleagues found that if even one parent is experiencing a mood disorder such as depression or anxiety, the newborn can experience impaired bonding, behavioral problems, and other harms later in life.

If both parents are experiencing perinatal depression, those negative outcomes could be amplified, although Dr. Smythe said more research is needed to solidify the link.

“I think one quick takeaway for pediatricians, clinicians, and any other health care providers taking care of mothers and infants is to ask about the nonbirthing parent,” Dr. Parker said. “All clinicians can do that right away, even if the mother does not have depression.”

The study was independently supported. Dr. Smythe and her colleagues report no relevant financial relationships.

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

Physicians have screened new and expectant mothers for perinatal depression for years. But what about fathers?

A new systematic review and meta-analysis suggests it’s time for health care providers to ask both parents about any mental health symptoms before and after their baby is born.

“We are screening most mothers for signs of perinatal depression,” said Kara Smythe, MD, at the department of primary care and population health and Institute of Epidemiology and Health Care at the University College London, who is the lead author of the study. “But we aren’t always asking about the relationship between them and the person helping them care for this newborn. If we don’t consider the experience of new fathers, we’re doing a disservice to everyone.”

Without screening both parents, health care providers can miss important clues to why child and parents experience adverse health outcomes post birth.

The study, published in JAMA Network Open, found that for 3.18% of couples, both parents concurrently experienced depression before and following a birth. The mental illness was more common in the late postnatal period (3-12 months).

According to the Centers for Disease Control and Prevention, about 1 in 8 women experience symptoms of postpartum depression. Other sources indicate the incidence may be much higher. Findings from a mobile app using the Edinburgh Postnatal Depression Scale presented at the American Psychiatric Association’s annual meeting in 2019 indicated more than half of the 164,237 women who used the free app reported symptoms of depression for up to a year following the birth of their baby.
 

The findings

Dr. Smythe and her team reviewed previously published observational studies on the prevalence of perinatal depression or anxiety in couples from the Ovid and Web of Science between Jan. 1, 1990, and June 8, 2021.

They ultimately included 23 studies with data from 29,286 couples. They broke the data into subgroups of persons with antenatal depression, early postnatal depression (0-12 weeks), late postnatal depression (3-13 months), and perinatal anxiety.

About 1.7% (P < .001) of couples experienced antenatal depression, and about 2.4% (P < .001) experienced early postnatal depression. About 3.2% (P < .001) experienced late postnatal depression. The data on perinatal anxiety were insufficient, they write.

The vast majority of couples included in the samples were White, heterosexual, and highly educated with a middle to high socioeconomic background. The pregnancies were reportedly wanted, if not planned. The majority of the studies – 21 – included in the analysis were from countries other than the United States.

According to the study, evidence suggests that paternal depression can lead to increased symptoms of depression in mothers during pregnancy and the following 6 months. Men reported perinatal depression at similar rates as women, and Dr. Smythe said it’s becoming clear that men experience similar struggles as they transition into fatherhood.

J. J. Parker, MD, a pediatric and internal attending physician at Lurie Children’s Hospital of Chicago and Northwestern Medicine, said the findings solidify what he has observed from his own experience as a new father and resident.

“You’re at higher risk of having depression if your partner has depression, but it’s important to see that in the numbers,” Dr. Parker told this news organization. “I think from a clinician standpoint, this demonstrates that 3% of infants are living in households where both parents are depressed, and that has major implications for the development and health of those children.”

Dr. Smythe and her colleagues found that if even one parent is experiencing a mood disorder such as depression or anxiety, the newborn can experience impaired bonding, behavioral problems, and other harms later in life.

If both parents are experiencing perinatal depression, those negative outcomes could be amplified, although Dr. Smythe said more research is needed to solidify the link.

“I think one quick takeaway for pediatricians, clinicians, and any other health care providers taking care of mothers and infants is to ask about the nonbirthing parent,” Dr. Parker said. “All clinicians can do that right away, even if the mother does not have depression.”

The study was independently supported. Dr. Smythe and her colleagues report no relevant financial relationships.

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

Physicians have screened new and expectant mothers for perinatal depression for years. But what about fathers?

A new systematic review and meta-analysis suggests it’s time for health care providers to ask both parents about any mental health symptoms before and after their baby is born.

“We are screening most mothers for signs of perinatal depression,” said Kara Smythe, MD, at the department of primary care and population health and Institute of Epidemiology and Health Care at the University College London, who is the lead author of the study. “But we aren’t always asking about the relationship between them and the person helping them care for this newborn. If we don’t consider the experience of new fathers, we’re doing a disservice to everyone.”

Without screening both parents, health care providers can miss important clues to why child and parents experience adverse health outcomes post birth.

The study, published in JAMA Network Open, found that for 3.18% of couples, both parents concurrently experienced depression before and following a birth. The mental illness was more common in the late postnatal period (3-12 months).

According to the Centers for Disease Control and Prevention, about 1 in 8 women experience symptoms of postpartum depression. Other sources indicate the incidence may be much higher. Findings from a mobile app using the Edinburgh Postnatal Depression Scale presented at the American Psychiatric Association’s annual meeting in 2019 indicated more than half of the 164,237 women who used the free app reported symptoms of depression for up to a year following the birth of their baby.
 

The findings

Dr. Smythe and her team reviewed previously published observational studies on the prevalence of perinatal depression or anxiety in couples from the Ovid and Web of Science between Jan. 1, 1990, and June 8, 2021.

They ultimately included 23 studies with data from 29,286 couples. They broke the data into subgroups of persons with antenatal depression, early postnatal depression (0-12 weeks), late postnatal depression (3-13 months), and perinatal anxiety.

About 1.7% (P < .001) of couples experienced antenatal depression, and about 2.4% (P < .001) experienced early postnatal depression. About 3.2% (P < .001) experienced late postnatal depression. The data on perinatal anxiety were insufficient, they write.

The vast majority of couples included in the samples were White, heterosexual, and highly educated with a middle to high socioeconomic background. The pregnancies were reportedly wanted, if not planned. The majority of the studies – 21 – included in the analysis were from countries other than the United States.

According to the study, evidence suggests that paternal depression can lead to increased symptoms of depression in mothers during pregnancy and the following 6 months. Men reported perinatal depression at similar rates as women, and Dr. Smythe said it’s becoming clear that men experience similar struggles as they transition into fatherhood.

J. J. Parker, MD, a pediatric and internal attending physician at Lurie Children’s Hospital of Chicago and Northwestern Medicine, said the findings solidify what he has observed from his own experience as a new father and resident.

“You’re at higher risk of having depression if your partner has depression, but it’s important to see that in the numbers,” Dr. Parker told this news organization. “I think from a clinician standpoint, this demonstrates that 3% of infants are living in households where both parents are depressed, and that has major implications for the development and health of those children.”

Dr. Smythe and her colleagues found that if even one parent is experiencing a mood disorder such as depression or anxiety, the newborn can experience impaired bonding, behavioral problems, and other harms later in life.

If both parents are experiencing perinatal depression, those negative outcomes could be amplified, although Dr. Smythe said more research is needed to solidify the link.

“I think one quick takeaway for pediatricians, clinicians, and any other health care providers taking care of mothers and infants is to ask about the nonbirthing parent,” Dr. Parker said. “All clinicians can do that right away, even if the mother does not have depression.”

The study was independently supported. Dr. Smythe and her colleagues report no relevant financial relationships.

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

Although most psychiatrists have encountered patients who don’t improve with treatment, novel research sheds some light on one possible explanation for this phenomenon.

Investigators found that among patients who were “stuck” many believed that they didn’t deserve to get better and were significantly less likely to adhere to, or complete, a treatment program.

“To the best of my knowledge, this subject hasn’t been written about or explored before because we operate under the assumption that someone coming for ambulatory treatment, of course, wants to get better and thinks that they deserve to get better,” lead author Mark Zimmerman, MD, professor of psychiatry and human behavior at Brown University, Providence, R.I., said in an interview.

“This issue is not something complicated that a clinician would need to explore by administering some scale or clinical rating instrument. All you have to do is ask patients if they think they deserve to get better, particularly patients who seem to be ‘stuck,’ and explore what’s underlying that belief,” added Zimmerman, who is also the director of the Outpatient Division at the partial hospital program, Rhode Island Hospital, Providence.

The findings were published online in the Journal of Clinical Psychiatry.
 

Obstacle to therapy

Results from a study examining the prevalence of this belief in more than 400 patients admitted to a partial hospital program showed that 17% of the participants either did not believe they deserved to get better or weren’t sure if they deserved to get better.

When compared with their peers, patients who felt they were undeserving were significantly less likely to complete the treatment program and missed significantly more days of treatment while in the program.

Of the patients who did complete the program, those who believed they were undeserving were in treatment for significantly longer periods of time than those who believed they deserved to get better.

The average length of stay for patients in the partial hospital program is usually about 2 weeks, the investigators note. However, a minority of patients end up in treatment for more than a month and during this prolonged period, some do not seem to improve in their symptoms or functioning despite “intensive psychotherapy and ongoing pharmacotherapy.”

The researchers wanted to understand the reasons for some patients’ lack of progress and examined whether those who did not believe they were worthy of getting better actually took longer to respond to treatment.

In the current research, Dr. Zimmerman wanted to focus on these patients and assess whether they did take longer to improve and what diagnoses might be associated with feeling undeserving.

Of the 405 patients in the study, the majority (83%) reported they believed they deserved to get better, 12.8% said they were unsure, and 4.2% reported they did not believe they deserved to get better.

The researchers combined those who were unsure and those who did not believe they deserved to get better and compared them with patients who believed they did deserve to get better.

Although there were no differences between these patients in gender, race, or marital status, those who did not believe they deserved to get better were significantly younger than their counterparts who believed they deserved to get better (mean age, 32.2 years vs. 37.7 years, respectively; P < .01).

They also were diagnosed with a greater number of disorders at the time of the evaluation (mean, 3.6 vs. 2.9; P < .01).
 

Mirrors clinical experience

Participants who did not indicate they deserved to get better were significantly more often diagnosed with several conditions, compared with their counterparts who indicated they did deserve to get better:

• Major depressive disorder (MDD): 75.4% vs. 53.3%, respectively; P < .01.
• Panic disorder: 36.2% vs. 23.2%; P < .05.
• Agoraphobia: 27.5% vs. 11.6%; P < .01.
• Obsessive-compulsive disorder (OCD): 14.5% vs. 4.5%; P < .01.
• Posttraumatic stress disorder: 44.9% vs. 25.9%; P < .01.
• Borderline personality disorder: 29.0% vs. 17.9%; P < .05.

There were also significant differences between those who did not vs, did believe they deserved to get better in program completion (52.3% vs. 68.8%, respectively; P < .01), missed days (mean, 1.7 vs. 1.3; P < .05), and length of treatment (mean days, 14.1 vs. 11.8; P < .05).

Dr. Zimmerman called these preliminary findings “consistent” with his clinical experience.

He noted he was “surprised” that OCD had the highest odds ratio (OR, 3.5) of being associated with a sense of undeservingness. “But when I thought about it, I realized that it makes sense because people with OCD have insight and are often embarrassed by their symptoms,” he added.

Dr. Zimmerman was not surprised that MDD was associated with this sense of undeservingness. A second study currently under review is focusing specifically on MDD.

“One of the things we found, not surprisingly, was that some of the cognitive symptoms of depression, such as guilt and sense of worthlessness, are associated with it,” he said.
 

‘Snapshot in time’

Commenting for this news organization, Ken Duckworth, MD, chief medical officer of the National Alliance on Mental Illness called this a “novel, important, and creative study.”

The “hypothesized role of shame squares with my experience. And the association with OCD, depression, and trauma are also consistent with what I have seen,” said Dr. Duckworth, who is also an assistant clinical professor at Harvard Medical School, Boston. He was not involved with the current research.

“The role of hopelessness, often seen as a core feature of depression and to some extent OCD and trauma, is an opportunity to see if treatments like cognitive-behavioral therapy [CBT] can make a difference. How to engage people in CBT, which works directly at changing one’s automatic negative thoughts, is important,” Dr. Duckworth said.

Describing the study as a “snapshot in time,” he noted it would be interesting to follow patients longitudinally.

“I think a whole subset would look back and say, ‘I remember feeling [undeserving] but now that I’ve gotten medication or CBT or therapy, I’m happy I got better,’” said Dr. Duckworth.

No source of study funding was listed. Dr. Zimmerman, his coauthor, and Dr. Duckworth report no relevant financial relationships.

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

Although most psychiatrists have encountered patients who don’t improve with treatment, novel research sheds some light on one possible explanation for this phenomenon.

Investigators found that among patients who were “stuck” many believed that they didn’t deserve to get better and were significantly less likely to adhere to, or complete, a treatment program.

“To the best of my knowledge, this subject hasn’t been written about or explored before because we operate under the assumption that someone coming for ambulatory treatment, of course, wants to get better and thinks that they deserve to get better,” lead author Mark Zimmerman, MD, professor of psychiatry and human behavior at Brown University, Providence, R.I., said in an interview.

“This issue is not something complicated that a clinician would need to explore by administering some scale or clinical rating instrument. All you have to do is ask patients if they think they deserve to get better, particularly patients who seem to be ‘stuck,’ and explore what’s underlying that belief,” added Zimmerman, who is also the director of the Outpatient Division at the partial hospital program, Rhode Island Hospital, Providence.

The findings were published online in the Journal of Clinical Psychiatry.
 

Obstacle to therapy

Results from a study examining the prevalence of this belief in more than 400 patients admitted to a partial hospital program showed that 17% of the participants either did not believe they deserved to get better or weren’t sure if they deserved to get better.

When compared with their peers, patients who felt they were undeserving were significantly less likely to complete the treatment program and missed significantly more days of treatment while in the program.

Of the patients who did complete the program, those who believed they were undeserving were in treatment for significantly longer periods of time than those who believed they deserved to get better.

The average length of stay for patients in the partial hospital program is usually about 2 weeks, the investigators note. However, a minority of patients end up in treatment for more than a month and during this prolonged period, some do not seem to improve in their symptoms or functioning despite “intensive psychotherapy and ongoing pharmacotherapy.”

The researchers wanted to understand the reasons for some patients’ lack of progress and examined whether those who did not believe they were worthy of getting better actually took longer to respond to treatment.

In the current research, Dr. Zimmerman wanted to focus on these patients and assess whether they did take longer to improve and what diagnoses might be associated with feeling undeserving.

Of the 405 patients in the study, the majority (83%) reported they believed they deserved to get better, 12.8% said they were unsure, and 4.2% reported they did not believe they deserved to get better.

The researchers combined those who were unsure and those who did not believe they deserved to get better and compared them with patients who believed they did deserve to get better.

Although there were no differences between these patients in gender, race, or marital status, those who did not believe they deserved to get better were significantly younger than their counterparts who believed they deserved to get better (mean age, 32.2 years vs. 37.7 years, respectively; P < .01).

They also were diagnosed with a greater number of disorders at the time of the evaluation (mean, 3.6 vs. 2.9; P < .01).
 

Mirrors clinical experience

Participants who did not indicate they deserved to get better were significantly more often diagnosed with several conditions, compared with their counterparts who indicated they did deserve to get better:

• Major depressive disorder (MDD): 75.4% vs. 53.3%, respectively; P < .01.
• Panic disorder: 36.2% vs. 23.2%; P < .05.
• Agoraphobia: 27.5% vs. 11.6%; P < .01.
• Obsessive-compulsive disorder (OCD): 14.5% vs. 4.5%; P < .01.
• Posttraumatic stress disorder: 44.9% vs. 25.9%; P < .01.
• Borderline personality disorder: 29.0% vs. 17.9%; P < .05.

There were also significant differences between those who did not vs, did believe they deserved to get better in program completion (52.3% vs. 68.8%, respectively; P < .01), missed days (mean, 1.7 vs. 1.3; P < .05), and length of treatment (mean days, 14.1 vs. 11.8; P < .05).

Dr. Zimmerman called these preliminary findings “consistent” with his clinical experience.

He noted he was “surprised” that OCD had the highest odds ratio (OR, 3.5) of being associated with a sense of undeservingness. “But when I thought about it, I realized that it makes sense because people with OCD have insight and are often embarrassed by their symptoms,” he added.

Dr. Zimmerman was not surprised that MDD was associated with this sense of undeservingness. A second study currently under review is focusing specifically on MDD.

“One of the things we found, not surprisingly, was that some of the cognitive symptoms of depression, such as guilt and sense of worthlessness, are associated with it,” he said.
 

‘Snapshot in time’

Commenting for this news organization, Ken Duckworth, MD, chief medical officer of the National Alliance on Mental Illness called this a “novel, important, and creative study.”

The “hypothesized role of shame squares with my experience. And the association with OCD, depression, and trauma are also consistent with what I have seen,” said Dr. Duckworth, who is also an assistant clinical professor at Harvard Medical School, Boston. He was not involved with the current research.

“The role of hopelessness, often seen as a core feature of depression and to some extent OCD and trauma, is an opportunity to see if treatments like cognitive-behavioral therapy [CBT] can make a difference. How to engage people in CBT, which works directly at changing one’s automatic negative thoughts, is important,” Dr. Duckworth said.

Describing the study as a “snapshot in time,” he noted it would be interesting to follow patients longitudinally.

“I think a whole subset would look back and say, ‘I remember feeling [undeserving] but now that I’ve gotten medication or CBT or therapy, I’m happy I got better,’” said Dr. Duckworth.

No source of study funding was listed. Dr. Zimmerman, his coauthor, and Dr. Duckworth report no relevant financial relationships.

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

Although most psychiatrists have encountered patients who don’t improve with treatment, novel research sheds some light on one possible explanation for this phenomenon.

Investigators found that among patients who were “stuck” many believed that they didn’t deserve to get better and were significantly less likely to adhere to, or complete, a treatment program.

“To the best of my knowledge, this subject hasn’t been written about or explored before because we operate under the assumption that someone coming for ambulatory treatment, of course, wants to get better and thinks that they deserve to get better,” lead author Mark Zimmerman, MD, professor of psychiatry and human behavior at Brown University, Providence, R.I., said in an interview.

“This issue is not something complicated that a clinician would need to explore by administering some scale or clinical rating instrument. All you have to do is ask patients if they think they deserve to get better, particularly patients who seem to be ‘stuck,’ and explore what’s underlying that belief,” added Zimmerman, who is also the director of the Outpatient Division at the partial hospital program, Rhode Island Hospital, Providence.

The findings were published online in the Journal of Clinical Psychiatry.
 

Obstacle to therapy

Results from a study examining the prevalence of this belief in more than 400 patients admitted to a partial hospital program showed that 17% of the participants either did not believe they deserved to get better or weren’t sure if they deserved to get better.

When compared with their peers, patients who felt they were undeserving were significantly less likely to complete the treatment program and missed significantly more days of treatment while in the program.

Of the patients who did complete the program, those who believed they were undeserving were in treatment for significantly longer periods of time than those who believed they deserved to get better.

The average length of stay for patients in the partial hospital program is usually about 2 weeks, the investigators note. However, a minority of patients end up in treatment for more than a month and during this prolonged period, some do not seem to improve in their symptoms or functioning despite “intensive psychotherapy and ongoing pharmacotherapy.”

The researchers wanted to understand the reasons for some patients’ lack of progress and examined whether those who did not believe they were worthy of getting better actually took longer to respond to treatment.

In the current research, Dr. Zimmerman wanted to focus on these patients and assess whether they did take longer to improve and what diagnoses might be associated with feeling undeserving.

Of the 405 patients in the study, the majority (83%) reported they believed they deserved to get better, 12.8% said they were unsure, and 4.2% reported they did not believe they deserved to get better.

The researchers combined those who were unsure and those who did not believe they deserved to get better and compared them with patients who believed they did deserve to get better.

Although there were no differences between these patients in gender, race, or marital status, those who did not believe they deserved to get better were significantly younger than their counterparts who believed they deserved to get better (mean age, 32.2 years vs. 37.7 years, respectively; P < .01).

They also were diagnosed with a greater number of disorders at the time of the evaluation (mean, 3.6 vs. 2.9; P < .01).
 

Mirrors clinical experience

Participants who did not indicate they deserved to get better were significantly more often diagnosed with several conditions, compared with their counterparts who indicated they did deserve to get better:

• Major depressive disorder (MDD): 75.4% vs. 53.3%, respectively; P < .01.
• Panic disorder: 36.2% vs. 23.2%; P < .05.
• Agoraphobia: 27.5% vs. 11.6%; P < .01.
• Obsessive-compulsive disorder (OCD): 14.5% vs. 4.5%; P < .01.
• Posttraumatic stress disorder: 44.9% vs. 25.9%; P < .01.
• Borderline personality disorder: 29.0% vs. 17.9%; P < .05.

There were also significant differences between those who did not vs, did believe they deserved to get better in program completion (52.3% vs. 68.8%, respectively; P < .01), missed days (mean, 1.7 vs. 1.3; P < .05), and length of treatment (mean days, 14.1 vs. 11.8; P < .05).

Dr. Zimmerman called these preliminary findings “consistent” with his clinical experience.

He noted he was “surprised” that OCD had the highest odds ratio (OR, 3.5) of being associated with a sense of undeservingness. “But when I thought about it, I realized that it makes sense because people with OCD have insight and are often embarrassed by their symptoms,” he added.

Dr. Zimmerman was not surprised that MDD was associated with this sense of undeservingness. A second study currently under review is focusing specifically on MDD.

“One of the things we found, not surprisingly, was that some of the cognitive symptoms of depression, such as guilt and sense of worthlessness, are associated with it,” he said.
 

‘Snapshot in time’

Commenting for this news organization, Ken Duckworth, MD, chief medical officer of the National Alliance on Mental Illness called this a “novel, important, and creative study.”

The “hypothesized role of shame squares with my experience. And the association with OCD, depression, and trauma are also consistent with what I have seen,” said Dr. Duckworth, who is also an assistant clinical professor at Harvard Medical School, Boston. He was not involved with the current research.

“The role of hopelessness, often seen as a core feature of depression and to some extent OCD and trauma, is an opportunity to see if treatments like cognitive-behavioral therapy [CBT] can make a difference. How to engage people in CBT, which works directly at changing one’s automatic negative thoughts, is important,” Dr. Duckworth said.

Describing the study as a “snapshot in time,” he noted it would be interesting to follow patients longitudinally.

“I think a whole subset would look back and say, ‘I remember feeling [undeserving] but now that I’ve gotten medication or CBT or therapy, I’m happy I got better,’” said Dr. Duckworth.

No source of study funding was listed. Dr. Zimmerman, his coauthor, and Dr. Duckworth report no relevant financial relationships.

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

Kip Wenger, DO, an emergency physician and systems medical director of Team Health, Knoxville, Tenn., was asked to see a patient in the emergency department. He was shocked when he realized who the patient was – a 33-year-old female physician friend and colleague.

She was bleeding from multiple self-inflicted injuries and ultimately died. “I was devastated and couldn’t wrap my head around what had just happened,” Dr. Wenger told this news organization.

It’s important for physicians to be aware of warning signs in their colleagues, such as showing up late, being irritable and short-tempered with staff, missing shifts, making mistakes, or receiving an increasing number of patient complaints, Dr. Wenger says.

Dr. Wenger had had dinner with her several weeks earlier and saw some subtle changes. He had known her as a “positive, upbeat person,” but her demeanor was different during dinner.

“There were no typical telltale signs – she was talking about her plans for the future, including buying a new bicycle – but she wasn’t herself and seemed to become tearful when I hugged her at the end of the evening,” he said. He later heard from another colleague that she had shared feeling “hopeless.”
 

The scope of the problem

According to the American Society for Suicide Prevention, roughly 300-400 physicians die by suicide annually. Although one study suggests a lower number, official reports likely underestimate suicides, study author Katherine Gold, MD, MSW, associate professor of family medicine, obstetrics, and gynecology, Michigan Medicine, University of Michigan, Ann Arbor, said in an interview.

Peter Yellowlees, MD, MBBS, professor of psychiatry, University of California, Davis, concurs, suggesting that some single-car accidents involving physicians might be suicides. Perry Lin, MD, assistant clinical professor, Heritage College of Osteopathic Medicine, Ohio University, Athens, and national co-chair of the Physician Suicide Awareness Committee of the American Association of Suicidology, says that some death certificates state that the deceased died of “accidental causes” because the physician who completes the certificate, possibly a colleague, is reluctant to list the actual cause of death to protect his colleague’s memory or the family’s feelings.

In general, and among physicians, White men older than 65 “represent the largest percentage of people who die from suicide nationwide,” says Dr. Lin.

But younger people are also susceptible, Dr. Lin adds. One of the most vulnerable periods for potential suicide is during the first few months of residency. This dovetails with the findings of Medscape’s 2022 report Suicide: A Tragedy of the Profession. In that report, a difference was found between frequency of suicidal thoughts in younger physicians, compared with older physicians (14% in those < 35 years vs. 8% for those ≥ 45 years).
 

Hurdles to preventing physician suicide

“The best thing that can happen in our profession is upstream intervention – if people seek help before they get to the point of suicidality, recognizing they’re under stress and duress and that they might be going down a bad pathway,” says Dr. Lin. But research suggests that many physicians don’t do so.

Gary Price, MD, attending surgeon and clinical assistant professor of surgery, Yale–New Haven Hospital, Connecticut, and president of the Physicians Foundation, says his organization has identified barriers that prevent physicians from seeking help.

The major concern is that, in many states, licensing applications still ask whether the physician has been in treatment for a mental health condition. Physicians feel they may put their licensure at risk if they admit to receiving help for mental issues. These concerns were expressed by respondents in Medscape’s above mentioned 2022 report, many of whom didn’t seek treatment for depression, burnout, or suicidal thoughts lest it affect their professional standing when renewing their license or seeking credentialing.

Although organizations and societies are advocating against these questions, a recent study found that almost 70% of U.S. states and territories continue to ask physicians about their mental health, and 28% ask for diagnoses (beyond current impairments) – a violation of the Americans With Disabilities Act.

“Mental health illness is different from mental health impairment,” Ryan Mire, MD, a Nashville, Tenn.–based internist, said in an interview. “As physicians, we’re comfortable with licensing boards asking whether the physician has any condition that might impair their care for patients, but not about a history of mental illness.”

The second barrier, says Dr. Price, is that hospital credentialing committees sometimes ask similar questions, as do commercial and malpractice insurers.

Another roadblock is that in some states, undergoing treatment for a mental health problem could be subject to discovery by a plaintiff’s attorney in a malpractice case, even if the physician’s mental health history had no effect on patient care. But that’s uncommon, says Daniel Shapiro, PhD, author of “Delivering Doctor Amelia,” a book about his treatment of a suicidal physician who underwent a malpractice lawsuit. “I’ve never seen that happen.”

A final barrier is that many employers require employees to receive treatment within their own institution or health system. “Physicians may be reluctant to get help where they work, with colleagues and friends knowing about their illness or being involved with their care,” says Dr. Price.

In 2022, the American College of Physicians (ACP) issued a toolkit to help members encourage licensing and credentialing boards to remove questions about mental health on applications and include language that supports receiving treatment, Dr. Mire says.
 

Layers of vulnerability

There are few data regarding relative risk among particular races or ethnicities, “but we know racism is a social stressor,” says Dr. Mire. “Obviously, people from historically disadvantaged populations tend to have societal stressors like discrimination and racism that add an extra layer of burden.”

Intersectionality – having multiple intersecting risk factors – may confer even higher risk. “For example, if you’re a female physician from a historically marginalized race and a resident dealing with the ‘hidden curriculum’ of trying to be resilient, you have multiple layers of vulnerability.”

There are also limited data regarding which specialties or work environments are associated with highest risk. “Obviously, challenges exist in every segment of medicine and at different ages, stages, and work environments, and they intersect with each individual physician’s personal risk factors,” says Dr. Mire, president of the ACP and assistant clinical professor of clinical medical education, University of Tennessee Health Science Center, Memphis.

Pamela Wible, MD, is an Oregon-based retired physician who herself went through a suicidal period about 11 years into her career that motivated her to embrace a new vision of clinical practice and change her practice model. After a series of physician suicides in her area, she began to speak and write openly about physician suicide, and since her retirement from clinical practice, she makes herself available on a full-time basis to distressed physicians. “When I address a conference of a particular medical specialty or a group in a particular geographical region, I focus on the specific vulnerabilities in that specialty or region,” she says.
 

What increases the chances of suicide?

“Many factors, both within and outside the professional setting, affect someone’s decision to die by suicide – after all, physicians have the same stressors as other people, like family, finances, and their own health,” Dr. Mire says. When it comes to non–work-related factors, marital stressors and comorbid psychiatric illness particularly raise the risk, says Dr. Lin.

But certain drivers are specific to the practice of medicine, with burnout and depression first in line.

Dr. Shapiro, who is vice dean for faculty and administrative affairs, Penn State University, Hershey, and the Garner James Cline Professor of Medical Humanism, conducts burnout evaluations throughout the country. “Simple depression screeners prior to the pandemic showed about a 10% major depression rate in physicians,” he told this news organization. “Now, we’re seeing a 30%-33% depression rate, even in those who weren’t frontline providers during the pandemic.”

Dr. Price agrees, noting that burnout in physicians has gone from 40% to 60% since the pandemic. But burnout doesn’t always lead to suicide. It’s when burnout progresses to depression, becomes more severe, and is untreated that the suicidal risk arises, he emphasizes.

Additionally, being a doctor isn’t “just a profession” but a “calling and identity,” says Dr. Gold. Job-related problems (for example, a malpractice suit, complaints to the medical board, loss of autonomy, changing work demands) can raise suicidal risk.

And job-related problems can inform the location of suicide, says Dr. Wible, who is the author of “Physicians Suicide Letters – Answered.”

“A work-related catalyst makes it more likely that the person will attempt or complete suicide in the work setting. Physicians have stepped off hospital rooftops, shot or stabbed themselves in hospital parking lots, or [hanged] themselves in hospital chapels. Perhaps it’s because they’re choosing to die in the place where they’ve been most wounded.”
 

You are not at fault

“If you’re feeling suicidal, you might feel utterly alone, but if there’s one message I can give you, it’s that you’re not alone, and there are many things you can do to mitigate your pain and despair,” Dr. Wible says. “And you’re not defective. It’s the health care system that’s defective. You have nothing to be ashamed of.”

Some institutions have a “buddy system” that pairs clinicians to provide mutual peer support. A partner who notices concerning signs can refer the other partner for help. Physicians can also be paired with a “buddy,” even without a formal institutional structure.

A “buddy” is a step in the right direction, but Dr. Shapiro cautions it might be necessary to consult a trained professional for serious depression or suicidality. Several states provide connection to local resources. Employee assistance programs (EAPs) might be helpful, although many physicians don’t trust their institution’s EAP. Or physicians can ask colleagues to recommend a “doctor’s doctor” who specializes in treating physicians, suggests Dr. Yellowlees, author of “Physician Suicide: Cases and Commentaries.”

In Medscape’s 2022 report, almost all respondents who reported having suicidal colleagues said they offered help, including emotional support, practical assistance, referrals, speaking to family members, or even personally taking the colleague to the ED or to a therapist.

To enhance physicians’ ability to help each other, Dr. Lin recommends “gatekeeper training,” which has been shown to reduce suicide. “This strategy utilizes a peer-to-peer model, but, rather than a single ‘peer buddy,’ everyone is a ‘gatekeeper’ trained in approaches, such as QPR – Question, Persuade, Refer. ‘Gatekeepers’ are taught how to recognize warning signs of suicide, question the potentially suicidal individual, persuade him/her to get help, and provide referrals.”
 

Other ways to prevent suicide

Dr. Lin advises physicians to “create a personalized safety plan and write down signs and clues that they may be going down the wrong path and what they can do – like breathing exercises, relaxation – and identifying people to talk to, places to go, or phone numbers to call, if those initial measures aren’t enough.” The plan is private and allows the physician to determine at what point help is needed and who should be consulted. “Sometimes, when a person is in acute stress, even looking up a phone number can seem insurmountable. But having it on paper lowers the barrier, making it more achievable.”

Resources should be posted in places where physicians gather so that those who don’t already have a safety plan have easy access to that information, he suggests.

In addition, consideration may be given to reaching out for support if a colleague has died by suicide, experts suggest. Whether offered by one’s institution, a peer arrangement, spiritual counseling, or psychotherapy, one may need help dealing with the trauma, guilt, and grief that often accompany this type of loss.

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

Kip Wenger, DO, an emergency physician and systems medical director of Team Health, Knoxville, Tenn., was asked to see a patient in the emergency department. He was shocked when he realized who the patient was – a 33-year-old female physician friend and colleague.

She was bleeding from multiple self-inflicted injuries and ultimately died. “I was devastated and couldn’t wrap my head around what had just happened,” Dr. Wenger told this news organization.

It’s important for physicians to be aware of warning signs in their colleagues, such as showing up late, being irritable and short-tempered with staff, missing shifts, making mistakes, or receiving an increasing number of patient complaints, Dr. Wenger says.

Dr. Wenger had had dinner with her several weeks earlier and saw some subtle changes. He had known her as a “positive, upbeat person,” but her demeanor was different during dinner.

“There were no typical telltale signs – she was talking about her plans for the future, including buying a new bicycle – but she wasn’t herself and seemed to become tearful when I hugged her at the end of the evening,” he said. He later heard from another colleague that she had shared feeling “hopeless.”
 

The scope of the problem

According to the American Society for Suicide Prevention, roughly 300-400 physicians die by suicide annually. Although one study suggests a lower number, official reports likely underestimate suicides, study author Katherine Gold, MD, MSW, associate professor of family medicine, obstetrics, and gynecology, Michigan Medicine, University of Michigan, Ann Arbor, said in an interview.

Peter Yellowlees, MD, MBBS, professor of psychiatry, University of California, Davis, concurs, suggesting that some single-car accidents involving physicians might be suicides. Perry Lin, MD, assistant clinical professor, Heritage College of Osteopathic Medicine, Ohio University, Athens, and national co-chair of the Physician Suicide Awareness Committee of the American Association of Suicidology, says that some death certificates state that the deceased died of “accidental causes” because the physician who completes the certificate, possibly a colleague, is reluctant to list the actual cause of death to protect his colleague’s memory or the family’s feelings.

In general, and among physicians, White men older than 65 “represent the largest percentage of people who die from suicide nationwide,” says Dr. Lin.

But younger people are also susceptible, Dr. Lin adds. One of the most vulnerable periods for potential suicide is during the first few months of residency. This dovetails with the findings of Medscape’s 2022 report Suicide: A Tragedy of the Profession. In that report, a difference was found between frequency of suicidal thoughts in younger physicians, compared with older physicians (14% in those < 35 years vs. 8% for those ≥ 45 years).
 

Hurdles to preventing physician suicide

“The best thing that can happen in our profession is upstream intervention – if people seek help before they get to the point of suicidality, recognizing they’re under stress and duress and that they might be going down a bad pathway,” says Dr. Lin. But research suggests that many physicians don’t do so.

Gary Price, MD, attending surgeon and clinical assistant professor of surgery, Yale–New Haven Hospital, Connecticut, and president of the Physicians Foundation, says his organization has identified barriers that prevent physicians from seeking help.

The major concern is that, in many states, licensing applications still ask whether the physician has been in treatment for a mental health condition. Physicians feel they may put their licensure at risk if they admit to receiving help for mental issues. These concerns were expressed by respondents in Medscape’s above mentioned 2022 report, many of whom didn’t seek treatment for depression, burnout, or suicidal thoughts lest it affect their professional standing when renewing their license or seeking credentialing.

Although organizations and societies are advocating against these questions, a recent study found that almost 70% of U.S. states and territories continue to ask physicians about their mental health, and 28% ask for diagnoses (beyond current impairments) – a violation of the Americans With Disabilities Act.

“Mental health illness is different from mental health impairment,” Ryan Mire, MD, a Nashville, Tenn.–based internist, said in an interview. “As physicians, we’re comfortable with licensing boards asking whether the physician has any condition that might impair their care for patients, but not about a history of mental illness.”

The second barrier, says Dr. Price, is that hospital credentialing committees sometimes ask similar questions, as do commercial and malpractice insurers.

Another roadblock is that in some states, undergoing treatment for a mental health problem could be subject to discovery by a plaintiff’s attorney in a malpractice case, even if the physician’s mental health history had no effect on patient care. But that’s uncommon, says Daniel Shapiro, PhD, author of “Delivering Doctor Amelia,” a book about his treatment of a suicidal physician who underwent a malpractice lawsuit. “I’ve never seen that happen.”

A final barrier is that many employers require employees to receive treatment within their own institution or health system. “Physicians may be reluctant to get help where they work, with colleagues and friends knowing about their illness or being involved with their care,” says Dr. Price.

In 2022, the American College of Physicians (ACP) issued a toolkit to help members encourage licensing and credentialing boards to remove questions about mental health on applications and include language that supports receiving treatment, Dr. Mire says.
 

Layers of vulnerability

There are few data regarding relative risk among particular races or ethnicities, “but we know racism is a social stressor,” says Dr. Mire. “Obviously, people from historically disadvantaged populations tend to have societal stressors like discrimination and racism that add an extra layer of burden.”

Intersectionality – having multiple intersecting risk factors – may confer even higher risk. “For example, if you’re a female physician from a historically marginalized race and a resident dealing with the ‘hidden curriculum’ of trying to be resilient, you have multiple layers of vulnerability.”

There are also limited data regarding which specialties or work environments are associated with highest risk. “Obviously, challenges exist in every segment of medicine and at different ages, stages, and work environments, and they intersect with each individual physician’s personal risk factors,” says Dr. Mire, president of the ACP and assistant clinical professor of clinical medical education, University of Tennessee Health Science Center, Memphis.

Pamela Wible, MD, is an Oregon-based retired physician who herself went through a suicidal period about 11 years into her career that motivated her to embrace a new vision of clinical practice and change her practice model. After a series of physician suicides in her area, she began to speak and write openly about physician suicide, and since her retirement from clinical practice, she makes herself available on a full-time basis to distressed physicians. “When I address a conference of a particular medical specialty or a group in a particular geographical region, I focus on the specific vulnerabilities in that specialty or region,” she says.
 

What increases the chances of suicide?

“Many factors, both within and outside the professional setting, affect someone’s decision to die by suicide – after all, physicians have the same stressors as other people, like family, finances, and their own health,” Dr. Mire says. When it comes to non–work-related factors, marital stressors and comorbid psychiatric illness particularly raise the risk, says Dr. Lin.

But certain drivers are specific to the practice of medicine, with burnout and depression first in line.

Dr. Shapiro, who is vice dean for faculty and administrative affairs, Penn State University, Hershey, and the Garner James Cline Professor of Medical Humanism, conducts burnout evaluations throughout the country. “Simple depression screeners prior to the pandemic showed about a 10% major depression rate in physicians,” he told this news organization. “Now, we’re seeing a 30%-33% depression rate, even in those who weren’t frontline providers during the pandemic.”

Dr. Price agrees, noting that burnout in physicians has gone from 40% to 60% since the pandemic. But burnout doesn’t always lead to suicide. It’s when burnout progresses to depression, becomes more severe, and is untreated that the suicidal risk arises, he emphasizes.

Additionally, being a doctor isn’t “just a profession” but a “calling and identity,” says Dr. Gold. Job-related problems (for example, a malpractice suit, complaints to the medical board, loss of autonomy, changing work demands) can raise suicidal risk.

And job-related problems can inform the location of suicide, says Dr. Wible, who is the author of “Physicians Suicide Letters – Answered.”

“A work-related catalyst makes it more likely that the person will attempt or complete suicide in the work setting. Physicians have stepped off hospital rooftops, shot or stabbed themselves in hospital parking lots, or [hanged] themselves in hospital chapels. Perhaps it’s because they’re choosing to die in the place where they’ve been most wounded.”
 

You are not at fault

“If you’re feeling suicidal, you might feel utterly alone, but if there’s one message I can give you, it’s that you’re not alone, and there are many things you can do to mitigate your pain and despair,” Dr. Wible says. “And you’re not defective. It’s the health care system that’s defective. You have nothing to be ashamed of.”

Some institutions have a “buddy system” that pairs clinicians to provide mutual peer support. A partner who notices concerning signs can refer the other partner for help. Physicians can also be paired with a “buddy,” even without a formal institutional structure.

A “buddy” is a step in the right direction, but Dr. Shapiro cautions it might be necessary to consult a trained professional for serious depression or suicidality. Several states provide connection to local resources. Employee assistance programs (EAPs) might be helpful, although many physicians don’t trust their institution’s EAP. Or physicians can ask colleagues to recommend a “doctor’s doctor” who specializes in treating physicians, suggests Dr. Yellowlees, author of “Physician Suicide: Cases and Commentaries.”

In Medscape’s 2022 report, almost all respondents who reported having suicidal colleagues said they offered help, including emotional support, practical assistance, referrals, speaking to family members, or even personally taking the colleague to the ED or to a therapist.

To enhance physicians’ ability to help each other, Dr. Lin recommends “gatekeeper training,” which has been shown to reduce suicide. “This strategy utilizes a peer-to-peer model, but, rather than a single ‘peer buddy,’ everyone is a ‘gatekeeper’ trained in approaches, such as QPR – Question, Persuade, Refer. ‘Gatekeepers’ are taught how to recognize warning signs of suicide, question the potentially suicidal individual, persuade him/her to get help, and provide referrals.”
 

Other ways to prevent suicide

Dr. Lin advises physicians to “create a personalized safety plan and write down signs and clues that they may be going down the wrong path and what they can do – like breathing exercises, relaxation – and identifying people to talk to, places to go, or phone numbers to call, if those initial measures aren’t enough.” The plan is private and allows the physician to determine at what point help is needed and who should be consulted. “Sometimes, when a person is in acute stress, even looking up a phone number can seem insurmountable. But having it on paper lowers the barrier, making it more achievable.”

Resources should be posted in places where physicians gather so that those who don’t already have a safety plan have easy access to that information, he suggests.

In addition, consideration may be given to reaching out for support if a colleague has died by suicide, experts suggest. Whether offered by one’s institution, a peer arrangement, spiritual counseling, or psychotherapy, one may need help dealing with the trauma, guilt, and grief that often accompany this type of loss.

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

Kip Wenger, DO, an emergency physician and systems medical director of Team Health, Knoxville, Tenn., was asked to see a patient in the emergency department. He was shocked when he realized who the patient was – a 33-year-old female physician friend and colleague.

She was bleeding from multiple self-inflicted injuries and ultimately died. “I was devastated and couldn’t wrap my head around what had just happened,” Dr. Wenger told this news organization.

It’s important for physicians to be aware of warning signs in their colleagues, such as showing up late, being irritable and short-tempered with staff, missing shifts, making mistakes, or receiving an increasing number of patient complaints, Dr. Wenger says.

Dr. Wenger had had dinner with her several weeks earlier and saw some subtle changes. He had known her as a “positive, upbeat person,” but her demeanor was different during dinner.

“There were no typical telltale signs – she was talking about her plans for the future, including buying a new bicycle – but she wasn’t herself and seemed to become tearful when I hugged her at the end of the evening,” he said. He later heard from another colleague that she had shared feeling “hopeless.”
 

The scope of the problem

According to the American Society for Suicide Prevention, roughly 300-400 physicians die by suicide annually. Although one study suggests a lower number, official reports likely underestimate suicides, study author Katherine Gold, MD, MSW, associate professor of family medicine, obstetrics, and gynecology, Michigan Medicine, University of Michigan, Ann Arbor, said in an interview.

Peter Yellowlees, MD, MBBS, professor of psychiatry, University of California, Davis, concurs, suggesting that some single-car accidents involving physicians might be suicides. Perry Lin, MD, assistant clinical professor, Heritage College of Osteopathic Medicine, Ohio University, Athens, and national co-chair of the Physician Suicide Awareness Committee of the American Association of Suicidology, says that some death certificates state that the deceased died of “accidental causes” because the physician who completes the certificate, possibly a colleague, is reluctant to list the actual cause of death to protect his colleague’s memory or the family’s feelings.

In general, and among physicians, White men older than 65 “represent the largest percentage of people who die from suicide nationwide,” says Dr. Lin.

But younger people are also susceptible, Dr. Lin adds. One of the most vulnerable periods for potential suicide is during the first few months of residency. This dovetails with the findings of Medscape’s 2022 report Suicide: A Tragedy of the Profession. In that report, a difference was found between frequency of suicidal thoughts in younger physicians, compared with older physicians (14% in those < 35 years vs. 8% for those ≥ 45 years).
 

Hurdles to preventing physician suicide

“The best thing that can happen in our profession is upstream intervention – if people seek help before they get to the point of suicidality, recognizing they’re under stress and duress and that they might be going down a bad pathway,” says Dr. Lin. But research suggests that many physicians don’t do so.

Gary Price, MD, attending surgeon and clinical assistant professor of surgery, Yale–New Haven Hospital, Connecticut, and president of the Physicians Foundation, says his organization has identified barriers that prevent physicians from seeking help.

The major concern is that, in many states, licensing applications still ask whether the physician has been in treatment for a mental health condition. Physicians feel they may put their licensure at risk if they admit to receiving help for mental issues. These concerns were expressed by respondents in Medscape’s above mentioned 2022 report, many of whom didn’t seek treatment for depression, burnout, or suicidal thoughts lest it affect their professional standing when renewing their license or seeking credentialing.

Although organizations and societies are advocating against these questions, a recent study found that almost 70% of U.S. states and territories continue to ask physicians about their mental health, and 28% ask for diagnoses (beyond current impairments) – a violation of the Americans With Disabilities Act.

“Mental health illness is different from mental health impairment,” Ryan Mire, MD, a Nashville, Tenn.–based internist, said in an interview. “As physicians, we’re comfortable with licensing boards asking whether the physician has any condition that might impair their care for patients, but not about a history of mental illness.”

The second barrier, says Dr. Price, is that hospital credentialing committees sometimes ask similar questions, as do commercial and malpractice insurers.

Another roadblock is that in some states, undergoing treatment for a mental health problem could be subject to discovery by a plaintiff’s attorney in a malpractice case, even if the physician’s mental health history had no effect on patient care. But that’s uncommon, says Daniel Shapiro, PhD, author of “Delivering Doctor Amelia,” a book about his treatment of a suicidal physician who underwent a malpractice lawsuit. “I’ve never seen that happen.”

A final barrier is that many employers require employees to receive treatment within their own institution or health system. “Physicians may be reluctant to get help where they work, with colleagues and friends knowing about their illness or being involved with their care,” says Dr. Price.

In 2022, the American College of Physicians (ACP) issued a toolkit to help members encourage licensing and credentialing boards to remove questions about mental health on applications and include language that supports receiving treatment, Dr. Mire says.
 

Layers of vulnerability

There are few data regarding relative risk among particular races or ethnicities, “but we know racism is a social stressor,” says Dr. Mire. “Obviously, people from historically disadvantaged populations tend to have societal stressors like discrimination and racism that add an extra layer of burden.”

Intersectionality – having multiple intersecting risk factors – may confer even higher risk. “For example, if you’re a female physician from a historically marginalized race and a resident dealing with the ‘hidden curriculum’ of trying to be resilient, you have multiple layers of vulnerability.”

There are also limited data regarding which specialties or work environments are associated with highest risk. “Obviously, challenges exist in every segment of medicine and at different ages, stages, and work environments, and they intersect with each individual physician’s personal risk factors,” says Dr. Mire, president of the ACP and assistant clinical professor of clinical medical education, University of Tennessee Health Science Center, Memphis.

Pamela Wible, MD, is an Oregon-based retired physician who herself went through a suicidal period about 11 years into her career that motivated her to embrace a new vision of clinical practice and change her practice model. After a series of physician suicides in her area, she began to speak and write openly about physician suicide, and since her retirement from clinical practice, she makes herself available on a full-time basis to distressed physicians. “When I address a conference of a particular medical specialty or a group in a particular geographical region, I focus on the specific vulnerabilities in that specialty or region,” she says.
 

What increases the chances of suicide?

“Many factors, both within and outside the professional setting, affect someone’s decision to die by suicide – after all, physicians have the same stressors as other people, like family, finances, and their own health,” Dr. Mire says. When it comes to non–work-related factors, marital stressors and comorbid psychiatric illness particularly raise the risk, says Dr. Lin.

But certain drivers are specific to the practice of medicine, with burnout and depression first in line.

Dr. Shapiro, who is vice dean for faculty and administrative affairs, Penn State University, Hershey, and the Garner James Cline Professor of Medical Humanism, conducts burnout evaluations throughout the country. “Simple depression screeners prior to the pandemic showed about a 10% major depression rate in physicians,” he told this news organization. “Now, we’re seeing a 30%-33% depression rate, even in those who weren’t frontline providers during the pandemic.”

Dr. Price agrees, noting that burnout in physicians has gone from 40% to 60% since the pandemic. But burnout doesn’t always lead to suicide. It’s when burnout progresses to depression, becomes more severe, and is untreated that the suicidal risk arises, he emphasizes.

Additionally, being a doctor isn’t “just a profession” but a “calling and identity,” says Dr. Gold. Job-related problems (for example, a malpractice suit, complaints to the medical board, loss of autonomy, changing work demands) can raise suicidal risk.

And job-related problems can inform the location of suicide, says Dr. Wible, who is the author of “Physicians Suicide Letters – Answered.”

“A work-related catalyst makes it more likely that the person will attempt or complete suicide in the work setting. Physicians have stepped off hospital rooftops, shot or stabbed themselves in hospital parking lots, or [hanged] themselves in hospital chapels. Perhaps it’s because they’re choosing to die in the place where they’ve been most wounded.”
 

You are not at fault

“If you’re feeling suicidal, you might feel utterly alone, but if there’s one message I can give you, it’s that you’re not alone, and there are many things you can do to mitigate your pain and despair,” Dr. Wible says. “And you’re not defective. It’s the health care system that’s defective. You have nothing to be ashamed of.”

Some institutions have a “buddy system” that pairs clinicians to provide mutual peer support. A partner who notices concerning signs can refer the other partner for help. Physicians can also be paired with a “buddy,” even without a formal institutional structure.

A “buddy” is a step in the right direction, but Dr. Shapiro cautions it might be necessary to consult a trained professional for serious depression or suicidality. Several states provide connection to local resources. Employee assistance programs (EAPs) might be helpful, although many physicians don’t trust their institution’s EAP. Or physicians can ask colleagues to recommend a “doctor’s doctor” who specializes in treating physicians, suggests Dr. Yellowlees, author of “Physician Suicide: Cases and Commentaries.”

In Medscape’s 2022 report, almost all respondents who reported having suicidal colleagues said they offered help, including emotional support, practical assistance, referrals, speaking to family members, or even personally taking the colleague to the ED or to a therapist.

To enhance physicians’ ability to help each other, Dr. Lin recommends “gatekeeper training,” which has been shown to reduce suicide. “This strategy utilizes a peer-to-peer model, but, rather than a single ‘peer buddy,’ everyone is a ‘gatekeeper’ trained in approaches, such as QPR – Question, Persuade, Refer. ‘Gatekeepers’ are taught how to recognize warning signs of suicide, question the potentially suicidal individual, persuade him/her to get help, and provide referrals.”
 

Other ways to prevent suicide

Dr. Lin advises physicians to “create a personalized safety plan and write down signs and clues that they may be going down the wrong path and what they can do – like breathing exercises, relaxation – and identifying people to talk to, places to go, or phone numbers to call, if those initial measures aren’t enough.” The plan is private and allows the physician to determine at what point help is needed and who should be consulted. “Sometimes, when a person is in acute stress, even looking up a phone number can seem insurmountable. But having it on paper lowers the barrier, making it more achievable.”

Resources should be posted in places where physicians gather so that those who don’t already have a safety plan have easy access to that information, he suggests.

In addition, consideration may be given to reaching out for support if a colleague has died by suicide, experts suggest. Whether offered by one’s institution, a peer arrangement, spiritual counseling, or psychotherapy, one may need help dealing with the trauma, guilt, and grief that often accompany this type of loss.

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

Longer circadian periods and irregular sleep were significantly associated with mental health problems in adolescents including depression, anxiety, suicidality, social anxiety, and panic disorder, according to results from a European study.

A range of psychiatric symptoms and conditions has been linked to sleep pathologies, wrote Liisa Kuula, PhD, of the University of Helsinki, Finland, and colleagues. Some research suggests that late circadian rhythms and irregular sleep patterns increase the risk for psychiatric conditions, but the association has not been well studied, especially in adolescents, although the onset of psychiatric problems often occurs at this age, they said.

In a study published in the Journal of Psychiatric Research (2022 Apr 4. doi: 10.1016/j.jpsychires.2022.03.056.), the investigators reviewed data from 342 adolescents who were part of SleepHelsinki! a large cohort study of delayed sleep phase disorder (DSPD) in adolescents. The mean age of the participants was 17.4 years, and 70% were female.

The participants completed the Mini International Neuropsychiatric Interview (MINI) and wore temperature loggers for 3 days to assess circadian rhythms. The primary outcome was the impact of circadian dynamics on different psychiatric problems. Delayed Sleep Phase (DSP) behavior was defined as going to sleep later than 1 a.m. at least three times a week.

Circadian length was determined through the temperature loggers worn for 3 days. Most participants also completed 1-week GeneActiv Original actigraphy measurements (wearing the actigraph for 1 week) and responded to the Morningness-Eveningness Questionnaire, which divided participants into three circadian preference groups: morning, intermediate, and evening. Sleep duration was calculated as total sleep time, sleep quality was estimated by sleep efficiency, and sleep timing was assessed by the midpoint of the sleep period.

Overall, the MINI interview results suggested that approximately one-third (36%) of the teens had at least one psychiatric problem, and 21% had comorbid conditions.

Severe depression was significantly associated with a longer circadian period (P = .002), while suicidality was significantly associated with a later midpoint and more irregular sleep (P = .007 for both).

Participants with agoraphobia slept longer than did those without, the researchers noted (P = .013). However, sleep duration was not significantly associated with other psychiatric conditions.

Manic episodes and psychotic disorders were associated with irregular sleep timing (P < .018 and P < .017, respectively).

When the researchers examined DSP and circadian preferences, they found that 21.5% of individuals with suicidality had characteristics of DSP, as did 21.5% of those with panic disorder.

Individuals with a preference for eveningness were significantly more likely to meet criteria for severe depression, panic disorder, generalized anxiety disorder, and obsessive-compulsive disorder than were those without a preference for eveningness, the researchers noted.

“Our findings are the first to encompass diverse circadian measures alongside an array of psychiatric symptoms in such a focused age range,” the researchers wrote in their discussion. The data reflect results from other studies and extend the likely role of circadian patterns in mental wellbeing, they said.

The study findings were limited by several factors including the lack of actual diagnoses from medical records and use of self-reported symptoms, the researchers noted. Other limitations included the lack of polysomnography data and small size of subgroups of the study sample.

However, the results were strengthened by the heterogenous study population and use of multiple measures to examine sleep and circadian rhythms, as well as consideration of personal circadian preferences, the researchers said.

“The importance of overall synchronization with environment is perhaps best highlighted by response to treatment: most psychopathologic symptoms benefit from sleep-targeted therapeutic approaches,” they concluded.

The study received no outside funding. The researchers had no financial conflicts to disclose.

Longer circadian periods and irregular sleep were significantly associated with mental health problems in adolescents including depression, anxiety, suicidality, social anxiety, and panic disorder, according to results from a European study.

A range of psychiatric symptoms and conditions has been linked to sleep pathologies, wrote Liisa Kuula, PhD, of the University of Helsinki, Finland, and colleagues. Some research suggests that late circadian rhythms and irregular sleep patterns increase the risk for psychiatric conditions, but the association has not been well studied, especially in adolescents, although the onset of psychiatric problems often occurs at this age, they said.

In a study published in the Journal of Psychiatric Research (2022 Apr 4. doi: 10.1016/j.jpsychires.2022.03.056.), the investigators reviewed data from 342 adolescents who were part of SleepHelsinki! a large cohort study of delayed sleep phase disorder (DSPD) in adolescents. The mean age of the participants was 17.4 years, and 70% were female.

The participants completed the Mini International Neuropsychiatric Interview (MINI) and wore temperature loggers for 3 days to assess circadian rhythms. The primary outcome was the impact of circadian dynamics on different psychiatric problems. Delayed Sleep Phase (DSP) behavior was defined as going to sleep later than 1 a.m. at least three times a week.

Circadian length was determined through the temperature loggers worn for 3 days. Most participants also completed 1-week GeneActiv Original actigraphy measurements (wearing the actigraph for 1 week) and responded to the Morningness-Eveningness Questionnaire, which divided participants into three circadian preference groups: morning, intermediate, and evening. Sleep duration was calculated as total sleep time, sleep quality was estimated by sleep efficiency, and sleep timing was assessed by the midpoint of the sleep period.

Overall, the MINI interview results suggested that approximately one-third (36%) of the teens had at least one psychiatric problem, and 21% had comorbid conditions.

Severe depression was significantly associated with a longer circadian period (P = .002), while suicidality was significantly associated with a later midpoint and more irregular sleep (P = .007 for both).

Participants with agoraphobia slept longer than did those without, the researchers noted (P = .013). However, sleep duration was not significantly associated with other psychiatric conditions.

Manic episodes and psychotic disorders were associated with irregular sleep timing (P < .018 and P < .017, respectively).

When the researchers examined DSP and circadian preferences, they found that 21.5% of individuals with suicidality had characteristics of DSP, as did 21.5% of those with panic disorder.

Individuals with a preference for eveningness were significantly more likely to meet criteria for severe depression, panic disorder, generalized anxiety disorder, and obsessive-compulsive disorder than were those without a preference for eveningness, the researchers noted.

“Our findings are the first to encompass diverse circadian measures alongside an array of psychiatric symptoms in such a focused age range,” the researchers wrote in their discussion. The data reflect results from other studies and extend the likely role of circadian patterns in mental wellbeing, they said.

The study findings were limited by several factors including the lack of actual diagnoses from medical records and use of self-reported symptoms, the researchers noted. Other limitations included the lack of polysomnography data and small size of subgroups of the study sample.

However, the results were strengthened by the heterogenous study population and use of multiple measures to examine sleep and circadian rhythms, as well as consideration of personal circadian preferences, the researchers said.

“The importance of overall synchronization with environment is perhaps best highlighted by response to treatment: most psychopathologic symptoms benefit from sleep-targeted therapeutic approaches,” they concluded.

The study received no outside funding. The researchers had no financial conflicts to disclose.

Longer circadian periods and irregular sleep were significantly associated with mental health problems in adolescents including depression, anxiety, suicidality, social anxiety, and panic disorder, according to results from a European study.

A range of psychiatric symptoms and conditions has been linked to sleep pathologies, wrote Liisa Kuula, PhD, of the University of Helsinki, Finland, and colleagues. Some research suggests that late circadian rhythms and irregular sleep patterns increase the risk for psychiatric conditions, but the association has not been well studied, especially in adolescents, although the onset of psychiatric problems often occurs at this age, they said.

In a study published in the Journal of Psychiatric Research (2022 Apr 4. doi: 10.1016/j.jpsychires.2022.03.056.), the investigators reviewed data from 342 adolescents who were part of SleepHelsinki! a large cohort study of delayed sleep phase disorder (DSPD) in adolescents. The mean age of the participants was 17.4 years, and 70% were female.

The participants completed the Mini International Neuropsychiatric Interview (MINI) and wore temperature loggers for 3 days to assess circadian rhythms. The primary outcome was the impact of circadian dynamics on different psychiatric problems. Delayed Sleep Phase (DSP) behavior was defined as going to sleep later than 1 a.m. at least three times a week.

Circadian length was determined through the temperature loggers worn for 3 days. Most participants also completed 1-week GeneActiv Original actigraphy measurements (wearing the actigraph for 1 week) and responded to the Morningness-Eveningness Questionnaire, which divided participants into three circadian preference groups: morning, intermediate, and evening. Sleep duration was calculated as total sleep time, sleep quality was estimated by sleep efficiency, and sleep timing was assessed by the midpoint of the sleep period.

Overall, the MINI interview results suggested that approximately one-third (36%) of the teens had at least one psychiatric problem, and 21% had comorbid conditions.

Severe depression was significantly associated with a longer circadian period (P = .002), while suicidality was significantly associated with a later midpoint and more irregular sleep (P = .007 for both).

Participants with agoraphobia slept longer than did those without, the researchers noted (P = .013). However, sleep duration was not significantly associated with other psychiatric conditions.

Manic episodes and psychotic disorders were associated with irregular sleep timing (P < .018 and P < .017, respectively).

When the researchers examined DSP and circadian preferences, they found that 21.5% of individuals with suicidality had characteristics of DSP, as did 21.5% of those with panic disorder.

Individuals with a preference for eveningness were significantly more likely to meet criteria for severe depression, panic disorder, generalized anxiety disorder, and obsessive-compulsive disorder than were those without a preference for eveningness, the researchers noted.

“Our findings are the first to encompass diverse circadian measures alongside an array of psychiatric symptoms in such a focused age range,” the researchers wrote in their discussion. The data reflect results from other studies and extend the likely role of circadian patterns in mental wellbeing, they said.

The study findings were limited by several factors including the lack of actual diagnoses from medical records and use of self-reported symptoms, the researchers noted. Other limitations included the lack of polysomnography data and small size of subgroups of the study sample.

However, the results were strengthened by the heterogenous study population and use of multiple measures to examine sleep and circadian rhythms, as well as consideration of personal circadian preferences, the researchers said.

“The importance of overall synchronization with environment is perhaps best highlighted by response to treatment: most psychopathologic symptoms benefit from sleep-targeted therapeutic approaches,” they concluded.

The study received no outside funding. The researchers had no financial conflicts to disclose.

A unique primary care program successfully manages patients with depression and comorbid posttraumatic stress disorder and, if widely implemented, may result in more rapid treatment and help alleviate wait times for specialty psychiatric care.

“We know there are strains on the mental health care system, and sometimes something as simple as getting to see a psychiatrist can be incredibly challenging,” coinvestigator Zachary Zuschlag, MD, staff psychiatrist at the James A. Haley Veterans’ Hospital and assistant professor at the University of South Florida, both in Tampa, said in an interview.

“So, a model that encourages primary care doctors, together with consultation from us [psychiatrists] to effectively treat these patients in a more proactive way, is very beneficial,” Dr. Zuschlag said.

The findings were presented at the American Society of Clinical Psychopharmacology annual meeting.
 

Common bedfellows

Dr. Zuschlag noted that comorbid PTSD and depression is common, but it is often considered too complex to be managed in a primary care setting.

Although treating these patients can be challenging, Dr. Zuschlag, who also heads his Veterans Administration facility’s antidepressant monitoring program (ADM), said that when he started the program for this patient population, he used “a much more inclusive model and welcomed these patients even if they had co-occurring issues.”

“Anecdotally, we had seen that our patients with [depression and] co-occurring PTSD appeared to be doing as well as their peers without PTSD, and we just wanted to look at it more systematically,” he added.

The ADM program is specifically designed for psychopharmacologic management of depression and anxiety in the primary care setting. It involves an interdisciplinary team of RN care managers, consulting psychiatrists, psychologists, and primary care physicians. Patients in primary care clinics deemed likely to benefit from psychiatric medications can be enrolled and followed in the program.

The program consists of structured, protocol-based telephone contacts from the RN care managers at scheduled intervals, usually every 3-4 weeks, said Dr. Zuschlag.

During calls, information is collected via evidence-based mental health symptomatic assessment scales. The consulting psychiatrists use this and other information to help guide treatment and coordinate with patients’ primary care physicians to adjust the treatment plan, including medication changes and additional psychotherapy.

To determine the program’s efficacy the investigators retrospectively reviewed all patients enrolled in the ADM program during its first 10 months. Of the 433 program participants, 112 (26%) were identified with active PTSD symptoms at baseline. Another 43 patients had a prior diagnosis of PTSD.

Program completion rates for the cohort with PTSD did not differ from that of the cohort without PTSD.

Overall, mean improvements in depression and anxiety symptoms were evidenced by changes in Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder Assessment-7 (GAD-7) scores of 44% and 43%, respectively.

No differences in mean reduction in symptoms of depression were observed when comparing those with no history of PTSD with those with any history of PTSD (–6.16 vs. –5.42; P = .3244) or with those with active PTSD symptoms (–6.16 vs. –5.54; P = .4543).

Similarly, for anxiety, a mean reduction of –5.61 on the GAD-7 score was observed for the cohort without PTSD, compared with –4.99 in the cohort with any history of PTSD and –5.35 in the cohort with active PTSD symptoms. Again, these differences were nonsignificant.

Dr. Zuschlag noted that the VA setting is unique, with a lot of resources available to conduct such a program as ADM.

“Care management programs that are multidisciplinary are very effective and, in our experience, those who have completed the program do exceptionally well. The patients love it because there is a lot of contact between them and their various care providers,” he said.
 

A model for other settings?

Commenting on the study, Nagy A. Youssef, MD, PhD, professor of psychiatry and director of clinical research at Ohio State University, Columbus, called the results “interesting.”

“Treating patients with comorbid mild to moderate depression and current or past PTSD within the primary care setting using a care management program could be a model for other VA hospitals as well as in non-VA settings,” said Dr. Youssef, who was not part of the study.

Dr. Youssef noted that not only was there no difference in symptomatic improvement between the depression-plus-PTSD and depression-only groups, but program completion rates did not differ.

This further emphasizes “the potential utility of this approach in initial patient treatment, especially with limited mental health resources and the need to help more patients,” he said.

Dr. Zuschlag and Dr. Youssef report no relevant financial relationships.

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

A unique primary care program successfully manages patients with depression and comorbid posttraumatic stress disorder and, if widely implemented, may result in more rapid treatment and help alleviate wait times for specialty psychiatric care.

“We know there are strains on the mental health care system, and sometimes something as simple as getting to see a psychiatrist can be incredibly challenging,” coinvestigator Zachary Zuschlag, MD, staff psychiatrist at the James A. Haley Veterans’ Hospital and assistant professor at the University of South Florida, both in Tampa, said in an interview.

“So, a model that encourages primary care doctors, together with consultation from us [psychiatrists] to effectively treat these patients in a more proactive way, is very beneficial,” Dr. Zuschlag said.

The findings were presented at the American Society of Clinical Psychopharmacology annual meeting.
 

Common bedfellows

Dr. Zuschlag noted that comorbid PTSD and depression is common, but it is often considered too complex to be managed in a primary care setting.

Although treating these patients can be challenging, Dr. Zuschlag, who also heads his Veterans Administration facility’s antidepressant monitoring program (ADM), said that when he started the program for this patient population, he used “a much more inclusive model and welcomed these patients even if they had co-occurring issues.”

“Anecdotally, we had seen that our patients with [depression and] co-occurring PTSD appeared to be doing as well as their peers without PTSD, and we just wanted to look at it more systematically,” he added.

The ADM program is specifically designed for psychopharmacologic management of depression and anxiety in the primary care setting. It involves an interdisciplinary team of RN care managers, consulting psychiatrists, psychologists, and primary care physicians. Patients in primary care clinics deemed likely to benefit from psychiatric medications can be enrolled and followed in the program.

The program consists of structured, protocol-based telephone contacts from the RN care managers at scheduled intervals, usually every 3-4 weeks, said Dr. Zuschlag.

During calls, information is collected via evidence-based mental health symptomatic assessment scales. The consulting psychiatrists use this and other information to help guide treatment and coordinate with patients’ primary care physicians to adjust the treatment plan, including medication changes and additional psychotherapy.

To determine the program’s efficacy the investigators retrospectively reviewed all patients enrolled in the ADM program during its first 10 months. Of the 433 program participants, 112 (26%) were identified with active PTSD symptoms at baseline. Another 43 patients had a prior diagnosis of PTSD.

Program completion rates for the cohort with PTSD did not differ from that of the cohort without PTSD.

Overall, mean improvements in depression and anxiety symptoms were evidenced by changes in Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder Assessment-7 (GAD-7) scores of 44% and 43%, respectively.

No differences in mean reduction in symptoms of depression were observed when comparing those with no history of PTSD with those with any history of PTSD (–6.16 vs. –5.42; P = .3244) or with those with active PTSD symptoms (–6.16 vs. –5.54; P = .4543).

Similarly, for anxiety, a mean reduction of –5.61 on the GAD-7 score was observed for the cohort without PTSD, compared with –4.99 in the cohort with any history of PTSD and –5.35 in the cohort with active PTSD symptoms. Again, these differences were nonsignificant.

Dr. Zuschlag noted that the VA setting is unique, with a lot of resources available to conduct such a program as ADM.

“Care management programs that are multidisciplinary are very effective and, in our experience, those who have completed the program do exceptionally well. The patients love it because there is a lot of contact between them and their various care providers,” he said.
 

A model for other settings?

Commenting on the study, Nagy A. Youssef, MD, PhD, professor of psychiatry and director of clinical research at Ohio State University, Columbus, called the results “interesting.”

“Treating patients with comorbid mild to moderate depression and current or past PTSD within the primary care setting using a care management program could be a model for other VA hospitals as well as in non-VA settings,” said Dr. Youssef, who was not part of the study.

Dr. Youssef noted that not only was there no difference in symptomatic improvement between the depression-plus-PTSD and depression-only groups, but program completion rates did not differ.

This further emphasizes “the potential utility of this approach in initial patient treatment, especially with limited mental health resources and the need to help more patients,” he said.

Dr. Zuschlag and Dr. Youssef report no relevant financial relationships.

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

A unique primary care program successfully manages patients with depression and comorbid posttraumatic stress disorder and, if widely implemented, may result in more rapid treatment and help alleviate wait times for specialty psychiatric care.

“We know there are strains on the mental health care system, and sometimes something as simple as getting to see a psychiatrist can be incredibly challenging,” coinvestigator Zachary Zuschlag, MD, staff psychiatrist at the James A. Haley Veterans’ Hospital and assistant professor at the University of South Florida, both in Tampa, said in an interview.

“So, a model that encourages primary care doctors, together with consultation from us [psychiatrists] to effectively treat these patients in a more proactive way, is very beneficial,” Dr. Zuschlag said.

The findings were presented at the American Society of Clinical Psychopharmacology annual meeting.
 

Common bedfellows

Dr. Zuschlag noted that comorbid PTSD and depression is common, but it is often considered too complex to be managed in a primary care setting.

Although treating these patients can be challenging, Dr. Zuschlag, who also heads his Veterans Administration facility’s antidepressant monitoring program (ADM), said that when he started the program for this patient population, he used “a much more inclusive model and welcomed these patients even if they had co-occurring issues.”

“Anecdotally, we had seen that our patients with [depression and] co-occurring PTSD appeared to be doing as well as their peers without PTSD, and we just wanted to look at it more systematically,” he added.

The ADM program is specifically designed for psychopharmacologic management of depression and anxiety in the primary care setting. It involves an interdisciplinary team of RN care managers, consulting psychiatrists, psychologists, and primary care physicians. Patients in primary care clinics deemed likely to benefit from psychiatric medications can be enrolled and followed in the program.

The program consists of structured, protocol-based telephone contacts from the RN care managers at scheduled intervals, usually every 3-4 weeks, said Dr. Zuschlag.

During calls, information is collected via evidence-based mental health symptomatic assessment scales. The consulting psychiatrists use this and other information to help guide treatment and coordinate with patients’ primary care physicians to adjust the treatment plan, including medication changes and additional psychotherapy.

To determine the program’s efficacy the investigators retrospectively reviewed all patients enrolled in the ADM program during its first 10 months. Of the 433 program participants, 112 (26%) were identified with active PTSD symptoms at baseline. Another 43 patients had a prior diagnosis of PTSD.

Program completion rates for the cohort with PTSD did not differ from that of the cohort without PTSD.

Overall, mean improvements in depression and anxiety symptoms were evidenced by changes in Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder Assessment-7 (GAD-7) scores of 44% and 43%, respectively.

No differences in mean reduction in symptoms of depression were observed when comparing those with no history of PTSD with those with any history of PTSD (–6.16 vs. –5.42; P = .3244) or with those with active PTSD symptoms (–6.16 vs. –5.54; P = .4543).

Similarly, for anxiety, a mean reduction of –5.61 on the GAD-7 score was observed for the cohort without PTSD, compared with –4.99 in the cohort with any history of PTSD and –5.35 in the cohort with active PTSD symptoms. Again, these differences were nonsignificant.

Dr. Zuschlag noted that the VA setting is unique, with a lot of resources available to conduct such a program as ADM.

“Care management programs that are multidisciplinary are very effective and, in our experience, those who have completed the program do exceptionally well. The patients love it because there is a lot of contact between them and their various care providers,” he said.
 

A model for other settings?

Commenting on the study, Nagy A. Youssef, MD, PhD, professor of psychiatry and director of clinical research at Ohio State University, Columbus, called the results “interesting.”

“Treating patients with comorbid mild to moderate depression and current or past PTSD within the primary care setting using a care management program could be a model for other VA hospitals as well as in non-VA settings,” said Dr. Youssef, who was not part of the study.

Dr. Youssef noted that not only was there no difference in symptomatic improvement between the depression-plus-PTSD and depression-only groups, but program completion rates did not differ.

This further emphasizes “the potential utility of this approach in initial patient treatment, especially with limited mental health resources and the need to help more patients,” he said.

Dr. Zuschlag and Dr. Youssef report no relevant financial relationships.

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

DENVER – Psychedelics such as psilocybin “truly have the potential to transform how we treat a number of neuropsychiatric diseases, including headaches,” a neuropharmacologist told colleagues at the annual meeting of the American Headache Society.

However, Bryan Roth, MD, PhD, professor of pharmacology at the University of North Carolina at Chapel Hill, also offered a major cautionary note: There have been no randomized, phase 3 trials of psychedelics, and he bluntly said that “I do not recommend the use of psychedelics for any medical condition.”

The potential disease-altering powers of psychedelics have received a tremendous amount of research and media attention over the past several years. A landmark randomized, double-blind study released in 2016 triggered much of the interest, Dr. Roth said, when it suggested that high-dose psilocybin significantly lowered levels of depressed mood/anxiety in patients with life-threatening cancer. At 6 months, 80% of patients who took the dose reported moderate or greater improvement in well-being/life satisfaction.

“You have the potential – unprecedented in psychiatry – that a single dose of a therapeutic agent may induce a rapid, robust, and sustained antidepressant action,” he said. Also of note: The “vast majority” of subjects say their encounter with a psychedelic was “one of the most meaningful experiences of their lives.”

Dr. Roth said his own research suggests that psychedelics cause a “huge increase” in the asynchronous firing of neurons. “Noise is being injected into the system and is interpreted by the brain or the mind, which always likes to make a story about what’s going on. The story it makes up is idiosyncratic to every person and memorable for reasons that are not understood.”

Now, Dr. Roth said, he and colleagues are working to “create drugs that have this potential remarkable therapeutic efficacy in psychiatric and neurologic disorders without the psychedelic effects.” A $27 million grant from the Defense Advanced Research Projects Agency is providing support for their efforts, he said.

For the moment, he said, there’s no way to know if “the psychedelic experience is essential to the therapeutic action of these drugs. But it’s a testable hypothesis.”

As he noted, a tiny 2010 study of 2-bromo-lysergic acid diethylamide (LSD), which doesn’t cause hallucinations, showed promise as a treatment for cluster headaches.

For now, Dr. Roth said, his lab is synthesizing and testing new compounds that interact with the crucial 5-HT2A receptor.
 

Additional research

In another presentation at the AHS annual meeting, neurologist Emmanuelle A. D. Schindler, MD, PhD, of Yale School of Medicine, highlighted her 2021 study of an exploratory double-blind, placebo-controlled, cross-over study of psilocybin versus placebo for migraine headache. A single oral dose of the drug, the researchers found, reduced headache frequency and pain over 2 weeks. The study is small, with just 10 subjects, and multiple exclusion criteria.

She also revealed preliminary findings from an ongoing randomized, double-blind, placebo-controlled study of psilocybin versus placebo in cluster headaches. In 14 subjects, a psilocybin pulse was linked to fewer cluster attacks over 3 weeks, although the effect wasn’t statistically significant. However, there was a statistically significant reduction over 8 weeks in patients with chronic headache.

Dr. Schindler noted that “with these early studies, we only looked out to 2 weeks for migraine, and we only looked out to 2 months for cluster.” There are multiple other limitations, she acknowledged. “We have to do a lot more research and consider safety as well.”

However, “there is a really unique capacity for lasting effects after limited dosing,” she added, and the studies do show reductions in headache burden “that do not correlate with acute psychedelic effects.”

Moving forward, Dr. Roth cautioned that while U.S. states are allowing the use of psychedelics for medical purposes, “we don’t know if they ultimately are therapeutic. And we have strong reason to believe that microdosing or chronic dosing of these compounds is ultimately going to be deleterious to the health of our patients.”

Dr. Roth did not provide disclosure information. Dr. Schindler discloses research funding (Ceruvia Lifesciences, Wallace Research Foundation, Clusterbusters, Department of Veterans Affairs), serves on advisory boards (Ceruvia Lifesciences, Clusterbusters), and has a patent.

DENVER – Psychedelics such as psilocybin “truly have the potential to transform how we treat a number of neuropsychiatric diseases, including headaches,” a neuropharmacologist told colleagues at the annual meeting of the American Headache Society.

However, Bryan Roth, MD, PhD, professor of pharmacology at the University of North Carolina at Chapel Hill, also offered a major cautionary note: There have been no randomized, phase 3 trials of psychedelics, and he bluntly said that “I do not recommend the use of psychedelics for any medical condition.”

The potential disease-altering powers of psychedelics have received a tremendous amount of research and media attention over the past several years. A landmark randomized, double-blind study released in 2016 triggered much of the interest, Dr. Roth said, when it suggested that high-dose psilocybin significantly lowered levels of depressed mood/anxiety in patients with life-threatening cancer. At 6 months, 80% of patients who took the dose reported moderate or greater improvement in well-being/life satisfaction.

“You have the potential – unprecedented in psychiatry – that a single dose of a therapeutic agent may induce a rapid, robust, and sustained antidepressant action,” he said. Also of note: The “vast majority” of subjects say their encounter with a psychedelic was “one of the most meaningful experiences of their lives.”

Dr. Roth said his own research suggests that psychedelics cause a “huge increase” in the asynchronous firing of neurons. “Noise is being injected into the system and is interpreted by the brain or the mind, which always likes to make a story about what’s going on. The story it makes up is idiosyncratic to every person and memorable for reasons that are not understood.”

Now, Dr. Roth said, he and colleagues are working to “create drugs that have this potential remarkable therapeutic efficacy in psychiatric and neurologic disorders without the psychedelic effects.” A $27 million grant from the Defense Advanced Research Projects Agency is providing support for their efforts, he said.

For the moment, he said, there’s no way to know if “the psychedelic experience is essential to the therapeutic action of these drugs. But it’s a testable hypothesis.”

As he noted, a tiny 2010 study of 2-bromo-lysergic acid diethylamide (LSD), which doesn’t cause hallucinations, showed promise as a treatment for cluster headaches.

For now, Dr. Roth said, his lab is synthesizing and testing new compounds that interact with the crucial 5-HT2A receptor.
 

Additional research

In another presentation at the AHS annual meeting, neurologist Emmanuelle A. D. Schindler, MD, PhD, of Yale School of Medicine, highlighted her 2021 study of an exploratory double-blind, placebo-controlled, cross-over study of psilocybin versus placebo for migraine headache. A single oral dose of the drug, the researchers found, reduced headache frequency and pain over 2 weeks. The study is small, with just 10 subjects, and multiple exclusion criteria.

She also revealed preliminary findings from an ongoing randomized, double-blind, placebo-controlled study of psilocybin versus placebo in cluster headaches. In 14 subjects, a psilocybin pulse was linked to fewer cluster attacks over 3 weeks, although the effect wasn’t statistically significant. However, there was a statistically significant reduction over 8 weeks in patients with chronic headache.

Dr. Schindler noted that “with these early studies, we only looked out to 2 weeks for migraine, and we only looked out to 2 months for cluster.” There are multiple other limitations, she acknowledged. “We have to do a lot more research and consider safety as well.”

However, “there is a really unique capacity for lasting effects after limited dosing,” she added, and the studies do show reductions in headache burden “that do not correlate with acute psychedelic effects.”

Moving forward, Dr. Roth cautioned that while U.S. states are allowing the use of psychedelics for medical purposes, “we don’t know if they ultimately are therapeutic. And we have strong reason to believe that microdosing or chronic dosing of these compounds is ultimately going to be deleterious to the health of our patients.”

Dr. Roth did not provide disclosure information. Dr. Schindler discloses research funding (Ceruvia Lifesciences, Wallace Research Foundation, Clusterbusters, Department of Veterans Affairs), serves on advisory boards (Ceruvia Lifesciences, Clusterbusters), and has a patent.

DENVER – Psychedelics such as psilocybin “truly have the potential to transform how we treat a number of neuropsychiatric diseases, including headaches,” a neuropharmacologist told colleagues at the annual meeting of the American Headache Society.

However, Bryan Roth, MD, PhD, professor of pharmacology at the University of North Carolina at Chapel Hill, also offered a major cautionary note: There have been no randomized, phase 3 trials of psychedelics, and he bluntly said that “I do not recommend the use of psychedelics for any medical condition.”

The potential disease-altering powers of psychedelics have received a tremendous amount of research and media attention over the past several years. A landmark randomized, double-blind study released in 2016 triggered much of the interest, Dr. Roth said, when it suggested that high-dose psilocybin significantly lowered levels of depressed mood/anxiety in patients with life-threatening cancer. At 6 months, 80% of patients who took the dose reported moderate or greater improvement in well-being/life satisfaction.

“You have the potential – unprecedented in psychiatry – that a single dose of a therapeutic agent may induce a rapid, robust, and sustained antidepressant action,” he said. Also of note: The “vast majority” of subjects say their encounter with a psychedelic was “one of the most meaningful experiences of their lives.”

Dr. Roth said his own research suggests that psychedelics cause a “huge increase” in the asynchronous firing of neurons. “Noise is being injected into the system and is interpreted by the brain or the mind, which always likes to make a story about what’s going on. The story it makes up is idiosyncratic to every person and memorable for reasons that are not understood.”

Now, Dr. Roth said, he and colleagues are working to “create drugs that have this potential remarkable therapeutic efficacy in psychiatric and neurologic disorders without the psychedelic effects.” A $27 million grant from the Defense Advanced Research Projects Agency is providing support for their efforts, he said.

For the moment, he said, there’s no way to know if “the psychedelic experience is essential to the therapeutic action of these drugs. But it’s a testable hypothesis.”

As he noted, a tiny 2010 study of 2-bromo-lysergic acid diethylamide (LSD), which doesn’t cause hallucinations, showed promise as a treatment for cluster headaches.

For now, Dr. Roth said, his lab is synthesizing and testing new compounds that interact with the crucial 5-HT2A receptor.
 

Additional research

In another presentation at the AHS annual meeting, neurologist Emmanuelle A. D. Schindler, MD, PhD, of Yale School of Medicine, highlighted her 2021 study of an exploratory double-blind, placebo-controlled, cross-over study of psilocybin versus placebo for migraine headache. A single oral dose of the drug, the researchers found, reduced headache frequency and pain over 2 weeks. The study is small, with just 10 subjects, and multiple exclusion criteria.

She also revealed preliminary findings from an ongoing randomized, double-blind, placebo-controlled study of psilocybin versus placebo in cluster headaches. In 14 subjects, a psilocybin pulse was linked to fewer cluster attacks over 3 weeks, although the effect wasn’t statistically significant. However, there was a statistically significant reduction over 8 weeks in patients with chronic headache.

Dr. Schindler noted that “with these early studies, we only looked out to 2 weeks for migraine, and we only looked out to 2 months for cluster.” There are multiple other limitations, she acknowledged. “We have to do a lot more research and consider safety as well.”

However, “there is a really unique capacity for lasting effects after limited dosing,” she added, and the studies do show reductions in headache burden “that do not correlate with acute psychedelic effects.”

Moving forward, Dr. Roth cautioned that while U.S. states are allowing the use of psychedelics for medical purposes, “we don’t know if they ultimately are therapeutic. And we have strong reason to believe that microdosing or chronic dosing of these compounds is ultimately going to be deleterious to the health of our patients.”

Dr. Roth did not provide disclosure information. Dr. Schindler discloses research funding (Ceruvia Lifesciences, Wallace Research Foundation, Clusterbusters, Department of Veterans Affairs), serves on advisory boards (Ceruvia Lifesciences, Clusterbusters), and has a patent.

CHARLOTTE, N.C. – Erratic sleep patterns over years or even decades, along with a patient’s age and history of depression, may be harbingers of cognitive impairment later in life, an analysis of decades of data from a large sleep study has found.

“What we were a little surprised to find in this model was that sleep duration, whether short, long or average, was not significant, but the sleep variability – the change in sleep across those time measurements—was significantly impacting the incidence of cognitive impairment,” Samantha Keil, PhD, a postdoctoral fellow at the University of Washington, Seattle, reported at the at the annual meeting of the Associated Professional Sleep Societies.

The researchers analyzed sleep and cognition data collected over decades on 1,104 adults who participated in the Seattle Longitudinal Study. Study participants ranged from age 55 to over 100, with almost 80% of the study cohort aged 65 and older.

The Seattle Longitudinal Study first started gathering data in the 1950s. Participants in the study cohort underwent an extensive cognitive battery, which was added to the study in 1984 and gathered every 5-7 years, and completed a health behavioral questionnaire (HBQ), which was added in 1993 and administered every 3-5 years, Dr. Keil said. The HBQ included a question on average nightly sleep duration.

The study used a multivariable Cox proportional hazard regression model to evaluate the overall effect of average sleep duration and changes in sleep duration over time on cognitive impairment. Covariates used in the model included apolipoprotein E4 (APOE4) genotype, gender, years of education, ethnicity, and depression.

Dr. Keil said the model found, as expected, that the  demographic variables of education, APOE status, and depression were significantly associated with cognitive impairment (hazard ratios of 1.11; 95% confidence interval [CI], 1.02-1.21; P = .01; and 2.08; 95% CI, 1.31-3.31; P < .005; and 1.08; 95% CI, 1.04-1.13; P < .005, respectively). Importantly, when evaluating the duration, change and variability of sleep, the researchers found that increased sleep variability was significantly associated with cognitive impairment (HR, 3.15; 95% CI, 1.69-5.87; P < .005).  

Under this analysis, “sleep variability over time and not median sleep duration was associated with cognitive impairment,” she said. When sleep variability was added into the model, it improved the concordance score – a value that reflects the ability of a model to predict an outcome better than random chance – from .63 to .73 (a value of .5 indicates the model is no better at predicting an outcome than a random chance model; a value of .7 or greater indicates a good model).

Identification of sleep variability as a sleep pattern of interest in longitudinal studies is important, Dr. Keil said, because simply evaluating mean or median sleep duration across time might not account for a subject’s variable sleep phenotype. Most importantly, further evaluation of sleep variability with a linear regression prediction analysis (F statistic 8.796, P < .0001, adjusted R-squared .235) found that increased age, depression, and sleep variability significantly predicted cognitive impairment 10 years downstream. “Longitudinal sleep variability is perhaps for the first time being reported as significantly associated with the development of downstream cognitive impairment,” Dr. Keil said.

What makes this study unique, Dr. Keil said in an interview, is that it used self-reported longitudinal data gathered at 3- to 5-year intervals for up to 25 years, allowing for the assessment of variation of sleep duration across this entire time frame. “If you could use that shift in sleep duration as a point of therapeutic intervention, that would be really exciting,” she said.

Future research will evaluate how sleep variability and cognitive function are impacted by other variables gathered in the Seattle Longitudinal Study over the years, including factors such as diabetes and hypertension status, diet, alcohol and tobacco use, and marital and family status. Follow-up studies will be investigating the impact of sleep variability on neuropathologic disease progression and lymphatic system impairment, Dr. Keil said.
 

A newer approach

By linking sleep variability and daytime functioning, the study employs a “newer approach,” said Joseph M. Dzierzewski, PhD, director of behavioral medicine concentration in the department of psychology at Virginia Commonwealth University in Richmond. “While some previous work has examined night-to-night fluctuation in various sleep characteristics and cognitive functioning, what differentiates the present study from these previous works is the duration of the investigation,” he said. The “richness of data” in the Seattle Longitudinal Study and how it tracks sleep and cognition over years make it “quite unique and novel.”

Future studies, he said, should be deliberate in how they evaluate sleep and neurocognitive function across years. “Disentangling short-term moment-to-moment and day-to-day fluctuation, which may be more reversible in nature, from long-term, enduring month-to-month or year-to-year fluctuation, which may be more permanent, will be important for continuing to advance our understanding of these complex phenomena,” Dr. Dzierzewski said. “An additional important area of future investigation would be to continue the hunt for a common biological factor underpinning both sleep variability and Alzheimer’s disease.” That, he said, may help identify potential intervention targets.

Dr. Keil and Dr. Dzierzewski have no relevant disclosures.

CHARLOTTE, N.C. – Erratic sleep patterns over years or even decades, along with a patient’s age and history of depression, may be harbingers of cognitive impairment later in life, an analysis of decades of data from a large sleep study has found.

“What we were a little surprised to find in this model was that sleep duration, whether short, long or average, was not significant, but the sleep variability – the change in sleep across those time measurements—was significantly impacting the incidence of cognitive impairment,” Samantha Keil, PhD, a postdoctoral fellow at the University of Washington, Seattle, reported at the at the annual meeting of the Associated Professional Sleep Societies.

The researchers analyzed sleep and cognition data collected over decades on 1,104 adults who participated in the Seattle Longitudinal Study. Study participants ranged from age 55 to over 100, with almost 80% of the study cohort aged 65 and older.

The Seattle Longitudinal Study first started gathering data in the 1950s. Participants in the study cohort underwent an extensive cognitive battery, which was added to the study in 1984 and gathered every 5-7 years, and completed a health behavioral questionnaire (HBQ), which was added in 1993 and administered every 3-5 years, Dr. Keil said. The HBQ included a question on average nightly sleep duration.

The study used a multivariable Cox proportional hazard regression model to evaluate the overall effect of average sleep duration and changes in sleep duration over time on cognitive impairment. Covariates used in the model included apolipoprotein E4 (APOE4) genotype, gender, years of education, ethnicity, and depression.

Dr. Keil said the model found, as expected, that the  demographic variables of education, APOE status, and depression were significantly associated with cognitive impairment (hazard ratios of 1.11; 95% confidence interval [CI], 1.02-1.21; P = .01; and 2.08; 95% CI, 1.31-3.31; P < .005; and 1.08; 95% CI, 1.04-1.13; P < .005, respectively). Importantly, when evaluating the duration, change and variability of sleep, the researchers found that increased sleep variability was significantly associated with cognitive impairment (HR, 3.15; 95% CI, 1.69-5.87; P < .005).  

Under this analysis, “sleep variability over time and not median sleep duration was associated with cognitive impairment,” she said. When sleep variability was added into the model, it improved the concordance score – a value that reflects the ability of a model to predict an outcome better than random chance – from .63 to .73 (a value of .5 indicates the model is no better at predicting an outcome than a random chance model; a value of .7 or greater indicates a good model).

Identification of sleep variability as a sleep pattern of interest in longitudinal studies is important, Dr. Keil said, because simply evaluating mean or median sleep duration across time might not account for a subject’s variable sleep phenotype. Most importantly, further evaluation of sleep variability with a linear regression prediction analysis (F statistic 8.796, P < .0001, adjusted R-squared .235) found that increased age, depression, and sleep variability significantly predicted cognitive impairment 10 years downstream. “Longitudinal sleep variability is perhaps for the first time being reported as significantly associated with the development of downstream cognitive impairment,” Dr. Keil said.

What makes this study unique, Dr. Keil said in an interview, is that it used self-reported longitudinal data gathered at 3- to 5-year intervals for up to 25 years, allowing for the assessment of variation of sleep duration across this entire time frame. “If you could use that shift in sleep duration as a point of therapeutic intervention, that would be really exciting,” she said.

Future research will evaluate how sleep variability and cognitive function are impacted by other variables gathered in the Seattle Longitudinal Study over the years, including factors such as diabetes and hypertension status, diet, alcohol and tobacco use, and marital and family status. Follow-up studies will be investigating the impact of sleep variability on neuropathologic disease progression and lymphatic system impairment, Dr. Keil said.
 

A newer approach

By linking sleep variability and daytime functioning, the study employs a “newer approach,” said Joseph M. Dzierzewski, PhD, director of behavioral medicine concentration in the department of psychology at Virginia Commonwealth University in Richmond. “While some previous work has examined night-to-night fluctuation in various sleep characteristics and cognitive functioning, what differentiates the present study from these previous works is the duration of the investigation,” he said. The “richness of data” in the Seattle Longitudinal Study and how it tracks sleep and cognition over years make it “quite unique and novel.”

Future studies, he said, should be deliberate in how they evaluate sleep and neurocognitive function across years. “Disentangling short-term moment-to-moment and day-to-day fluctuation, which may be more reversible in nature, from long-term, enduring month-to-month or year-to-year fluctuation, which may be more permanent, will be important for continuing to advance our understanding of these complex phenomena,” Dr. Dzierzewski said. “An additional important area of future investigation would be to continue the hunt for a common biological factor underpinning both sleep variability and Alzheimer’s disease.” That, he said, may help identify potential intervention targets.

Dr. Keil and Dr. Dzierzewski have no relevant disclosures.

CHARLOTTE, N.C. – Erratic sleep patterns over years or even decades, along with a patient’s age and history of depression, may be harbingers of cognitive impairment later in life, an analysis of decades of data from a large sleep study has found.

“What we were a little surprised to find in this model was that sleep duration, whether short, long or average, was not significant, but the sleep variability – the change in sleep across those time measurements—was significantly impacting the incidence of cognitive impairment,” Samantha Keil, PhD, a postdoctoral fellow at the University of Washington, Seattle, reported at the at the annual meeting of the Associated Professional Sleep Societies.

The researchers analyzed sleep and cognition data collected over decades on 1,104 adults who participated in the Seattle Longitudinal Study. Study participants ranged from age 55 to over 100, with almost 80% of the study cohort aged 65 and older.

The Seattle Longitudinal Study first started gathering data in the 1950s. Participants in the study cohort underwent an extensive cognitive battery, which was added to the study in 1984 and gathered every 5-7 years, and completed a health behavioral questionnaire (HBQ), which was added in 1993 and administered every 3-5 years, Dr. Keil said. The HBQ included a question on average nightly sleep duration.

The study used a multivariable Cox proportional hazard regression model to evaluate the overall effect of average sleep duration and changes in sleep duration over time on cognitive impairment. Covariates used in the model included apolipoprotein E4 (APOE4) genotype, gender, years of education, ethnicity, and depression.

Dr. Keil said the model found, as expected, that the  demographic variables of education, APOE status, and depression were significantly associated with cognitive impairment (hazard ratios of 1.11; 95% confidence interval [CI], 1.02-1.21; P = .01; and 2.08; 95% CI, 1.31-3.31; P < .005; and 1.08; 95% CI, 1.04-1.13; P < .005, respectively). Importantly, when evaluating the duration, change and variability of sleep, the researchers found that increased sleep variability was significantly associated with cognitive impairment (HR, 3.15; 95% CI, 1.69-5.87; P < .005).  

Under this analysis, “sleep variability over time and not median sleep duration was associated with cognitive impairment,” she said. When sleep variability was added into the model, it improved the concordance score – a value that reflects the ability of a model to predict an outcome better than random chance – from .63 to .73 (a value of .5 indicates the model is no better at predicting an outcome than a random chance model; a value of .7 or greater indicates a good model).

Identification of sleep variability as a sleep pattern of interest in longitudinal studies is important, Dr. Keil said, because simply evaluating mean or median sleep duration across time might not account for a subject’s variable sleep phenotype. Most importantly, further evaluation of sleep variability with a linear regression prediction analysis (F statistic 8.796, P < .0001, adjusted R-squared .235) found that increased age, depression, and sleep variability significantly predicted cognitive impairment 10 years downstream. “Longitudinal sleep variability is perhaps for the first time being reported as significantly associated with the development of downstream cognitive impairment,” Dr. Keil said.

What makes this study unique, Dr. Keil said in an interview, is that it used self-reported longitudinal data gathered at 3- to 5-year intervals for up to 25 years, allowing for the assessment of variation of sleep duration across this entire time frame. “If you could use that shift in sleep duration as a point of therapeutic intervention, that would be really exciting,” she said.

Future research will evaluate how sleep variability and cognitive function are impacted by other variables gathered in the Seattle Longitudinal Study over the years, including factors such as diabetes and hypertension status, diet, alcohol and tobacco use, and marital and family status. Follow-up studies will be investigating the impact of sleep variability on neuropathologic disease progression and lymphatic system impairment, Dr. Keil said.
 

A newer approach

By linking sleep variability and daytime functioning, the study employs a “newer approach,” said Joseph M. Dzierzewski, PhD, director of behavioral medicine concentration in the department of psychology at Virginia Commonwealth University in Richmond. “While some previous work has examined night-to-night fluctuation in various sleep characteristics and cognitive functioning, what differentiates the present study from these previous works is the duration of the investigation,” he said. The “richness of data” in the Seattle Longitudinal Study and how it tracks sleep and cognition over years make it “quite unique and novel.”

Future studies, he said, should be deliberate in how they evaluate sleep and neurocognitive function across years. “Disentangling short-term moment-to-moment and day-to-day fluctuation, which may be more reversible in nature, from long-term, enduring month-to-month or year-to-year fluctuation, which may be more permanent, will be important for continuing to advance our understanding of these complex phenomena,” Dr. Dzierzewski said. “An additional important area of future investigation would be to continue the hunt for a common biological factor underpinning both sleep variability and Alzheimer’s disease.” That, he said, may help identify potential intervention targets.

Dr. Keil and Dr. Dzierzewski have no relevant disclosures.

The development of depression after a rheumatoid arthritis diagnosis increased the risk for death “more than sixfold” when compared with having no depression at diagnosis, according to Danish researchers.

Cumulative mortality at 10 years was approximately 37% in patients with comorbid RA and depression versus around 13.5% of RA patients with no depression, Jens Kristian Pedersen, MD, PhD, of Odense (Denmark) University Hospital–Svendborg Hospital and the department of clinical research at the University of Southern Denmark, also in Odense, reported at the annual European Congress of Rheumatology.

“According to [antidepressant] exposure status, the cumulative mortality followed two clearly different paths,” Dr. Pedersen said. “The mortality curves separated early and already within the first and second year of follow-up.”
 

RA, depression, and mortality

Rates of depression in patients with RA are high, Dr. Pedersen said, and while it’s previously been reported that their coexistence can increase mortality, this is the first time that the link has been investigated in a population newly diagnosed with RA.

In this study, Dr. Pedersen and collaborators wanted to look at the association in incident RA and defined depression as the first filling of an antidepressant prescription.

“Although antidepressants are used for different indications, we have recently described that in RA the most frequent indication for filling antidepressants is depression,” he explained. Moreover, that research found that “the frequency of filling coincides with the occurrence of depressive disorder previously reported in the scientific literature.”
 

Data sourced from multiple Danish registers

To examine the mortality risk associated with newly diagnosed RA and new-onset depression, Dr. Pedersen described how five different Danish registers were used.

First, data from the DANBIO register were used to identify patients with incident RA living in Denmark over a 10-year period ending in December 2018. Although perhaps widely known as a biologics register, DANBIO is required by the Danish National Board of Health to collect information on all patients with RA, regardless of their treatment.

Next, the Danish National Prescription Register and Danish National Patient Register were consulted to obtain data on patients who had a first prescription for antidepressant treatment and information on those who developed a diagnosis of depression. Demographic, vital status, and socioeconomic data were collated from the Danish Civil Registration System and Statistics Denmark databases.

To be sure they were looking at incident cases of RA and new cases of depression, the researchers excluded anyone with an existing prescription of antidepressants or methotrexate, or who had a confirmed diagnosis of either disorder 3 years prior to the index date of Jan. 1, 2008.

This meant that, from a total population of 18,000 patients in the DANBIO database, there were just over 11,000 who could be included in the analyses.

Overall, the median age at RA diagnosis was 61 years, two-thirds were female, and two-thirds had seropositive disease.

New-onset depression in incident RA

“During follow-up, about 10% filled a prescription of antidepressants,” said Dr. Pedersen, adding that there were 671 deaths, representing around 57,000 person-years at risk.

“The majority died from natural causes,” he said, although the cause of death was unknown in 30% of cases.

Comparing those who did and did not have a prescription for antidepressants, there were some differences in the age at which death occurred, the percentage of females to males, the presence of other comorbidities, and levels of higher education and income. These were all adjusted for in the analyses.

Adjusted hazard rate ratios were calculated to look at the mortality risk in patients who had antidepressant exposure. The highest HRR for mortality with antidepressant use was seen in patients aged 55 years or younger at 6.66, with the next highest HRRs being for male gender (3.70) and seropositive RA (3.45).

But HRRs for seronegative RA, female gender, and age 55-70 years or older than 75 years were all still around 3.0.
 

Depression definition questioned

“My only concern is about the definition of depression in your analysis,” said a member of the audience at the congress.

“You used antidepressant use as a proxy of depression diagnosis, but it might be that most or many patients have taken [medication] like duloxetine for pain control, and you are just seeing higher disease activity and more aggressive RA.”

Dr. Pedersen responded: “After the EULAR 2022 submission deadline, we reanalyzed our data using two other measures of depression.

“First, we use treatment with antidepressants with a positive indication of depression, according to the prescribing physician, and secondly, we used first diagnosis with depression according to ICD-10 Code F32 – ‘depressive episode after discharge from hospital as an outpatient,’ ” he said.

“All definitions end up with a hazard rate ratio of about three. So, in my opinion, it doesn’t matter whether you focus on one measure of depression or the other.”

David Isenberg, MD, FRCP, professor of rheumatology at University College London, wanted to know more about the antecedent history of depression and whether people who had been depressed maybe a decade or 2 decades before, were more likely to get RA.

That calculation has not been done, Dr. Pedersen said, adding that the study also can’t account for people who may have had recurrent depression. Depression treatment guidelines often recommend nonpharmacologic intervention in the first instance, “so we do not necessarily get the right picture of recurrent depression if we look further back.”

Pointing out that the sixfold increase in mortality was impressive, another delegate asked about whether it was because of a higher disease activity or joint damage and if the mortality risk might be lower in patients who are in remission.

“We don’t know that yet,” Dr. Pedersen answered. “We haven’t done the calculations, but there is the issue of residual confounding if we don’t take all relevant covariates into account. So, we need to do that calculation as well.”

The study was supported by the Danish Rheumatism Association. Dr. Pedersen had no conflicts of interest to disclose.
 

The development of depression after a rheumatoid arthritis diagnosis increased the risk for death “more than sixfold” when compared with having no depression at diagnosis, according to Danish researchers.

Cumulative mortality at 10 years was approximately 37% in patients with comorbid RA and depression versus around 13.5% of RA patients with no depression, Jens Kristian Pedersen, MD, PhD, of Odense (Denmark) University Hospital–Svendborg Hospital and the department of clinical research at the University of Southern Denmark, also in Odense, reported at the annual European Congress of Rheumatology.

“According to [antidepressant] exposure status, the cumulative mortality followed two clearly different paths,” Dr. Pedersen said. “The mortality curves separated early and already within the first and second year of follow-up.”
 

RA, depression, and mortality

Rates of depression in patients with RA are high, Dr. Pedersen said, and while it’s previously been reported that their coexistence can increase mortality, this is the first time that the link has been investigated in a population newly diagnosed with RA.

In this study, Dr. Pedersen and collaborators wanted to look at the association in incident RA and defined depression as the first filling of an antidepressant prescription.

“Although antidepressants are used for different indications, we have recently described that in RA the most frequent indication for filling antidepressants is depression,” he explained. Moreover, that research found that “the frequency of filling coincides with the occurrence of depressive disorder previously reported in the scientific literature.”
 

Data sourced from multiple Danish registers

To examine the mortality risk associated with newly diagnosed RA and new-onset depression, Dr. Pedersen described how five different Danish registers were used.

First, data from the DANBIO register were used to identify patients with incident RA living in Denmark over a 10-year period ending in December 2018. Although perhaps widely known as a biologics register, DANBIO is required by the Danish National Board of Health to collect information on all patients with RA, regardless of their treatment.

Next, the Danish National Prescription Register and Danish National Patient Register were consulted to obtain data on patients who had a first prescription for antidepressant treatment and information on those who developed a diagnosis of depression. Demographic, vital status, and socioeconomic data were collated from the Danish Civil Registration System and Statistics Denmark databases.

To be sure they were looking at incident cases of RA and new cases of depression, the researchers excluded anyone with an existing prescription of antidepressants or methotrexate, or who had a confirmed diagnosis of either disorder 3 years prior to the index date of Jan. 1, 2008.

This meant that, from a total population of 18,000 patients in the DANBIO database, there were just over 11,000 who could be included in the analyses.

Overall, the median age at RA diagnosis was 61 years, two-thirds were female, and two-thirds had seropositive disease.

New-onset depression in incident RA

“During follow-up, about 10% filled a prescription of antidepressants,” said Dr. Pedersen, adding that there were 671 deaths, representing around 57,000 person-years at risk.

“The majority died from natural causes,” he said, although the cause of death was unknown in 30% of cases.

Comparing those who did and did not have a prescription for antidepressants, there were some differences in the age at which death occurred, the percentage of females to males, the presence of other comorbidities, and levels of higher education and income. These were all adjusted for in the analyses.

Adjusted hazard rate ratios were calculated to look at the mortality risk in patients who had antidepressant exposure. The highest HRR for mortality with antidepressant use was seen in patients aged 55 years or younger at 6.66, with the next highest HRRs being for male gender (3.70) and seropositive RA (3.45).

But HRRs for seronegative RA, female gender, and age 55-70 years or older than 75 years were all still around 3.0.
 

Depression definition questioned

“My only concern is about the definition of depression in your analysis,” said a member of the audience at the congress.

“You used antidepressant use as a proxy of depression diagnosis, but it might be that most or many patients have taken [medication] like duloxetine for pain control, and you are just seeing higher disease activity and more aggressive RA.”

Dr. Pedersen responded: “After the EULAR 2022 submission deadline, we reanalyzed our data using two other measures of depression.

“First, we use treatment with antidepressants with a positive indication of depression, according to the prescribing physician, and secondly, we used first diagnosis with depression according to ICD-10 Code F32 – ‘depressive episode after discharge from hospital as an outpatient,’ ” he said.

“All definitions end up with a hazard rate ratio of about three. So, in my opinion, it doesn’t matter whether you focus on one measure of depression or the other.”

David Isenberg, MD, FRCP, professor of rheumatology at University College London, wanted to know more about the antecedent history of depression and whether people who had been depressed maybe a decade or 2 decades before, were more likely to get RA.

That calculation has not been done, Dr. Pedersen said, adding that the study also can’t account for people who may have had recurrent depression. Depression treatment guidelines often recommend nonpharmacologic intervention in the first instance, “so we do not necessarily get the right picture of recurrent depression if we look further back.”

Pointing out that the sixfold increase in mortality was impressive, another delegate asked about whether it was because of a higher disease activity or joint damage and if the mortality risk might be lower in patients who are in remission.

“We don’t know that yet,” Dr. Pedersen answered. “We haven’t done the calculations, but there is the issue of residual confounding if we don’t take all relevant covariates into account. So, we need to do that calculation as well.”

The study was supported by the Danish Rheumatism Association. Dr. Pedersen had no conflicts of interest to disclose.
 

The development of depression after a rheumatoid arthritis diagnosis increased the risk for death “more than sixfold” when compared with having no depression at diagnosis, according to Danish researchers.

Cumulative mortality at 10 years was approximately 37% in patients with comorbid RA and depression versus around 13.5% of RA patients with no depression, Jens Kristian Pedersen, MD, PhD, of Odense (Denmark) University Hospital–Svendborg Hospital and the department of clinical research at the University of Southern Denmark, also in Odense, reported at the annual European Congress of Rheumatology.

“According to [antidepressant] exposure status, the cumulative mortality followed two clearly different paths,” Dr. Pedersen said. “The mortality curves separated early and already within the first and second year of follow-up.”
 

RA, depression, and mortality

Rates of depression in patients with RA are high, Dr. Pedersen said, and while it’s previously been reported that their coexistence can increase mortality, this is the first time that the link has been investigated in a population newly diagnosed with RA.

In this study, Dr. Pedersen and collaborators wanted to look at the association in incident RA and defined depression as the first filling of an antidepressant prescription.

“Although antidepressants are used for different indications, we have recently described that in RA the most frequent indication for filling antidepressants is depression,” he explained. Moreover, that research found that “the frequency of filling coincides with the occurrence of depressive disorder previously reported in the scientific literature.”
 

Data sourced from multiple Danish registers

To examine the mortality risk associated with newly diagnosed RA and new-onset depression, Dr. Pedersen described how five different Danish registers were used.

First, data from the DANBIO register were used to identify patients with incident RA living in Denmark over a 10-year period ending in December 2018. Although perhaps widely known as a biologics register, DANBIO is required by the Danish National Board of Health to collect information on all patients with RA, regardless of their treatment.

Next, the Danish National Prescription Register and Danish National Patient Register were consulted to obtain data on patients who had a first prescription for antidepressant treatment and information on those who developed a diagnosis of depression. Demographic, vital status, and socioeconomic data were collated from the Danish Civil Registration System and Statistics Denmark databases.

To be sure they were looking at incident cases of RA and new cases of depression, the researchers excluded anyone with an existing prescription of antidepressants or methotrexate, or who had a confirmed diagnosis of either disorder 3 years prior to the index date of Jan. 1, 2008.

This meant that, from a total population of 18,000 patients in the DANBIO database, there were just over 11,000 who could be included in the analyses.

Overall, the median age at RA diagnosis was 61 years, two-thirds were female, and two-thirds had seropositive disease.

New-onset depression in incident RA

“During follow-up, about 10% filled a prescription of antidepressants,” said Dr. Pedersen, adding that there were 671 deaths, representing around 57,000 person-years at risk.

“The majority died from natural causes,” he said, although the cause of death was unknown in 30% of cases.

Comparing those who did and did not have a prescription for antidepressants, there were some differences in the age at which death occurred, the percentage of females to males, the presence of other comorbidities, and levels of higher education and income. These were all adjusted for in the analyses.

Adjusted hazard rate ratios were calculated to look at the mortality risk in patients who had antidepressant exposure. The highest HRR for mortality with antidepressant use was seen in patients aged 55 years or younger at 6.66, with the next highest HRRs being for male gender (3.70) and seropositive RA (3.45).

But HRRs for seronegative RA, female gender, and age 55-70 years or older than 75 years were all still around 3.0.
 

Depression definition questioned

“My only concern is about the definition of depression in your analysis,” said a member of the audience at the congress.

“You used antidepressant use as a proxy of depression diagnosis, but it might be that most or many patients have taken [medication] like duloxetine for pain control, and you are just seeing higher disease activity and more aggressive RA.”

Dr. Pedersen responded: “After the EULAR 2022 submission deadline, we reanalyzed our data using two other measures of depression.

“First, we use treatment with antidepressants with a positive indication of depression, according to the prescribing physician, and secondly, we used first diagnosis with depression according to ICD-10 Code F32 – ‘depressive episode after discharge from hospital as an outpatient,’ ” he said.

“All definitions end up with a hazard rate ratio of about three. So, in my opinion, it doesn’t matter whether you focus on one measure of depression or the other.”

David Isenberg, MD, FRCP, professor of rheumatology at University College London, wanted to know more about the antecedent history of depression and whether people who had been depressed maybe a decade or 2 decades before, were more likely to get RA.

That calculation has not been done, Dr. Pedersen said, adding that the study also can’t account for people who may have had recurrent depression. Depression treatment guidelines often recommend nonpharmacologic intervention in the first instance, “so we do not necessarily get the right picture of recurrent depression if we look further back.”

Pointing out that the sixfold increase in mortality was impressive, another delegate asked about whether it was because of a higher disease activity or joint damage and if the mortality risk might be lower in patients who are in remission.

“We don’t know that yet,” Dr. Pedersen answered. “We haven’t done the calculations, but there is the issue of residual confounding if we don’t take all relevant covariates into account. So, we need to do that calculation as well.”

The study was supported by the Danish Rheumatism Association. Dr. Pedersen had no conflicts of interest to disclose.
 

Adding psychotherapy to pharmacologic treatment does not appear to improve treatment outcomes for patients with major depression, new research suggests.

Results of a cross-sectional, naturalistic, multicenter European study showed there were no significant differences in response rates between patients with major depressive disorder (MDD) who received combination treatment with psychotherapy and antidepressant medication in comparison with those who received antidepressant monotherapy, even when comparing different types of psychotherapy.

This “might emphasize the fundamental role of the underlying complex biological interrelationships in MDD and its treatment,” said study investigator Lucie Bartova, MD, PhD, Clinical Division of General Psychiatry, Medical University of Vienna.

However, she noted that patients who received psychotherapy in combination with antidepressants also had “beneficial sociodemographic and clinical characteristics,” which might reflect poorer access to “psychotherapeutic techniques for patients who are more severely ill and have less socioeconomic privilege.”

The resulting selection bias may cause patients with more severe illness to “fall by the wayside,” Dr. Bartova said.

Lead researcher Siegfried Kasper, MD, also from the Medical University of Vienna, agreed, saying in a press release that, by implication, “additional psychotherapy tends to be given to more highly educated and healthier patients, which may reflect the greater availability of psychotherapy to more socially and economically advantaged patients.”

The findings, some of which were previously published in the Journal of Psychiatry Research, were presented at the virtual European Psychiatric Association 2022 Congress.
 

Inconsistent guidelines

During her presentation, Dr. Bartova said that while “numerous effective antidepressant strategies are available for the treatment of MDD, many patients do not achieve a satisfactory treatment response,” which often leads to further management refinement and the use of off-label treatments.

She continued, saying that the “most obvious” approach in these situations is to try the available treatment options in a “systematic and individualized” manner, ideally by following recommended treatment algorithms.

Meta-analyses have suggested that standardized psychotherapy with fixed, regular sessions that follows an established rationale and is based on a defined school of thought is effective in MDD, “with at least moderate effects.”

Among the psychotherapy approaches, cognitive-behavioral therapy (CBT) is the “best and most investigated,” Dr. Bartova said, but international clinical practice guidelines “lack consistency” regarding recommendations for psychotherapy.

To examine the use and impact of psychotherapy for MDD patients, the researchers studied 1,410 adult inpatients and outpatients from 10 centers in eight countries who were surveyed between 2011 and 2016 by the European Group for the Study of Resistant Depression.

Participants were assessed via the Mini–International Neuropsychiatric Interview, the Montgomery-Åsberg Depression Rating Scale, and the Hamilton Depression Rating Scale.

Results showed that among 1,279 MDD patients who were included in the final analysis, 880 (68.8%) received only antidepressants, while 399 (31.2%) received some form of structured psychotherapy as part of their treatment.

These patients included 22.8% who received CBT, 3.4% who underwent psychoanalytic psychotherapy, and 1.3% who received systemic psychotherapy. The additional psychotherapy was not specified for 3.8%.

Dr. Bartova explained that the use of psychotherapy in combination pharmacologic treatment was significantly associated with younger age, higher educational attainment, and ongoing employment in comparison with antidepressant use alone (P < .001 for all).

In addition, combination therapy was associated with an earlier average age of MDD onset, lower severity of current depressive symptoms, a lower risk of suicidality, higher rates of additional melancholic features in the patients’ symptomatology, and higher rates of comorbid asthma and migraine (P < .001 for all).

There was also a significant association between the use of psychotherapy plus pharmacologic treatment and lower average daily doses of first-line antidepressant medication (P < .001), as well as more frequent administration of agomelatine (P < .001) and a trend toward greater use of vortioxetine (P = .006).

In contrast, among patients who received antidepressants alone, there was a trend toward higher rates of additional psychotic features (P = .054), and the patients were more likely to have received selective serotonin reuptake inhibitors as their first-line antidepressant medication (P < .001).

The researchers found there was no significant difference in rates of response, nonresponse, and treatment-resistant depression (TRD) between patients who received combination psychotherapy and pharmacotherapy and those who received antidepressants alone (P = .369).

Dr. Bartova showed that 25.8% of MDD patients who received combination therapy were classified as responders, compared with 23.5% of those given only antidepressants. Nonresponse was identified in 35.6% and 33.8% of patients, respectively, while 38.6% versus 42.7% had TRD.

Dr. Bartova and colleagues performed an additional analysis to determine whether there was any difference in response depending on the type of psychotherapy.

They divided patients who received combination therapy into those who had received CBT and those who had been given another form of psychotherapy.

Again, there were no significant differences in response, nonresponse, and TRD (P = .256). The response rate was 27.1% among patients given combination CBT, versus 22.4% among those who received another psychotherapy.

“Despite clinical guidelines and studies which advocate for psychotherapy and combining psychotherapy with antidepressants, this study shows that in real life, no added value can be demonstrated for psychotherapy in those already treated with antidepressants for severe depression,” Livia De Picker, MD, PhD, Collaborative Antwerp Psychiatric Research Institute, University of Antwerp, Belgium, said in the press release.

“This doesn’t necessarily mean that psychotherapy is not useful, but it is a clear sign that the way we are currently managing these depressed patients with psychotherapy is not effective and needs critical evaluation,” added Dr. De Picker, who was not involved in the research.

However, Michael E. Thase, MD, professor of psychiatry, University of Pennsylvania, Philadelphia, told this news organization that the current study “is a secondary analysis of a naturalistic study.”

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

Adding psychotherapy to pharmacologic treatment does not appear to improve treatment outcomes for patients with major depression, new research suggests.

Results of a cross-sectional, naturalistic, multicenter European study showed there were no significant differences in response rates between patients with major depressive disorder (MDD) who received combination treatment with psychotherapy and antidepressant medication in comparison with those who received antidepressant monotherapy, even when comparing different types of psychotherapy.

This “might emphasize the fundamental role of the underlying complex biological interrelationships in MDD and its treatment,” said study investigator Lucie Bartova, MD, PhD, Clinical Division of General Psychiatry, Medical University of Vienna.

However, she noted that patients who received psychotherapy in combination with antidepressants also had “beneficial sociodemographic and clinical characteristics,” which might reflect poorer access to “psychotherapeutic techniques for patients who are more severely ill and have less socioeconomic privilege.”

The resulting selection bias may cause patients with more severe illness to “fall by the wayside,” Dr. Bartova said.

Lead researcher Siegfried Kasper, MD, also from the Medical University of Vienna, agreed, saying in a press release that, by implication, “additional psychotherapy tends to be given to more highly educated and healthier patients, which may reflect the greater availability of psychotherapy to more socially and economically advantaged patients.”

The findings, some of which were previously published in the Journal of Psychiatry Research, were presented at the virtual European Psychiatric Association 2022 Congress.
 

Inconsistent guidelines

During her presentation, Dr. Bartova said that while “numerous effective antidepressant strategies are available for the treatment of MDD, many patients do not achieve a satisfactory treatment response,” which often leads to further management refinement and the use of off-label treatments.

She continued, saying that the “most obvious” approach in these situations is to try the available treatment options in a “systematic and individualized” manner, ideally by following recommended treatment algorithms.

Meta-analyses have suggested that standardized psychotherapy with fixed, regular sessions that follows an established rationale and is based on a defined school of thought is effective in MDD, “with at least moderate effects.”

Among the psychotherapy approaches, cognitive-behavioral therapy (CBT) is the “best and most investigated,” Dr. Bartova said, but international clinical practice guidelines “lack consistency” regarding recommendations for psychotherapy.

To examine the use and impact of psychotherapy for MDD patients, the researchers studied 1,410 adult inpatients and outpatients from 10 centers in eight countries who were surveyed between 2011 and 2016 by the European Group for the Study of Resistant Depression.

Participants were assessed via the Mini–International Neuropsychiatric Interview, the Montgomery-Åsberg Depression Rating Scale, and the Hamilton Depression Rating Scale.

Results showed that among 1,279 MDD patients who were included in the final analysis, 880 (68.8%) received only antidepressants, while 399 (31.2%) received some form of structured psychotherapy as part of their treatment.

These patients included 22.8% who received CBT, 3.4% who underwent psychoanalytic psychotherapy, and 1.3% who received systemic psychotherapy. The additional psychotherapy was not specified for 3.8%.

Dr. Bartova explained that the use of psychotherapy in combination pharmacologic treatment was significantly associated with younger age, higher educational attainment, and ongoing employment in comparison with antidepressant use alone (P < .001 for all).

In addition, combination therapy was associated with an earlier average age of MDD onset, lower severity of current depressive symptoms, a lower risk of suicidality, higher rates of additional melancholic features in the patients’ symptomatology, and higher rates of comorbid asthma and migraine (P < .001 for all).

There was also a significant association between the use of psychotherapy plus pharmacologic treatment and lower average daily doses of first-line antidepressant medication (P < .001), as well as more frequent administration of agomelatine (P < .001) and a trend toward greater use of vortioxetine (P = .006).

In contrast, among patients who received antidepressants alone, there was a trend toward higher rates of additional psychotic features (P = .054), and the patients were more likely to have received selective serotonin reuptake inhibitors as their first-line antidepressant medication (P < .001).

The researchers found there was no significant difference in rates of response, nonresponse, and treatment-resistant depression (TRD) between patients who received combination psychotherapy and pharmacotherapy and those who received antidepressants alone (P = .369).

Dr. Bartova showed that 25.8% of MDD patients who received combination therapy were classified as responders, compared with 23.5% of those given only antidepressants. Nonresponse was identified in 35.6% and 33.8% of patients, respectively, while 38.6% versus 42.7% had TRD.

Dr. Bartova and colleagues performed an additional analysis to determine whether there was any difference in response depending on the type of psychotherapy.

They divided patients who received combination therapy into those who had received CBT and those who had been given another form of psychotherapy.

Again, there were no significant differences in response, nonresponse, and TRD (P = .256). The response rate was 27.1% among patients given combination CBT, versus 22.4% among those who received another psychotherapy.

“Despite clinical guidelines and studies which advocate for psychotherapy and combining psychotherapy with antidepressants, this study shows that in real life, no added value can be demonstrated for psychotherapy in those already treated with antidepressants for severe depression,” Livia De Picker, MD, PhD, Collaborative Antwerp Psychiatric Research Institute, University of Antwerp, Belgium, said in the press release.

“This doesn’t necessarily mean that psychotherapy is not useful, but it is a clear sign that the way we are currently managing these depressed patients with psychotherapy is not effective and needs critical evaluation,” added Dr. De Picker, who was not involved in the research.

However, Michael E. Thase, MD, professor of psychiatry, University of Pennsylvania, Philadelphia, told this news organization that the current study “is a secondary analysis of a naturalistic study.”

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

Adding psychotherapy to pharmacologic treatment does not appear to improve treatment outcomes for patients with major depression, new research suggests.

Results of a cross-sectional, naturalistic, multicenter European study showed there were no significant differences in response rates between patients with major depressive disorder (MDD) who received combination treatment with psychotherapy and antidepressant medication in comparison with those who received antidepressant monotherapy, even when comparing different types of psychotherapy.

This “might emphasize the fundamental role of the underlying complex biological interrelationships in MDD and its treatment,” said study investigator Lucie Bartova, MD, PhD, Clinical Division of General Psychiatry, Medical University of Vienna.

However, she noted that patients who received psychotherapy in combination with antidepressants also had “beneficial sociodemographic and clinical characteristics,” which might reflect poorer access to “psychotherapeutic techniques for patients who are more severely ill and have less socioeconomic privilege.”

The resulting selection bias may cause patients with more severe illness to “fall by the wayside,” Dr. Bartova said.

Lead researcher Siegfried Kasper, MD, also from the Medical University of Vienna, agreed, saying in a press release that, by implication, “additional psychotherapy tends to be given to more highly educated and healthier patients, which may reflect the greater availability of psychotherapy to more socially and economically advantaged patients.”

The findings, some of which were previously published in the Journal of Psychiatry Research, were presented at the virtual European Psychiatric Association 2022 Congress.
 

Inconsistent guidelines

During her presentation, Dr. Bartova said that while “numerous effective antidepressant strategies are available for the treatment of MDD, many patients do not achieve a satisfactory treatment response,” which often leads to further management refinement and the use of off-label treatments.

She continued, saying that the “most obvious” approach in these situations is to try the available treatment options in a “systematic and individualized” manner, ideally by following recommended treatment algorithms.

Meta-analyses have suggested that standardized psychotherapy with fixed, regular sessions that follows an established rationale and is based on a defined school of thought is effective in MDD, “with at least moderate effects.”

Among the psychotherapy approaches, cognitive-behavioral therapy (CBT) is the “best and most investigated,” Dr. Bartova said, but international clinical practice guidelines “lack consistency” regarding recommendations for psychotherapy.

To examine the use and impact of psychotherapy for MDD patients, the researchers studied 1,410 adult inpatients and outpatients from 10 centers in eight countries who were surveyed between 2011 and 2016 by the European Group for the Study of Resistant Depression.

Participants were assessed via the Mini–International Neuropsychiatric Interview, the Montgomery-Åsberg Depression Rating Scale, and the Hamilton Depression Rating Scale.

Results showed that among 1,279 MDD patients who were included in the final analysis, 880 (68.8%) received only antidepressants, while 399 (31.2%) received some form of structured psychotherapy as part of their treatment.

These patients included 22.8% who received CBT, 3.4% who underwent psychoanalytic psychotherapy, and 1.3% who received systemic psychotherapy. The additional psychotherapy was not specified for 3.8%.

Dr. Bartova explained that the use of psychotherapy in combination pharmacologic treatment was significantly associated with younger age, higher educational attainment, and ongoing employment in comparison with antidepressant use alone (P < .001 for all).

In addition, combination therapy was associated with an earlier average age of MDD onset, lower severity of current depressive symptoms, a lower risk of suicidality, higher rates of additional melancholic features in the patients’ symptomatology, and higher rates of comorbid asthma and migraine (P < .001 for all).

There was also a significant association between the use of psychotherapy plus pharmacologic treatment and lower average daily doses of first-line antidepressant medication (P < .001), as well as more frequent administration of agomelatine (P < .001) and a trend toward greater use of vortioxetine (P = .006).

In contrast, among patients who received antidepressants alone, there was a trend toward higher rates of additional psychotic features (P = .054), and the patients were more likely to have received selective serotonin reuptake inhibitors as their first-line antidepressant medication (P < .001).

The researchers found there was no significant difference in rates of response, nonresponse, and treatment-resistant depression (TRD) between patients who received combination psychotherapy and pharmacotherapy and those who received antidepressants alone (P = .369).

Dr. Bartova showed that 25.8% of MDD patients who received combination therapy were classified as responders, compared with 23.5% of those given only antidepressants. Nonresponse was identified in 35.6% and 33.8% of patients, respectively, while 38.6% versus 42.7% had TRD.

Dr. Bartova and colleagues performed an additional analysis to determine whether there was any difference in response depending on the type of psychotherapy.

They divided patients who received combination therapy into those who had received CBT and those who had been given another form of psychotherapy.

Again, there were no significant differences in response, nonresponse, and TRD (P = .256). The response rate was 27.1% among patients given combination CBT, versus 22.4% among those who received another psychotherapy.

“Despite clinical guidelines and studies which advocate for psychotherapy and combining psychotherapy with antidepressants, this study shows that in real life, no added value can be demonstrated for psychotherapy in those already treated with antidepressants for severe depression,” Livia De Picker, MD, PhD, Collaborative Antwerp Psychiatric Research Institute, University of Antwerp, Belgium, said in the press release.

“This doesn’t necessarily mean that psychotherapy is not useful, but it is a clear sign that the way we are currently managing these depressed patients with psychotherapy is not effective and needs critical evaluation,” added Dr. De Picker, who was not involved in the research.

However, Michael E. Thase, MD, professor of psychiatry, University of Pennsylvania, Philadelphia, told this news organization that the current study “is a secondary analysis of a naturalistic study.”

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