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Kids already coping with mental disorders spiral as pandemic topples vital support systems
A bag of Doritos, that’s all Princess wanted.
Her mom calls her Princess, but her real name is Lindsey. She’s 17 and lives with her mom, Sandra, a nurse, outside Atlanta. On May 17, 2020, a Sunday, Lindsey decided she didn’t want breakfast; she wanted Doritos. So she left home and walked to Family Dollar, taking her pants off on the way, while her mom followed on foot, talking to the police on her phone as they went.
Lindsey has autism. It can be hard for her to communicate and navigate social situations. She thrives on routine and gets special help at school. Or got help, before the coronavirus pandemic closed schools and forced tens of millions of children to stay home. Sandra said that’s when their living hell started.
“It’s like her brain was wired,” she said. “She’d just put on her jacket, and she’s out the door. And I’m chasing her.”
On May 17, Sandra chased her all the way to Family Dollar. Hours later, Lindsey was in jail, charged with assaulting her mom. (KHN and NPR are not using the family’s last name.)
Lindsey is 1 of almost 3 million children in the United States who have a serious emotional or behavioral health condition. When the pandemic forced schools and doctors’ offices to close last spring, it also cut children off from the trained teachers and therapists who understand their needs.
As a result, many, like Lindsey, spiraled into EDs and even police custody. Federal data shows a nationwide surge of children in mental health crisis during the pandemic – a surge that’s further taxing an already overstretched safety net.
‘Take her’
Even after schools closed, Lindsey continued to wake up early, get dressed and wait for the bus. When she realized it had stopped coming, Sandra said, her daughter just started walking out of the house, wandering, a few times a week.
In those situations, Sandra did what many families in crisis report they’ve had to do since the pandemic began: Race through the short list of places she could call for help.
First, her state’s mental health crisis hotline. But they often put Sandra on hold.
“This is ridiculous,” she said of the wait. “It’s supposed to be a crisis team. But I’m on hold for 40, 50 minutes. And by the time you get on the phone, [the crisis] is done!”
Then there’s the local hospital’s ED, but Sandra said she had taken Lindsey there for previous crises and been told there isn’t much they can do.
That’s why, on May 17, when Lindsey walked to Family Dollar in just a red T-shirt and underwear to get that bag of Doritos, Sandra called the last option on her list: the police.
Sandra arrived at the store before the police and paid for the chips. According to Sandra and police records, when an officer approached, Lindsey grew agitated and hit her mom on the back, hard.
Sandra said she explained to the officer: “‘She’s autistic. You know, I’m okay. I’m a nurse. I just need to take her home and give her her medication.’ ”
Lindsey takes a mood stabilizer, but because she left home before breakfast, she hadn’t taken it that morning. The officer asked if Sandra wanted to take her to the nearest hospital.
The hospital wouldn’t be able to help Lindsey, Sandra said. It hadn’t before. “They already told me: ‘Ma’am, there’s nothing we can do.’ They just check her labs, it’s fine, and they ship her back home. There’s nothing [the hospital] can do,” she recalled telling the officer.
Sandra asked if the police could drive her daughter home so the teen could take her medication, but the officer said no, they couldn’t. The only other thing they could do, the officer said, was take Lindsey to jail for hitting her mom.
“I’ve tried everything,” Sandra said, exasperated. She paced the parking lot, feeling hopeless, sad and out of options. Finally, in tears, she told the officers: “Take her.”
Lindsey does not like to be touched and fought back when authorities tried to handcuff her. Several officers wrestled her to the ground. At that point, Sandra protested and said an officer threatened to arrest her, too, if she didn’t back away. Lindsey was taken to jail, where she spent much of the night until Sandra was able to post bail.
Clayton County Solicitor-General Charles Brooks denied that Sandra was threatened with arrest and said that, while Lindsey’s case is still pending, his office “is working to ensure that the resolution in this matter involves a plan for medication compliance and not punitive action.”
Sandra isn’t alone in her experience. Multiple families interviewed for this story reported similar experiences of calling in the police when a child was in crisis because caretakers didn’t feel they had any other option.
‘The whole system is really grinding to a halt’
Roughly 6% of U.S. children ages 6-17 years are living with serious emotional or behavioral difficulties, including children with autism, severe anxiety, depression and trauma-related mental health conditions.
Many of these children depend on schools for access to vital therapies. When schools and doctors’ offices stopped providing in-person services last spring, kids were untethered from the people and supports they rely on.
“The lack of in-person services is really detrimental,” said Susan Duffy, MD,a pediatrician and professor of emergency medicine at Brown University, Providence, R.I.
Marjorie, a mother in Florida, said her 15-year-old son has suffered during these disruptions. He has ADHD and oppositional defiant disorder, a condition marked by frequent and persistent hostility. Little things – like being asked to do schoolwork – can send him into a rage, leading to holes punched in walls, broken doors and violent threats. (The family’s last name or her son’s first name are not used to protect her son’s privacy and future prospects.)
The pandemic has shifted both school and her son’s therapy sessions online. But Marjorie said virtual therapy isn’t working because her son doesn’t focus well during sessions and tries to watch television instead. Lately, she has simply been canceling them.
“I was paying for appointments and there was no therapeutic value,” Marjorie said.
The issues cut across socioeconomic lines – affecting families with private insurance, like Marjorie, as well as those who receive coverage through Medicaid, a federal-state program that provides health insurance to low-income people and those with disabilities.
In the first few months of the pandemic, between March and May, children on Medicaid received 44% fewer outpatient mental health services – including therapy and in-home support – compared with the same time period in 2019, according to the Centers for Medicare & Medicaid Services. That’s even after accounting for increased telehealth appointments.
And while the nation’s EDs have seen a decline in overall visits, there was a relative increase in mental health visits for kids in 2020, compared with 2019.
The Centers for Disease Control and Prevention found that, from April to October 2020, hospitals across the United States saw a 24% increase in the proportion of mental health emergency visits for children aged 5-11 years, and a 31% increase for children aged 12-17.
“Not only are we seeing more children, more children are being admitted” to inpatient care.
That’s because there are fewer outpatient services now available to children, she said, and because the conditions of the children showing up at EDs “are more serious.”
This crisis is not only making life harder for these kids and their families, but it’s also stressing the entire health care system.
Child and adolescent psychiatrists working in hospitals around the country said children are increasingly “boarding” in EDs for days, waiting for inpatient admission to a regular hospital or psychiatric hospital.
Before the pandemic, there was already a shortage of inpatient psychiatric beds for children, said Christopher Bellonci, MD, a child psychiatrist at Judge Baker Children’s Center in Boston. That shortage has only gotten worse as hospitals cut capacity to allow for more physical distancing within psychiatric units.
“The whole system is really grinding to a halt at a time when we have unprecedented need,” Dr. Bellonci said.
‘A signal that the rest of your system doesn’t work’
Psychiatrists on the front lines share the frustrations of parents struggling to find help for their children.
Part of the problem is there have never been enough psychiatrists and therapists trained to work with children, intervening in the early stages of their illness, said Jennifer Havens, MD, a child psychiatrist at New York University.
“Tons of people showing up in emergency rooms in bad shape is a signal that the rest of your system doesn’t work,” she said.
Too often, Dr. Havens said, services aren’t available until children are older – and in crisis. “Often for people who don’t have access to services, we wait until they’re too big to be managed.”
While the pandemic has made life harder for Marjorie and her son in Florida, she said it has always been difficult to find the support and care he needs. Last fall, he needed a psychiatric evaluation, but the nearest specialist who would accept her commercial insurance was 100 miles away, in Alabama.
“Even when you have the money or you have the insurance, it is still a travesty,” Marjorie said. “You cannot get help for these kids.”
Parents are frustrated, and so are psychiatrists on the front lines. C.J. Glawe, MD, who leads the psychiatric crisis department at Nationwide Children’s Hospital in Columbus, Ohio, said that once a child is stabilized after a crisis it can be hard to explain to parents that they may not be able to find follow-up care anywhere near their home.
“Especially when I can clearly tell you I know exactly what you need, I just can’t give it to you,” Dr. Glawe said. “It’s demoralizing.”
When states and communities fail to provide children the services they need to live at home, kids can deteriorate and even wind up in jail, like Lindsey. At that point, Dr. Glawe said, the cost and level of care required will be even higher, whether that’s hospitalization or long stays in residential treatment facilities.
That’s exactly the scenario Sandra, Lindsey’s mom, is hoping to avoid for her Princess.
“For me, as a nurse and as a provider, that will be the last thing for my daughter,” she said. “It’s like [state and local leaders] leave it to the school and the parent to deal with, and they don’t care. And that’s the problem. It’s sad because, if I’m not here...”
Her voice trailed off as tears welled.
“She didn’t ask to have autism.”
To help families like Sandra’s and Marjorie’s, advocates said, all levels of government need to invest in creating a mental health system that’s accessible to anyone who needs it.
But given that many states have seen their revenues drop because of the pandemic, there’s a concern services will instead be cut – at a time when the need has never been greater.
This story is part of a reporting partnership that includes NPR, Illinois Public Media and Kaiser Health News. Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of KFF (Kaiser Family Foundation), which is not affiliated with Kaiser Permanente.
A bag of Doritos, that’s all Princess wanted.
Her mom calls her Princess, but her real name is Lindsey. She’s 17 and lives with her mom, Sandra, a nurse, outside Atlanta. On May 17, 2020, a Sunday, Lindsey decided she didn’t want breakfast; she wanted Doritos. So she left home and walked to Family Dollar, taking her pants off on the way, while her mom followed on foot, talking to the police on her phone as they went.
Lindsey has autism. It can be hard for her to communicate and navigate social situations. She thrives on routine and gets special help at school. Or got help, before the coronavirus pandemic closed schools and forced tens of millions of children to stay home. Sandra said that’s when their living hell started.
“It’s like her brain was wired,” she said. “She’d just put on her jacket, and she’s out the door. And I’m chasing her.”
On May 17, Sandra chased her all the way to Family Dollar. Hours later, Lindsey was in jail, charged with assaulting her mom. (KHN and NPR are not using the family’s last name.)
Lindsey is 1 of almost 3 million children in the United States who have a serious emotional or behavioral health condition. When the pandemic forced schools and doctors’ offices to close last spring, it also cut children off from the trained teachers and therapists who understand their needs.
As a result, many, like Lindsey, spiraled into EDs and even police custody. Federal data shows a nationwide surge of children in mental health crisis during the pandemic – a surge that’s further taxing an already overstretched safety net.
‘Take her’
Even after schools closed, Lindsey continued to wake up early, get dressed and wait for the bus. When she realized it had stopped coming, Sandra said, her daughter just started walking out of the house, wandering, a few times a week.
In those situations, Sandra did what many families in crisis report they’ve had to do since the pandemic began: Race through the short list of places she could call for help.
First, her state’s mental health crisis hotline. But they often put Sandra on hold.
“This is ridiculous,” she said of the wait. “It’s supposed to be a crisis team. But I’m on hold for 40, 50 minutes. And by the time you get on the phone, [the crisis] is done!”
Then there’s the local hospital’s ED, but Sandra said she had taken Lindsey there for previous crises and been told there isn’t much they can do.
That’s why, on May 17, when Lindsey walked to Family Dollar in just a red T-shirt and underwear to get that bag of Doritos, Sandra called the last option on her list: the police.
Sandra arrived at the store before the police and paid for the chips. According to Sandra and police records, when an officer approached, Lindsey grew agitated and hit her mom on the back, hard.
Sandra said she explained to the officer: “‘She’s autistic. You know, I’m okay. I’m a nurse. I just need to take her home and give her her medication.’ ”
Lindsey takes a mood stabilizer, but because she left home before breakfast, she hadn’t taken it that morning. The officer asked if Sandra wanted to take her to the nearest hospital.
The hospital wouldn’t be able to help Lindsey, Sandra said. It hadn’t before. “They already told me: ‘Ma’am, there’s nothing we can do.’ They just check her labs, it’s fine, and they ship her back home. There’s nothing [the hospital] can do,” she recalled telling the officer.
Sandra asked if the police could drive her daughter home so the teen could take her medication, but the officer said no, they couldn’t. The only other thing they could do, the officer said, was take Lindsey to jail for hitting her mom.
“I’ve tried everything,” Sandra said, exasperated. She paced the parking lot, feeling hopeless, sad and out of options. Finally, in tears, she told the officers: “Take her.”
Lindsey does not like to be touched and fought back when authorities tried to handcuff her. Several officers wrestled her to the ground. At that point, Sandra protested and said an officer threatened to arrest her, too, if she didn’t back away. Lindsey was taken to jail, where she spent much of the night until Sandra was able to post bail.
Clayton County Solicitor-General Charles Brooks denied that Sandra was threatened with arrest and said that, while Lindsey’s case is still pending, his office “is working to ensure that the resolution in this matter involves a plan for medication compliance and not punitive action.”
Sandra isn’t alone in her experience. Multiple families interviewed for this story reported similar experiences of calling in the police when a child was in crisis because caretakers didn’t feel they had any other option.
‘The whole system is really grinding to a halt’
Roughly 6% of U.S. children ages 6-17 years are living with serious emotional or behavioral difficulties, including children with autism, severe anxiety, depression and trauma-related mental health conditions.
Many of these children depend on schools for access to vital therapies. When schools and doctors’ offices stopped providing in-person services last spring, kids were untethered from the people and supports they rely on.
“The lack of in-person services is really detrimental,” said Susan Duffy, MD,a pediatrician and professor of emergency medicine at Brown University, Providence, R.I.
Marjorie, a mother in Florida, said her 15-year-old son has suffered during these disruptions. He has ADHD and oppositional defiant disorder, a condition marked by frequent and persistent hostility. Little things – like being asked to do schoolwork – can send him into a rage, leading to holes punched in walls, broken doors and violent threats. (The family’s last name or her son’s first name are not used to protect her son’s privacy and future prospects.)
The pandemic has shifted both school and her son’s therapy sessions online. But Marjorie said virtual therapy isn’t working because her son doesn’t focus well during sessions and tries to watch television instead. Lately, she has simply been canceling them.
“I was paying for appointments and there was no therapeutic value,” Marjorie said.
The issues cut across socioeconomic lines – affecting families with private insurance, like Marjorie, as well as those who receive coverage through Medicaid, a federal-state program that provides health insurance to low-income people and those with disabilities.
In the first few months of the pandemic, between March and May, children on Medicaid received 44% fewer outpatient mental health services – including therapy and in-home support – compared with the same time period in 2019, according to the Centers for Medicare & Medicaid Services. That’s even after accounting for increased telehealth appointments.
And while the nation’s EDs have seen a decline in overall visits, there was a relative increase in mental health visits for kids in 2020, compared with 2019.
The Centers for Disease Control and Prevention found that, from April to October 2020, hospitals across the United States saw a 24% increase in the proportion of mental health emergency visits for children aged 5-11 years, and a 31% increase for children aged 12-17.
“Not only are we seeing more children, more children are being admitted” to inpatient care.
That’s because there are fewer outpatient services now available to children, she said, and because the conditions of the children showing up at EDs “are more serious.”
This crisis is not only making life harder for these kids and their families, but it’s also stressing the entire health care system.
Child and adolescent psychiatrists working in hospitals around the country said children are increasingly “boarding” in EDs for days, waiting for inpatient admission to a regular hospital or psychiatric hospital.
Before the pandemic, there was already a shortage of inpatient psychiatric beds for children, said Christopher Bellonci, MD, a child psychiatrist at Judge Baker Children’s Center in Boston. That shortage has only gotten worse as hospitals cut capacity to allow for more physical distancing within psychiatric units.
“The whole system is really grinding to a halt at a time when we have unprecedented need,” Dr. Bellonci said.
‘A signal that the rest of your system doesn’t work’
Psychiatrists on the front lines share the frustrations of parents struggling to find help for their children.
Part of the problem is there have never been enough psychiatrists and therapists trained to work with children, intervening in the early stages of their illness, said Jennifer Havens, MD, a child psychiatrist at New York University.
“Tons of people showing up in emergency rooms in bad shape is a signal that the rest of your system doesn’t work,” she said.
Too often, Dr. Havens said, services aren’t available until children are older – and in crisis. “Often for people who don’t have access to services, we wait until they’re too big to be managed.”
While the pandemic has made life harder for Marjorie and her son in Florida, she said it has always been difficult to find the support and care he needs. Last fall, he needed a psychiatric evaluation, but the nearest specialist who would accept her commercial insurance was 100 miles away, in Alabama.
“Even when you have the money or you have the insurance, it is still a travesty,” Marjorie said. “You cannot get help for these kids.”
Parents are frustrated, and so are psychiatrists on the front lines. C.J. Glawe, MD, who leads the psychiatric crisis department at Nationwide Children’s Hospital in Columbus, Ohio, said that once a child is stabilized after a crisis it can be hard to explain to parents that they may not be able to find follow-up care anywhere near their home.
“Especially when I can clearly tell you I know exactly what you need, I just can’t give it to you,” Dr. Glawe said. “It’s demoralizing.”
When states and communities fail to provide children the services they need to live at home, kids can deteriorate and even wind up in jail, like Lindsey. At that point, Dr. Glawe said, the cost and level of care required will be even higher, whether that’s hospitalization or long stays in residential treatment facilities.
That’s exactly the scenario Sandra, Lindsey’s mom, is hoping to avoid for her Princess.
“For me, as a nurse and as a provider, that will be the last thing for my daughter,” she said. “It’s like [state and local leaders] leave it to the school and the parent to deal with, and they don’t care. And that’s the problem. It’s sad because, if I’m not here...”
Her voice trailed off as tears welled.
“She didn’t ask to have autism.”
To help families like Sandra’s and Marjorie’s, advocates said, all levels of government need to invest in creating a mental health system that’s accessible to anyone who needs it.
But given that many states have seen their revenues drop because of the pandemic, there’s a concern services will instead be cut – at a time when the need has never been greater.
This story is part of a reporting partnership that includes NPR, Illinois Public Media and Kaiser Health News. Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of KFF (Kaiser Family Foundation), which is not affiliated with Kaiser Permanente.
A bag of Doritos, that’s all Princess wanted.
Her mom calls her Princess, but her real name is Lindsey. She’s 17 and lives with her mom, Sandra, a nurse, outside Atlanta. On May 17, 2020, a Sunday, Lindsey decided she didn’t want breakfast; she wanted Doritos. So she left home and walked to Family Dollar, taking her pants off on the way, while her mom followed on foot, talking to the police on her phone as they went.
Lindsey has autism. It can be hard for her to communicate and navigate social situations. She thrives on routine and gets special help at school. Or got help, before the coronavirus pandemic closed schools and forced tens of millions of children to stay home. Sandra said that’s when their living hell started.
“It’s like her brain was wired,” she said. “She’d just put on her jacket, and she’s out the door. And I’m chasing her.”
On May 17, Sandra chased her all the way to Family Dollar. Hours later, Lindsey was in jail, charged with assaulting her mom. (KHN and NPR are not using the family’s last name.)
Lindsey is 1 of almost 3 million children in the United States who have a serious emotional or behavioral health condition. When the pandemic forced schools and doctors’ offices to close last spring, it also cut children off from the trained teachers and therapists who understand their needs.
As a result, many, like Lindsey, spiraled into EDs and even police custody. Federal data shows a nationwide surge of children in mental health crisis during the pandemic – a surge that’s further taxing an already overstretched safety net.
‘Take her’
Even after schools closed, Lindsey continued to wake up early, get dressed and wait for the bus. When she realized it had stopped coming, Sandra said, her daughter just started walking out of the house, wandering, a few times a week.
In those situations, Sandra did what many families in crisis report they’ve had to do since the pandemic began: Race through the short list of places she could call for help.
First, her state’s mental health crisis hotline. But they often put Sandra on hold.
“This is ridiculous,” she said of the wait. “It’s supposed to be a crisis team. But I’m on hold for 40, 50 minutes. And by the time you get on the phone, [the crisis] is done!”
Then there’s the local hospital’s ED, but Sandra said she had taken Lindsey there for previous crises and been told there isn’t much they can do.
That’s why, on May 17, when Lindsey walked to Family Dollar in just a red T-shirt and underwear to get that bag of Doritos, Sandra called the last option on her list: the police.
Sandra arrived at the store before the police and paid for the chips. According to Sandra and police records, when an officer approached, Lindsey grew agitated and hit her mom on the back, hard.
Sandra said she explained to the officer: “‘She’s autistic. You know, I’m okay. I’m a nurse. I just need to take her home and give her her medication.’ ”
Lindsey takes a mood stabilizer, but because she left home before breakfast, she hadn’t taken it that morning. The officer asked if Sandra wanted to take her to the nearest hospital.
The hospital wouldn’t be able to help Lindsey, Sandra said. It hadn’t before. “They already told me: ‘Ma’am, there’s nothing we can do.’ They just check her labs, it’s fine, and they ship her back home. There’s nothing [the hospital] can do,” she recalled telling the officer.
Sandra asked if the police could drive her daughter home so the teen could take her medication, but the officer said no, they couldn’t. The only other thing they could do, the officer said, was take Lindsey to jail for hitting her mom.
“I’ve tried everything,” Sandra said, exasperated. She paced the parking lot, feeling hopeless, sad and out of options. Finally, in tears, she told the officers: “Take her.”
Lindsey does not like to be touched and fought back when authorities tried to handcuff her. Several officers wrestled her to the ground. At that point, Sandra protested and said an officer threatened to arrest her, too, if she didn’t back away. Lindsey was taken to jail, where she spent much of the night until Sandra was able to post bail.
Clayton County Solicitor-General Charles Brooks denied that Sandra was threatened with arrest and said that, while Lindsey’s case is still pending, his office “is working to ensure that the resolution in this matter involves a plan for medication compliance and not punitive action.”
Sandra isn’t alone in her experience. Multiple families interviewed for this story reported similar experiences of calling in the police when a child was in crisis because caretakers didn’t feel they had any other option.
‘The whole system is really grinding to a halt’
Roughly 6% of U.S. children ages 6-17 years are living with serious emotional or behavioral difficulties, including children with autism, severe anxiety, depression and trauma-related mental health conditions.
Many of these children depend on schools for access to vital therapies. When schools and doctors’ offices stopped providing in-person services last spring, kids were untethered from the people and supports they rely on.
“The lack of in-person services is really detrimental,” said Susan Duffy, MD,a pediatrician and professor of emergency medicine at Brown University, Providence, R.I.
Marjorie, a mother in Florida, said her 15-year-old son has suffered during these disruptions. He has ADHD and oppositional defiant disorder, a condition marked by frequent and persistent hostility. Little things – like being asked to do schoolwork – can send him into a rage, leading to holes punched in walls, broken doors and violent threats. (The family’s last name or her son’s first name are not used to protect her son’s privacy and future prospects.)
The pandemic has shifted both school and her son’s therapy sessions online. But Marjorie said virtual therapy isn’t working because her son doesn’t focus well during sessions and tries to watch television instead. Lately, she has simply been canceling them.
“I was paying for appointments and there was no therapeutic value,” Marjorie said.
The issues cut across socioeconomic lines – affecting families with private insurance, like Marjorie, as well as those who receive coverage through Medicaid, a federal-state program that provides health insurance to low-income people and those with disabilities.
In the first few months of the pandemic, between March and May, children on Medicaid received 44% fewer outpatient mental health services – including therapy and in-home support – compared with the same time period in 2019, according to the Centers for Medicare & Medicaid Services. That’s even after accounting for increased telehealth appointments.
And while the nation’s EDs have seen a decline in overall visits, there was a relative increase in mental health visits for kids in 2020, compared with 2019.
The Centers for Disease Control and Prevention found that, from April to October 2020, hospitals across the United States saw a 24% increase in the proportion of mental health emergency visits for children aged 5-11 years, and a 31% increase for children aged 12-17.
“Not only are we seeing more children, more children are being admitted” to inpatient care.
That’s because there are fewer outpatient services now available to children, she said, and because the conditions of the children showing up at EDs “are more serious.”
This crisis is not only making life harder for these kids and their families, but it’s also stressing the entire health care system.
Child and adolescent psychiatrists working in hospitals around the country said children are increasingly “boarding” in EDs for days, waiting for inpatient admission to a regular hospital or psychiatric hospital.
Before the pandemic, there was already a shortage of inpatient psychiatric beds for children, said Christopher Bellonci, MD, a child psychiatrist at Judge Baker Children’s Center in Boston. That shortage has only gotten worse as hospitals cut capacity to allow for more physical distancing within psychiatric units.
“The whole system is really grinding to a halt at a time when we have unprecedented need,” Dr. Bellonci said.
‘A signal that the rest of your system doesn’t work’
Psychiatrists on the front lines share the frustrations of parents struggling to find help for their children.
Part of the problem is there have never been enough psychiatrists and therapists trained to work with children, intervening in the early stages of their illness, said Jennifer Havens, MD, a child psychiatrist at New York University.
“Tons of people showing up in emergency rooms in bad shape is a signal that the rest of your system doesn’t work,” she said.
Too often, Dr. Havens said, services aren’t available until children are older – and in crisis. “Often for people who don’t have access to services, we wait until they’re too big to be managed.”
While the pandemic has made life harder for Marjorie and her son in Florida, she said it has always been difficult to find the support and care he needs. Last fall, he needed a psychiatric evaluation, but the nearest specialist who would accept her commercial insurance was 100 miles away, in Alabama.
“Even when you have the money or you have the insurance, it is still a travesty,” Marjorie said. “You cannot get help for these kids.”
Parents are frustrated, and so are psychiatrists on the front lines. C.J. Glawe, MD, who leads the psychiatric crisis department at Nationwide Children’s Hospital in Columbus, Ohio, said that once a child is stabilized after a crisis it can be hard to explain to parents that they may not be able to find follow-up care anywhere near their home.
“Especially when I can clearly tell you I know exactly what you need, I just can’t give it to you,” Dr. Glawe said. “It’s demoralizing.”
When states and communities fail to provide children the services they need to live at home, kids can deteriorate and even wind up in jail, like Lindsey. At that point, Dr. Glawe said, the cost and level of care required will be even higher, whether that’s hospitalization or long stays in residential treatment facilities.
That’s exactly the scenario Sandra, Lindsey’s mom, is hoping to avoid for her Princess.
“For me, as a nurse and as a provider, that will be the last thing for my daughter,” she said. “It’s like [state and local leaders] leave it to the school and the parent to deal with, and they don’t care. And that’s the problem. It’s sad because, if I’m not here...”
Her voice trailed off as tears welled.
“She didn’t ask to have autism.”
To help families like Sandra’s and Marjorie’s, advocates said, all levels of government need to invest in creating a mental health system that’s accessible to anyone who needs it.
But given that many states have seen their revenues drop because of the pandemic, there’s a concern services will instead be cut – at a time when the need has never been greater.
This story is part of a reporting partnership that includes NPR, Illinois Public Media and Kaiser Health News. Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of KFF (Kaiser Family Foundation), which is not affiliated with Kaiser Permanente.
The brother’s keeper: A psychiatrist writes about his career treating physicians and their families
I started reading “Becoming a Doctors’ Doctor: A Memoir” by Michael F. Myers, MD, with high expectations and enthusiasm. Dr. Myers is a Canadian psychiatrist who has devoted his career to caring for physicians in his half-time private practice; he turns all other comers away.
This career path began in 1962 during his first year in medical school when Dr. Myers returned to his apartment after Thanksgiving break to be greeted with tragic news: One of the young men he shared the apartment with had died of suicide. The tragedy marked him – along with the silence about what had transpired – and he would later look back to realize it was the beginning of his journey to becoming a psychiatrist, one who cares for other physicians.
The book is filled with patient vignettes, gentle musings that Dr. Myers recounts with warmth, adding what he has learned from them.
There is, for example, the heart-wrenching account of “DJ,” a lonely medical student who is emergently hospitalized for depression, after the worried author anxiously drove the patient from his office to the hospital. DJ is all alone, and he writes to a friend and offers to pay for her transportation if she will come visit him in the hospital, a fact Dr. Myers knows only because he was later shown a letter DJ had written to his friend.
“He has been diminished and altered by his disease and the requisite hospital treatment, factors that we as mental health caregivers must never forget – or minimize. Visits from friends become visits of the representatives from the outside world, the link to normality, sanity, and anticipated return. These encounters are precious,” Dr. Myers writes.
As the book progressed, I began to wonder more about the author as a person. It is a memoir, so stated on the cover, but very little about his life is revealed. There are résumé-style facts: where he studied, or worked, or went to conferences, what he learned and what he spoke about, but I wanted to know more about how his experiences intertwined with his life. In the foreword, he talks about having an alcoholic mother. He tells the reader that being a husband and father was important to him, and that his conversion to Judaism – his wife’s religion – was meaningful, but there is no backstory, and I was looking for more. A quick reference is made to visiting a therapist, but those few sentences are the total of what I knew about Michael Myers midway through his memoir.
I looked for a photo of the author. I found it at the back of the book with a brief biography beneath it, ending with the fact that he lives with his husband. I had gotten halfway through the memoir, including chapters about how Myers had treated gay physicians, gay couples, and physicians with AIDS, and yet there was no mention of his husband, and how his sexual orientation influenced these encounters. I didn’t quite know what to think.
And then, in a section called “Getting Personal,” suddenly the tone of the book changed. Dr. Myers talked about his own sexual confusion as a young man and about the decision to marry a woman, knowing he was bisexual. He wrote about the shame he felt concerning his sexual desires at a time when homosexuality was still classified as a psychiatric disorder, the fear of judgment, and the sense that this – his ninth book – was his first genuine book.
“And so, I come full circle. It is my otherness that fundamentally – but not with full awareness – attracted me to psychiatry, and ultimately to becoming a doctors’ doctor. I’ve been able to empathize with my doctor patients’ burden with the scourge of mental illness, coping with brokenness, and struggling for acceptance and belonging in a profession of perfection and stature. And I understand what it’s like to feel a bit of a misfit, less than, unclean and tattered. But as a wounded healer, I know the restorative value of listening, acceptance, caring, doggedness, and hope.” And so I found Dr. Myers.
These few pages in the middle of the book pulled everything else into focus. The writing opened and the rest of the book flowed. The author’s insights about physician-patients became even more insightful. It’s almost as though he was anxious about revealing himself, and his writing infused itself with this worry, so that once his secret was revealed, he was free to be genuine in a way that makes this book a gem of a read.
His insights about treating troubled physicians are invaluable. He talks of their struggles with loss, and of their flawed roles as patients.
“At the point that they become a patient these individuals may already be quite ill, and this needs to be recognized and accepted by the treating psychiatrist. Judging the doctor for so many self-defeating behaviors is unacceptable and unprofessional. I have found it best to simply accept the old adage ‘It is what it is.’ And I try my best to be patient and understanding with such difficult and interwoven issues, in that for physicians becoming a patient is a process not an event.”
Written with empathy, warmth, and vulnerability, “Becoming a Doctors’ Doctor” is a worthwhile read for any psychiatrist who treats other physicians.
Dr. Miller is coauthor of “Committed: The Battle over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins, both in Baltimore. Dr. Miller has no conflicts of interest.
I started reading “Becoming a Doctors’ Doctor: A Memoir” by Michael F. Myers, MD, with high expectations and enthusiasm. Dr. Myers is a Canadian psychiatrist who has devoted his career to caring for physicians in his half-time private practice; he turns all other comers away.
This career path began in 1962 during his first year in medical school when Dr. Myers returned to his apartment after Thanksgiving break to be greeted with tragic news: One of the young men he shared the apartment with had died of suicide. The tragedy marked him – along with the silence about what had transpired – and he would later look back to realize it was the beginning of his journey to becoming a psychiatrist, one who cares for other physicians.
The book is filled with patient vignettes, gentle musings that Dr. Myers recounts with warmth, adding what he has learned from them.
There is, for example, the heart-wrenching account of “DJ,” a lonely medical student who is emergently hospitalized for depression, after the worried author anxiously drove the patient from his office to the hospital. DJ is all alone, and he writes to a friend and offers to pay for her transportation if she will come visit him in the hospital, a fact Dr. Myers knows only because he was later shown a letter DJ had written to his friend.
“He has been diminished and altered by his disease and the requisite hospital treatment, factors that we as mental health caregivers must never forget – or minimize. Visits from friends become visits of the representatives from the outside world, the link to normality, sanity, and anticipated return. These encounters are precious,” Dr. Myers writes.
As the book progressed, I began to wonder more about the author as a person. It is a memoir, so stated on the cover, but very little about his life is revealed. There are résumé-style facts: where he studied, or worked, or went to conferences, what he learned and what he spoke about, but I wanted to know more about how his experiences intertwined with his life. In the foreword, he talks about having an alcoholic mother. He tells the reader that being a husband and father was important to him, and that his conversion to Judaism – his wife’s religion – was meaningful, but there is no backstory, and I was looking for more. A quick reference is made to visiting a therapist, but those few sentences are the total of what I knew about Michael Myers midway through his memoir.
I looked for a photo of the author. I found it at the back of the book with a brief biography beneath it, ending with the fact that he lives with his husband. I had gotten halfway through the memoir, including chapters about how Myers had treated gay physicians, gay couples, and physicians with AIDS, and yet there was no mention of his husband, and how his sexual orientation influenced these encounters. I didn’t quite know what to think.
And then, in a section called “Getting Personal,” suddenly the tone of the book changed. Dr. Myers talked about his own sexual confusion as a young man and about the decision to marry a woman, knowing he was bisexual. He wrote about the shame he felt concerning his sexual desires at a time when homosexuality was still classified as a psychiatric disorder, the fear of judgment, and the sense that this – his ninth book – was his first genuine book.
“And so, I come full circle. It is my otherness that fundamentally – but not with full awareness – attracted me to psychiatry, and ultimately to becoming a doctors’ doctor. I’ve been able to empathize with my doctor patients’ burden with the scourge of mental illness, coping with brokenness, and struggling for acceptance and belonging in a profession of perfection and stature. And I understand what it’s like to feel a bit of a misfit, less than, unclean and tattered. But as a wounded healer, I know the restorative value of listening, acceptance, caring, doggedness, and hope.” And so I found Dr. Myers.
These few pages in the middle of the book pulled everything else into focus. The writing opened and the rest of the book flowed. The author’s insights about physician-patients became even more insightful. It’s almost as though he was anxious about revealing himself, and his writing infused itself with this worry, so that once his secret was revealed, he was free to be genuine in a way that makes this book a gem of a read.
His insights about treating troubled physicians are invaluable. He talks of their struggles with loss, and of their flawed roles as patients.
“At the point that they become a patient these individuals may already be quite ill, and this needs to be recognized and accepted by the treating psychiatrist. Judging the doctor for so many self-defeating behaviors is unacceptable and unprofessional. I have found it best to simply accept the old adage ‘It is what it is.’ And I try my best to be patient and understanding with such difficult and interwoven issues, in that for physicians becoming a patient is a process not an event.”
Written with empathy, warmth, and vulnerability, “Becoming a Doctors’ Doctor” is a worthwhile read for any psychiatrist who treats other physicians.
Dr. Miller is coauthor of “Committed: The Battle over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins, both in Baltimore. Dr. Miller has no conflicts of interest.
I started reading “Becoming a Doctors’ Doctor: A Memoir” by Michael F. Myers, MD, with high expectations and enthusiasm. Dr. Myers is a Canadian psychiatrist who has devoted his career to caring for physicians in his half-time private practice; he turns all other comers away.
This career path began in 1962 during his first year in medical school when Dr. Myers returned to his apartment after Thanksgiving break to be greeted with tragic news: One of the young men he shared the apartment with had died of suicide. The tragedy marked him – along with the silence about what had transpired – and he would later look back to realize it was the beginning of his journey to becoming a psychiatrist, one who cares for other physicians.
The book is filled with patient vignettes, gentle musings that Dr. Myers recounts with warmth, adding what he has learned from them.
There is, for example, the heart-wrenching account of “DJ,” a lonely medical student who is emergently hospitalized for depression, after the worried author anxiously drove the patient from his office to the hospital. DJ is all alone, and he writes to a friend and offers to pay for her transportation if she will come visit him in the hospital, a fact Dr. Myers knows only because he was later shown a letter DJ had written to his friend.
“He has been diminished and altered by his disease and the requisite hospital treatment, factors that we as mental health caregivers must never forget – or minimize. Visits from friends become visits of the representatives from the outside world, the link to normality, sanity, and anticipated return. These encounters are precious,” Dr. Myers writes.
As the book progressed, I began to wonder more about the author as a person. It is a memoir, so stated on the cover, but very little about his life is revealed. There are résumé-style facts: where he studied, or worked, or went to conferences, what he learned and what he spoke about, but I wanted to know more about how his experiences intertwined with his life. In the foreword, he talks about having an alcoholic mother. He tells the reader that being a husband and father was important to him, and that his conversion to Judaism – his wife’s religion – was meaningful, but there is no backstory, and I was looking for more. A quick reference is made to visiting a therapist, but those few sentences are the total of what I knew about Michael Myers midway through his memoir.
I looked for a photo of the author. I found it at the back of the book with a brief biography beneath it, ending with the fact that he lives with his husband. I had gotten halfway through the memoir, including chapters about how Myers had treated gay physicians, gay couples, and physicians with AIDS, and yet there was no mention of his husband, and how his sexual orientation influenced these encounters. I didn’t quite know what to think.
And then, in a section called “Getting Personal,” suddenly the tone of the book changed. Dr. Myers talked about his own sexual confusion as a young man and about the decision to marry a woman, knowing he was bisexual. He wrote about the shame he felt concerning his sexual desires at a time when homosexuality was still classified as a psychiatric disorder, the fear of judgment, and the sense that this – his ninth book – was his first genuine book.
“And so, I come full circle. It is my otherness that fundamentally – but not with full awareness – attracted me to psychiatry, and ultimately to becoming a doctors’ doctor. I’ve been able to empathize with my doctor patients’ burden with the scourge of mental illness, coping with brokenness, and struggling for acceptance and belonging in a profession of perfection and stature. And I understand what it’s like to feel a bit of a misfit, less than, unclean and tattered. But as a wounded healer, I know the restorative value of listening, acceptance, caring, doggedness, and hope.” And so I found Dr. Myers.
These few pages in the middle of the book pulled everything else into focus. The writing opened and the rest of the book flowed. The author’s insights about physician-patients became even more insightful. It’s almost as though he was anxious about revealing himself, and his writing infused itself with this worry, so that once his secret was revealed, he was free to be genuine in a way that makes this book a gem of a read.
His insights about treating troubled physicians are invaluable. He talks of their struggles with loss, and of their flawed roles as patients.
“At the point that they become a patient these individuals may already be quite ill, and this needs to be recognized and accepted by the treating psychiatrist. Judging the doctor for so many self-defeating behaviors is unacceptable and unprofessional. I have found it best to simply accept the old adage ‘It is what it is.’ And I try my best to be patient and understanding with such difficult and interwoven issues, in that for physicians becoming a patient is a process not an event.”
Written with empathy, warmth, and vulnerability, “Becoming a Doctors’ Doctor” is a worthwhile read for any psychiatrist who treats other physicians.
Dr. Miller is coauthor of “Committed: The Battle over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins, both in Baltimore. Dr. Miller has no conflicts of interest.
COVID-19 and the risk of homicide-suicide among older adults
On March 25, 2020, in Cambridge, United Kingdom, a 71-year-old man stabbed his 71-year-old wife before suffocating himself to death. The couple was reportedly anxious about the coronavirus disease 2019 (COVID-19) pandemic lockdown measures and were on the verge of running out of food and medicine.1
One week later, in Chicago, Illinois, a 54-year-old man shot and killed his female partner, age 54, before killing himself. The couple was tested for COVID-19 2 days earlier and the man believed they had contracted the virus; however, the test results for both of them had come back negative.2
Intimate partner homicide-suicide is the most dramatic domestic abuse outcome.3 Homicide-suicide is defined as “homicide committed by a person who subsequently commits suicide within one week of the homicide. In most cases the subsequent suicide occurs within a 24-hour period.”4 Approximately one-quarter of all homicide-suicides are committed by persons age ≥55 years.5,6 We believe that during the COVID-19 pandemic, the risk of homicide-suicide among older adults may be increased due to several factors, including:
- physical distancing and quarantine measures. Protocols established to slow the spread of the virus may be associated with increased rates of depression and anxiety7 and an increased risk of suicide among older adults8
- increased intimate partner violence9
- increased firearm ownership rates in the United States.10
In this article, we review studies that identified risk factors for homicide-suicide among older adults, discuss the impact the COVID-19 pandemic has had on these risks, and describe steps clinicians can take to intervene.
A review of the literature
To better characterize the perpetrators of older adult homicide-suicide, we conducted a literature search of relevant terms. We identified 9 original research publications that examined homicide-suicide in older adults.
Bourget et al11 (2010) reviewed coroners’ charts of individuals killed by an older (age ≥65) spouse or family member from 1992 through 2007 in Quebec, Canada. They identified 19 cases of homicide-suicide, 17 (90%) of which were perpetrated by men. Perpetrators and victims were married (63%), in common-law relationships (16%), or separated/divorced (16%). A history of domestic violence was documented in 4 (21%) cases. The authors found that 13 of 15 perpetrators (87%) had “major depression” and 2 perpetrators had a psychotic disorder. Substance use at the time of the event was confirmed in 6 (32%) cases. Firearms and strangulation were the top methods used to carry out the homicide-suicide.11
Cheung et al12 (2016) conducted a review of coroners’ records of homicide-suicide cases among individuals age ≥65 in New Zealand from 2007 through 2012. In all 4 cases, the perpetrators were men, and their victims were predominantly female, live-in family members. Two cases involved men with a history of domestic violence who were undergoing significant changes in their home and social lives. Both men had a history suggestive of depression and used a firearm to carry out the homicide-suicide.12
Continue to: Cohen et al
Cohen et al13 (1998) conducted a review of coroners’ records from 1988 through 1994 in 2 regions in Florida. They found 48 intimate partner homicide-suicide cases among “old couples” (age ≥55). All were perpetrated by men. The authors identified sociocultural differences in risk factors between the 2 regions. In west-central Florida, perpetrators and victims were predominantly white and in a spousal relationship. Domestic violence was documented in <4% of cases. Approximately 55% of the couples were reported to be ill, and a substantial proportion were documented to be declining in health. One-quarter of the perpetrators and one-third of the victims had “pain and suffering.” More than one-third of perpetrators were reported to have “depression,” 15% were reported to have talked about suicide, and 4% had a history of a suicide attempt. Only 11% of perpetrators were described as abusing substances.
The authors noted several differences in cases in southeastern Florida. Approximately two-thirds of the couples were Hispanic, and 14% had a history of domestic violence. A minority of the couples were in a live-in relationship. Less than 15% of the perpetrators and victims were described as having a decline in health. Additionally, only 19% of perpetrators were reported to have “depression,” and none of the perpetrators had a documented history of attempted suicide or substance abuse. No information was provided regarding the methods used to carry out the homicide-suicide in the southeastern region.13 Financial stress was not a factor in either region.
Malphurs et al14 (2001) used the same database described in the Cohen et al13 study to compare 27 perpetrators of homicide-suicide to 36 age-matched suicide decedents in west central Florida. They found that homicide-suicide perpetrators were significantly less likely to have health problems and were 3 times more likely to be caregivers to their spouses. Approximately 52% of perpetrators had at least 1 documented psychiatric symptom (“depression” and/or substance abuse or other), but only 5% were seeking mental health services at the time of death.14
De Koning and Piette15 (2014) conducted a retrospective medicolegal chart review from 1935 to 2010 to identify homicide-suicide cases in West and East Flanders, Belgium. They found 19 cases of intimate partner homicide-suicide committed by offenders age ≥55 years. Ninety-five percent of the perpetrators were men who killed their female partners. In one-quarter of the cases, either the perpetrator or the victim had a health issue; 21% of the perpetrators were documented as having depression and 27% had alcohol intoxication at the time of death. A motive was documented in 14 out of 19 cases; “mercy killing” was determined as the motive in 6 (43%) cases and “amorous jealousy” in 5 cases (36%).15 Starting in the 1970s, firearms were the most prevalent method used to kill a partner.
Logan et al16 (2019) used data from the National Violent Death Reporting System between 2003 and 2015 to identify characteristics that differentiated male suicide decedents from male perpetrators of intimate partner homicide-suicide. They found that men age 50 to 64 years were 3 times more likely than men age 18 to 34 years to commit intimate partner homicide-suicide, and that men age ≥65 years were approximately 5 times more likely than men age 18 to 34 years to commit intimate partner homicide-suicide. The authors found that approximately 22% of all perpetrators had a documented history of physical domestic violence, and close to 17% had a prior interaction with the criminal justice system. Furthermore, one-third of perpetrators had relationship difficulties and were in the process of a breakup. Health issues were prevalent in 34% of the victims and 26% of the perpetrators. Perpetrator-caregiver burden was reported as a contributing factor for homicide-suicide in 16% of cases. In 27% of cases, multiple health-related contributing factors were mentioned.16
Continue to: Malphurs and Cohen
Malphurs and Cohen5 (2002) reviewed American newspapers from 1997 through 1999 and identified 673 homicide-suicide events, of which 152 (27%) were committed by individuals age ≥55 years. The victims and perpetrators (95% of which were men) were intimate partners in three-quarters of cases. In nearly one-third of cases, caregiving was a contributing factor for the homicide-suicide. A history of or a pending divorce was reported in nearly 14% of cases. Substance use history was rarely recorded. Firearms were used in 88% of the homicide-suicide cases.5
Malphurs and Cohen17 (2005) reviewed coroner records between 1998 and 1999 in Florida and compared 20 cases of intimate partner homicide-suicide involving perpetrators age ≥55 years with matched suicide decedents. They found that 60% of homicide-suicide perpetrators had documented health issues. The authors reported that a “recent change in health status” was more prevalent among perpetrators compared with decedents. Perpetrators were also more likely to be caregivers to their spouses. The authors found that 65% of perpetrators were reported to have a “depressed mood” and 15% of perpetrators had reportedly threatened suicide prior to the incident. However, none of the perpetrators tested positive for antidepressants as documented on post-mortem toxicology reports. Firearms were used in 100% of homicide-suicide cases.17
Salari3 (2007) reviewed multiple American media sources and published police reports between 1999 and 2005 to retrieve data about intimate partner homicide-suicide events in the United States. There were 225 events identified where the perpetrator and/or the victim were age ≥60 years. Ninety-six percent of the perpetrators were men and most homicide-suicide events were committed at the home. A history of domestic violence was reported in 14% of homicide-suicide cases. Thirteen percent of couples were separated or divorced. The perpetrator and/or victim had health issues in 124 (55%) events. Dementia was reported in 7.5% of cases, but overwhelmingly among the victims. Substance abuse was rarely mentioned as a contributing factor. In three-quarters of cases where a motive was described, the perpetrator was “suicidal”; however, a “suicide pact” was mentioned in only 4% of cases. Firearms were used in 87% of cases.3
Focus on common risk factors
The scarcity and heterogeneity of research regarding older adult homicide-suicide were major limitations to our review. Because most of the studies we identified had a small sample size and limited information regarding the mental health of victims and perpetrators, it would be an overreach to claim to have identified a typical profile of an older perpetrator of homicide-suicide. However, the literature has repeatedly identified several common characteristics of such perpetrators. They are significantly more likely to be men who use firearms to murder their intimate partners and then die by suicide in their home (Table3,5,11-17). Health issues afflicting 1 or both individuals in the couple appear to be a contributing factor, particularly when the perpetrator is in a caregiving role. Relational discord, with or without a history of domestic violence, increases the risk of homicide-suicide. Finally, older perpetrators are highly likely to be depressed and have suicidal ideations.
How COVID-19 affects these risks
Although it is too early to determine if there is a causal relationship between the COVID-19 pandemic and an increase in homicide-suicide, the pandemic is likely to promote risk factors for these events, especially among older adults. Confinement measures put into place during the pandemic context have already been shown to increase rates of domestic violence18 and depression and anxiety among older individuals.7 Furthermore,
Continue to: Late-life psychiatric disorders
Late-life psychiatric disorders
Early recognition and effective treatment of late-life psychiatric disorders is crucial. Unfortunately, depression in geriatric patients is often underdiagnosed and undertreated.20 Older adults have more frequent contact with their primary care physicians, and rarely consult mental health professionals.21,22 Several models of integrated depression care within primary care settings have shown the positive impact of this collaborative approach in treating late-life depression and preventing suicide in older individuals.23 Additionally, because alcohol abuse is also a risk factor for domestic violence and breaking the law in this population,24,25 older adults should be screened for alcohol use disorders, and referred to treatment when necessary.
Take steps to keep patients safe
In the context of the COVID-19 pandemic, there are several steps clinicians need to keep in mind when interacting with older patients:
- Screen for depressive symptoms, suicidality, and alcohol and substance use disorders. Individuals who have tested positive for COVID-19 or who have been in contact with a carrier are a particularly vulnerable population.
- Screen for domestic violence and access to weapons at home.4 Any older adult who has a psychiatric disorder and/or suicide ideation should receive immediate intervention through a social worker that includes providing gun-risk education to other family members or contacting law-enforcement officials.26
- Refer patients with a suspected psychiatric disorder to specialized mental health clinicians. Telemental health services can provide rapid access to subspecialists, allowing patients to be treated from their homes.27 These services need to be promoted among older adults during this critical period and reimbursed by public and private insurance systems to ensure accessibility and affordability.28
- Create psychiatric inpatient units specifically designed for suicidal and/or homicidal patients with COVID-19.
Additionally, informing the public about these major health issues is crucial. The media can raise awareness about domestic violence and depression among older adults; however, this should be done responsibly and with accuracy to prevent the spread of misinformation, confusion, fear, and panic.29
Bottom Line
The mental health burden of the coronavirus disease 2019 pandemic has significantly impacted individuals who are older and most vulnerable. Reducing the incidence of homicide-suicide among older adults requires timely screening and interventions by primary care providers, mental health specialists, social workers, media, and governmental agencies.
Related Resources
- Saeed SA, Hebishi K. The psychiatric consequences of COVID-19: 8 studies. Current Psychiatry. 2020;19(11):22-24,28-30,32-35.
- Schwab-Reese LM, Murfree L, Coppola EC, et al. Homicidesuicide across the lifespan: a mixed methods examination of factors contributing to older adult perpetration. Aging Ment Health. 2020;20:1-9.
1. Christodoulou H. LOCKDOWN ‘MURDER-SUICIDE’ OAP, 71, ‘stabbed wife to death then killed himself as he worried about coping with coronavirus lockdown.’ The Sun. Updated April 4, 2020. Accessed December 22, 2020. https://www.thesun.co.uk/news/11327095/coronavirus-lockdown-murder-suicide-cambridge/
2. Farberov S. Illinois man, 54, shoots dead his wife then kills himself in murder-suicide because he feared they had coronavirus - but tests later show the couple were NOT ill. Updated April 6, 2020. Accessed December 22, 2020. https://www.dailymail.co.uk/news/article-8191933/Man-kills-wife-feared-coronavirus.html
3. Salari S. Patterns of intimate partner homicide suicide in later life: strategies for prevention. Clin Interv Aging. 2007;2(3):441-452.
4. Kotzé C, Roos JL. Homicide–suicide: practical implications for risk reduction and support services at primary care level. South African Family Practice. 2019;61(4):165-169.
5. Malphurs JE, Cohen D. A newspaper surveillance study of homicide-suicide in the United States. Am J Forensic Med Pathol. 2002;23(2):142-148.
6. Eliason S. Murder-suicide: a review of the recent literature. J Am Acad Psychiatry Law. 2009;37(3):371-376.
7. Armitage R, Nellums LB. COVID-19 and the consequences of isolating the elderly. Lancet Public Health. 2020;5(5):e256. doi: 10.1016/S2468-2667(20)30061-X
8. Gunnell D, Appleby L, Arensman E, et al. Suicide risk and prevention during the COVID-19 pandemic. Lancet Psychiatry 2020;7(6):468-471.
9. Gosangi B, Park H, Thomas R, et al. Exacerbation of physical intimate partner violence during COVID-19 pandemic. Radiology. 2021;298(1):E38-E45.
10. Mannix R, Lee LK, Fleegler EW. Coronavirus disease 2019 (COVID-19) and firearms in the United States: will an epidemic of suicide follow? Ann Intern Med. 2020;173(3):228-229.
11. Bourget D, Gagne P, Whitehurst L. Domestic homicide and homicide-suicide: the older offender. J Am Acad Psychiatry Law. 2010;38(3):305-311.
12. Cheung G, Hatters Friedman S, Sundram F. Late-life homicide-suicide: a national case series in New Zealand. Psychogeriatrics. 2016;16(1):76-81.
13. Cohen D, Llorente M, Eisdorfer C. Homicide-suicide in older persons. Am J Psychiatry. 1998;155(3):390-396.
14. Malphurs JE, Eisdorfer C, Cohen D. A comparison of antecedents of homicide-suicide and suicide in older married men. Am J Geriatr Psychiatry. 2001;9(1):49-57.
15. De Koning E, Piette MHA. A retrospective study of murder–suicide at the Forensic Institute of Ghent University, Belgium: 1935–2010. Med Sci Law. 2014;54(2):88-98.
16. Logan JE, Ertl A, Bossarte R. Correlates of intimate partner homicide among male suicide decedents with known intimate partner problems. Suicide Life Threat Behav. 2019;49(6):1693-1706.
17. Malphurs JE, Cohen D. A statewide case-control study of spousal homicide-suicide in older persons. Am J Geriatr Psychiatry. 2005;13(3):211-217.
18. Sanford A. ‘Horrifying surge in domestic violence’ against women amid coronavirus-lockdowns, UN chief warns. Euronews. Published June 4, 2020. Accessed December 22, 2020. https://www.euronews.com/2020/04/06/horrifying-surge-in-domestic-violence-against-women-amid-coronavirus-lockdowns-un-chief-w
19. Appel JM. Intimate partner homicide in elderly populations. In: Friedman SH, ed. Family murder: pathologies of love and hate. American Psychiatric Association Publishing; 2019:131-142.
20. Hall CA, Reynolds-III CF. Late-life depression in the primary care setting: challenges, collaborative care, and prevention. Maturitas. 2014;79(2):147-152.
21. Unützer J. Diagnosis and treatment of older adults with depression in primary care. Biological Psychiatry. 2002;52(3):285-292.
22. Byers AL, Arean PA, Yaffe K. Low use of mental health services among older Americans with mood and anxiety disorders. Psychiatr Serv. 2012;63(1):66-72.
23. Bruce ML, Sirey JA. Integrated care for depression in older primary care patients. Can J Psychiatry. 2018;63(7):439-446.
24. Rao R, Roche A. Substance misuse in older people. BMJ. 2017;358:j3885. doi: 10.1136/bmj.j3885
25. Ghossoub E, Khoury R. Prevalence and correlates of criminal behavior among the non-institutionalized elderly: results from the National Survey on Drug Use and Health. J Geriatr Psychiatry Neurol. 2018;31(4):211-222.
26. Slater MAG. Older adults at risk for suicide. In: Berkman B. Handbook of social work in health and aging. Oxford University Press; 2006:149-161.
27. Hollander JE, Carr BG. Virtually perfect? Telemedicine for Covid-19. N Engl J Med. 2020;382(18):1679-1681.
28. Centers for Medicare & Medicaid Services. President Trump expands telehealth benefits for Medicare beneficiaries during COVID-19 outbreak. Published March 17, 2020. Accessed December 23, 2020. https://www.cms.gov/newsroom/press-releases/president-trump-expands-telehealth-benefits-medicare-beneficiaries-during-covid-19-outbreak
29. Mian A, Khan S. Coronavirus: the spread of misinformation. BMC Med. 2020;18(1):89.
On March 25, 2020, in Cambridge, United Kingdom, a 71-year-old man stabbed his 71-year-old wife before suffocating himself to death. The couple was reportedly anxious about the coronavirus disease 2019 (COVID-19) pandemic lockdown measures and were on the verge of running out of food and medicine.1
One week later, in Chicago, Illinois, a 54-year-old man shot and killed his female partner, age 54, before killing himself. The couple was tested for COVID-19 2 days earlier and the man believed they had contracted the virus; however, the test results for both of them had come back negative.2
Intimate partner homicide-suicide is the most dramatic domestic abuse outcome.3 Homicide-suicide is defined as “homicide committed by a person who subsequently commits suicide within one week of the homicide. In most cases the subsequent suicide occurs within a 24-hour period.”4 Approximately one-quarter of all homicide-suicides are committed by persons age ≥55 years.5,6 We believe that during the COVID-19 pandemic, the risk of homicide-suicide among older adults may be increased due to several factors, including:
- physical distancing and quarantine measures. Protocols established to slow the spread of the virus may be associated with increased rates of depression and anxiety7 and an increased risk of suicide among older adults8
- increased intimate partner violence9
- increased firearm ownership rates in the United States.10
In this article, we review studies that identified risk factors for homicide-suicide among older adults, discuss the impact the COVID-19 pandemic has had on these risks, and describe steps clinicians can take to intervene.
A review of the literature
To better characterize the perpetrators of older adult homicide-suicide, we conducted a literature search of relevant terms. We identified 9 original research publications that examined homicide-suicide in older adults.
Bourget et al11 (2010) reviewed coroners’ charts of individuals killed by an older (age ≥65) spouse or family member from 1992 through 2007 in Quebec, Canada. They identified 19 cases of homicide-suicide, 17 (90%) of which were perpetrated by men. Perpetrators and victims were married (63%), in common-law relationships (16%), or separated/divorced (16%). A history of domestic violence was documented in 4 (21%) cases. The authors found that 13 of 15 perpetrators (87%) had “major depression” and 2 perpetrators had a psychotic disorder. Substance use at the time of the event was confirmed in 6 (32%) cases. Firearms and strangulation were the top methods used to carry out the homicide-suicide.11
Cheung et al12 (2016) conducted a review of coroners’ records of homicide-suicide cases among individuals age ≥65 in New Zealand from 2007 through 2012. In all 4 cases, the perpetrators were men, and their victims were predominantly female, live-in family members. Two cases involved men with a history of domestic violence who were undergoing significant changes in their home and social lives. Both men had a history suggestive of depression and used a firearm to carry out the homicide-suicide.12
Continue to: Cohen et al
Cohen et al13 (1998) conducted a review of coroners’ records from 1988 through 1994 in 2 regions in Florida. They found 48 intimate partner homicide-suicide cases among “old couples” (age ≥55). All were perpetrated by men. The authors identified sociocultural differences in risk factors between the 2 regions. In west-central Florida, perpetrators and victims were predominantly white and in a spousal relationship. Domestic violence was documented in <4% of cases. Approximately 55% of the couples were reported to be ill, and a substantial proportion were documented to be declining in health. One-quarter of the perpetrators and one-third of the victims had “pain and suffering.” More than one-third of perpetrators were reported to have “depression,” 15% were reported to have talked about suicide, and 4% had a history of a suicide attempt. Only 11% of perpetrators were described as abusing substances.
The authors noted several differences in cases in southeastern Florida. Approximately two-thirds of the couples were Hispanic, and 14% had a history of domestic violence. A minority of the couples were in a live-in relationship. Less than 15% of the perpetrators and victims were described as having a decline in health. Additionally, only 19% of perpetrators were reported to have “depression,” and none of the perpetrators had a documented history of attempted suicide or substance abuse. No information was provided regarding the methods used to carry out the homicide-suicide in the southeastern region.13 Financial stress was not a factor in either region.
Malphurs et al14 (2001) used the same database described in the Cohen et al13 study to compare 27 perpetrators of homicide-suicide to 36 age-matched suicide decedents in west central Florida. They found that homicide-suicide perpetrators were significantly less likely to have health problems and were 3 times more likely to be caregivers to their spouses. Approximately 52% of perpetrators had at least 1 documented psychiatric symptom (“depression” and/or substance abuse or other), but only 5% were seeking mental health services at the time of death.14
De Koning and Piette15 (2014) conducted a retrospective medicolegal chart review from 1935 to 2010 to identify homicide-suicide cases in West and East Flanders, Belgium. They found 19 cases of intimate partner homicide-suicide committed by offenders age ≥55 years. Ninety-five percent of the perpetrators were men who killed their female partners. In one-quarter of the cases, either the perpetrator or the victim had a health issue; 21% of the perpetrators were documented as having depression and 27% had alcohol intoxication at the time of death. A motive was documented in 14 out of 19 cases; “mercy killing” was determined as the motive in 6 (43%) cases and “amorous jealousy” in 5 cases (36%).15 Starting in the 1970s, firearms were the most prevalent method used to kill a partner.
Logan et al16 (2019) used data from the National Violent Death Reporting System between 2003 and 2015 to identify characteristics that differentiated male suicide decedents from male perpetrators of intimate partner homicide-suicide. They found that men age 50 to 64 years were 3 times more likely than men age 18 to 34 years to commit intimate partner homicide-suicide, and that men age ≥65 years were approximately 5 times more likely than men age 18 to 34 years to commit intimate partner homicide-suicide. The authors found that approximately 22% of all perpetrators had a documented history of physical domestic violence, and close to 17% had a prior interaction with the criminal justice system. Furthermore, one-third of perpetrators had relationship difficulties and were in the process of a breakup. Health issues were prevalent in 34% of the victims and 26% of the perpetrators. Perpetrator-caregiver burden was reported as a contributing factor for homicide-suicide in 16% of cases. In 27% of cases, multiple health-related contributing factors were mentioned.16
Continue to: Malphurs and Cohen
Malphurs and Cohen5 (2002) reviewed American newspapers from 1997 through 1999 and identified 673 homicide-suicide events, of which 152 (27%) were committed by individuals age ≥55 years. The victims and perpetrators (95% of which were men) were intimate partners in three-quarters of cases. In nearly one-third of cases, caregiving was a contributing factor for the homicide-suicide. A history of or a pending divorce was reported in nearly 14% of cases. Substance use history was rarely recorded. Firearms were used in 88% of the homicide-suicide cases.5
Malphurs and Cohen17 (2005) reviewed coroner records between 1998 and 1999 in Florida and compared 20 cases of intimate partner homicide-suicide involving perpetrators age ≥55 years with matched suicide decedents. They found that 60% of homicide-suicide perpetrators had documented health issues. The authors reported that a “recent change in health status” was more prevalent among perpetrators compared with decedents. Perpetrators were also more likely to be caregivers to their spouses. The authors found that 65% of perpetrators were reported to have a “depressed mood” and 15% of perpetrators had reportedly threatened suicide prior to the incident. However, none of the perpetrators tested positive for antidepressants as documented on post-mortem toxicology reports. Firearms were used in 100% of homicide-suicide cases.17
Salari3 (2007) reviewed multiple American media sources and published police reports between 1999 and 2005 to retrieve data about intimate partner homicide-suicide events in the United States. There were 225 events identified where the perpetrator and/or the victim were age ≥60 years. Ninety-six percent of the perpetrators were men and most homicide-suicide events were committed at the home. A history of domestic violence was reported in 14% of homicide-suicide cases. Thirteen percent of couples were separated or divorced. The perpetrator and/or victim had health issues in 124 (55%) events. Dementia was reported in 7.5% of cases, but overwhelmingly among the victims. Substance abuse was rarely mentioned as a contributing factor. In three-quarters of cases where a motive was described, the perpetrator was “suicidal”; however, a “suicide pact” was mentioned in only 4% of cases. Firearms were used in 87% of cases.3
Focus on common risk factors
The scarcity and heterogeneity of research regarding older adult homicide-suicide were major limitations to our review. Because most of the studies we identified had a small sample size and limited information regarding the mental health of victims and perpetrators, it would be an overreach to claim to have identified a typical profile of an older perpetrator of homicide-suicide. However, the literature has repeatedly identified several common characteristics of such perpetrators. They are significantly more likely to be men who use firearms to murder their intimate partners and then die by suicide in their home (Table3,5,11-17). Health issues afflicting 1 or both individuals in the couple appear to be a contributing factor, particularly when the perpetrator is in a caregiving role. Relational discord, with or without a history of domestic violence, increases the risk of homicide-suicide. Finally, older perpetrators are highly likely to be depressed and have suicidal ideations.
How COVID-19 affects these risks
Although it is too early to determine if there is a causal relationship between the COVID-19 pandemic and an increase in homicide-suicide, the pandemic is likely to promote risk factors for these events, especially among older adults. Confinement measures put into place during the pandemic context have already been shown to increase rates of domestic violence18 and depression and anxiety among older individuals.7 Furthermore,
Continue to: Late-life psychiatric disorders
Late-life psychiatric disorders
Early recognition and effective treatment of late-life psychiatric disorders is crucial. Unfortunately, depression in geriatric patients is often underdiagnosed and undertreated.20 Older adults have more frequent contact with their primary care physicians, and rarely consult mental health professionals.21,22 Several models of integrated depression care within primary care settings have shown the positive impact of this collaborative approach in treating late-life depression and preventing suicide in older individuals.23 Additionally, because alcohol abuse is also a risk factor for domestic violence and breaking the law in this population,24,25 older adults should be screened for alcohol use disorders, and referred to treatment when necessary.
Take steps to keep patients safe
In the context of the COVID-19 pandemic, there are several steps clinicians need to keep in mind when interacting with older patients:
- Screen for depressive symptoms, suicidality, and alcohol and substance use disorders. Individuals who have tested positive for COVID-19 or who have been in contact with a carrier are a particularly vulnerable population.
- Screen for domestic violence and access to weapons at home.4 Any older adult who has a psychiatric disorder and/or suicide ideation should receive immediate intervention through a social worker that includes providing gun-risk education to other family members or contacting law-enforcement officials.26
- Refer patients with a suspected psychiatric disorder to specialized mental health clinicians. Telemental health services can provide rapid access to subspecialists, allowing patients to be treated from their homes.27 These services need to be promoted among older adults during this critical period and reimbursed by public and private insurance systems to ensure accessibility and affordability.28
- Create psychiatric inpatient units specifically designed for suicidal and/or homicidal patients with COVID-19.
Additionally, informing the public about these major health issues is crucial. The media can raise awareness about domestic violence and depression among older adults; however, this should be done responsibly and with accuracy to prevent the spread of misinformation, confusion, fear, and panic.29
Bottom Line
The mental health burden of the coronavirus disease 2019 pandemic has significantly impacted individuals who are older and most vulnerable. Reducing the incidence of homicide-suicide among older adults requires timely screening and interventions by primary care providers, mental health specialists, social workers, media, and governmental agencies.
Related Resources
- Saeed SA, Hebishi K. The psychiatric consequences of COVID-19: 8 studies. Current Psychiatry. 2020;19(11):22-24,28-30,32-35.
- Schwab-Reese LM, Murfree L, Coppola EC, et al. Homicidesuicide across the lifespan: a mixed methods examination of factors contributing to older adult perpetration. Aging Ment Health. 2020;20:1-9.
On March 25, 2020, in Cambridge, United Kingdom, a 71-year-old man stabbed his 71-year-old wife before suffocating himself to death. The couple was reportedly anxious about the coronavirus disease 2019 (COVID-19) pandemic lockdown measures and were on the verge of running out of food and medicine.1
One week later, in Chicago, Illinois, a 54-year-old man shot and killed his female partner, age 54, before killing himself. The couple was tested for COVID-19 2 days earlier and the man believed they had contracted the virus; however, the test results for both of them had come back negative.2
Intimate partner homicide-suicide is the most dramatic domestic abuse outcome.3 Homicide-suicide is defined as “homicide committed by a person who subsequently commits suicide within one week of the homicide. In most cases the subsequent suicide occurs within a 24-hour period.”4 Approximately one-quarter of all homicide-suicides are committed by persons age ≥55 years.5,6 We believe that during the COVID-19 pandemic, the risk of homicide-suicide among older adults may be increased due to several factors, including:
- physical distancing and quarantine measures. Protocols established to slow the spread of the virus may be associated with increased rates of depression and anxiety7 and an increased risk of suicide among older adults8
- increased intimate partner violence9
- increased firearm ownership rates in the United States.10
In this article, we review studies that identified risk factors for homicide-suicide among older adults, discuss the impact the COVID-19 pandemic has had on these risks, and describe steps clinicians can take to intervene.
A review of the literature
To better characterize the perpetrators of older adult homicide-suicide, we conducted a literature search of relevant terms. We identified 9 original research publications that examined homicide-suicide in older adults.
Bourget et al11 (2010) reviewed coroners’ charts of individuals killed by an older (age ≥65) spouse or family member from 1992 through 2007 in Quebec, Canada. They identified 19 cases of homicide-suicide, 17 (90%) of which were perpetrated by men. Perpetrators and victims were married (63%), in common-law relationships (16%), or separated/divorced (16%). A history of domestic violence was documented in 4 (21%) cases. The authors found that 13 of 15 perpetrators (87%) had “major depression” and 2 perpetrators had a psychotic disorder. Substance use at the time of the event was confirmed in 6 (32%) cases. Firearms and strangulation were the top methods used to carry out the homicide-suicide.11
Cheung et al12 (2016) conducted a review of coroners’ records of homicide-suicide cases among individuals age ≥65 in New Zealand from 2007 through 2012. In all 4 cases, the perpetrators were men, and their victims were predominantly female, live-in family members. Two cases involved men with a history of domestic violence who were undergoing significant changes in their home and social lives. Both men had a history suggestive of depression and used a firearm to carry out the homicide-suicide.12
Continue to: Cohen et al
Cohen et al13 (1998) conducted a review of coroners’ records from 1988 through 1994 in 2 regions in Florida. They found 48 intimate partner homicide-suicide cases among “old couples” (age ≥55). All were perpetrated by men. The authors identified sociocultural differences in risk factors between the 2 regions. In west-central Florida, perpetrators and victims were predominantly white and in a spousal relationship. Domestic violence was documented in <4% of cases. Approximately 55% of the couples were reported to be ill, and a substantial proportion were documented to be declining in health. One-quarter of the perpetrators and one-third of the victims had “pain and suffering.” More than one-third of perpetrators were reported to have “depression,” 15% were reported to have talked about suicide, and 4% had a history of a suicide attempt. Only 11% of perpetrators were described as abusing substances.
The authors noted several differences in cases in southeastern Florida. Approximately two-thirds of the couples were Hispanic, and 14% had a history of domestic violence. A minority of the couples were in a live-in relationship. Less than 15% of the perpetrators and victims were described as having a decline in health. Additionally, only 19% of perpetrators were reported to have “depression,” and none of the perpetrators had a documented history of attempted suicide or substance abuse. No information was provided regarding the methods used to carry out the homicide-suicide in the southeastern region.13 Financial stress was not a factor in either region.
Malphurs et al14 (2001) used the same database described in the Cohen et al13 study to compare 27 perpetrators of homicide-suicide to 36 age-matched suicide decedents in west central Florida. They found that homicide-suicide perpetrators were significantly less likely to have health problems and were 3 times more likely to be caregivers to their spouses. Approximately 52% of perpetrators had at least 1 documented psychiatric symptom (“depression” and/or substance abuse or other), but only 5% were seeking mental health services at the time of death.14
De Koning and Piette15 (2014) conducted a retrospective medicolegal chart review from 1935 to 2010 to identify homicide-suicide cases in West and East Flanders, Belgium. They found 19 cases of intimate partner homicide-suicide committed by offenders age ≥55 years. Ninety-five percent of the perpetrators were men who killed their female partners. In one-quarter of the cases, either the perpetrator or the victim had a health issue; 21% of the perpetrators were documented as having depression and 27% had alcohol intoxication at the time of death. A motive was documented in 14 out of 19 cases; “mercy killing” was determined as the motive in 6 (43%) cases and “amorous jealousy” in 5 cases (36%).15 Starting in the 1970s, firearms were the most prevalent method used to kill a partner.
Logan et al16 (2019) used data from the National Violent Death Reporting System between 2003 and 2015 to identify characteristics that differentiated male suicide decedents from male perpetrators of intimate partner homicide-suicide. They found that men age 50 to 64 years were 3 times more likely than men age 18 to 34 years to commit intimate partner homicide-suicide, and that men age ≥65 years were approximately 5 times more likely than men age 18 to 34 years to commit intimate partner homicide-suicide. The authors found that approximately 22% of all perpetrators had a documented history of physical domestic violence, and close to 17% had a prior interaction with the criminal justice system. Furthermore, one-third of perpetrators had relationship difficulties and were in the process of a breakup. Health issues were prevalent in 34% of the victims and 26% of the perpetrators. Perpetrator-caregiver burden was reported as a contributing factor for homicide-suicide in 16% of cases. In 27% of cases, multiple health-related contributing factors were mentioned.16
Continue to: Malphurs and Cohen
Malphurs and Cohen5 (2002) reviewed American newspapers from 1997 through 1999 and identified 673 homicide-suicide events, of which 152 (27%) were committed by individuals age ≥55 years. The victims and perpetrators (95% of which were men) were intimate partners in three-quarters of cases. In nearly one-third of cases, caregiving was a contributing factor for the homicide-suicide. A history of or a pending divorce was reported in nearly 14% of cases. Substance use history was rarely recorded. Firearms were used in 88% of the homicide-suicide cases.5
Malphurs and Cohen17 (2005) reviewed coroner records between 1998 and 1999 in Florida and compared 20 cases of intimate partner homicide-suicide involving perpetrators age ≥55 years with matched suicide decedents. They found that 60% of homicide-suicide perpetrators had documented health issues. The authors reported that a “recent change in health status” was more prevalent among perpetrators compared with decedents. Perpetrators were also more likely to be caregivers to their spouses. The authors found that 65% of perpetrators were reported to have a “depressed mood” and 15% of perpetrators had reportedly threatened suicide prior to the incident. However, none of the perpetrators tested positive for antidepressants as documented on post-mortem toxicology reports. Firearms were used in 100% of homicide-suicide cases.17
Salari3 (2007) reviewed multiple American media sources and published police reports between 1999 and 2005 to retrieve data about intimate partner homicide-suicide events in the United States. There were 225 events identified where the perpetrator and/or the victim were age ≥60 years. Ninety-six percent of the perpetrators were men and most homicide-suicide events were committed at the home. A history of domestic violence was reported in 14% of homicide-suicide cases. Thirteen percent of couples were separated or divorced. The perpetrator and/or victim had health issues in 124 (55%) events. Dementia was reported in 7.5% of cases, but overwhelmingly among the victims. Substance abuse was rarely mentioned as a contributing factor. In three-quarters of cases where a motive was described, the perpetrator was “suicidal”; however, a “suicide pact” was mentioned in only 4% of cases. Firearms were used in 87% of cases.3
Focus on common risk factors
The scarcity and heterogeneity of research regarding older adult homicide-suicide were major limitations to our review. Because most of the studies we identified had a small sample size and limited information regarding the mental health of victims and perpetrators, it would be an overreach to claim to have identified a typical profile of an older perpetrator of homicide-suicide. However, the literature has repeatedly identified several common characteristics of such perpetrators. They are significantly more likely to be men who use firearms to murder their intimate partners and then die by suicide in their home (Table3,5,11-17). Health issues afflicting 1 or both individuals in the couple appear to be a contributing factor, particularly when the perpetrator is in a caregiving role. Relational discord, with or without a history of domestic violence, increases the risk of homicide-suicide. Finally, older perpetrators are highly likely to be depressed and have suicidal ideations.
How COVID-19 affects these risks
Although it is too early to determine if there is a causal relationship between the COVID-19 pandemic and an increase in homicide-suicide, the pandemic is likely to promote risk factors for these events, especially among older adults. Confinement measures put into place during the pandemic context have already been shown to increase rates of domestic violence18 and depression and anxiety among older individuals.7 Furthermore,
Continue to: Late-life psychiatric disorders
Late-life psychiatric disorders
Early recognition and effective treatment of late-life psychiatric disorders is crucial. Unfortunately, depression in geriatric patients is often underdiagnosed and undertreated.20 Older adults have more frequent contact with their primary care physicians, and rarely consult mental health professionals.21,22 Several models of integrated depression care within primary care settings have shown the positive impact of this collaborative approach in treating late-life depression and preventing suicide in older individuals.23 Additionally, because alcohol abuse is also a risk factor for domestic violence and breaking the law in this population,24,25 older adults should be screened for alcohol use disorders, and referred to treatment when necessary.
Take steps to keep patients safe
In the context of the COVID-19 pandemic, there are several steps clinicians need to keep in mind when interacting with older patients:
- Screen for depressive symptoms, suicidality, and alcohol and substance use disorders. Individuals who have tested positive for COVID-19 or who have been in contact with a carrier are a particularly vulnerable population.
- Screen for domestic violence and access to weapons at home.4 Any older adult who has a psychiatric disorder and/or suicide ideation should receive immediate intervention through a social worker that includes providing gun-risk education to other family members or contacting law-enforcement officials.26
- Refer patients with a suspected psychiatric disorder to specialized mental health clinicians. Telemental health services can provide rapid access to subspecialists, allowing patients to be treated from their homes.27 These services need to be promoted among older adults during this critical period and reimbursed by public and private insurance systems to ensure accessibility and affordability.28
- Create psychiatric inpatient units specifically designed for suicidal and/or homicidal patients with COVID-19.
Additionally, informing the public about these major health issues is crucial. The media can raise awareness about domestic violence and depression among older adults; however, this should be done responsibly and with accuracy to prevent the spread of misinformation, confusion, fear, and panic.29
Bottom Line
The mental health burden of the coronavirus disease 2019 pandemic has significantly impacted individuals who are older and most vulnerable. Reducing the incidence of homicide-suicide among older adults requires timely screening and interventions by primary care providers, mental health specialists, social workers, media, and governmental agencies.
Related Resources
- Saeed SA, Hebishi K. The psychiatric consequences of COVID-19: 8 studies. Current Psychiatry. 2020;19(11):22-24,28-30,32-35.
- Schwab-Reese LM, Murfree L, Coppola EC, et al. Homicidesuicide across the lifespan: a mixed methods examination of factors contributing to older adult perpetration. Aging Ment Health. 2020;20:1-9.
1. Christodoulou H. LOCKDOWN ‘MURDER-SUICIDE’ OAP, 71, ‘stabbed wife to death then killed himself as he worried about coping with coronavirus lockdown.’ The Sun. Updated April 4, 2020. Accessed December 22, 2020. https://www.thesun.co.uk/news/11327095/coronavirus-lockdown-murder-suicide-cambridge/
2. Farberov S. Illinois man, 54, shoots dead his wife then kills himself in murder-suicide because he feared they had coronavirus - but tests later show the couple were NOT ill. Updated April 6, 2020. Accessed December 22, 2020. https://www.dailymail.co.uk/news/article-8191933/Man-kills-wife-feared-coronavirus.html
3. Salari S. Patterns of intimate partner homicide suicide in later life: strategies for prevention. Clin Interv Aging. 2007;2(3):441-452.
4. Kotzé C, Roos JL. Homicide–suicide: practical implications for risk reduction and support services at primary care level. South African Family Practice. 2019;61(4):165-169.
5. Malphurs JE, Cohen D. A newspaper surveillance study of homicide-suicide in the United States. Am J Forensic Med Pathol. 2002;23(2):142-148.
6. Eliason S. Murder-suicide: a review of the recent literature. J Am Acad Psychiatry Law. 2009;37(3):371-376.
7. Armitage R, Nellums LB. COVID-19 and the consequences of isolating the elderly. Lancet Public Health. 2020;5(5):e256. doi: 10.1016/S2468-2667(20)30061-X
8. Gunnell D, Appleby L, Arensman E, et al. Suicide risk and prevention during the COVID-19 pandemic. Lancet Psychiatry 2020;7(6):468-471.
9. Gosangi B, Park H, Thomas R, et al. Exacerbation of physical intimate partner violence during COVID-19 pandemic. Radiology. 2021;298(1):E38-E45.
10. Mannix R, Lee LK, Fleegler EW. Coronavirus disease 2019 (COVID-19) and firearms in the United States: will an epidemic of suicide follow? Ann Intern Med. 2020;173(3):228-229.
11. Bourget D, Gagne P, Whitehurst L. Domestic homicide and homicide-suicide: the older offender. J Am Acad Psychiatry Law. 2010;38(3):305-311.
12. Cheung G, Hatters Friedman S, Sundram F. Late-life homicide-suicide: a national case series in New Zealand. Psychogeriatrics. 2016;16(1):76-81.
13. Cohen D, Llorente M, Eisdorfer C. Homicide-suicide in older persons. Am J Psychiatry. 1998;155(3):390-396.
14. Malphurs JE, Eisdorfer C, Cohen D. A comparison of antecedents of homicide-suicide and suicide in older married men. Am J Geriatr Psychiatry. 2001;9(1):49-57.
15. De Koning E, Piette MHA. A retrospective study of murder–suicide at the Forensic Institute of Ghent University, Belgium: 1935–2010. Med Sci Law. 2014;54(2):88-98.
16. Logan JE, Ertl A, Bossarte R. Correlates of intimate partner homicide among male suicide decedents with known intimate partner problems. Suicide Life Threat Behav. 2019;49(6):1693-1706.
17. Malphurs JE, Cohen D. A statewide case-control study of spousal homicide-suicide in older persons. Am J Geriatr Psychiatry. 2005;13(3):211-217.
18. Sanford A. ‘Horrifying surge in domestic violence’ against women amid coronavirus-lockdowns, UN chief warns. Euronews. Published June 4, 2020. Accessed December 22, 2020. https://www.euronews.com/2020/04/06/horrifying-surge-in-domestic-violence-against-women-amid-coronavirus-lockdowns-un-chief-w
19. Appel JM. Intimate partner homicide in elderly populations. In: Friedman SH, ed. Family murder: pathologies of love and hate. American Psychiatric Association Publishing; 2019:131-142.
20. Hall CA, Reynolds-III CF. Late-life depression in the primary care setting: challenges, collaborative care, and prevention. Maturitas. 2014;79(2):147-152.
21. Unützer J. Diagnosis and treatment of older adults with depression in primary care. Biological Psychiatry. 2002;52(3):285-292.
22. Byers AL, Arean PA, Yaffe K. Low use of mental health services among older Americans with mood and anxiety disorders. Psychiatr Serv. 2012;63(1):66-72.
23. Bruce ML, Sirey JA. Integrated care for depression in older primary care patients. Can J Psychiatry. 2018;63(7):439-446.
24. Rao R, Roche A. Substance misuse in older people. BMJ. 2017;358:j3885. doi: 10.1136/bmj.j3885
25. Ghossoub E, Khoury R. Prevalence and correlates of criminal behavior among the non-institutionalized elderly: results from the National Survey on Drug Use and Health. J Geriatr Psychiatry Neurol. 2018;31(4):211-222.
26. Slater MAG. Older adults at risk for suicide. In: Berkman B. Handbook of social work in health and aging. Oxford University Press; 2006:149-161.
27. Hollander JE, Carr BG. Virtually perfect? Telemedicine for Covid-19. N Engl J Med. 2020;382(18):1679-1681.
28. Centers for Medicare & Medicaid Services. President Trump expands telehealth benefits for Medicare beneficiaries during COVID-19 outbreak. Published March 17, 2020. Accessed December 23, 2020. https://www.cms.gov/newsroom/press-releases/president-trump-expands-telehealth-benefits-medicare-beneficiaries-during-covid-19-outbreak
29. Mian A, Khan S. Coronavirus: the spread of misinformation. BMC Med. 2020;18(1):89.
1. Christodoulou H. LOCKDOWN ‘MURDER-SUICIDE’ OAP, 71, ‘stabbed wife to death then killed himself as he worried about coping with coronavirus lockdown.’ The Sun. Updated April 4, 2020. Accessed December 22, 2020. https://www.thesun.co.uk/news/11327095/coronavirus-lockdown-murder-suicide-cambridge/
2. Farberov S. Illinois man, 54, shoots dead his wife then kills himself in murder-suicide because he feared they had coronavirus - but tests later show the couple were NOT ill. Updated April 6, 2020. Accessed December 22, 2020. https://www.dailymail.co.uk/news/article-8191933/Man-kills-wife-feared-coronavirus.html
3. Salari S. Patterns of intimate partner homicide suicide in later life: strategies for prevention. Clin Interv Aging. 2007;2(3):441-452.
4. Kotzé C, Roos JL. Homicide–suicide: practical implications for risk reduction and support services at primary care level. South African Family Practice. 2019;61(4):165-169.
5. Malphurs JE, Cohen D. A newspaper surveillance study of homicide-suicide in the United States. Am J Forensic Med Pathol. 2002;23(2):142-148.
6. Eliason S. Murder-suicide: a review of the recent literature. J Am Acad Psychiatry Law. 2009;37(3):371-376.
7. Armitage R, Nellums LB. COVID-19 and the consequences of isolating the elderly. Lancet Public Health. 2020;5(5):e256. doi: 10.1016/S2468-2667(20)30061-X
8. Gunnell D, Appleby L, Arensman E, et al. Suicide risk and prevention during the COVID-19 pandemic. Lancet Psychiatry 2020;7(6):468-471.
9. Gosangi B, Park H, Thomas R, et al. Exacerbation of physical intimate partner violence during COVID-19 pandemic. Radiology. 2021;298(1):E38-E45.
10. Mannix R, Lee LK, Fleegler EW. Coronavirus disease 2019 (COVID-19) and firearms in the United States: will an epidemic of suicide follow? Ann Intern Med. 2020;173(3):228-229.
11. Bourget D, Gagne P, Whitehurst L. Domestic homicide and homicide-suicide: the older offender. J Am Acad Psychiatry Law. 2010;38(3):305-311.
12. Cheung G, Hatters Friedman S, Sundram F. Late-life homicide-suicide: a national case series in New Zealand. Psychogeriatrics. 2016;16(1):76-81.
13. Cohen D, Llorente M, Eisdorfer C. Homicide-suicide in older persons. Am J Psychiatry. 1998;155(3):390-396.
14. Malphurs JE, Eisdorfer C, Cohen D. A comparison of antecedents of homicide-suicide and suicide in older married men. Am J Geriatr Psychiatry. 2001;9(1):49-57.
15. De Koning E, Piette MHA. A retrospective study of murder–suicide at the Forensic Institute of Ghent University, Belgium: 1935–2010. Med Sci Law. 2014;54(2):88-98.
16. Logan JE, Ertl A, Bossarte R. Correlates of intimate partner homicide among male suicide decedents with known intimate partner problems. Suicide Life Threat Behav. 2019;49(6):1693-1706.
17. Malphurs JE, Cohen D. A statewide case-control study of spousal homicide-suicide in older persons. Am J Geriatr Psychiatry. 2005;13(3):211-217.
18. Sanford A. ‘Horrifying surge in domestic violence’ against women amid coronavirus-lockdowns, UN chief warns. Euronews. Published June 4, 2020. Accessed December 22, 2020. https://www.euronews.com/2020/04/06/horrifying-surge-in-domestic-violence-against-women-amid-coronavirus-lockdowns-un-chief-w
19. Appel JM. Intimate partner homicide in elderly populations. In: Friedman SH, ed. Family murder: pathologies of love and hate. American Psychiatric Association Publishing; 2019:131-142.
20. Hall CA, Reynolds-III CF. Late-life depression in the primary care setting: challenges, collaborative care, and prevention. Maturitas. 2014;79(2):147-152.
21. Unützer J. Diagnosis and treatment of older adults with depression in primary care. Biological Psychiatry. 2002;52(3):285-292.
22. Byers AL, Arean PA, Yaffe K. Low use of mental health services among older Americans with mood and anxiety disorders. Psychiatr Serv. 2012;63(1):66-72.
23. Bruce ML, Sirey JA. Integrated care for depression in older primary care patients. Can J Psychiatry. 2018;63(7):439-446.
24. Rao R, Roche A. Substance misuse in older people. BMJ. 2017;358:j3885. doi: 10.1136/bmj.j3885
25. Ghossoub E, Khoury R. Prevalence and correlates of criminal behavior among the non-institutionalized elderly: results from the National Survey on Drug Use and Health. J Geriatr Psychiatry Neurol. 2018;31(4):211-222.
26. Slater MAG. Older adults at risk for suicide. In: Berkman B. Handbook of social work in health and aging. Oxford University Press; 2006:149-161.
27. Hollander JE, Carr BG. Virtually perfect? Telemedicine for Covid-19. N Engl J Med. 2020;382(18):1679-1681.
28. Centers for Medicare & Medicaid Services. President Trump expands telehealth benefits for Medicare beneficiaries during COVID-19 outbreak. Published March 17, 2020. Accessed December 23, 2020. https://www.cms.gov/newsroom/press-releases/president-trump-expands-telehealth-benefits-medicare-beneficiaries-during-covid-19-outbreak
29. Mian A, Khan S. Coronavirus: the spread of misinformation. BMC Med. 2020;18(1):89.
Management of major depressive disorder with psychotic features
Mrs. C, age 56, has a history of major depressive disorder (MDD). She has been stable for 5 years without medication. Six months ago, she presented to you, along with her son, seeking help. She reported that she had been experiencing insomnia, fatigue, and was not engaging in hobbies. Her son told you that his mother had lost weight and had been avoiding family dinners. Mrs. C reported recurrent thoughts of dying and heard voices vividly telling her that she was a burden and that her family would be better off without her. However, there was no imminent danger of self-harm. At that appointment, you initiated
Since that time, Mrs. C has followed up with you monthly with good response to the medications. Currently, she states her depression is much improved, and she denies hearing voices for approximately 5 months.
Based on her presentation and response, what do the data suggest about her length of treatment, and when should you consider tapering the antipsychotic medication?
In DSM-5, MDD with psychotic features is a severe subtype of MDD that is defined as a major depressive episode characterized by delusions and/or hallucinations.1 In the general population, the lifetime prevalence of this disorder varies from 0.35% to 1%, and the rate is higher in older patients.2 Risk factors include female gender, family history, and concomitant bipolar disorder.2
Epidemiologic studies have shown that psychotic features can occur in 15% to 20% of patients with MDD. The psychotic features that occur during these episodes are delusions and hallucinations.1 These features can be either mood-congruent (related to the depressive themes of worthlessness or guilt) or mood-incongruent (ie, unrelated to depressive themes).1
Treatment options: ECT or pharmacotherapy
Guidelines from the American Psychiatric Association3 and the National Institute for Clinical Excellence4 recommend treating depression with psychosis with electroconvulsive therapy (ECT) or with combined antidepressant and antipsychotic medications as first-line options. The Texas Medication Algorithm Project (TMAP) Algorithm for MDD,5 which closely focuses on treatment of MDD with psychotic features, can be used for treatment decisions (see Related Resources).
Electroconvulsive therapy is known to be efficacious in treating patients with MDD with psychotic features and should be considered as a treatment option. However, medication therapy is often chosen as the initial treatment due to the limitations of ECT, including accessibility, cost, and patient preference. However, in certain cases, ECT is the preferred option because it can provide rapid and significant improvement in patients with severe psychosis, suicidality, or risk of imminent harm.
Continue to: Pharmacotherapy
Pharmacotherapy for the treatment of MDD with psychotic features should consist of a combination of an antidepressant and antipsychotic medication. This combination has been shown to be more effective than either agent alone. Some combinations have been studied specifically for MDD with psychosis. The Study of the Pharmacotherapy of Psychotic Depression (STOP-PD), a 12-week, double-blind, randomized controlled trial, found that the combination of sertraline and olanzapine was efficacious and superior to monotherapy with olanzapine in an acute setting.6 In another study, the combination of olanzapine and
How long should treatment last?
The optimal timeline for treating patients with MDD with psychotic features is unknown. According to the TMAP algorithm and expert opinion, the continuation phase of pharmacotherapy should include treatment for at least 4 months with an antipsychotic medication and at least 2 years to lifetime treatment with an antidepressant.5 The STOP-PD II study, which was a continuation of the 12-week STOP-PD study, examined antipsychotic duration to determine the effects of continuing olanzapine once an episode of psychotic depression had responded to olanzapine and sertraline.11 Patients who had achieved remission after receiving olanzapine and sertraline were randomized to continue to receive this combination or to receive sertraline plus placebo for 36 weeks. The primary outcome was relapse, which was broadly defined as 1 of the following11:
- a Structured Clinical Interview for the DSM (SCID)-rated assessment that revealed the patient had enough symptoms to meet criteria for a DSM-IV major depressive episode
- a 17-item HAM-D scoren of ≥18
- SCID-rated psychosis
- other significant clinical worsening, defined as having a suicide plan or attempting suicide, developing SCID-rated symptoms of mania or hypomania, or being hospitalized in a psychiatric unit.
Compared with sertraline plus placebo, continuing sertraline plus olanzapine reduced the risk of relapse over 36 weeks (hazard ratio, 0.25; 95% confidence interval, 0.13 to 0.48; P < .001).11 However, as expected, the incidence of adverse effects such as weight gain and parkinsonism was higher in the olanzapine group. Therefore, it is important to consider the potential long-term adverse effects of continuing antipsychotic medications.
Weighing the evidence
Electroconvulsive therapy is considered a first-line treatment option for MDD with psychotic features; however, because of limitations associated with this approach, antidepressants plus antipsychotics are often utilized as an initial treatment.
Continue to: CASE
CASE CONTINUED
Based on the results of the STOP-PD and STOP-PD II trials, Mrs. C should be continued on sertraline plus olanzapine for at least another 3 to 6 months before an olanzapine taper should be considered. At that time, the risks and benefits of a taper vs continuing therapy should be considered. Given her history of MDD and the severity of this most recent episode, sertraline therapy should be continued for at least 2 years, and possibly indefinitely.
Related Resources
- Texas Medication Algorithm Project. Algorithm for the treatment of major depressive disorder with psychotic features. https://chsciowa.org/sites/chsciowa.org/files/resource/files/9_-_depression_med_algorithm_supplement.pdf
- Dold M, Bartova L, Kautzky A, et al. Psychotic features in patients with major depressive disorder: a report from the European Group for the Study of Resistant Depression. J Clin Psychiatry. 2019;80(1):17m12090. doi: 10.4088/ JCP.17m12090
- Flint AJ, Meyers BS, Rothschild AJ, et al. Effect of continuing olanzapine vs placebo on relapse among patients with psychotic depression in remission: the STOP-PD II randomized clinical trial. JAMA. 2019;322(7): 622-631.
Drug Brand Names
Amitriptyline • Elavil, Endep
Fluoxetine • Prozac
Haloperidol • Haldol
Olanzapine • Zyprexa
Quetiapine • Seroquel
Sertraline • Zoloft
Venlafaxine • Effexor
1. Diagnostic and statistical manual of mental disorders, 5th ed. American Psychiatric Association; 2013.
2. Jääskeläinen E, Juola T, Korpela H, et al. Epidemiology of psychotic depression - systematic review and meta-analysis. Psychol Med. 2018;48(6):905-918.
3. American Psychiatric Association. Practice guideline for the treatment of patients with major depressive disorder (revision). Am J Psychiatry. 2000;157(4)(suppl):1-45.
4. National Institute for Clinical Excellence. Depression in adults: recognition and management: clinical guideline [CG90]. National Institute for Health and Clinical Excellence. Published October 28, 2009. Accessed January 12, 2021. https://www.nice.org.uk/guidance/cg90
5. Crimson ML, Trivedi M, Pigott TA, et al. The Texas Medication Algorithm Project: report of the Texas Consensus Conference Panel on medication treatment of major depressive disorder. J Clin Psychiatry. 1999;60(3):142-156.
6. Meyers BS, Flint AJ, Rothschild AJ, et al. A double-blind randomized controlled trial of olanzapine plus sertraline vs olanzapine plus placebo for psychotic depression: the study of pharmacotherapy for psychotic depression -- the STOP-PD study. Arch Gen Psychiatry. 2009;66(8):838-847.
7. Rothschild AJ, Williamson DJ, Tohen MF, et al. A double-blind, randomized study of olanzapine and olanzapine/fluoxetine combination for major depression with psychotic features. J Clin Psychopharmacol. 2004;24(4):365-373.
8. Wijkstra J, Burger H, van den Broek WW, et al. Treatment of unipolar psychotic depression: a randomized, doubleblind study comparing imipramine, venlafaxine, and venlafaxine plus quetiapine. Acta Psychiatr Scand. 2010;21(3):190-200.
9. Muller-Siecheneder F, Muller M, Hillert A, et al. Risperidone versus haloperidol and amitriptyline in the treatment of patients with a combined psychotic and depressive syndrome. J Clin Psychopharm. 1998;18(2):111-120.
10. Spiker DG, Weiss JC, Dealy RS, et al. The pharmacological treatment of delusional depression. Am J Psychiatry. 1985;142(4):430-436.
11. Flint AJ, Meyers BS, Rothschild AJ, et al. Effect of continuing olanzapine vs placebo on relapse among patients with psychotic depression in remission: the STOP-PD II randomized clinical trial. JAMA. 2019;322(7):622-631.
Mrs. C, age 56, has a history of major depressive disorder (MDD). She has been stable for 5 years without medication. Six months ago, she presented to you, along with her son, seeking help. She reported that she had been experiencing insomnia, fatigue, and was not engaging in hobbies. Her son told you that his mother had lost weight and had been avoiding family dinners. Mrs. C reported recurrent thoughts of dying and heard voices vividly telling her that she was a burden and that her family would be better off without her. However, there was no imminent danger of self-harm. At that appointment, you initiated
Since that time, Mrs. C has followed up with you monthly with good response to the medications. Currently, she states her depression is much improved, and she denies hearing voices for approximately 5 months.
Based on her presentation and response, what do the data suggest about her length of treatment, and when should you consider tapering the antipsychotic medication?
In DSM-5, MDD with psychotic features is a severe subtype of MDD that is defined as a major depressive episode characterized by delusions and/or hallucinations.1 In the general population, the lifetime prevalence of this disorder varies from 0.35% to 1%, and the rate is higher in older patients.2 Risk factors include female gender, family history, and concomitant bipolar disorder.2
Epidemiologic studies have shown that psychotic features can occur in 15% to 20% of patients with MDD. The psychotic features that occur during these episodes are delusions and hallucinations.1 These features can be either mood-congruent (related to the depressive themes of worthlessness or guilt) or mood-incongruent (ie, unrelated to depressive themes).1
Treatment options: ECT or pharmacotherapy
Guidelines from the American Psychiatric Association3 and the National Institute for Clinical Excellence4 recommend treating depression with psychosis with electroconvulsive therapy (ECT) or with combined antidepressant and antipsychotic medications as first-line options. The Texas Medication Algorithm Project (TMAP) Algorithm for MDD,5 which closely focuses on treatment of MDD with psychotic features, can be used for treatment decisions (see Related Resources).
Electroconvulsive therapy is known to be efficacious in treating patients with MDD with psychotic features and should be considered as a treatment option. However, medication therapy is often chosen as the initial treatment due to the limitations of ECT, including accessibility, cost, and patient preference. However, in certain cases, ECT is the preferred option because it can provide rapid and significant improvement in patients with severe psychosis, suicidality, or risk of imminent harm.
Continue to: Pharmacotherapy
Pharmacotherapy for the treatment of MDD with psychotic features should consist of a combination of an antidepressant and antipsychotic medication. This combination has been shown to be more effective than either agent alone. Some combinations have been studied specifically for MDD with psychosis. The Study of the Pharmacotherapy of Psychotic Depression (STOP-PD), a 12-week, double-blind, randomized controlled trial, found that the combination of sertraline and olanzapine was efficacious and superior to monotherapy with olanzapine in an acute setting.6 In another study, the combination of olanzapine and
How long should treatment last?
The optimal timeline for treating patients with MDD with psychotic features is unknown. According to the TMAP algorithm and expert opinion, the continuation phase of pharmacotherapy should include treatment for at least 4 months with an antipsychotic medication and at least 2 years to lifetime treatment with an antidepressant.5 The STOP-PD II study, which was a continuation of the 12-week STOP-PD study, examined antipsychotic duration to determine the effects of continuing olanzapine once an episode of psychotic depression had responded to olanzapine and sertraline.11 Patients who had achieved remission after receiving olanzapine and sertraline were randomized to continue to receive this combination or to receive sertraline plus placebo for 36 weeks. The primary outcome was relapse, which was broadly defined as 1 of the following11:
- a Structured Clinical Interview for the DSM (SCID)-rated assessment that revealed the patient had enough symptoms to meet criteria for a DSM-IV major depressive episode
- a 17-item HAM-D scoren of ≥18
- SCID-rated psychosis
- other significant clinical worsening, defined as having a suicide plan or attempting suicide, developing SCID-rated symptoms of mania or hypomania, or being hospitalized in a psychiatric unit.
Compared with sertraline plus placebo, continuing sertraline plus olanzapine reduced the risk of relapse over 36 weeks (hazard ratio, 0.25; 95% confidence interval, 0.13 to 0.48; P < .001).11 However, as expected, the incidence of adverse effects such as weight gain and parkinsonism was higher in the olanzapine group. Therefore, it is important to consider the potential long-term adverse effects of continuing antipsychotic medications.
Weighing the evidence
Electroconvulsive therapy is considered a first-line treatment option for MDD with psychotic features; however, because of limitations associated with this approach, antidepressants plus antipsychotics are often utilized as an initial treatment.
Continue to: CASE
CASE CONTINUED
Based on the results of the STOP-PD and STOP-PD II trials, Mrs. C should be continued on sertraline plus olanzapine for at least another 3 to 6 months before an olanzapine taper should be considered. At that time, the risks and benefits of a taper vs continuing therapy should be considered. Given her history of MDD and the severity of this most recent episode, sertraline therapy should be continued for at least 2 years, and possibly indefinitely.
Related Resources
- Texas Medication Algorithm Project. Algorithm for the treatment of major depressive disorder with psychotic features. https://chsciowa.org/sites/chsciowa.org/files/resource/files/9_-_depression_med_algorithm_supplement.pdf
- Dold M, Bartova L, Kautzky A, et al. Psychotic features in patients with major depressive disorder: a report from the European Group for the Study of Resistant Depression. J Clin Psychiatry. 2019;80(1):17m12090. doi: 10.4088/ JCP.17m12090
- Flint AJ, Meyers BS, Rothschild AJ, et al. Effect of continuing olanzapine vs placebo on relapse among patients with psychotic depression in remission: the STOP-PD II randomized clinical trial. JAMA. 2019;322(7): 622-631.
Drug Brand Names
Amitriptyline • Elavil, Endep
Fluoxetine • Prozac
Haloperidol • Haldol
Olanzapine • Zyprexa
Quetiapine • Seroquel
Sertraline • Zoloft
Venlafaxine • Effexor
Mrs. C, age 56, has a history of major depressive disorder (MDD). She has been stable for 5 years without medication. Six months ago, she presented to you, along with her son, seeking help. She reported that she had been experiencing insomnia, fatigue, and was not engaging in hobbies. Her son told you that his mother had lost weight and had been avoiding family dinners. Mrs. C reported recurrent thoughts of dying and heard voices vividly telling her that she was a burden and that her family would be better off without her. However, there was no imminent danger of self-harm. At that appointment, you initiated
Since that time, Mrs. C has followed up with you monthly with good response to the medications. Currently, she states her depression is much improved, and she denies hearing voices for approximately 5 months.
Based on her presentation and response, what do the data suggest about her length of treatment, and when should you consider tapering the antipsychotic medication?
In DSM-5, MDD with psychotic features is a severe subtype of MDD that is defined as a major depressive episode characterized by delusions and/or hallucinations.1 In the general population, the lifetime prevalence of this disorder varies from 0.35% to 1%, and the rate is higher in older patients.2 Risk factors include female gender, family history, and concomitant bipolar disorder.2
Epidemiologic studies have shown that psychotic features can occur in 15% to 20% of patients with MDD. The psychotic features that occur during these episodes are delusions and hallucinations.1 These features can be either mood-congruent (related to the depressive themes of worthlessness or guilt) or mood-incongruent (ie, unrelated to depressive themes).1
Treatment options: ECT or pharmacotherapy
Guidelines from the American Psychiatric Association3 and the National Institute for Clinical Excellence4 recommend treating depression with psychosis with electroconvulsive therapy (ECT) or with combined antidepressant and antipsychotic medications as first-line options. The Texas Medication Algorithm Project (TMAP) Algorithm for MDD,5 which closely focuses on treatment of MDD with psychotic features, can be used for treatment decisions (see Related Resources).
Electroconvulsive therapy is known to be efficacious in treating patients with MDD with psychotic features and should be considered as a treatment option. However, medication therapy is often chosen as the initial treatment due to the limitations of ECT, including accessibility, cost, and patient preference. However, in certain cases, ECT is the preferred option because it can provide rapid and significant improvement in patients with severe psychosis, suicidality, or risk of imminent harm.
Continue to: Pharmacotherapy
Pharmacotherapy for the treatment of MDD with psychotic features should consist of a combination of an antidepressant and antipsychotic medication. This combination has been shown to be more effective than either agent alone. Some combinations have been studied specifically for MDD with psychosis. The Study of the Pharmacotherapy of Psychotic Depression (STOP-PD), a 12-week, double-blind, randomized controlled trial, found that the combination of sertraline and olanzapine was efficacious and superior to monotherapy with olanzapine in an acute setting.6 In another study, the combination of olanzapine and
How long should treatment last?
The optimal timeline for treating patients with MDD with psychotic features is unknown. According to the TMAP algorithm and expert opinion, the continuation phase of pharmacotherapy should include treatment for at least 4 months with an antipsychotic medication and at least 2 years to lifetime treatment with an antidepressant.5 The STOP-PD II study, which was a continuation of the 12-week STOP-PD study, examined antipsychotic duration to determine the effects of continuing olanzapine once an episode of psychotic depression had responded to olanzapine and sertraline.11 Patients who had achieved remission after receiving olanzapine and sertraline were randomized to continue to receive this combination or to receive sertraline plus placebo for 36 weeks. The primary outcome was relapse, which was broadly defined as 1 of the following11:
- a Structured Clinical Interview for the DSM (SCID)-rated assessment that revealed the patient had enough symptoms to meet criteria for a DSM-IV major depressive episode
- a 17-item HAM-D scoren of ≥18
- SCID-rated psychosis
- other significant clinical worsening, defined as having a suicide plan or attempting suicide, developing SCID-rated symptoms of mania or hypomania, or being hospitalized in a psychiatric unit.
Compared with sertraline plus placebo, continuing sertraline plus olanzapine reduced the risk of relapse over 36 weeks (hazard ratio, 0.25; 95% confidence interval, 0.13 to 0.48; P < .001).11 However, as expected, the incidence of adverse effects such as weight gain and parkinsonism was higher in the olanzapine group. Therefore, it is important to consider the potential long-term adverse effects of continuing antipsychotic medications.
Weighing the evidence
Electroconvulsive therapy is considered a first-line treatment option for MDD with psychotic features; however, because of limitations associated with this approach, antidepressants plus antipsychotics are often utilized as an initial treatment.
Continue to: CASE
CASE CONTINUED
Based on the results of the STOP-PD and STOP-PD II trials, Mrs. C should be continued on sertraline plus olanzapine for at least another 3 to 6 months before an olanzapine taper should be considered. At that time, the risks and benefits of a taper vs continuing therapy should be considered. Given her history of MDD and the severity of this most recent episode, sertraline therapy should be continued for at least 2 years, and possibly indefinitely.
Related Resources
- Texas Medication Algorithm Project. Algorithm for the treatment of major depressive disorder with psychotic features. https://chsciowa.org/sites/chsciowa.org/files/resource/files/9_-_depression_med_algorithm_supplement.pdf
- Dold M, Bartova L, Kautzky A, et al. Psychotic features in patients with major depressive disorder: a report from the European Group for the Study of Resistant Depression. J Clin Psychiatry. 2019;80(1):17m12090. doi: 10.4088/ JCP.17m12090
- Flint AJ, Meyers BS, Rothschild AJ, et al. Effect of continuing olanzapine vs placebo on relapse among patients with psychotic depression in remission: the STOP-PD II randomized clinical trial. JAMA. 2019;322(7): 622-631.
Drug Brand Names
Amitriptyline • Elavil, Endep
Fluoxetine • Prozac
Haloperidol • Haldol
Olanzapine • Zyprexa
Quetiapine • Seroquel
Sertraline • Zoloft
Venlafaxine • Effexor
1. Diagnostic and statistical manual of mental disorders, 5th ed. American Psychiatric Association; 2013.
2. Jääskeläinen E, Juola T, Korpela H, et al. Epidemiology of psychotic depression - systematic review and meta-analysis. Psychol Med. 2018;48(6):905-918.
3. American Psychiatric Association. Practice guideline for the treatment of patients with major depressive disorder (revision). Am J Psychiatry. 2000;157(4)(suppl):1-45.
4. National Institute for Clinical Excellence. Depression in adults: recognition and management: clinical guideline [CG90]. National Institute for Health and Clinical Excellence. Published October 28, 2009. Accessed January 12, 2021. https://www.nice.org.uk/guidance/cg90
5. Crimson ML, Trivedi M, Pigott TA, et al. The Texas Medication Algorithm Project: report of the Texas Consensus Conference Panel on medication treatment of major depressive disorder. J Clin Psychiatry. 1999;60(3):142-156.
6. Meyers BS, Flint AJ, Rothschild AJ, et al. A double-blind randomized controlled trial of olanzapine plus sertraline vs olanzapine plus placebo for psychotic depression: the study of pharmacotherapy for psychotic depression -- the STOP-PD study. Arch Gen Psychiatry. 2009;66(8):838-847.
7. Rothschild AJ, Williamson DJ, Tohen MF, et al. A double-blind, randomized study of olanzapine and olanzapine/fluoxetine combination for major depression with psychotic features. J Clin Psychopharmacol. 2004;24(4):365-373.
8. Wijkstra J, Burger H, van den Broek WW, et al. Treatment of unipolar psychotic depression: a randomized, doubleblind study comparing imipramine, venlafaxine, and venlafaxine plus quetiapine. Acta Psychiatr Scand. 2010;21(3):190-200.
9. Muller-Siecheneder F, Muller M, Hillert A, et al. Risperidone versus haloperidol and amitriptyline in the treatment of patients with a combined psychotic and depressive syndrome. J Clin Psychopharm. 1998;18(2):111-120.
10. Spiker DG, Weiss JC, Dealy RS, et al. The pharmacological treatment of delusional depression. Am J Psychiatry. 1985;142(4):430-436.
11. Flint AJ, Meyers BS, Rothschild AJ, et al. Effect of continuing olanzapine vs placebo on relapse among patients with psychotic depression in remission: the STOP-PD II randomized clinical trial. JAMA. 2019;322(7):622-631.
1. Diagnostic and statistical manual of mental disorders, 5th ed. American Psychiatric Association; 2013.
2. Jääskeläinen E, Juola T, Korpela H, et al. Epidemiology of psychotic depression - systematic review and meta-analysis. Psychol Med. 2018;48(6):905-918.
3. American Psychiatric Association. Practice guideline for the treatment of patients with major depressive disorder (revision). Am J Psychiatry. 2000;157(4)(suppl):1-45.
4. National Institute for Clinical Excellence. Depression in adults: recognition and management: clinical guideline [CG90]. National Institute for Health and Clinical Excellence. Published October 28, 2009. Accessed January 12, 2021. https://www.nice.org.uk/guidance/cg90
5. Crimson ML, Trivedi M, Pigott TA, et al. The Texas Medication Algorithm Project: report of the Texas Consensus Conference Panel on medication treatment of major depressive disorder. J Clin Psychiatry. 1999;60(3):142-156.
6. Meyers BS, Flint AJ, Rothschild AJ, et al. A double-blind randomized controlled trial of olanzapine plus sertraline vs olanzapine plus placebo for psychotic depression: the study of pharmacotherapy for psychotic depression -- the STOP-PD study. Arch Gen Psychiatry. 2009;66(8):838-847.
7. Rothschild AJ, Williamson DJ, Tohen MF, et al. A double-blind, randomized study of olanzapine and olanzapine/fluoxetine combination for major depression with psychotic features. J Clin Psychopharmacol. 2004;24(4):365-373.
8. Wijkstra J, Burger H, van den Broek WW, et al. Treatment of unipolar psychotic depression: a randomized, doubleblind study comparing imipramine, venlafaxine, and venlafaxine plus quetiapine. Acta Psychiatr Scand. 2010;21(3):190-200.
9. Muller-Siecheneder F, Muller M, Hillert A, et al. Risperidone versus haloperidol and amitriptyline in the treatment of patients with a combined psychotic and depressive syndrome. J Clin Psychopharm. 1998;18(2):111-120.
10. Spiker DG, Weiss JC, Dealy RS, et al. The pharmacological treatment of delusional depression. Am J Psychiatry. 1985;142(4):430-436.
11. Flint AJ, Meyers BS, Rothschild AJ, et al. Effect of continuing olanzapine vs placebo on relapse among patients with psychotic depression in remission: the STOP-PD II randomized clinical trial. JAMA. 2019;322(7):622-631.
Pandemic binge-watching: Is excessive screen time undermining mental health?
During the ongoing COVID-19 pandemic, many people are spending endless hours at home looking at computer, phone, and television screens. Our population has turned to Internet use and television watching as a coping mechanism to deal with their isolation, boredom, stress, and fear of the virus. Indeed, some people have become addicted to watching television and binge-watching entire series in a single sitting on subscription streaming services.
A U.K. study showed that, during the lockdown, adults averaged spending 40% of their waking hours in front of a screen. After a long binge-watch, folks often forget what happened in the episodes or even the name of the program they viewed. When someone finds himself in this situation and can’t remember very much about what he actually watched, he feels as though he has wasted his own time and might become dysphoric and depressed. This type of viewer feels disconnected and forgets what he watched because he is experiencing passive enjoyment, rather than actively relating to the world.
So should television binge-watching give people feelings of guilt?
Fortunately, there are some positive factors about spending excessive time engrossed in these screens during a pandemic; some people use television viewing as a coping mechanism to deal with the reality and the fear of the coronavirus. Some beneficial aspects of television watching include:
- Escaping from the reality and stress of the pandemic in an emotionally safe, isolated cocoon.
- Experiencing safety from contracting COVID-19 by sheltering in place, isolating, and physical distancing from other people in the outside world.
- Experiencing a subdued, private, and mentally relaxing environment.
- Being productive and multitasking while watching television, for example, knit, sew, fold clothes, pay bills, write a letter, etc.
Despite many beneficial aspects of excessive television watching during the pandemic, we have to ask: Can too much television prove detrimental to our mental or physical well-being?
Associated mental, and physical problems
Cause and effect between excessive screen time and sleep disturbances is scientifically unproven, but there is an association between those factors.
Excessive screen time is associated with a sleep deficit, and a proper amount of sleep is necessary for optimal brain function, a healthy immune system, good memory, and overall well-being. Sleep cleans out the short-term memory stage from the information learned that day to make room for new memories. This allows us to store memories every day. An inadequate amount of sleep causes memory problems and cognitive deficits because we are not storing as many memories from days when we are sleep deprived. A good night’s sleep will prevent stress from one day to be carried over to the next day.
Lack of sleep affects people differently, but in some cases, a shortage of sleep can cause feelings of depression and isolation. Television, computer, and phone screens convey excessive damaging LED and blue light, detrimentally affecting our melatonin production and circadian rhythm. Blue light has wavelengths between 380 nm and 500 nm, and although blue wavelengths are beneficial in the day and increase positive mental mood, attention, and reaction times, blue wavelengths are destructive at night. Blue-light exposure suppresses the secretion of melatonin, which, as we know, is a hormone that influences circadian rhythms. The negative disruption of circadian rhythm throws the body’s biological clock in disarray and makes it more difficult for the mind to shut down at night.
Unfortunately, electronics with LED screens increase the amount of exposure to these blue wavelengths. In addition, the U.S. National Toxicology Program has suggested that a link exists between blue-light exposure at night to diabetes, heart disease, cancer, and obesity (Sci Tot Environ. 2017 Dec 31;[607-8]:1073-84).
Advice for patients and clinicians
Time spent watching television and using the Internet should be done in moderation. Make sure that patients understand that they should not feel guilty about watching television during these periods of isolation.
Encourage patients to be selective in their television viewing and to research available programs on streaming services and TV – and limit their screen time only to programs that truly interest them. Discourage them from watching television endlessly, hour after hour. Also, discourage patients from watching too much news. Instead, tell them to limit news to 1 hour per day, because news they perceive as bad might increase their overall anxiety.
Tell patients to engage in physical exercise every day; walk or run outside if possible. When inside, advise them to get up and walk around at least once per hour. Other advice we would like to offer patients and clinicians alike are:
- Put yourself on a schedule and go to sleep the same time each night and try to get 8 hours of sleep in a 24-hour period.
- Put away your devices 1 hour before going to bed or at least use dark mode, and wear blue-block glasses, since they are easier on the eyes and brain. Do not use television to put yourself to sleep. Spending too much time reading news stories is not a good idea, either, because doing so is mentally stimulating and can cause more uncertainty – making it difficult to sleep.
- Protect your eye health by purchasing and installing light bulbs with more internal red coating than blue. These bulbs will produce a warmer tone than the blue, and warmer tones will be less likely to shift circadian rhythm and suppress melatonin, thus reducing blue-light exposure. Blink your eyes often, and use eye solution for dry eyes.
- Sleep in total darkness to reduce your exposure to blue light. Take supplements with lutein and zeaxanthin, which may reduce the oxidative effects of blue light.
Encouraging patients to follow these guidelines – and adhering to them ourselves – should help us emerge from the COVID-19 pandemic mentally and physically healthy.
Dr. Cohen is board certified in psychiatry and has had a private practice in Philadelphia for more than 35 years. His areas of specialty include sports psychiatry, agoraphobia, depression, and substance abuse. In addition, Dr. Cohen is a former professor of psychiatry, family medicine, and otolaryngology at Thomas Jefferson University, Philadelphia. He has no conflicts of interest.
Ms. Cohen holds an MBA from Temple University, Philadelphia, with a focus on health care administration. Previously, Ms. Cohen was an associate administrator at Hahnemann University Hospital and an executive at the Health Services Council, both in Philadelphia. She currently writes biographical summaries of notable 18th- and 19th-century women. Ms. Cohen has no conflicts of interest.
During the ongoing COVID-19 pandemic, many people are spending endless hours at home looking at computer, phone, and television screens. Our population has turned to Internet use and television watching as a coping mechanism to deal with their isolation, boredom, stress, and fear of the virus. Indeed, some people have become addicted to watching television and binge-watching entire series in a single sitting on subscription streaming services.
A U.K. study showed that, during the lockdown, adults averaged spending 40% of their waking hours in front of a screen. After a long binge-watch, folks often forget what happened in the episodes or even the name of the program they viewed. When someone finds himself in this situation and can’t remember very much about what he actually watched, he feels as though he has wasted his own time and might become dysphoric and depressed. This type of viewer feels disconnected and forgets what he watched because he is experiencing passive enjoyment, rather than actively relating to the world.
So should television binge-watching give people feelings of guilt?
Fortunately, there are some positive factors about spending excessive time engrossed in these screens during a pandemic; some people use television viewing as a coping mechanism to deal with the reality and the fear of the coronavirus. Some beneficial aspects of television watching include:
- Escaping from the reality and stress of the pandemic in an emotionally safe, isolated cocoon.
- Experiencing safety from contracting COVID-19 by sheltering in place, isolating, and physical distancing from other people in the outside world.
- Experiencing a subdued, private, and mentally relaxing environment.
- Being productive and multitasking while watching television, for example, knit, sew, fold clothes, pay bills, write a letter, etc.
Despite many beneficial aspects of excessive television watching during the pandemic, we have to ask: Can too much television prove detrimental to our mental or physical well-being?
Associated mental, and physical problems
Cause and effect between excessive screen time and sleep disturbances is scientifically unproven, but there is an association between those factors.
Excessive screen time is associated with a sleep deficit, and a proper amount of sleep is necessary for optimal brain function, a healthy immune system, good memory, and overall well-being. Sleep cleans out the short-term memory stage from the information learned that day to make room for new memories. This allows us to store memories every day. An inadequate amount of sleep causes memory problems and cognitive deficits because we are not storing as many memories from days when we are sleep deprived. A good night’s sleep will prevent stress from one day to be carried over to the next day.
Lack of sleep affects people differently, but in some cases, a shortage of sleep can cause feelings of depression and isolation. Television, computer, and phone screens convey excessive damaging LED and blue light, detrimentally affecting our melatonin production and circadian rhythm. Blue light has wavelengths between 380 nm and 500 nm, and although blue wavelengths are beneficial in the day and increase positive mental mood, attention, and reaction times, blue wavelengths are destructive at night. Blue-light exposure suppresses the secretion of melatonin, which, as we know, is a hormone that influences circadian rhythms. The negative disruption of circadian rhythm throws the body’s biological clock in disarray and makes it more difficult for the mind to shut down at night.
Unfortunately, electronics with LED screens increase the amount of exposure to these blue wavelengths. In addition, the U.S. National Toxicology Program has suggested that a link exists between blue-light exposure at night to diabetes, heart disease, cancer, and obesity (Sci Tot Environ. 2017 Dec 31;[607-8]:1073-84).
Advice for patients and clinicians
Time spent watching television and using the Internet should be done in moderation. Make sure that patients understand that they should not feel guilty about watching television during these periods of isolation.
Encourage patients to be selective in their television viewing and to research available programs on streaming services and TV – and limit their screen time only to programs that truly interest them. Discourage them from watching television endlessly, hour after hour. Also, discourage patients from watching too much news. Instead, tell them to limit news to 1 hour per day, because news they perceive as bad might increase their overall anxiety.
Tell patients to engage in physical exercise every day; walk or run outside if possible. When inside, advise them to get up and walk around at least once per hour. Other advice we would like to offer patients and clinicians alike are:
- Put yourself on a schedule and go to sleep the same time each night and try to get 8 hours of sleep in a 24-hour period.
- Put away your devices 1 hour before going to bed or at least use dark mode, and wear blue-block glasses, since they are easier on the eyes and brain. Do not use television to put yourself to sleep. Spending too much time reading news stories is not a good idea, either, because doing so is mentally stimulating and can cause more uncertainty – making it difficult to sleep.
- Protect your eye health by purchasing and installing light bulbs with more internal red coating than blue. These bulbs will produce a warmer tone than the blue, and warmer tones will be less likely to shift circadian rhythm and suppress melatonin, thus reducing blue-light exposure. Blink your eyes often, and use eye solution for dry eyes.
- Sleep in total darkness to reduce your exposure to blue light. Take supplements with lutein and zeaxanthin, which may reduce the oxidative effects of blue light.
Encouraging patients to follow these guidelines – and adhering to them ourselves – should help us emerge from the COVID-19 pandemic mentally and physically healthy.
Dr. Cohen is board certified in psychiatry and has had a private practice in Philadelphia for more than 35 years. His areas of specialty include sports psychiatry, agoraphobia, depression, and substance abuse. In addition, Dr. Cohen is a former professor of psychiatry, family medicine, and otolaryngology at Thomas Jefferson University, Philadelphia. He has no conflicts of interest.
Ms. Cohen holds an MBA from Temple University, Philadelphia, with a focus on health care administration. Previously, Ms. Cohen was an associate administrator at Hahnemann University Hospital and an executive at the Health Services Council, both in Philadelphia. She currently writes biographical summaries of notable 18th- and 19th-century women. Ms. Cohen has no conflicts of interest.
During the ongoing COVID-19 pandemic, many people are spending endless hours at home looking at computer, phone, and television screens. Our population has turned to Internet use and television watching as a coping mechanism to deal with their isolation, boredom, stress, and fear of the virus. Indeed, some people have become addicted to watching television and binge-watching entire series in a single sitting on subscription streaming services.
A U.K. study showed that, during the lockdown, adults averaged spending 40% of their waking hours in front of a screen. After a long binge-watch, folks often forget what happened in the episodes or even the name of the program they viewed. When someone finds himself in this situation and can’t remember very much about what he actually watched, he feels as though he has wasted his own time and might become dysphoric and depressed. This type of viewer feels disconnected and forgets what he watched because he is experiencing passive enjoyment, rather than actively relating to the world.
So should television binge-watching give people feelings of guilt?
Fortunately, there are some positive factors about spending excessive time engrossed in these screens during a pandemic; some people use television viewing as a coping mechanism to deal with the reality and the fear of the coronavirus. Some beneficial aspects of television watching include:
- Escaping from the reality and stress of the pandemic in an emotionally safe, isolated cocoon.
- Experiencing safety from contracting COVID-19 by sheltering in place, isolating, and physical distancing from other people in the outside world.
- Experiencing a subdued, private, and mentally relaxing environment.
- Being productive and multitasking while watching television, for example, knit, sew, fold clothes, pay bills, write a letter, etc.
Despite many beneficial aspects of excessive television watching during the pandemic, we have to ask: Can too much television prove detrimental to our mental or physical well-being?
Associated mental, and physical problems
Cause and effect between excessive screen time and sleep disturbances is scientifically unproven, but there is an association between those factors.
Excessive screen time is associated with a sleep deficit, and a proper amount of sleep is necessary for optimal brain function, a healthy immune system, good memory, and overall well-being. Sleep cleans out the short-term memory stage from the information learned that day to make room for new memories. This allows us to store memories every day. An inadequate amount of sleep causes memory problems and cognitive deficits because we are not storing as many memories from days when we are sleep deprived. A good night’s sleep will prevent stress from one day to be carried over to the next day.
Lack of sleep affects people differently, but in some cases, a shortage of sleep can cause feelings of depression and isolation. Television, computer, and phone screens convey excessive damaging LED and blue light, detrimentally affecting our melatonin production and circadian rhythm. Blue light has wavelengths between 380 nm and 500 nm, and although blue wavelengths are beneficial in the day and increase positive mental mood, attention, and reaction times, blue wavelengths are destructive at night. Blue-light exposure suppresses the secretion of melatonin, which, as we know, is a hormone that influences circadian rhythms. The negative disruption of circadian rhythm throws the body’s biological clock in disarray and makes it more difficult for the mind to shut down at night.
Unfortunately, electronics with LED screens increase the amount of exposure to these blue wavelengths. In addition, the U.S. National Toxicology Program has suggested that a link exists between blue-light exposure at night to diabetes, heart disease, cancer, and obesity (Sci Tot Environ. 2017 Dec 31;[607-8]:1073-84).
Advice for patients and clinicians
Time spent watching television and using the Internet should be done in moderation. Make sure that patients understand that they should not feel guilty about watching television during these periods of isolation.
Encourage patients to be selective in their television viewing and to research available programs on streaming services and TV – and limit their screen time only to programs that truly interest them. Discourage them from watching television endlessly, hour after hour. Also, discourage patients from watching too much news. Instead, tell them to limit news to 1 hour per day, because news they perceive as bad might increase their overall anxiety.
Tell patients to engage in physical exercise every day; walk or run outside if possible. When inside, advise them to get up and walk around at least once per hour. Other advice we would like to offer patients and clinicians alike are:
- Put yourself on a schedule and go to sleep the same time each night and try to get 8 hours of sleep in a 24-hour period.
- Put away your devices 1 hour before going to bed or at least use dark mode, and wear blue-block glasses, since they are easier on the eyes and brain. Do not use television to put yourself to sleep. Spending too much time reading news stories is not a good idea, either, because doing so is mentally stimulating and can cause more uncertainty – making it difficult to sleep.
- Protect your eye health by purchasing and installing light bulbs with more internal red coating than blue. These bulbs will produce a warmer tone than the blue, and warmer tones will be less likely to shift circadian rhythm and suppress melatonin, thus reducing blue-light exposure. Blink your eyes often, and use eye solution for dry eyes.
- Sleep in total darkness to reduce your exposure to blue light. Take supplements with lutein and zeaxanthin, which may reduce the oxidative effects of blue light.
Encouraging patients to follow these guidelines – and adhering to them ourselves – should help us emerge from the COVID-19 pandemic mentally and physically healthy.
Dr. Cohen is board certified in psychiatry and has had a private practice in Philadelphia for more than 35 years. His areas of specialty include sports psychiatry, agoraphobia, depression, and substance abuse. In addition, Dr. Cohen is a former professor of psychiatry, family medicine, and otolaryngology at Thomas Jefferson University, Philadelphia. He has no conflicts of interest.
Ms. Cohen holds an MBA from Temple University, Philadelphia, with a focus on health care administration. Previously, Ms. Cohen was an associate administrator at Hahnemann University Hospital and an executive at the Health Services Council, both in Philadelphia. She currently writes biographical summaries of notable 18th- and 19th-century women. Ms. Cohen has no conflicts of interest.
Repeated ketamine infusions linked to rapid relief of PTSD
Repeated intravenous infusions of ketamine provide rapid relief for patients with posttraumatic stress disorder, new research suggests.
In what investigators are calling the first randomized controlled trial of repeated ketamine administration for chronic PTSD, 30 patients received six infusions of ketamine or midazolam (used as a psychoactive placebo) over 2 consecutive weeks.
Between baseline and week 2, those receiving ketamine showed significantly greater improvement than those receiving midazolam. Total scores on the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) for the first group were almost 12 points lower than the latter group at week 2, meeting the study’s primary outcome measure.
In addition, 67% vs. 20% of the patients, respectively, were considered to be treatment responders; time to loss of response for those in the ketamine group was 28 days.
Although the overall findings were as expected, “what was surprising was how robust the results were,” lead author Adriana Feder, MD, associate professor of psychiatry, Icahn School of Medicine, Mount Sinai, New York, told this news organization.
It was also a bit surprising that, in a study of just 30 participants, “we were able to show such a clear difference” between the two treatment groups, said Dr. Feder, who is also a coinventor on issued patents for the use of ketamine as therapy for PTSD, and codirector of the Ehrenkranz Lab for the Study of Human Resilience at Mount Sinai.
The findings were published online Jan. 5 in the American Journal of Psychiatry.
Unmet need
Ketamine is a glutamate N-methyl-D-aspartate (NMDA) receptor antagonist that was first approved by the U.S. Food and Drug Administration for anesthetic use in 1970. It has also been shown to be effective for treatment-resistant depression.
PTSD has a lifetime prevalence of about 6% in the United States. “While trauma-focused psychotherapies have the most empirical support, they are limited by significant rates of nonresponse, partial response, and treatment dropout,” the investigators write. Also, there are “few available pharmacotherapies for PTSD, and their efficacy is insufficient,” they add.
“There’s a real need for new treatment interventions that are effective for PTSD and also work rapidly, because it can take weeks to months for currently available treatments to work for PTSD,” Dr. Feder said.
The researchers previously conducted a “proof-of-concept” randomized controlled trial of single infusions of ketamine for chronic PTSD. Results published in 2014 in JAMA Psychiatry showed significant reduction in PTSD symptoms 24 hours after infusion.
For the current study, the investigative team wanted to assess whether ketamine was viable as a longer-term treatment.
“We were encouraged by our initial promising findings” of the earlier trial, Dr. Feder said. “We wanted to do the second study to see if ketamine really works for PTSD, to see if we could replicate the rapid improvement and also examine whether a course of six infusions over 2 weeks could maintain the improvement.”
Thirty patients (aged 18-70; mean age, 39 years) with chronic PTSD from civilian or military trauma were enrolled (mean PTSD duration, 15 years).
The most cited primary trauma was sexual assault or molestation (n = 13), followed by physical assault or abuse (n = 8), witnessing a violent assault or death (n = 4), witnessing the 9/11 attacks (n = 3), and combat exposure (n = 2).
During the 2-week treatment phase, half of the patients were randomly assigned to receive six infusions of ketamine hydrochloride at a dose of 0.5 mg/kg (86.7% women; mean CAPS-5 score, 42), while the other half received six infusions of midazolam at a dose of 0.045 mg/kg (66.7% women; mean CAPS-5 score, 40).
In addition to the primary outcome measure of 2-week changes on the CAPS-5, secondary outcomes included score changes on the Montgomery-Åsberg Depression Rating Scale (MADRS) and the Impact of Event Scale-Revised (IES-R).
Treatment response was defined as a 30% or more improvement in symptoms on the CAPS-5. A number of measures were also used to assess potential treatment-related adverse events (AEs).
Safe, effective
Results showed significantly lower total CAPS-5 scores for the ketamine group vs. the midazolam group at week 1 (score difference, 8.8 points; P = .03) and at week 2 (score difference, 11.88 points; P = .004).
Those receiving ketamine also showed improvements in three of the four PTSD symptom clusters on the CAPS-5: avoidance (P < .0001), negative mood and cognitions (P = .02), and intrusions (P = .03). The fourth symptom cluster – arousal and reactivity – did not show a significant improvement.
In addition, the ketamine group showed significantly greater improvement scores on the MADRS at both week 1 and week 2.
Treatment response at 2 weeks was achieved by 10 members of the ketamine group and by three members of the midazolam group (P = .03).
Secondary analyses showed rapid improvement in the treatment responders within the ketamine group, with a mean change of 26 points on the total IES-R score between baseline and 24 hours after their first infusion, and a mean change of 13.4 points on the MADRS total past-24-hour score, a 53% improvement on average.
“A response at 2 weeks is very rapid but they got better sometimes within the first day,” Dr. Feder noted.
There were no serious AEs reported. Although some dissociative symptoms occurred during ketamine infusions, with the highest levels reported at the end of the infusion, these symptoms had resolved by the next assessment, conducted 2 hours after infusion.
The most frequently reported AE in the ketamine group, compared with midazolam, after the start of infusions was blurred vision (53% vs. 0%), followed by dizziness (33% vs. 13%), fatigue (33% vs. 87%), headache (27% vs. 13%), and nausea or vomiting (20% vs. 7%).
‘Large-magnitude improvement’
The overall findings show that, in this patient population, “repeated intravenous ketamine infusions administered over 2 weeks were associated with a large-magnitude, clinically significant improvement in PTSD symptoms,” the investigators write.
The results “were very satisfying,” added Dr. Feder. “It was heartening also to hear what some of the participants would say. Some told us about how their symptoms and feelings had changed during the course of treatment with ketamine, where they felt stronger and better able to cope with their trauma and memories.”
She noted, however, that this was not a study designed to specifically assess ketamine in treatment-resistant PTSD. “Some patients had had multiple treatments before that hadn’t worked, while others had not received treatment before. Efficacy for treatment-resistant PTSD is an important question for future research,” Dr. Feder said.
Other areas worth future exploration include treatment efficacy in patients with different types of trauma and whether outcomes can last longer in patients receiving ketamine plus psychotherapy treatment, she noted.
“I don’t want to ignore the fact that currently available treatments work for a number of people with chronic PTSD. But because there are many more for whom [the treatments] don’t work, or they’re insufficiently helped by those treatments, this is certainly one potentially very promising approach that can be added” to a clinician’s toolbox, Dr. Feder said.
Speaks to clinical utility
Commenting for this news organization, Gerard Sanacora, MD, PhD, professor of psychiatry at Yale University, New Haven, Connecticut, called this a “very solid and well-designed” study.
“It definitely builds on what’s been found in the past, but it’s a critical piece of information speaking to the clinical utility of this treatment for PTSD,” said Dr. Sanacora, who is also director of the Yale Depression Research Program and was not involved with the current research.
He agreed with the investigators that PTSD has long been a condition that is difficult to treat.
“It’s an area that has a great unmet need for treatment options. Beyond that, as ketamine is becoming more widely used, there’s increasing demand for off-label uses. This [study] actually provides some evidence that there may be efficacy there,” Dr. Sanacora said.
Although he cautioned that this was a small study, and thus further research with a larger patient population will be needed, it provides a compelling foundation to build upon.
“This study provides clear evidence to support a larger study to really give a definitive statement on the efficacy and safety of its use for PTSD. I don’t think this is the study that provides that definitive evidence, but it is a very strong indication, and it very strongly supports the initiation of a large study to address that,” said Dr. Sanacora.
He noted that, although he’s used the term “cautious optimism” for studies in the past, he has “real optimism” that ketamine will be effective for PTSD based on the results of this current study.
“We still need some more data to really convince us of that before we can say with any clear statement that it is effective and safe, but I’m very optimistic,” Dr. Sanacora concluded.
The study was funded by the Brain and Behavior Research Foundation, Mount Sinai Innovation Partners and the Mount Sinai i3 Accelerator, Gerald and Glenda Greenwald, and the Ehrenkranz Laboratory for Human Resilience. Dr. Feder is a coinventor on issued patents for the use of ketamine as therapy for PTSD. A list of all disclosures for the other study authors are listed in the original article.
A version of this article first appeared on Medscape.com.
Repeated intravenous infusions of ketamine provide rapid relief for patients with posttraumatic stress disorder, new research suggests.
In what investigators are calling the first randomized controlled trial of repeated ketamine administration for chronic PTSD, 30 patients received six infusions of ketamine or midazolam (used as a psychoactive placebo) over 2 consecutive weeks.
Between baseline and week 2, those receiving ketamine showed significantly greater improvement than those receiving midazolam. Total scores on the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) for the first group were almost 12 points lower than the latter group at week 2, meeting the study’s primary outcome measure.
In addition, 67% vs. 20% of the patients, respectively, were considered to be treatment responders; time to loss of response for those in the ketamine group was 28 days.
Although the overall findings were as expected, “what was surprising was how robust the results were,” lead author Adriana Feder, MD, associate professor of psychiatry, Icahn School of Medicine, Mount Sinai, New York, told this news organization.
It was also a bit surprising that, in a study of just 30 participants, “we were able to show such a clear difference” between the two treatment groups, said Dr. Feder, who is also a coinventor on issued patents for the use of ketamine as therapy for PTSD, and codirector of the Ehrenkranz Lab for the Study of Human Resilience at Mount Sinai.
The findings were published online Jan. 5 in the American Journal of Psychiatry.
Unmet need
Ketamine is a glutamate N-methyl-D-aspartate (NMDA) receptor antagonist that was first approved by the U.S. Food and Drug Administration for anesthetic use in 1970. It has also been shown to be effective for treatment-resistant depression.
PTSD has a lifetime prevalence of about 6% in the United States. “While trauma-focused psychotherapies have the most empirical support, they are limited by significant rates of nonresponse, partial response, and treatment dropout,” the investigators write. Also, there are “few available pharmacotherapies for PTSD, and their efficacy is insufficient,” they add.
“There’s a real need for new treatment interventions that are effective for PTSD and also work rapidly, because it can take weeks to months for currently available treatments to work for PTSD,” Dr. Feder said.
The researchers previously conducted a “proof-of-concept” randomized controlled trial of single infusions of ketamine for chronic PTSD. Results published in 2014 in JAMA Psychiatry showed significant reduction in PTSD symptoms 24 hours after infusion.
For the current study, the investigative team wanted to assess whether ketamine was viable as a longer-term treatment.
“We were encouraged by our initial promising findings” of the earlier trial, Dr. Feder said. “We wanted to do the second study to see if ketamine really works for PTSD, to see if we could replicate the rapid improvement and also examine whether a course of six infusions over 2 weeks could maintain the improvement.”
Thirty patients (aged 18-70; mean age, 39 years) with chronic PTSD from civilian or military trauma were enrolled (mean PTSD duration, 15 years).
The most cited primary trauma was sexual assault or molestation (n = 13), followed by physical assault or abuse (n = 8), witnessing a violent assault or death (n = 4), witnessing the 9/11 attacks (n = 3), and combat exposure (n = 2).
During the 2-week treatment phase, half of the patients were randomly assigned to receive six infusions of ketamine hydrochloride at a dose of 0.5 mg/kg (86.7% women; mean CAPS-5 score, 42), while the other half received six infusions of midazolam at a dose of 0.045 mg/kg (66.7% women; mean CAPS-5 score, 40).
In addition to the primary outcome measure of 2-week changes on the CAPS-5, secondary outcomes included score changes on the Montgomery-Åsberg Depression Rating Scale (MADRS) and the Impact of Event Scale-Revised (IES-R).
Treatment response was defined as a 30% or more improvement in symptoms on the CAPS-5. A number of measures were also used to assess potential treatment-related adverse events (AEs).
Safe, effective
Results showed significantly lower total CAPS-5 scores for the ketamine group vs. the midazolam group at week 1 (score difference, 8.8 points; P = .03) and at week 2 (score difference, 11.88 points; P = .004).
Those receiving ketamine also showed improvements in three of the four PTSD symptom clusters on the CAPS-5: avoidance (P < .0001), negative mood and cognitions (P = .02), and intrusions (P = .03). The fourth symptom cluster – arousal and reactivity – did not show a significant improvement.
In addition, the ketamine group showed significantly greater improvement scores on the MADRS at both week 1 and week 2.
Treatment response at 2 weeks was achieved by 10 members of the ketamine group and by three members of the midazolam group (P = .03).
Secondary analyses showed rapid improvement in the treatment responders within the ketamine group, with a mean change of 26 points on the total IES-R score between baseline and 24 hours after their first infusion, and a mean change of 13.4 points on the MADRS total past-24-hour score, a 53% improvement on average.
“A response at 2 weeks is very rapid but they got better sometimes within the first day,” Dr. Feder noted.
There were no serious AEs reported. Although some dissociative symptoms occurred during ketamine infusions, with the highest levels reported at the end of the infusion, these symptoms had resolved by the next assessment, conducted 2 hours after infusion.
The most frequently reported AE in the ketamine group, compared with midazolam, after the start of infusions was blurred vision (53% vs. 0%), followed by dizziness (33% vs. 13%), fatigue (33% vs. 87%), headache (27% vs. 13%), and nausea or vomiting (20% vs. 7%).
‘Large-magnitude improvement’
The overall findings show that, in this patient population, “repeated intravenous ketamine infusions administered over 2 weeks were associated with a large-magnitude, clinically significant improvement in PTSD symptoms,” the investigators write.
The results “were very satisfying,” added Dr. Feder. “It was heartening also to hear what some of the participants would say. Some told us about how their symptoms and feelings had changed during the course of treatment with ketamine, where they felt stronger and better able to cope with their trauma and memories.”
She noted, however, that this was not a study designed to specifically assess ketamine in treatment-resistant PTSD. “Some patients had had multiple treatments before that hadn’t worked, while others had not received treatment before. Efficacy for treatment-resistant PTSD is an important question for future research,” Dr. Feder said.
Other areas worth future exploration include treatment efficacy in patients with different types of trauma and whether outcomes can last longer in patients receiving ketamine plus psychotherapy treatment, she noted.
“I don’t want to ignore the fact that currently available treatments work for a number of people with chronic PTSD. But because there are many more for whom [the treatments] don’t work, or they’re insufficiently helped by those treatments, this is certainly one potentially very promising approach that can be added” to a clinician’s toolbox, Dr. Feder said.
Speaks to clinical utility
Commenting for this news organization, Gerard Sanacora, MD, PhD, professor of psychiatry at Yale University, New Haven, Connecticut, called this a “very solid and well-designed” study.
“It definitely builds on what’s been found in the past, but it’s a critical piece of information speaking to the clinical utility of this treatment for PTSD,” said Dr. Sanacora, who is also director of the Yale Depression Research Program and was not involved with the current research.
He agreed with the investigators that PTSD has long been a condition that is difficult to treat.
“It’s an area that has a great unmet need for treatment options. Beyond that, as ketamine is becoming more widely used, there’s increasing demand for off-label uses. This [study] actually provides some evidence that there may be efficacy there,” Dr. Sanacora said.
Although he cautioned that this was a small study, and thus further research with a larger patient population will be needed, it provides a compelling foundation to build upon.
“This study provides clear evidence to support a larger study to really give a definitive statement on the efficacy and safety of its use for PTSD. I don’t think this is the study that provides that definitive evidence, but it is a very strong indication, and it very strongly supports the initiation of a large study to address that,” said Dr. Sanacora.
He noted that, although he’s used the term “cautious optimism” for studies in the past, he has “real optimism” that ketamine will be effective for PTSD based on the results of this current study.
“We still need some more data to really convince us of that before we can say with any clear statement that it is effective and safe, but I’m very optimistic,” Dr. Sanacora concluded.
The study was funded by the Brain and Behavior Research Foundation, Mount Sinai Innovation Partners and the Mount Sinai i3 Accelerator, Gerald and Glenda Greenwald, and the Ehrenkranz Laboratory for Human Resilience. Dr. Feder is a coinventor on issued patents for the use of ketamine as therapy for PTSD. A list of all disclosures for the other study authors are listed in the original article.
A version of this article first appeared on Medscape.com.
Repeated intravenous infusions of ketamine provide rapid relief for patients with posttraumatic stress disorder, new research suggests.
In what investigators are calling the first randomized controlled trial of repeated ketamine administration for chronic PTSD, 30 patients received six infusions of ketamine or midazolam (used as a psychoactive placebo) over 2 consecutive weeks.
Between baseline and week 2, those receiving ketamine showed significantly greater improvement than those receiving midazolam. Total scores on the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) for the first group were almost 12 points lower than the latter group at week 2, meeting the study’s primary outcome measure.
In addition, 67% vs. 20% of the patients, respectively, were considered to be treatment responders; time to loss of response for those in the ketamine group was 28 days.
Although the overall findings were as expected, “what was surprising was how robust the results were,” lead author Adriana Feder, MD, associate professor of psychiatry, Icahn School of Medicine, Mount Sinai, New York, told this news organization.
It was also a bit surprising that, in a study of just 30 participants, “we were able to show such a clear difference” between the two treatment groups, said Dr. Feder, who is also a coinventor on issued patents for the use of ketamine as therapy for PTSD, and codirector of the Ehrenkranz Lab for the Study of Human Resilience at Mount Sinai.
The findings were published online Jan. 5 in the American Journal of Psychiatry.
Unmet need
Ketamine is a glutamate N-methyl-D-aspartate (NMDA) receptor antagonist that was first approved by the U.S. Food and Drug Administration for anesthetic use in 1970. It has also been shown to be effective for treatment-resistant depression.
PTSD has a lifetime prevalence of about 6% in the United States. “While trauma-focused psychotherapies have the most empirical support, they are limited by significant rates of nonresponse, partial response, and treatment dropout,” the investigators write. Also, there are “few available pharmacotherapies for PTSD, and their efficacy is insufficient,” they add.
“There’s a real need for new treatment interventions that are effective for PTSD and also work rapidly, because it can take weeks to months for currently available treatments to work for PTSD,” Dr. Feder said.
The researchers previously conducted a “proof-of-concept” randomized controlled trial of single infusions of ketamine for chronic PTSD. Results published in 2014 in JAMA Psychiatry showed significant reduction in PTSD symptoms 24 hours after infusion.
For the current study, the investigative team wanted to assess whether ketamine was viable as a longer-term treatment.
“We were encouraged by our initial promising findings” of the earlier trial, Dr. Feder said. “We wanted to do the second study to see if ketamine really works for PTSD, to see if we could replicate the rapid improvement and also examine whether a course of six infusions over 2 weeks could maintain the improvement.”
Thirty patients (aged 18-70; mean age, 39 years) with chronic PTSD from civilian or military trauma were enrolled (mean PTSD duration, 15 years).
The most cited primary trauma was sexual assault or molestation (n = 13), followed by physical assault or abuse (n = 8), witnessing a violent assault or death (n = 4), witnessing the 9/11 attacks (n = 3), and combat exposure (n = 2).
During the 2-week treatment phase, half of the patients were randomly assigned to receive six infusions of ketamine hydrochloride at a dose of 0.5 mg/kg (86.7% women; mean CAPS-5 score, 42), while the other half received six infusions of midazolam at a dose of 0.045 mg/kg (66.7% women; mean CAPS-5 score, 40).
In addition to the primary outcome measure of 2-week changes on the CAPS-5, secondary outcomes included score changes on the Montgomery-Åsberg Depression Rating Scale (MADRS) and the Impact of Event Scale-Revised (IES-R).
Treatment response was defined as a 30% or more improvement in symptoms on the CAPS-5. A number of measures were also used to assess potential treatment-related adverse events (AEs).
Safe, effective
Results showed significantly lower total CAPS-5 scores for the ketamine group vs. the midazolam group at week 1 (score difference, 8.8 points; P = .03) and at week 2 (score difference, 11.88 points; P = .004).
Those receiving ketamine also showed improvements in three of the four PTSD symptom clusters on the CAPS-5: avoidance (P < .0001), negative mood and cognitions (P = .02), and intrusions (P = .03). The fourth symptom cluster – arousal and reactivity – did not show a significant improvement.
In addition, the ketamine group showed significantly greater improvement scores on the MADRS at both week 1 and week 2.
Treatment response at 2 weeks was achieved by 10 members of the ketamine group and by three members of the midazolam group (P = .03).
Secondary analyses showed rapid improvement in the treatment responders within the ketamine group, with a mean change of 26 points on the total IES-R score between baseline and 24 hours after their first infusion, and a mean change of 13.4 points on the MADRS total past-24-hour score, a 53% improvement on average.
“A response at 2 weeks is very rapid but they got better sometimes within the first day,” Dr. Feder noted.
There were no serious AEs reported. Although some dissociative symptoms occurred during ketamine infusions, with the highest levels reported at the end of the infusion, these symptoms had resolved by the next assessment, conducted 2 hours after infusion.
The most frequently reported AE in the ketamine group, compared with midazolam, after the start of infusions was blurred vision (53% vs. 0%), followed by dizziness (33% vs. 13%), fatigue (33% vs. 87%), headache (27% vs. 13%), and nausea or vomiting (20% vs. 7%).
‘Large-magnitude improvement’
The overall findings show that, in this patient population, “repeated intravenous ketamine infusions administered over 2 weeks were associated with a large-magnitude, clinically significant improvement in PTSD symptoms,” the investigators write.
The results “were very satisfying,” added Dr. Feder. “It was heartening also to hear what some of the participants would say. Some told us about how their symptoms and feelings had changed during the course of treatment with ketamine, where they felt stronger and better able to cope with their trauma and memories.”
She noted, however, that this was not a study designed to specifically assess ketamine in treatment-resistant PTSD. “Some patients had had multiple treatments before that hadn’t worked, while others had not received treatment before. Efficacy for treatment-resistant PTSD is an important question for future research,” Dr. Feder said.
Other areas worth future exploration include treatment efficacy in patients with different types of trauma and whether outcomes can last longer in patients receiving ketamine plus psychotherapy treatment, she noted.
“I don’t want to ignore the fact that currently available treatments work for a number of people with chronic PTSD. But because there are many more for whom [the treatments] don’t work, or they’re insufficiently helped by those treatments, this is certainly one potentially very promising approach that can be added” to a clinician’s toolbox, Dr. Feder said.
Speaks to clinical utility
Commenting for this news organization, Gerard Sanacora, MD, PhD, professor of psychiatry at Yale University, New Haven, Connecticut, called this a “very solid and well-designed” study.
“It definitely builds on what’s been found in the past, but it’s a critical piece of information speaking to the clinical utility of this treatment for PTSD,” said Dr. Sanacora, who is also director of the Yale Depression Research Program and was not involved with the current research.
He agreed with the investigators that PTSD has long been a condition that is difficult to treat.
“It’s an area that has a great unmet need for treatment options. Beyond that, as ketamine is becoming more widely used, there’s increasing demand for off-label uses. This [study] actually provides some evidence that there may be efficacy there,” Dr. Sanacora said.
Although he cautioned that this was a small study, and thus further research with a larger patient population will be needed, it provides a compelling foundation to build upon.
“This study provides clear evidence to support a larger study to really give a definitive statement on the efficacy and safety of its use for PTSD. I don’t think this is the study that provides that definitive evidence, but it is a very strong indication, and it very strongly supports the initiation of a large study to address that,” said Dr. Sanacora.
He noted that, although he’s used the term “cautious optimism” for studies in the past, he has “real optimism” that ketamine will be effective for PTSD based on the results of this current study.
“We still need some more data to really convince us of that before we can say with any clear statement that it is effective and safe, but I’m very optimistic,” Dr. Sanacora concluded.
The study was funded by the Brain and Behavior Research Foundation, Mount Sinai Innovation Partners and the Mount Sinai i3 Accelerator, Gerald and Glenda Greenwald, and the Ehrenkranz Laboratory for Human Resilience. Dr. Feder is a coinventor on issued patents for the use of ketamine as therapy for PTSD. A list of all disclosures for the other study authors are listed in the original article.
A version of this article first appeared on Medscape.com.
Give women's mental health a seat at the health care table
Why it’s time for women’s mental health to be recognized as the subspecialty it already is
It wasn’t until I (Dr. Leistikow) finished my psychiatry residency that I realized the training I had received in women’s mental health was unusual. It was simply a required experience for PGY-3 residents at Johns Hopkins University, Baltimore.
All of us, regardless of interest, spent 1 afternoon a week over 6 months caring for patients in a specialty psychiatric clinic for women (run by Dr. Payne and Dr. Osborne). We discussed cases and received didactics on such topics as risk factors for postpartum depression; the risks of untreated mental illness in pregnancy, compared with the risks of various psychiatric medications; how to choose and dose medications for bipolar disorder as blood levels change across pregnancy; which resources to consult to determine the amounts and risks of various medications passed on in breast milk; and how to diagnose and treat premenstrual dysphoric disorder, to name a few lecture subjects.
By the time we were done, all residents had received more than 20 hours of teaching about how to treat mental illness in women across the reproductive life cycle. This was 20 hours more than is currently required by the American College of Graduate Medical Education, the accrediting body for all residencies, including psychiatry.1 It is time for that to change.
Women’s need for psychiatric treatment that addresses reproductive transitions is not new; it is as old as time. Not only do women who previously needed psychiatric treatment continue to need treatment when they get pregnant or are breastfeeding, but it is now well recognized that times of reproductive transition or flux – whether premenstrual, post partum, or perimenopausal – confer increased risk for both new-onset and exacerbations of prior mental illnesses.
What has changed is psychiatry’s ability to finally meet that need. Previously, despite the fact that women make up the majority of patients presenting for treatment, that nearly all women will menstruate and go through menopause, and that more than 80% of American women will have at least one pregnancy during their lifetime,psychiatrists practice as if these reproductive transitions were unfortunate blips getting in the doctor’s way.2 We mostly threw up our hands when our patients became pregnant, reflexively stopped all medications, and expected women to suffer for the sake of their babies.
with a large and growing research base, with both agreed-upon best practices and evolving standards of care informed by and responsive to the scientific literature. We now know that untreated maternal psychiatric illness carries its own risks for infants both before and after delivery; that many maternal pharmacologic treatments are lower risk for infants than previously thought; that protecting and treating women’s mental health in pregnancy has benefits for women, their babies, and the families that depend on them; and that there is now a growing evidence base informing both new and older treatments and enabling women and their doctors to make complex decisions balancing risk and benefit across the life cycle.
Many psychiatrists-in-training are hungry for this knowledge. At last count, in the United States alone, there were 16 women’s mental health fellowships available, up from just 3 in 2008.3 The problem is that none of them are accredited or funded by the ACGME, because reproductive psychiatry (here used interchangeably with the term women’s mental health) has not been officially recognized as a subspecialty. This means that current funding frequently rests on philanthropy, which often cannot be sustained, and clinical billing, which gives fellows in some programs such heavy clinical responsibilities that little time is left for scholarly work. Lack of subspecialty status also blocks numerous important downstream effects that would flow from this recognition.
Reproductive psychiatry clearly already meets criteria laid out by the American Board of Medical Specialties for defining a subspecialty field. As argued elsewhere, it has a distinct patient population with definable care needs and a standalone body of scientific medical knowledge as well as a national (and international) community of experts that has already done much to improve women’s access to care they desperately need.4 It also meets the ACGME’s criteria for a new subspecialty except for approval by the American Board of Psychiatry and Neurology.5 Finally, it also meets the requirements of the ABPN except for having 25 fellowship programs with 50 fellowship positions and 50 trainees per year completing fellowships, a challenging Catch-22 without the necessary funding that would accrue from accreditation.6
Despite growing awareness and demand, there remains a shortage of psychiatrists trained to treat women during times of reproductive transition and to pass their recommendations and knowledge on to their primary care and ob.gyn. colleagues. What official recognition would bring, in addition to funding for fellowships post residency, is a guaranteed seat at the table in psychiatry residencies, in terms of a required number of hours devoted to these topics for trainees, ensuring that all graduating psychiatrists have at least some exposure to the knowledge and practices so material to their patients.
It isn’t enough to wait for residencies to see the writing on the wall and voluntarily carve out a slice of pie devoted to women’s mental health from the limited time and resources available to train residents. A 2017 survey of psychiatry residency program training directors found that 23%, or almost a quarter of programs that responded, offered no reproductive psychiatry training at all, that 49% required 5 hours or less across all 4 years of training, and that 75% of programs had no required clinical exposure to reproductive psychiatry patients.7 Despite the fact that 87% of training directors surveyed agreed either that reproductive psychiatry was “an important area of education” or a subject general residents should be competent in, ACGME-recognized specialties take precedence.
A system so patchy and insufficient won’t do. It’s not good enough for the trainees who frequently have to look outside of their own institutions for the training they know they need. It’s not good enough for the pregnant or postpartum patient looking for evidence-based advice, who is currently left on her own to determine, prior to booking an appointment, whether a specific psychiatrist has received any training relevant to treating her. Adding reproductive psychiatry to the topics a graduating psychiatrist must have some proficiency in also signals to recent graduates and experienced attendings, as well as the relevant examining boards and producers of continuing medical education content, that women’s mental health is no longer a fringe topic but rather foundational to all practicing psychiatrists.
The oil needed to prime this pump is official recognition of the subspecialty that reproductive psychiatry already is. The women’s mental health community is ready. The research base is well established and growing exponentially. The number of women’s mental health fellowships is healthy and would increase significantly with ACGME funding. Psychiatry residency training programs can turn to recent graduates of these fellowships as well as their own faculty with reproductive psychiatry experience to teach trainees. In addition, the National Curriculum in Reproductive Psychiatry, over the last 4 years, has created a repository of free online modules dedicated to facilitating this type of training, with case discussions across numerous topics for use by both educators and trainees. The American Psychiatric Association recently formed the Committee on Women’s Mental Health in 2020 and will be publishing a textbook based on work done by the NCRP within the coming year.
Imagine the changed world that would open to all psychiatrists if reproductive psychiatry were given the credentials it deserves. When writing prescriptions, we would view pregnancy as the potential outcome it is in any woman of reproductive age, given that 50% of pregnancies are unplanned, and let women know ahead of time how to think about possible fetal effects rather than waiting for their panicked phone messages or hearing that they have stopped their medications abruptly. We would work to identify our patient’s individual risk factors for postpartum depression predelivery to reduce that risk and prevent or limit illness. We would plan ahead for close follow-up post partum during the window of greatest risk, rather than expecting women to drop out of care while taking care of their infants or languish on scheduling waiting lists. We would feel confident in giving evidence-based advice to our patients around times of reproductive transition across the life cycle, but especially in pregnancy and lactation, empowering women to make healthy decisions for themselves and their families, no longer abandoning them just when they need us most.
References
1. ACGME Program Requirements for Graduate Medical Education in Psychiatry. Accreditation Counsel for Graduate Medical Education. 2020 Jul 1.
2. Livingston G. “They’re waiting longer, but U.S. women today more likely to have children than a decade ago.” Pew Research Center’s Social & Demographic Trends Project. pewsocialtrends.org. 2018 Jan 18.
3. Nagle-Yang S et al. Acad Psychiatry. 2018 Apr;42(2):202-6.
4. Payne JL. Int Rev Psychiatry. 2019 May;31(3):207-9.
5. Accreditation Council for Graduate Medical Education Policies and Procedures. 2020 Sep 26.
6. American Board of Psychiatry and Neurology. Requirements for Subspecialty Recognition, Attachment A. 2008.
7. Osborne LM et al. Acad Psychiatry. 2018 Apr;42(2):197-201.
Dr. Leistikow is a reproductive psychiatrist and clinical assistant professor in the department of psychiatry at the University of Maryland, Baltimore, where she sees patients and helps train residents and fellows. She is on the education committee of the National Curriculum in Reproductive Psychiatry (NCRPtraining.org) and has written about women’s mental health for textbooks, scientific journals and on her private practice blog at www.womenspsychiatrybaltimore.com. Dr. Leistikow has no conflicts of interest.
Dr. Payne is associate professor of psychiatry and behavioral sciences and director of the Women’s Mood Disorders Center at Johns Hopkins University, Baltimore. In addition to providing outstanding clinical care for women with mood disorders, she conducts research into the genetic, biological, and environmental factors involved in postpartum depression. She and her colleagues have recently identified two epigenetic biomarkers of postpartum depression and are working hard to replicate this work with National Institutes of Health funding. Most recently, she was appointed to the American Psychiatric Association’s committee on women’s mental health and is serving as president-elect for both the Marcé of North America and the International Marcé Perinatal Mental Health Societies. She disclosed the following relevant financial relationships: serve(d) as a director, officer, partner, employee, adviser, consultant, or trustee for Sage Therapeutics and Janssen Pharmaceuticals.
Dr. Osborne is associate professor of psychiatry and behavioral sciences and of gynecology and obstetrics at Johns Hopkins University, where she directs a postdoctoral fellowship program in reproductive psychiatry. She is an expert on the diagnosis and treatment of mood and anxiety disorders during pregnancy, the post partum, the premenstrual period, and perimenopause. Her work is supported by the Brain and Behavior Foundation, the Doris Duke Foundation, the American Board of Psychiatry and Neurology, and the National Institute of Mental Health. She has no conflicts of interest.
Why it’s time for women’s mental health to be recognized as the subspecialty it already is
Why it’s time for women’s mental health to be recognized as the subspecialty it already is
It wasn’t until I (Dr. Leistikow) finished my psychiatry residency that I realized the training I had received in women’s mental health was unusual. It was simply a required experience for PGY-3 residents at Johns Hopkins University, Baltimore.
All of us, regardless of interest, spent 1 afternoon a week over 6 months caring for patients in a specialty psychiatric clinic for women (run by Dr. Payne and Dr. Osborne). We discussed cases and received didactics on such topics as risk factors for postpartum depression; the risks of untreated mental illness in pregnancy, compared with the risks of various psychiatric medications; how to choose and dose medications for bipolar disorder as blood levels change across pregnancy; which resources to consult to determine the amounts and risks of various medications passed on in breast milk; and how to diagnose and treat premenstrual dysphoric disorder, to name a few lecture subjects.
By the time we were done, all residents had received more than 20 hours of teaching about how to treat mental illness in women across the reproductive life cycle. This was 20 hours more than is currently required by the American College of Graduate Medical Education, the accrediting body for all residencies, including psychiatry.1 It is time for that to change.
Women’s need for psychiatric treatment that addresses reproductive transitions is not new; it is as old as time. Not only do women who previously needed psychiatric treatment continue to need treatment when they get pregnant or are breastfeeding, but it is now well recognized that times of reproductive transition or flux – whether premenstrual, post partum, or perimenopausal – confer increased risk for both new-onset and exacerbations of prior mental illnesses.
What has changed is psychiatry’s ability to finally meet that need. Previously, despite the fact that women make up the majority of patients presenting for treatment, that nearly all women will menstruate and go through menopause, and that more than 80% of American women will have at least one pregnancy during their lifetime,psychiatrists practice as if these reproductive transitions were unfortunate blips getting in the doctor’s way.2 We mostly threw up our hands when our patients became pregnant, reflexively stopped all medications, and expected women to suffer for the sake of their babies.
with a large and growing research base, with both agreed-upon best practices and evolving standards of care informed by and responsive to the scientific literature. We now know that untreated maternal psychiatric illness carries its own risks for infants both before and after delivery; that many maternal pharmacologic treatments are lower risk for infants than previously thought; that protecting and treating women’s mental health in pregnancy has benefits for women, their babies, and the families that depend on them; and that there is now a growing evidence base informing both new and older treatments and enabling women and their doctors to make complex decisions balancing risk and benefit across the life cycle.
Many psychiatrists-in-training are hungry for this knowledge. At last count, in the United States alone, there were 16 women’s mental health fellowships available, up from just 3 in 2008.3 The problem is that none of them are accredited or funded by the ACGME, because reproductive psychiatry (here used interchangeably with the term women’s mental health) has not been officially recognized as a subspecialty. This means that current funding frequently rests on philanthropy, which often cannot be sustained, and clinical billing, which gives fellows in some programs such heavy clinical responsibilities that little time is left for scholarly work. Lack of subspecialty status also blocks numerous important downstream effects that would flow from this recognition.
Reproductive psychiatry clearly already meets criteria laid out by the American Board of Medical Specialties for defining a subspecialty field. As argued elsewhere, it has a distinct patient population with definable care needs and a standalone body of scientific medical knowledge as well as a national (and international) community of experts that has already done much to improve women’s access to care they desperately need.4 It also meets the ACGME’s criteria for a new subspecialty except for approval by the American Board of Psychiatry and Neurology.5 Finally, it also meets the requirements of the ABPN except for having 25 fellowship programs with 50 fellowship positions and 50 trainees per year completing fellowships, a challenging Catch-22 without the necessary funding that would accrue from accreditation.6
Despite growing awareness and demand, there remains a shortage of psychiatrists trained to treat women during times of reproductive transition and to pass their recommendations and knowledge on to their primary care and ob.gyn. colleagues. What official recognition would bring, in addition to funding for fellowships post residency, is a guaranteed seat at the table in psychiatry residencies, in terms of a required number of hours devoted to these topics for trainees, ensuring that all graduating psychiatrists have at least some exposure to the knowledge and practices so material to their patients.
It isn’t enough to wait for residencies to see the writing on the wall and voluntarily carve out a slice of pie devoted to women’s mental health from the limited time and resources available to train residents. A 2017 survey of psychiatry residency program training directors found that 23%, or almost a quarter of programs that responded, offered no reproductive psychiatry training at all, that 49% required 5 hours or less across all 4 years of training, and that 75% of programs had no required clinical exposure to reproductive psychiatry patients.7 Despite the fact that 87% of training directors surveyed agreed either that reproductive psychiatry was “an important area of education” or a subject general residents should be competent in, ACGME-recognized specialties take precedence.
A system so patchy and insufficient won’t do. It’s not good enough for the trainees who frequently have to look outside of their own institutions for the training they know they need. It’s not good enough for the pregnant or postpartum patient looking for evidence-based advice, who is currently left on her own to determine, prior to booking an appointment, whether a specific psychiatrist has received any training relevant to treating her. Adding reproductive psychiatry to the topics a graduating psychiatrist must have some proficiency in also signals to recent graduates and experienced attendings, as well as the relevant examining boards and producers of continuing medical education content, that women’s mental health is no longer a fringe topic but rather foundational to all practicing psychiatrists.
The oil needed to prime this pump is official recognition of the subspecialty that reproductive psychiatry already is. The women’s mental health community is ready. The research base is well established and growing exponentially. The number of women’s mental health fellowships is healthy and would increase significantly with ACGME funding. Psychiatry residency training programs can turn to recent graduates of these fellowships as well as their own faculty with reproductive psychiatry experience to teach trainees. In addition, the National Curriculum in Reproductive Psychiatry, over the last 4 years, has created a repository of free online modules dedicated to facilitating this type of training, with case discussions across numerous topics for use by both educators and trainees. The American Psychiatric Association recently formed the Committee on Women’s Mental Health in 2020 and will be publishing a textbook based on work done by the NCRP within the coming year.
Imagine the changed world that would open to all psychiatrists if reproductive psychiatry were given the credentials it deserves. When writing prescriptions, we would view pregnancy as the potential outcome it is in any woman of reproductive age, given that 50% of pregnancies are unplanned, and let women know ahead of time how to think about possible fetal effects rather than waiting for their panicked phone messages or hearing that they have stopped their medications abruptly. We would work to identify our patient’s individual risk factors for postpartum depression predelivery to reduce that risk and prevent or limit illness. We would plan ahead for close follow-up post partum during the window of greatest risk, rather than expecting women to drop out of care while taking care of their infants or languish on scheduling waiting lists. We would feel confident in giving evidence-based advice to our patients around times of reproductive transition across the life cycle, but especially in pregnancy and lactation, empowering women to make healthy decisions for themselves and their families, no longer abandoning them just when they need us most.
References
1. ACGME Program Requirements for Graduate Medical Education in Psychiatry. Accreditation Counsel for Graduate Medical Education. 2020 Jul 1.
2. Livingston G. “They’re waiting longer, but U.S. women today more likely to have children than a decade ago.” Pew Research Center’s Social & Demographic Trends Project. pewsocialtrends.org. 2018 Jan 18.
3. Nagle-Yang S et al. Acad Psychiatry. 2018 Apr;42(2):202-6.
4. Payne JL. Int Rev Psychiatry. 2019 May;31(3):207-9.
5. Accreditation Council for Graduate Medical Education Policies and Procedures. 2020 Sep 26.
6. American Board of Psychiatry and Neurology. Requirements for Subspecialty Recognition, Attachment A. 2008.
7. Osborne LM et al. Acad Psychiatry. 2018 Apr;42(2):197-201.
Dr. Leistikow is a reproductive psychiatrist and clinical assistant professor in the department of psychiatry at the University of Maryland, Baltimore, where she sees patients and helps train residents and fellows. She is on the education committee of the National Curriculum in Reproductive Psychiatry (NCRPtraining.org) and has written about women’s mental health for textbooks, scientific journals and on her private practice blog at www.womenspsychiatrybaltimore.com. Dr. Leistikow has no conflicts of interest.
Dr. Payne is associate professor of psychiatry and behavioral sciences and director of the Women’s Mood Disorders Center at Johns Hopkins University, Baltimore. In addition to providing outstanding clinical care for women with mood disorders, she conducts research into the genetic, biological, and environmental factors involved in postpartum depression. She and her colleagues have recently identified two epigenetic biomarkers of postpartum depression and are working hard to replicate this work with National Institutes of Health funding. Most recently, she was appointed to the American Psychiatric Association’s committee on women’s mental health and is serving as president-elect for both the Marcé of North America and the International Marcé Perinatal Mental Health Societies. She disclosed the following relevant financial relationships: serve(d) as a director, officer, partner, employee, adviser, consultant, or trustee for Sage Therapeutics and Janssen Pharmaceuticals.
Dr. Osborne is associate professor of psychiatry and behavioral sciences and of gynecology and obstetrics at Johns Hopkins University, where she directs a postdoctoral fellowship program in reproductive psychiatry. She is an expert on the diagnosis and treatment of mood and anxiety disorders during pregnancy, the post partum, the premenstrual period, and perimenopause. Her work is supported by the Brain and Behavior Foundation, the Doris Duke Foundation, the American Board of Psychiatry and Neurology, and the National Institute of Mental Health. She has no conflicts of interest.
It wasn’t until I (Dr. Leistikow) finished my psychiatry residency that I realized the training I had received in women’s mental health was unusual. It was simply a required experience for PGY-3 residents at Johns Hopkins University, Baltimore.
All of us, regardless of interest, spent 1 afternoon a week over 6 months caring for patients in a specialty psychiatric clinic for women (run by Dr. Payne and Dr. Osborne). We discussed cases and received didactics on such topics as risk factors for postpartum depression; the risks of untreated mental illness in pregnancy, compared with the risks of various psychiatric medications; how to choose and dose medications for bipolar disorder as blood levels change across pregnancy; which resources to consult to determine the amounts and risks of various medications passed on in breast milk; and how to diagnose and treat premenstrual dysphoric disorder, to name a few lecture subjects.
By the time we were done, all residents had received more than 20 hours of teaching about how to treat mental illness in women across the reproductive life cycle. This was 20 hours more than is currently required by the American College of Graduate Medical Education, the accrediting body for all residencies, including psychiatry.1 It is time for that to change.
Women’s need for psychiatric treatment that addresses reproductive transitions is not new; it is as old as time. Not only do women who previously needed psychiatric treatment continue to need treatment when they get pregnant or are breastfeeding, but it is now well recognized that times of reproductive transition or flux – whether premenstrual, post partum, or perimenopausal – confer increased risk for both new-onset and exacerbations of prior mental illnesses.
What has changed is psychiatry’s ability to finally meet that need. Previously, despite the fact that women make up the majority of patients presenting for treatment, that nearly all women will menstruate and go through menopause, and that more than 80% of American women will have at least one pregnancy during their lifetime,psychiatrists practice as if these reproductive transitions were unfortunate blips getting in the doctor’s way.2 We mostly threw up our hands when our patients became pregnant, reflexively stopped all medications, and expected women to suffer for the sake of their babies.
with a large and growing research base, with both agreed-upon best practices and evolving standards of care informed by and responsive to the scientific literature. We now know that untreated maternal psychiatric illness carries its own risks for infants both before and after delivery; that many maternal pharmacologic treatments are lower risk for infants than previously thought; that protecting and treating women’s mental health in pregnancy has benefits for women, their babies, and the families that depend on them; and that there is now a growing evidence base informing both new and older treatments and enabling women and their doctors to make complex decisions balancing risk and benefit across the life cycle.
Many psychiatrists-in-training are hungry for this knowledge. At last count, in the United States alone, there were 16 women’s mental health fellowships available, up from just 3 in 2008.3 The problem is that none of them are accredited or funded by the ACGME, because reproductive psychiatry (here used interchangeably with the term women’s mental health) has not been officially recognized as a subspecialty. This means that current funding frequently rests on philanthropy, which often cannot be sustained, and clinical billing, which gives fellows in some programs such heavy clinical responsibilities that little time is left for scholarly work. Lack of subspecialty status also blocks numerous important downstream effects that would flow from this recognition.
Reproductive psychiatry clearly already meets criteria laid out by the American Board of Medical Specialties for defining a subspecialty field. As argued elsewhere, it has a distinct patient population with definable care needs and a standalone body of scientific medical knowledge as well as a national (and international) community of experts that has already done much to improve women’s access to care they desperately need.4 It also meets the ACGME’s criteria for a new subspecialty except for approval by the American Board of Psychiatry and Neurology.5 Finally, it also meets the requirements of the ABPN except for having 25 fellowship programs with 50 fellowship positions and 50 trainees per year completing fellowships, a challenging Catch-22 without the necessary funding that would accrue from accreditation.6
Despite growing awareness and demand, there remains a shortage of psychiatrists trained to treat women during times of reproductive transition and to pass their recommendations and knowledge on to their primary care and ob.gyn. colleagues. What official recognition would bring, in addition to funding for fellowships post residency, is a guaranteed seat at the table in psychiatry residencies, in terms of a required number of hours devoted to these topics for trainees, ensuring that all graduating psychiatrists have at least some exposure to the knowledge and practices so material to their patients.
It isn’t enough to wait for residencies to see the writing on the wall and voluntarily carve out a slice of pie devoted to women’s mental health from the limited time and resources available to train residents. A 2017 survey of psychiatry residency program training directors found that 23%, or almost a quarter of programs that responded, offered no reproductive psychiatry training at all, that 49% required 5 hours or less across all 4 years of training, and that 75% of programs had no required clinical exposure to reproductive psychiatry patients.7 Despite the fact that 87% of training directors surveyed agreed either that reproductive psychiatry was “an important area of education” or a subject general residents should be competent in, ACGME-recognized specialties take precedence.
A system so patchy and insufficient won’t do. It’s not good enough for the trainees who frequently have to look outside of their own institutions for the training they know they need. It’s not good enough for the pregnant or postpartum patient looking for evidence-based advice, who is currently left on her own to determine, prior to booking an appointment, whether a specific psychiatrist has received any training relevant to treating her. Adding reproductive psychiatry to the topics a graduating psychiatrist must have some proficiency in also signals to recent graduates and experienced attendings, as well as the relevant examining boards and producers of continuing medical education content, that women’s mental health is no longer a fringe topic but rather foundational to all practicing psychiatrists.
The oil needed to prime this pump is official recognition of the subspecialty that reproductive psychiatry already is. The women’s mental health community is ready. The research base is well established and growing exponentially. The number of women’s mental health fellowships is healthy and would increase significantly with ACGME funding. Psychiatry residency training programs can turn to recent graduates of these fellowships as well as their own faculty with reproductive psychiatry experience to teach trainees. In addition, the National Curriculum in Reproductive Psychiatry, over the last 4 years, has created a repository of free online modules dedicated to facilitating this type of training, with case discussions across numerous topics for use by both educators and trainees. The American Psychiatric Association recently formed the Committee on Women’s Mental Health in 2020 and will be publishing a textbook based on work done by the NCRP within the coming year.
Imagine the changed world that would open to all psychiatrists if reproductive psychiatry were given the credentials it deserves. When writing prescriptions, we would view pregnancy as the potential outcome it is in any woman of reproductive age, given that 50% of pregnancies are unplanned, and let women know ahead of time how to think about possible fetal effects rather than waiting for their panicked phone messages or hearing that they have stopped their medications abruptly. We would work to identify our patient’s individual risk factors for postpartum depression predelivery to reduce that risk and prevent or limit illness. We would plan ahead for close follow-up post partum during the window of greatest risk, rather than expecting women to drop out of care while taking care of their infants or languish on scheduling waiting lists. We would feel confident in giving evidence-based advice to our patients around times of reproductive transition across the life cycle, but especially in pregnancy and lactation, empowering women to make healthy decisions for themselves and their families, no longer abandoning them just when they need us most.
References
1. ACGME Program Requirements for Graduate Medical Education in Psychiatry. Accreditation Counsel for Graduate Medical Education. 2020 Jul 1.
2. Livingston G. “They’re waiting longer, but U.S. women today more likely to have children than a decade ago.” Pew Research Center’s Social & Demographic Trends Project. pewsocialtrends.org. 2018 Jan 18.
3. Nagle-Yang S et al. Acad Psychiatry. 2018 Apr;42(2):202-6.
4. Payne JL. Int Rev Psychiatry. 2019 May;31(3):207-9.
5. Accreditation Council for Graduate Medical Education Policies and Procedures. 2020 Sep 26.
6. American Board of Psychiatry and Neurology. Requirements for Subspecialty Recognition, Attachment A. 2008.
7. Osborne LM et al. Acad Psychiatry. 2018 Apr;42(2):197-201.
Dr. Leistikow is a reproductive psychiatrist and clinical assistant professor in the department of psychiatry at the University of Maryland, Baltimore, where she sees patients and helps train residents and fellows. She is on the education committee of the National Curriculum in Reproductive Psychiatry (NCRPtraining.org) and has written about women’s mental health for textbooks, scientific journals and on her private practice blog at www.womenspsychiatrybaltimore.com. Dr. Leistikow has no conflicts of interest.
Dr. Payne is associate professor of psychiatry and behavioral sciences and director of the Women’s Mood Disorders Center at Johns Hopkins University, Baltimore. In addition to providing outstanding clinical care for women with mood disorders, she conducts research into the genetic, biological, and environmental factors involved in postpartum depression. She and her colleagues have recently identified two epigenetic biomarkers of postpartum depression and are working hard to replicate this work with National Institutes of Health funding. Most recently, she was appointed to the American Psychiatric Association’s committee on women’s mental health and is serving as president-elect for both the Marcé of North America and the International Marcé Perinatal Mental Health Societies. She disclosed the following relevant financial relationships: serve(d) as a director, officer, partner, employee, adviser, consultant, or trustee for Sage Therapeutics and Janssen Pharmaceuticals.
Dr. Osborne is associate professor of psychiatry and behavioral sciences and of gynecology and obstetrics at Johns Hopkins University, where she directs a postdoctoral fellowship program in reproductive psychiatry. She is an expert on the diagnosis and treatment of mood and anxiety disorders during pregnancy, the post partum, the premenstrual period, and perimenopause. Her work is supported by the Brain and Behavior Foundation, the Doris Duke Foundation, the American Board of Psychiatry and Neurology, and the National Institute of Mental Health. She has no conflicts of interest.
Childhood smoking and depression contribute to young adult opioid use
Depression and tobacco use in childhood significantly increased the risk for opioid use in young adults, according to data from a prospective study of approximately 1,000 individuals.
Previous research, including the annual Monitoring the Future study, documents opioid use among adolescents in the United States, but childhood risk factors for opioid use in young adults have not been well studied, wrote Lilly Shanahan, PhD, of the University of Zürich, and colleagues.
In a prospective cohort study published in JAMA Pediatrics, the researchers identified 1,252 non-Hispanic White and American Indian opioid-naive individuals aged 9-16 years in rural North Carolina. They interviewed participants and parents up to 7 times between January 1993 and December 2000, and interviewed participants only at ages 19, 21, 25, and 30 years between January 1999 and December 2015.
Overall, 24.2% of study participants had used a nonheroin opioid by age 30 years, and both chronic depression and dysthymia were significantly associated with this use (odds ratios 5.43 and 7.13, respectively).
In addition, 155 participants (8.8%) reported weekly use of a nonheroin opioid, and 95 (6.6%) reported weekly heroin use by age 30 years. Chronic depression and dysthymia also were strongly associated with weekly nonheroin opioid use (OR 8.89 and 11.51, respectively).
In a multivariate analysis, depression, tobacco use, and cannabis use at ages 9-16 years were strongly associated with overall opioid use at ages 19-30 years.
“One possible reason childhood chronic depression increases the risk of later opioid use is self-medication, including the use of psychoactive substances, to alleviate depression,” the researchers noted. In addition, the mood-altering properties of opioids may increase their appeal to depressed youth as a way to relieve impaired reward system function, they said.
Potential mechanisms for the association between early tobacco use and later opioid use include the alterations to neurodevelopment caused by nicotine exposure in adolescence, as well as increased risk for depression, reduced pain thresholds, and use of nicotine as a gateway to harder drugs, the researchers added.
Several childhood risk factors were not associated with young adult opioid use in multivariate analysis in this study, including alcohol use, sociodemographic status, maltreatment, family dysfunction, and anxiety, the researchers wrote. “Previous studies typically measured these risk factors retrospectively or in late adolescence and young adulthood, and most did not consider depressive disorders, which may mediate associations between select childhood risk factors and later opioid use,” they said.
The study findings were limited by several factors, including the inability to distinguish between medical and nonmedical opioid use, the incomplete list of available opioids, and the exclusion of Black participants because of low sample size, the researchers noted. However, the results were strengthened by the longitudinal, community-representative design and the inclusion of up to 11 assessments of opioid use, they said.
“Our findings suggest strong opportunities for early prevention and intervention, including in primary care settings,” using known evidence-based strategies, they concluded.
More screening is needed
“Children in the United States are at high risk of serious adult health issues as a result of childhood factors such as ACEs (adverse childhood experiences),” said Suzanne C. Boulter, MD, of the Geisel School of Medicine at Dartmouth, Hanover, N.H. “This study looks prospectively at other factors in childhood over a long period of time leading to opioid usage, with its serious risks and health consequences including overdose death,” she said. “It is unclear what the effects of COVID-19 will be on the population of children growing up now and how opioid usage might change as a result,” she noted.
“Some of the links to adult usage are predictable, such as depression, tobacco use, and cannabis use in early adolescence,” said Dr. Boulter. “Surprising was the lack of correlation between anxiety, early alcohol use, child mistreatment, and sociodemographic factors with future opioid use,” she said.
The take-home message for clinicians is to screen children and adolescents for factors leading to opioid usage in young adults “with preventive strategies including avoidance of pain medication prescriptions and early referral and treatment for depression and use of cannabis and tobacco products using tools like SBIRT (Screening, Brief Intervention, and Referral to Treatment),” Dr. Boulter emphasized.
As for additional research, “It would be interesting to study e-cigarette usage and see if the correlation with future opioid usage is similar to older tobacco products,” she said. “Also helpful would be to delve deeper into connections between medical or dental diagnoses when opioids were first prescribed and later usage of those products,” Dr. Boulter noted.
The study was supported in part by the by the National Institute of Mental Health and the National Institute on Drug Abuse. The researchers had no financial conflicts to disclose. Dr. Boulter had no disclosures but serves on the Pediatric News Editorial Advisory Board.
Depression and tobacco use in childhood significantly increased the risk for opioid use in young adults, according to data from a prospective study of approximately 1,000 individuals.
Previous research, including the annual Monitoring the Future study, documents opioid use among adolescents in the United States, but childhood risk factors for opioid use in young adults have not been well studied, wrote Lilly Shanahan, PhD, of the University of Zürich, and colleagues.
In a prospective cohort study published in JAMA Pediatrics, the researchers identified 1,252 non-Hispanic White and American Indian opioid-naive individuals aged 9-16 years in rural North Carolina. They interviewed participants and parents up to 7 times between January 1993 and December 2000, and interviewed participants only at ages 19, 21, 25, and 30 years between January 1999 and December 2015.
Overall, 24.2% of study participants had used a nonheroin opioid by age 30 years, and both chronic depression and dysthymia were significantly associated with this use (odds ratios 5.43 and 7.13, respectively).
In addition, 155 participants (8.8%) reported weekly use of a nonheroin opioid, and 95 (6.6%) reported weekly heroin use by age 30 years. Chronic depression and dysthymia also were strongly associated with weekly nonheroin opioid use (OR 8.89 and 11.51, respectively).
In a multivariate analysis, depression, tobacco use, and cannabis use at ages 9-16 years were strongly associated with overall opioid use at ages 19-30 years.
“One possible reason childhood chronic depression increases the risk of later opioid use is self-medication, including the use of psychoactive substances, to alleviate depression,” the researchers noted. In addition, the mood-altering properties of opioids may increase their appeal to depressed youth as a way to relieve impaired reward system function, they said.
Potential mechanisms for the association between early tobacco use and later opioid use include the alterations to neurodevelopment caused by nicotine exposure in adolescence, as well as increased risk for depression, reduced pain thresholds, and use of nicotine as a gateway to harder drugs, the researchers added.
Several childhood risk factors were not associated with young adult opioid use in multivariate analysis in this study, including alcohol use, sociodemographic status, maltreatment, family dysfunction, and anxiety, the researchers wrote. “Previous studies typically measured these risk factors retrospectively or in late adolescence and young adulthood, and most did not consider depressive disorders, which may mediate associations between select childhood risk factors and later opioid use,” they said.
The study findings were limited by several factors, including the inability to distinguish between medical and nonmedical opioid use, the incomplete list of available opioids, and the exclusion of Black participants because of low sample size, the researchers noted. However, the results were strengthened by the longitudinal, community-representative design and the inclusion of up to 11 assessments of opioid use, they said.
“Our findings suggest strong opportunities for early prevention and intervention, including in primary care settings,” using known evidence-based strategies, they concluded.
More screening is needed
“Children in the United States are at high risk of serious adult health issues as a result of childhood factors such as ACEs (adverse childhood experiences),” said Suzanne C. Boulter, MD, of the Geisel School of Medicine at Dartmouth, Hanover, N.H. “This study looks prospectively at other factors in childhood over a long period of time leading to opioid usage, with its serious risks and health consequences including overdose death,” she said. “It is unclear what the effects of COVID-19 will be on the population of children growing up now and how opioid usage might change as a result,” she noted.
“Some of the links to adult usage are predictable, such as depression, tobacco use, and cannabis use in early adolescence,” said Dr. Boulter. “Surprising was the lack of correlation between anxiety, early alcohol use, child mistreatment, and sociodemographic factors with future opioid use,” she said.
The take-home message for clinicians is to screen children and adolescents for factors leading to opioid usage in young adults “with preventive strategies including avoidance of pain medication prescriptions and early referral and treatment for depression and use of cannabis and tobacco products using tools like SBIRT (Screening, Brief Intervention, and Referral to Treatment),” Dr. Boulter emphasized.
As for additional research, “It would be interesting to study e-cigarette usage and see if the correlation with future opioid usage is similar to older tobacco products,” she said. “Also helpful would be to delve deeper into connections between medical or dental diagnoses when opioids were first prescribed and later usage of those products,” Dr. Boulter noted.
The study was supported in part by the by the National Institute of Mental Health and the National Institute on Drug Abuse. The researchers had no financial conflicts to disclose. Dr. Boulter had no disclosures but serves on the Pediatric News Editorial Advisory Board.
Depression and tobacco use in childhood significantly increased the risk for opioid use in young adults, according to data from a prospective study of approximately 1,000 individuals.
Previous research, including the annual Monitoring the Future study, documents opioid use among adolescents in the United States, but childhood risk factors for opioid use in young adults have not been well studied, wrote Lilly Shanahan, PhD, of the University of Zürich, and colleagues.
In a prospective cohort study published in JAMA Pediatrics, the researchers identified 1,252 non-Hispanic White and American Indian opioid-naive individuals aged 9-16 years in rural North Carolina. They interviewed participants and parents up to 7 times between January 1993 and December 2000, and interviewed participants only at ages 19, 21, 25, and 30 years between January 1999 and December 2015.
Overall, 24.2% of study participants had used a nonheroin opioid by age 30 years, and both chronic depression and dysthymia were significantly associated with this use (odds ratios 5.43 and 7.13, respectively).
In addition, 155 participants (8.8%) reported weekly use of a nonheroin opioid, and 95 (6.6%) reported weekly heroin use by age 30 years. Chronic depression and dysthymia also were strongly associated with weekly nonheroin opioid use (OR 8.89 and 11.51, respectively).
In a multivariate analysis, depression, tobacco use, and cannabis use at ages 9-16 years were strongly associated with overall opioid use at ages 19-30 years.
“One possible reason childhood chronic depression increases the risk of later opioid use is self-medication, including the use of psychoactive substances, to alleviate depression,” the researchers noted. In addition, the mood-altering properties of opioids may increase their appeal to depressed youth as a way to relieve impaired reward system function, they said.
Potential mechanisms for the association between early tobacco use and later opioid use include the alterations to neurodevelopment caused by nicotine exposure in adolescence, as well as increased risk for depression, reduced pain thresholds, and use of nicotine as a gateway to harder drugs, the researchers added.
Several childhood risk factors were not associated with young adult opioid use in multivariate analysis in this study, including alcohol use, sociodemographic status, maltreatment, family dysfunction, and anxiety, the researchers wrote. “Previous studies typically measured these risk factors retrospectively or in late adolescence and young adulthood, and most did not consider depressive disorders, which may mediate associations between select childhood risk factors and later opioid use,” they said.
The study findings were limited by several factors, including the inability to distinguish between medical and nonmedical opioid use, the incomplete list of available opioids, and the exclusion of Black participants because of low sample size, the researchers noted. However, the results were strengthened by the longitudinal, community-representative design and the inclusion of up to 11 assessments of opioid use, they said.
“Our findings suggest strong opportunities for early prevention and intervention, including in primary care settings,” using known evidence-based strategies, they concluded.
More screening is needed
“Children in the United States are at high risk of serious adult health issues as a result of childhood factors such as ACEs (adverse childhood experiences),” said Suzanne C. Boulter, MD, of the Geisel School of Medicine at Dartmouth, Hanover, N.H. “This study looks prospectively at other factors in childhood over a long period of time leading to opioid usage, with its serious risks and health consequences including overdose death,” she said. “It is unclear what the effects of COVID-19 will be on the population of children growing up now and how opioid usage might change as a result,” she noted.
“Some of the links to adult usage are predictable, such as depression, tobacco use, and cannabis use in early adolescence,” said Dr. Boulter. “Surprising was the lack of correlation between anxiety, early alcohol use, child mistreatment, and sociodemographic factors with future opioid use,” she said.
The take-home message for clinicians is to screen children and adolescents for factors leading to opioid usage in young adults “with preventive strategies including avoidance of pain medication prescriptions and early referral and treatment for depression and use of cannabis and tobacco products using tools like SBIRT (Screening, Brief Intervention, and Referral to Treatment),” Dr. Boulter emphasized.
As for additional research, “It would be interesting to study e-cigarette usage and see if the correlation with future opioid usage is similar to older tobacco products,” she said. “Also helpful would be to delve deeper into connections between medical or dental diagnoses when opioids were first prescribed and later usage of those products,” Dr. Boulter noted.
The study was supported in part by the by the National Institute of Mental Health and the National Institute on Drug Abuse. The researchers had no financial conflicts to disclose. Dr. Boulter had no disclosures but serves on the Pediatric News Editorial Advisory Board.
FROM JAMA PEDIATRICS
Machine learning flags key risk factors for suicide attempts
A history of suicidal behaviors or ideation, functional impairment related to mental health disorders, and socioeconomic disadvantage are the three most important risk factors predicting subsequent suicide attempts, new research suggests.
Investigators applied a machine-learning model to data on over 34,500 adults drawn from a large national survey database. After analyzing more than 2,500 survey questions, key areas were identified that yielded the most accurate predictions of who might be at risk for later suicide attempt.
These predictors included experiencing previous suicidal behaviors and ideation or functional impairment because of emotional problems, being at a younger age, having a lower educational achievement, and experiencing a recent financial crisis.
“Our machine learning model confirmed well-known risk factors of suicide attempt, including previous suicidal behavior and depression; and we also identified functional impairment, such as doing activities less carefully or accomplishing less because of emotional problems, as a new important risk,” lead author Angel Garcia de la Garza, PhD candidate in the department of biostatistics, Columbia University, New York, said in an interview.
“We hope our results provide a novel avenue for future suicide risk assessment,” Mr. Garcia de la Garza said.
The findings were published online Jan. 6 in JAMA Psychiatry.
‘Rich’ dataset
Previous research using machine learning approaches to study nonfatal suicide attempt prediction has focused on high-risk patients in clinical treatment. However, more than one-third of individuals making nonfatal suicide attempts do not receive mental health treatment, Mr. Garcia de la Garza noted.
To gain further insight into predictors of suicide risk in nonclinical populations, the researchers turned to the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a longitudinal survey of noninstitutionalized U.S. adults.
“We wanted to extend our understanding of suicide attempt risk factors beyond high-risk clinical populations to the general adult population; and the richness of the NESARC dataset provides a unique opportunity to do so,” Mr. Garcia de la Garza said.
The NESARC surveys were conducted in two waves: Wave 1 (2001-2002) and wave 2 (2004-2005), in which participants self-reported nonfatal suicide attempts in the preceding 3 years since wave 1.
Assessment of wave 1 participants was based on the Alcohol Use Disorder and Associated Disabilities Interview Schedule DSM-IV.
“This survey’s extensive assessment instrument contained a detailed evaluation of substance use, psychiatric disorders, and symptoms not routinely available in electronic health records,” Mr. Garcia de la Garza noted.
The wave 1 survey contained 2,805 separate questions. From participants’ responses, the investigators derived 180 variables for three categories: past-year, prior-to-past-year, and lifetime mental disorders.
They then identified 2,978 factors associated with suicide attempts and used a statistical method called balanced random forest to classify suicide attempts at wave 2. Each variable was accorded an “importance score” using identified wave 1 features.
The outcome variable of attempted suicide at any point during the 3 years prior to the wave 2 interview was defined by combining responses to three wave 2 questions:
- In your entire life, did you ever attempt suicide?
- If yes, how old were you the first time?
- If the most recent event occurred within the last 3 years, how old were you during the most recent time?
Suicide risk severity was classified into four groups (low, medium, high, and very high) on the basis of the top-performing risk factors.
A statistical model combining survey design and nonresponse weights enabled estimates to be representative of the U.S. population, based on the 2000 census.
Out-of-fold model prediction assessed performance of the model, using area under receiver operator curve (AUC), sensitivity, and specificity.
Daily functioning
Of all participants, 70.2% (n = 34,653; almost 60% women) completed wave 2 interviews. The weighted mean ages at waves 1 and 2 were 45.1 and 48.2 years, respectively.
Of wave 2 respondents, 0.6% (n = 222) attempted suicide during the preceding 3 years.
Half of those who attempted suicide within the first year were classified as “very high risk,” while 33.2% of those who attempted suicide between the first and second year and 33.3% of those who attempted suicide between the second and third year were classified as “very high risk.”
Among participants who attempted suicide between the third year and follow-up, 16.48% were classified as “very high risk.”
The model accurately captured classification of participants, even across demographic characteristics, such as age, sex, race, and income.
Younger individuals (aged 18-36 years) were at higher risk, compared with older individuals. In addition, women were at higher risk than were men, White participants were at higher risk than were non-White participants, and individuals with lower income were at greater risk than were those with higher income.
The model found that 1.8% of the U.S. population had a 10% or greater risk of a suicide attempt.
The most important risk factors identified were the three questions about previous suicidal ideation or behavior; three items from the 12-Item Short Form Health Survey (feeling downhearted, doing activities less carefully, or accomplishing less because of emotional problems); younger age; lower educational achievement; and recent financial crisis.
“The clinical assessment of suicide risk typically focuses on acute suicidal symptoms, together with depression, anxiety, substance misuse, and recent stressful events,” coinvestigator Mark Olfson, MD, PhD, professor of epidemiology, Columbia University Irving Medical Center, New York, said in an interview.
Dr. Olfson said.
Extra vigilance
Commenting on the study in an interview, April C. Foreman, PhD, an executive board member of the American Association of Suicidology, noted that some of the findings were not surprising.
“When discharging a patient from inpatient care, or seeing them in primary care, bring up mental health concerns proactively and ask whether they have ever attempted suicide or harmed themselves – even a long time ago – just as you ask about a family history of heart disease or cancer, or other health issues,” said Dr. Foreman, chief medical officer of the Kevin and Margaret Hines Foundation.
She noted that half of people who die by suicide have a primary care visit within the preceding month.
“Primary care is a great place to get a suicide history and follow the patient with extra vigilance, just as you would with any other risk factors,” Dr. Foreman said.
The study was funded by the National Institute on Alcohol Abuse and Alcoholism and its Intramural Program. The study authors and Dr. Foreman have reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
A history of suicidal behaviors or ideation, functional impairment related to mental health disorders, and socioeconomic disadvantage are the three most important risk factors predicting subsequent suicide attempts, new research suggests.
Investigators applied a machine-learning model to data on over 34,500 adults drawn from a large national survey database. After analyzing more than 2,500 survey questions, key areas were identified that yielded the most accurate predictions of who might be at risk for later suicide attempt.
These predictors included experiencing previous suicidal behaviors and ideation or functional impairment because of emotional problems, being at a younger age, having a lower educational achievement, and experiencing a recent financial crisis.
“Our machine learning model confirmed well-known risk factors of suicide attempt, including previous suicidal behavior and depression; and we also identified functional impairment, such as doing activities less carefully or accomplishing less because of emotional problems, as a new important risk,” lead author Angel Garcia de la Garza, PhD candidate in the department of biostatistics, Columbia University, New York, said in an interview.
“We hope our results provide a novel avenue for future suicide risk assessment,” Mr. Garcia de la Garza said.
The findings were published online Jan. 6 in JAMA Psychiatry.
‘Rich’ dataset
Previous research using machine learning approaches to study nonfatal suicide attempt prediction has focused on high-risk patients in clinical treatment. However, more than one-third of individuals making nonfatal suicide attempts do not receive mental health treatment, Mr. Garcia de la Garza noted.
To gain further insight into predictors of suicide risk in nonclinical populations, the researchers turned to the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a longitudinal survey of noninstitutionalized U.S. adults.
“We wanted to extend our understanding of suicide attempt risk factors beyond high-risk clinical populations to the general adult population; and the richness of the NESARC dataset provides a unique opportunity to do so,” Mr. Garcia de la Garza said.
The NESARC surveys were conducted in two waves: Wave 1 (2001-2002) and wave 2 (2004-2005), in which participants self-reported nonfatal suicide attempts in the preceding 3 years since wave 1.
Assessment of wave 1 participants was based on the Alcohol Use Disorder and Associated Disabilities Interview Schedule DSM-IV.
“This survey’s extensive assessment instrument contained a detailed evaluation of substance use, psychiatric disorders, and symptoms not routinely available in electronic health records,” Mr. Garcia de la Garza noted.
The wave 1 survey contained 2,805 separate questions. From participants’ responses, the investigators derived 180 variables for three categories: past-year, prior-to-past-year, and lifetime mental disorders.
They then identified 2,978 factors associated with suicide attempts and used a statistical method called balanced random forest to classify suicide attempts at wave 2. Each variable was accorded an “importance score” using identified wave 1 features.
The outcome variable of attempted suicide at any point during the 3 years prior to the wave 2 interview was defined by combining responses to three wave 2 questions:
- In your entire life, did you ever attempt suicide?
- If yes, how old were you the first time?
- If the most recent event occurred within the last 3 years, how old were you during the most recent time?
Suicide risk severity was classified into four groups (low, medium, high, and very high) on the basis of the top-performing risk factors.
A statistical model combining survey design and nonresponse weights enabled estimates to be representative of the U.S. population, based on the 2000 census.
Out-of-fold model prediction assessed performance of the model, using area under receiver operator curve (AUC), sensitivity, and specificity.
Daily functioning
Of all participants, 70.2% (n = 34,653; almost 60% women) completed wave 2 interviews. The weighted mean ages at waves 1 and 2 were 45.1 and 48.2 years, respectively.
Of wave 2 respondents, 0.6% (n = 222) attempted suicide during the preceding 3 years.
Half of those who attempted suicide within the first year were classified as “very high risk,” while 33.2% of those who attempted suicide between the first and second year and 33.3% of those who attempted suicide between the second and third year were classified as “very high risk.”
Among participants who attempted suicide between the third year and follow-up, 16.48% were classified as “very high risk.”
The model accurately captured classification of participants, even across demographic characteristics, such as age, sex, race, and income.
Younger individuals (aged 18-36 years) were at higher risk, compared with older individuals. In addition, women were at higher risk than were men, White participants were at higher risk than were non-White participants, and individuals with lower income were at greater risk than were those with higher income.
The model found that 1.8% of the U.S. population had a 10% or greater risk of a suicide attempt.
The most important risk factors identified were the three questions about previous suicidal ideation or behavior; three items from the 12-Item Short Form Health Survey (feeling downhearted, doing activities less carefully, or accomplishing less because of emotional problems); younger age; lower educational achievement; and recent financial crisis.
“The clinical assessment of suicide risk typically focuses on acute suicidal symptoms, together with depression, anxiety, substance misuse, and recent stressful events,” coinvestigator Mark Olfson, MD, PhD, professor of epidemiology, Columbia University Irving Medical Center, New York, said in an interview.
Dr. Olfson said.
Extra vigilance
Commenting on the study in an interview, April C. Foreman, PhD, an executive board member of the American Association of Suicidology, noted that some of the findings were not surprising.
“When discharging a patient from inpatient care, or seeing them in primary care, bring up mental health concerns proactively and ask whether they have ever attempted suicide or harmed themselves – even a long time ago – just as you ask about a family history of heart disease or cancer, or other health issues,” said Dr. Foreman, chief medical officer of the Kevin and Margaret Hines Foundation.
She noted that half of people who die by suicide have a primary care visit within the preceding month.
“Primary care is a great place to get a suicide history and follow the patient with extra vigilance, just as you would with any other risk factors,” Dr. Foreman said.
The study was funded by the National Institute on Alcohol Abuse and Alcoholism and its Intramural Program. The study authors and Dr. Foreman have reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
A history of suicidal behaviors or ideation, functional impairment related to mental health disorders, and socioeconomic disadvantage are the three most important risk factors predicting subsequent suicide attempts, new research suggests.
Investigators applied a machine-learning model to data on over 34,500 adults drawn from a large national survey database. After analyzing more than 2,500 survey questions, key areas were identified that yielded the most accurate predictions of who might be at risk for later suicide attempt.
These predictors included experiencing previous suicidal behaviors and ideation or functional impairment because of emotional problems, being at a younger age, having a lower educational achievement, and experiencing a recent financial crisis.
“Our machine learning model confirmed well-known risk factors of suicide attempt, including previous suicidal behavior and depression; and we also identified functional impairment, such as doing activities less carefully or accomplishing less because of emotional problems, as a new important risk,” lead author Angel Garcia de la Garza, PhD candidate in the department of biostatistics, Columbia University, New York, said in an interview.
“We hope our results provide a novel avenue for future suicide risk assessment,” Mr. Garcia de la Garza said.
The findings were published online Jan. 6 in JAMA Psychiatry.
‘Rich’ dataset
Previous research using machine learning approaches to study nonfatal suicide attempt prediction has focused on high-risk patients in clinical treatment. However, more than one-third of individuals making nonfatal suicide attempts do not receive mental health treatment, Mr. Garcia de la Garza noted.
To gain further insight into predictors of suicide risk in nonclinical populations, the researchers turned to the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a longitudinal survey of noninstitutionalized U.S. adults.
“We wanted to extend our understanding of suicide attempt risk factors beyond high-risk clinical populations to the general adult population; and the richness of the NESARC dataset provides a unique opportunity to do so,” Mr. Garcia de la Garza said.
The NESARC surveys were conducted in two waves: Wave 1 (2001-2002) and wave 2 (2004-2005), in which participants self-reported nonfatal suicide attempts in the preceding 3 years since wave 1.
Assessment of wave 1 participants was based on the Alcohol Use Disorder and Associated Disabilities Interview Schedule DSM-IV.
“This survey’s extensive assessment instrument contained a detailed evaluation of substance use, psychiatric disorders, and symptoms not routinely available in electronic health records,” Mr. Garcia de la Garza noted.
The wave 1 survey contained 2,805 separate questions. From participants’ responses, the investigators derived 180 variables for three categories: past-year, prior-to-past-year, and lifetime mental disorders.
They then identified 2,978 factors associated with suicide attempts and used a statistical method called balanced random forest to classify suicide attempts at wave 2. Each variable was accorded an “importance score” using identified wave 1 features.
The outcome variable of attempted suicide at any point during the 3 years prior to the wave 2 interview was defined by combining responses to three wave 2 questions:
- In your entire life, did you ever attempt suicide?
- If yes, how old were you the first time?
- If the most recent event occurred within the last 3 years, how old were you during the most recent time?
Suicide risk severity was classified into four groups (low, medium, high, and very high) on the basis of the top-performing risk factors.
A statistical model combining survey design and nonresponse weights enabled estimates to be representative of the U.S. population, based on the 2000 census.
Out-of-fold model prediction assessed performance of the model, using area under receiver operator curve (AUC), sensitivity, and specificity.
Daily functioning
Of all participants, 70.2% (n = 34,653; almost 60% women) completed wave 2 interviews. The weighted mean ages at waves 1 and 2 were 45.1 and 48.2 years, respectively.
Of wave 2 respondents, 0.6% (n = 222) attempted suicide during the preceding 3 years.
Half of those who attempted suicide within the first year were classified as “very high risk,” while 33.2% of those who attempted suicide between the first and second year and 33.3% of those who attempted suicide between the second and third year were classified as “very high risk.”
Among participants who attempted suicide between the third year and follow-up, 16.48% were classified as “very high risk.”
The model accurately captured classification of participants, even across demographic characteristics, such as age, sex, race, and income.
Younger individuals (aged 18-36 years) were at higher risk, compared with older individuals. In addition, women were at higher risk than were men, White participants were at higher risk than were non-White participants, and individuals with lower income were at greater risk than were those with higher income.
The model found that 1.8% of the U.S. population had a 10% or greater risk of a suicide attempt.
The most important risk factors identified were the three questions about previous suicidal ideation or behavior; three items from the 12-Item Short Form Health Survey (feeling downhearted, doing activities less carefully, or accomplishing less because of emotional problems); younger age; lower educational achievement; and recent financial crisis.
“The clinical assessment of suicide risk typically focuses on acute suicidal symptoms, together with depression, anxiety, substance misuse, and recent stressful events,” coinvestigator Mark Olfson, MD, PhD, professor of epidemiology, Columbia University Irving Medical Center, New York, said in an interview.
Dr. Olfson said.
Extra vigilance
Commenting on the study in an interview, April C. Foreman, PhD, an executive board member of the American Association of Suicidology, noted that some of the findings were not surprising.
“When discharging a patient from inpatient care, or seeing them in primary care, bring up mental health concerns proactively and ask whether they have ever attempted suicide or harmed themselves – even a long time ago – just as you ask about a family history of heart disease or cancer, or other health issues,” said Dr. Foreman, chief medical officer of the Kevin and Margaret Hines Foundation.
She noted that half of people who die by suicide have a primary care visit within the preceding month.
“Primary care is a great place to get a suicide history and follow the patient with extra vigilance, just as you would with any other risk factors,” Dr. Foreman said.
The study was funded by the National Institute on Alcohol Abuse and Alcoholism and its Intramural Program. The study authors and Dr. Foreman have reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
‘Peer respites’ provide an alternative to psychiatric wards during pandemic
Mia McDermott is no stranger to isolation. Abandoned as an infant in China, she lived in an orphanage until a family in California adopted her as a toddler. She spent her adolescence in boarding schools and early adult years in and out of psychiatric hospitals, where she underwent treatment for bipolar disorder, anxiety, and anorexia.
The pandemic left Ms. McDermott feeling especially lonely. She restricted social interactions because her fatty liver disease put her at greater risk of complications should she contract COVID-19. The 26-year-old Santa Cruz, Calif., resident stopped regularly eating and taking her psychiatric medications, and contemplated suicide.
When Ms. McDermott’s thoughts grew increasingly dark in June, she checked into Second Story, a mental health program based in a home not far from her own, where she finds nonclinical support in a peaceful environment from people who have faced similar challenges.
Second Story is what is known as a “peer respite,” a welcoming place where people can stay when they’re experiencing or nearing a mental health crisis. Betting that a low-key wellness approach, coupled with empathy from people who have “been there,” can help people in distress recover, this unorthodox strategy has gained popularity in recent years as the nation grapples with a severe shortage of psychiatric beds that has been exacerbated by the pandemic.
Peer respites allow guests to avoid psychiatric hospitalization and ED visits. They now operate in at least 14 states. California has five, in the San Francisco Bay Area and Los Angeles County.
“When things are really tough and you need extra support but you don’t need hospitalization, where’s that middle ground?” asked Keris Myrick, founder of Hacienda of Hope, a peer respite in Long Beach, Calif.
People with serious mental illness are more likely to experience emotional distress in the pandemic than the general population, said Benjamin Druss, MD, a psychiatrist and professor at Emory University, Atlanta, elaborating that they tend to have smaller social networks and more medical problems.
That was the case with Ms. McDermott. “I don’t have a full-on relationship with my family. My friends are my family,” she said. She yearned to “give them a hug, see their smile, or stand close and take a selfie.”
The next best thing was Second Story, located in a pewter-gray split-level, five-bedroom house in Aptos, a quaint beach community near Ms. McDermott’s Santa Cruz home.
– people who have experienced mental health conditions and are trained and often certified by states to support others with similar issues – and activities like arts, meditation and support groups.
“You can’t tell who’s the guest and who’s the staff. We don’t wear uniforms or badges,” said Angelica Garcia-Guerrero, associate director of Hacienda of Hope’s parent organization.
Peer respites are free for guests but rarely covered by insurance. States and counties typically pick up the tab. Hacienda of Hope’s $900,000 annual operating costs are covered by Los Angeles County through the Mental Health Services Act, a policy that directs proceeds from a statewide tax on people who earn more than $1 million annually to behavioral health programs.
In September, California Gov. Gavin Newsom signed a bill that would establish a statewide certification process for mental health peer providers by July 2022.
For now, however, peer-respite staff members in California are not licensed or certified. Peer respites typically don’t offer clinical care or dispense psychiatric drugs, though guests can bring theirs. Peers share personal stories with guests but avoid labeling them with diagnoses. Guests must come – and can leave – voluntarily. Some respites have few restrictions on who can stay; others don’t allow guests who express suicidal thoughts or are homeless.
Peer respite is one of several types of programs that divert people facing behavioral health crises from the hospital, but the only one without clinical involvement, said Travis Atkinson, a consultant at TBD Solutions, a behavioral health care company. The first peer respites arose around 2000, said Laysha Ostrow, CEO of Live & Learn, which conducts behavioral health research.
The approach seems to be expanding. Live & Learn currently counts 33 peer respites in the United States, up from 19 6 years ago. All are overseen and staffed by people with histories of psychiatric disorders. About a dozen other programs employ a mix of peers and laypeople who don’t have psychiatric diagnoses, or aren’t peer led, Mr. Atkinson said.
Though she had stayed at Second Story several times over the past 5 years, Ms. McDermott hesitated to return during the pandemic. However, she felt reassured after learning that guests were required to wear a mask in common areas and get a COVID test before their stay. To ensure physical distancing, the respite reduced capacity from six to five guests at a time.
During her 2-week stay, Ms. McDermott played with the respite’s two cats and piano – activities she found therapeutic. But most helpful was talking to peers in a way she couldn’t with her mental health providers. In the past, Ms. McDermott said, she had been involuntarily admitted to a psychiatric hospital after she expressed suicidal thoughts. When she shared similar sentiments with Second Story peers, they offered to talk, or call the hospital if she wanted.
“They were willing to listen,” she said. “But they’re not forceful about helping.”
By the end of the visit, Ms. McDermott said that she felt understood and her loneliness and suicidal feelings had waned. She started eating and taking her medications more consistently.
The small number of studies on respites have found that guests had fewer hospitalizations and accounted for lower Medicaid spending for nearly a year after a respite stay than people with similar conditions who did not stay in a respite. Respite visitors spent less time in the hospital and emergency room the longer they stayed in the respite.
Financial struggles and opposition from neighbors have hindered the growth of respites, however. Live & Learn said that, although five peer respites have been created since 2018, at least two others closed because of budget cuts.
Neighbors have challenged nearby respite placements in a few instances. Santa Cruz–area media outlets reported in 2019 that Second Story neighbors had voiced safety concerns with the respite. Neighbor Tony Crane said in an interview that guests have used drugs and consumed alcohol in the neighborhood, and he worried that peers are not licensed or certified to support people in crisis. He felt it was too risky to let his children ride their bikes near the respite when they were younger.
In a written response, Monica Martinez, whose organization runs Second Story, said neighbors often target community mental health programs because of concerns that “come from misconceptions and stigma surrounding those seeking mental health support.”
Many respites are struggling with increased demand and decreased availability during the pandemic. Sherry Jenkins Tucker, executive director of Georgia Mental Health Consumer Network, said its four respites have had to reduce capacity to enable physical distancing, despite increased demand for services. Other respites have temporarily suspended stays because of the pandemic.
Ms. McDermott said her mental health had improved since staying at Second Story in June, but she still struggles with isolation amid the pandemic. “Holidays are hard for me,” said Ms. McDermott, who returned to Second Story in November. “I really wanted to be able to have Thanksgiving with people.”
Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of KFF (Kaiser Family Foundation), which is not affiliated with Kaiser Permanente.
Mia McDermott is no stranger to isolation. Abandoned as an infant in China, she lived in an orphanage until a family in California adopted her as a toddler. She spent her adolescence in boarding schools and early adult years in and out of psychiatric hospitals, where she underwent treatment for bipolar disorder, anxiety, and anorexia.
The pandemic left Ms. McDermott feeling especially lonely. She restricted social interactions because her fatty liver disease put her at greater risk of complications should she contract COVID-19. The 26-year-old Santa Cruz, Calif., resident stopped regularly eating and taking her psychiatric medications, and contemplated suicide.
When Ms. McDermott’s thoughts grew increasingly dark in June, she checked into Second Story, a mental health program based in a home not far from her own, where she finds nonclinical support in a peaceful environment from people who have faced similar challenges.
Second Story is what is known as a “peer respite,” a welcoming place where people can stay when they’re experiencing or nearing a mental health crisis. Betting that a low-key wellness approach, coupled with empathy from people who have “been there,” can help people in distress recover, this unorthodox strategy has gained popularity in recent years as the nation grapples with a severe shortage of psychiatric beds that has been exacerbated by the pandemic.
Peer respites allow guests to avoid psychiatric hospitalization and ED visits. They now operate in at least 14 states. California has five, in the San Francisco Bay Area and Los Angeles County.
“When things are really tough and you need extra support but you don’t need hospitalization, where’s that middle ground?” asked Keris Myrick, founder of Hacienda of Hope, a peer respite in Long Beach, Calif.
People with serious mental illness are more likely to experience emotional distress in the pandemic than the general population, said Benjamin Druss, MD, a psychiatrist and professor at Emory University, Atlanta, elaborating that they tend to have smaller social networks and more medical problems.
That was the case with Ms. McDermott. “I don’t have a full-on relationship with my family. My friends are my family,” she said. She yearned to “give them a hug, see their smile, or stand close and take a selfie.”
The next best thing was Second Story, located in a pewter-gray split-level, five-bedroom house in Aptos, a quaint beach community near Ms. McDermott’s Santa Cruz home.
– people who have experienced mental health conditions and are trained and often certified by states to support others with similar issues – and activities like arts, meditation and support groups.
“You can’t tell who’s the guest and who’s the staff. We don’t wear uniforms or badges,” said Angelica Garcia-Guerrero, associate director of Hacienda of Hope’s parent organization.
Peer respites are free for guests but rarely covered by insurance. States and counties typically pick up the tab. Hacienda of Hope’s $900,000 annual operating costs are covered by Los Angeles County through the Mental Health Services Act, a policy that directs proceeds from a statewide tax on people who earn more than $1 million annually to behavioral health programs.
In September, California Gov. Gavin Newsom signed a bill that would establish a statewide certification process for mental health peer providers by July 2022.
For now, however, peer-respite staff members in California are not licensed or certified. Peer respites typically don’t offer clinical care or dispense psychiatric drugs, though guests can bring theirs. Peers share personal stories with guests but avoid labeling them with diagnoses. Guests must come – and can leave – voluntarily. Some respites have few restrictions on who can stay; others don’t allow guests who express suicidal thoughts or are homeless.
Peer respite is one of several types of programs that divert people facing behavioral health crises from the hospital, but the only one without clinical involvement, said Travis Atkinson, a consultant at TBD Solutions, a behavioral health care company. The first peer respites arose around 2000, said Laysha Ostrow, CEO of Live & Learn, which conducts behavioral health research.
The approach seems to be expanding. Live & Learn currently counts 33 peer respites in the United States, up from 19 6 years ago. All are overseen and staffed by people with histories of psychiatric disorders. About a dozen other programs employ a mix of peers and laypeople who don’t have psychiatric diagnoses, or aren’t peer led, Mr. Atkinson said.
Though she had stayed at Second Story several times over the past 5 years, Ms. McDermott hesitated to return during the pandemic. However, she felt reassured after learning that guests were required to wear a mask in common areas and get a COVID test before their stay. To ensure physical distancing, the respite reduced capacity from six to five guests at a time.
During her 2-week stay, Ms. McDermott played with the respite’s two cats and piano – activities she found therapeutic. But most helpful was talking to peers in a way she couldn’t with her mental health providers. In the past, Ms. McDermott said, she had been involuntarily admitted to a psychiatric hospital after she expressed suicidal thoughts. When she shared similar sentiments with Second Story peers, they offered to talk, or call the hospital if she wanted.
“They were willing to listen,” she said. “But they’re not forceful about helping.”
By the end of the visit, Ms. McDermott said that she felt understood and her loneliness and suicidal feelings had waned. She started eating and taking her medications more consistently.
The small number of studies on respites have found that guests had fewer hospitalizations and accounted for lower Medicaid spending for nearly a year after a respite stay than people with similar conditions who did not stay in a respite. Respite visitors spent less time in the hospital and emergency room the longer they stayed in the respite.
Financial struggles and opposition from neighbors have hindered the growth of respites, however. Live & Learn said that, although five peer respites have been created since 2018, at least two others closed because of budget cuts.
Neighbors have challenged nearby respite placements in a few instances. Santa Cruz–area media outlets reported in 2019 that Second Story neighbors had voiced safety concerns with the respite. Neighbor Tony Crane said in an interview that guests have used drugs and consumed alcohol in the neighborhood, and he worried that peers are not licensed or certified to support people in crisis. He felt it was too risky to let his children ride their bikes near the respite when they were younger.
In a written response, Monica Martinez, whose organization runs Second Story, said neighbors often target community mental health programs because of concerns that “come from misconceptions and stigma surrounding those seeking mental health support.”
Many respites are struggling with increased demand and decreased availability during the pandemic. Sherry Jenkins Tucker, executive director of Georgia Mental Health Consumer Network, said its four respites have had to reduce capacity to enable physical distancing, despite increased demand for services. Other respites have temporarily suspended stays because of the pandemic.
Ms. McDermott said her mental health had improved since staying at Second Story in June, but she still struggles with isolation amid the pandemic. “Holidays are hard for me,” said Ms. McDermott, who returned to Second Story in November. “I really wanted to be able to have Thanksgiving with people.”
Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of KFF (Kaiser Family Foundation), which is not affiliated with Kaiser Permanente.
Mia McDermott is no stranger to isolation. Abandoned as an infant in China, she lived in an orphanage until a family in California adopted her as a toddler. She spent her adolescence in boarding schools and early adult years in and out of psychiatric hospitals, where she underwent treatment for bipolar disorder, anxiety, and anorexia.
The pandemic left Ms. McDermott feeling especially lonely. She restricted social interactions because her fatty liver disease put her at greater risk of complications should she contract COVID-19. The 26-year-old Santa Cruz, Calif., resident stopped regularly eating and taking her psychiatric medications, and contemplated suicide.
When Ms. McDermott’s thoughts grew increasingly dark in June, she checked into Second Story, a mental health program based in a home not far from her own, where she finds nonclinical support in a peaceful environment from people who have faced similar challenges.
Second Story is what is known as a “peer respite,” a welcoming place where people can stay when they’re experiencing or nearing a mental health crisis. Betting that a low-key wellness approach, coupled with empathy from people who have “been there,” can help people in distress recover, this unorthodox strategy has gained popularity in recent years as the nation grapples with a severe shortage of psychiatric beds that has been exacerbated by the pandemic.
Peer respites allow guests to avoid psychiatric hospitalization and ED visits. They now operate in at least 14 states. California has five, in the San Francisco Bay Area and Los Angeles County.
“When things are really tough and you need extra support but you don’t need hospitalization, where’s that middle ground?” asked Keris Myrick, founder of Hacienda of Hope, a peer respite in Long Beach, Calif.
People with serious mental illness are more likely to experience emotional distress in the pandemic than the general population, said Benjamin Druss, MD, a psychiatrist and professor at Emory University, Atlanta, elaborating that they tend to have smaller social networks and more medical problems.
That was the case with Ms. McDermott. “I don’t have a full-on relationship with my family. My friends are my family,” she said. She yearned to “give them a hug, see their smile, or stand close and take a selfie.”
The next best thing was Second Story, located in a pewter-gray split-level, five-bedroom house in Aptos, a quaint beach community near Ms. McDermott’s Santa Cruz home.
– people who have experienced mental health conditions and are trained and often certified by states to support others with similar issues – and activities like arts, meditation and support groups.
“You can’t tell who’s the guest and who’s the staff. We don’t wear uniforms or badges,” said Angelica Garcia-Guerrero, associate director of Hacienda of Hope’s parent organization.
Peer respites are free for guests but rarely covered by insurance. States and counties typically pick up the tab. Hacienda of Hope’s $900,000 annual operating costs are covered by Los Angeles County through the Mental Health Services Act, a policy that directs proceeds from a statewide tax on people who earn more than $1 million annually to behavioral health programs.
In September, California Gov. Gavin Newsom signed a bill that would establish a statewide certification process for mental health peer providers by July 2022.
For now, however, peer-respite staff members in California are not licensed or certified. Peer respites typically don’t offer clinical care or dispense psychiatric drugs, though guests can bring theirs. Peers share personal stories with guests but avoid labeling them with diagnoses. Guests must come – and can leave – voluntarily. Some respites have few restrictions on who can stay; others don’t allow guests who express suicidal thoughts or are homeless.
Peer respite is one of several types of programs that divert people facing behavioral health crises from the hospital, but the only one without clinical involvement, said Travis Atkinson, a consultant at TBD Solutions, a behavioral health care company. The first peer respites arose around 2000, said Laysha Ostrow, CEO of Live & Learn, which conducts behavioral health research.
The approach seems to be expanding. Live & Learn currently counts 33 peer respites in the United States, up from 19 6 years ago. All are overseen and staffed by people with histories of psychiatric disorders. About a dozen other programs employ a mix of peers and laypeople who don’t have psychiatric diagnoses, or aren’t peer led, Mr. Atkinson said.
Though she had stayed at Second Story several times over the past 5 years, Ms. McDermott hesitated to return during the pandemic. However, she felt reassured after learning that guests were required to wear a mask in common areas and get a COVID test before their stay. To ensure physical distancing, the respite reduced capacity from six to five guests at a time.
During her 2-week stay, Ms. McDermott played with the respite’s two cats and piano – activities she found therapeutic. But most helpful was talking to peers in a way she couldn’t with her mental health providers. In the past, Ms. McDermott said, she had been involuntarily admitted to a psychiatric hospital after she expressed suicidal thoughts. When she shared similar sentiments with Second Story peers, they offered to talk, or call the hospital if she wanted.
“They were willing to listen,” she said. “But they’re not forceful about helping.”
By the end of the visit, Ms. McDermott said that she felt understood and her loneliness and suicidal feelings had waned. She started eating and taking her medications more consistently.
The small number of studies on respites have found that guests had fewer hospitalizations and accounted for lower Medicaid spending for nearly a year after a respite stay than people with similar conditions who did not stay in a respite. Respite visitors spent less time in the hospital and emergency room the longer they stayed in the respite.
Financial struggles and opposition from neighbors have hindered the growth of respites, however. Live & Learn said that, although five peer respites have been created since 2018, at least two others closed because of budget cuts.
Neighbors have challenged nearby respite placements in a few instances. Santa Cruz–area media outlets reported in 2019 that Second Story neighbors had voiced safety concerns with the respite. Neighbor Tony Crane said in an interview that guests have used drugs and consumed alcohol in the neighborhood, and he worried that peers are not licensed or certified to support people in crisis. He felt it was too risky to let his children ride their bikes near the respite when they were younger.
In a written response, Monica Martinez, whose organization runs Second Story, said neighbors often target community mental health programs because of concerns that “come from misconceptions and stigma surrounding those seeking mental health support.”
Many respites are struggling with increased demand and decreased availability during the pandemic. Sherry Jenkins Tucker, executive director of Georgia Mental Health Consumer Network, said its four respites have had to reduce capacity to enable physical distancing, despite increased demand for services. Other respites have temporarily suspended stays because of the pandemic.
Ms. McDermott said her mental health had improved since staying at Second Story in June, but she still struggles with isolation amid the pandemic. “Holidays are hard for me,” said Ms. McDermott, who returned to Second Story in November. “I really wanted to be able to have Thanksgiving with people.”
Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of KFF (Kaiser Family Foundation), which is not affiliated with Kaiser Permanente.