Pooled data from four phase 2 trials reveal that patients with recent SSRI exposure were significantly more likely to continue to meet PTSD diagnostic criteria after methylenedioxymethamphetamine (MDMA)-assisted psychotherapy than their peers who had not recently taken SSRIs.
Although preliminary, the findings have implications for clinical practice if MDMA-assisted psychotherapy is approved by the Food and Drug Administration, Allison Feduccia, PhD, study coauthor and founder of the education platform Psychedelic.Support, said in an interview.
“As psychedelic medicines become available, it’s going to be important that we try to understand what factors impact the response rate and if there are ways that we can improve the treatment outcomes. Allowing for a longer period for tapering completely off SSRIs before initiating MDMA sessions might increase the effectiveness of MDMA,” Dr. Feduccia said.
The study was published online Nov. 20, 2020, in Psychopharmacology (doi: 10.1007/s00213-020-05710-w).
Reduced response
The primary mechanism of action of MDMA involves the same reuptake transporters that are targeted by antidepressant medications commonly prescribed for PTSD. These medications include SSRIs, serotonin-norepinephrine reuptake inhibitors (SNRIs), NRIs, and norepinephrine-dopamine reuptake inhibitors (NDRIs).
Prior research shows that, when MDMA is coadministered with a reuptake inhibitor, subjective and psychological effects of the therapy are attenuated.
The researchers sought to determine whether or not recent tapering off of an antidepressant that targets the same primary binding sites as MDMA would affect treatment response. They analyzed data on 50 adults who underwent two sessions of MDMA-assisted psychotherapy in phase 2 clinical trials.
For 16 of these patients, SSRI therapy was tapered off prior to the MDMA sessions. For 34 patients, SSRI therapy was not tapered off, because the patients had not been taking the medication at the time of initial study screening (nontaper group).
The taper protocols specified that medications be tapered gradually over a period of weeks to minimize withdrawal symptoms and for them to be discontinued at least five half-lives of each drug prior to MDMA administration. Most participants were tapered off one drug, but some were tapered off multiple drugs.
Demographics, baseline PTSD, and depression severity were similar between the taper and the nontaper groups. Participants in the studies had chronic PTSD (symptoms lasting >6 months). Severity scores on the Clinician-Administered PTSD Scale for DSM IV (CAPS-IV) were at least 50.
After MDMA-assisted psychotherapy, the nontaper group had significantly lower (better) CAPS-IV total scores, compared with the taper group (mean, 45.7 vs. 70.3; P = .009).
About two-thirds (63.6%) of the nontaper group no longer met PTSD criteria after MDMA-assisted therapy, compared with only 25% of those in the taper group.
The nontaper group also had lower depression symptom severity scores on the Beck Depression Inventory–II, compared with the taper group (mean, 12.7 vs. 22.6; P = .010).
“Another really interesting” observation, said Dr. Feduccia, is that the expected increases in systolic and diastolic blood pressure following MDMA administration were reduced in the taper group, compared with the nontaper group.
“This suggests that MDMA didn’t have the same physiological response in individuals who tapered SSRIs. This should be followed up,” she said.
The investigators offerred several potential mechanisms for the negative effect of recent SSRI use on MDMA-assisted psychotherapy for PTSD.
These include the down-regulation of binding sites (serotonin, dopamine, and/or norepinephrine) related to SSRI use, reduced MDMA treatment-relevant increases in blood pressure in patients with recent SSRI use, and the possibility that withdrawal symptoms from SSRIs may reduce the effectiveness of MDMA psychotherapy.
Important clinical implications
In a comment, Steven R. Thorp, PhD, professor at Alliant International University, San Diego, said the findings are “very interesting” and likely “not well known.”
“There has been great interest in MDMA-assisted psychotherapy in recent years, and if this finding is replicated, it will have important implications for that research,” Dr. Thorp said.
“Although psychotherapy is often preferred by clients with PTSD, compared to medications, and typically shows efficacy that is as strong or stronger (and longer lasting) than medications, many individuals with PTSD are provided with medication only,” Dr. Thorp noted.
“This study suggests that, in addition to the other potential disadvantages of medications (e.g., cost, side effects, potential for addiction), those who take SSRIs, SNRIs, NRIs, and NDRIs for PTSD may also benefit less from MDMA-assisted psychotherapy,” Dr. Thorp added.
The four phase 2 studies used in the analysis were sponsored by the Multidisciplinary Association for Psychedelic Studies, a nonprofit organization. Dr. Feduccia received salary support for full-time employment with MAPS Public Benefit Corporation. Dr. Thorp disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Pooled data from four phase 2 trials reveal that patients with recent SSRI exposure were significantly more likely to continue to meet PTSD diagnostic criteria after methylenedioxymethamphetamine (MDMA)-assisted psychotherapy than their peers who had not recently taken SSRIs.
Although preliminary, the findings have implications for clinical practice if MDMA-assisted psychotherapy is approved by the Food and Drug Administration, Allison Feduccia, PhD, study coauthor and founder of the education platform Psychedelic.Support, said in an interview.
“As psychedelic medicines become available, it’s going to be important that we try to understand what factors impact the response rate and if there are ways that we can improve the treatment outcomes. Allowing for a longer period for tapering completely off SSRIs before initiating MDMA sessions might increase the effectiveness of MDMA,” Dr. Feduccia said.
The study was published online Nov. 20, 2020, in Psychopharmacology (doi: 10.1007/s00213-020-05710-w).
Reduced response
The primary mechanism of action of MDMA involves the same reuptake transporters that are targeted by antidepressant medications commonly prescribed for PTSD. These medications include SSRIs, serotonin-norepinephrine reuptake inhibitors (SNRIs), NRIs, and norepinephrine-dopamine reuptake inhibitors (NDRIs).
Prior research shows that, when MDMA is coadministered with a reuptake inhibitor, subjective and psychological effects of the therapy are attenuated.
The researchers sought to determine whether or not recent tapering off of an antidepressant that targets the same primary binding sites as MDMA would affect treatment response. They analyzed data on 50 adults who underwent two sessions of MDMA-assisted psychotherapy in phase 2 clinical trials.
For 16 of these patients, SSRI therapy was tapered off prior to the MDMA sessions. For 34 patients, SSRI therapy was not tapered off, because the patients had not been taking the medication at the time of initial study screening (nontaper group).
The taper protocols specified that medications be tapered gradually over a period of weeks to minimize withdrawal symptoms and for them to be discontinued at least five half-lives of each drug prior to MDMA administration. Most participants were tapered off one drug, but some were tapered off multiple drugs.
Demographics, baseline PTSD, and depression severity were similar between the taper and the nontaper groups. Participants in the studies had chronic PTSD (symptoms lasting >6 months). Severity scores on the Clinician-Administered PTSD Scale for DSM IV (CAPS-IV) were at least 50.
After MDMA-assisted psychotherapy, the nontaper group had significantly lower (better) CAPS-IV total scores, compared with the taper group (mean, 45.7 vs. 70.3; P = .009).
About two-thirds (63.6%) of the nontaper group no longer met PTSD criteria after MDMA-assisted therapy, compared with only 25% of those in the taper group.
The nontaper group also had lower depression symptom severity scores on the Beck Depression Inventory–II, compared with the taper group (mean, 12.7 vs. 22.6; P = .010).
“Another really interesting” observation, said Dr. Feduccia, is that the expected increases in systolic and diastolic blood pressure following MDMA administration were reduced in the taper group, compared with the nontaper group.
“This suggests that MDMA didn’t have the same physiological response in individuals who tapered SSRIs. This should be followed up,” she said.
The investigators offerred several potential mechanisms for the negative effect of recent SSRI use on MDMA-assisted psychotherapy for PTSD.
These include the down-regulation of binding sites (serotonin, dopamine, and/or norepinephrine) related to SSRI use, reduced MDMA treatment-relevant increases in blood pressure in patients with recent SSRI use, and the possibility that withdrawal symptoms from SSRIs may reduce the effectiveness of MDMA psychotherapy.
Important clinical implications
In a comment, Steven R. Thorp, PhD, professor at Alliant International University, San Diego, said the findings are “very interesting” and likely “not well known.”
“There has been great interest in MDMA-assisted psychotherapy in recent years, and if this finding is replicated, it will have important implications for that research,” Dr. Thorp said.
“Although psychotherapy is often preferred by clients with PTSD, compared to medications, and typically shows efficacy that is as strong or stronger (and longer lasting) than medications, many individuals with PTSD are provided with medication only,” Dr. Thorp noted.
“This study suggests that, in addition to the other potential disadvantages of medications (e.g., cost, side effects, potential for addiction), those who take SSRIs, SNRIs, NRIs, and NDRIs for PTSD may also benefit less from MDMA-assisted psychotherapy,” Dr. Thorp added.
The four phase 2 studies used in the analysis were sponsored by the Multidisciplinary Association for Psychedelic Studies, a nonprofit organization. Dr. Feduccia received salary support for full-time employment with MAPS Public Benefit Corporation. Dr. Thorp disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Pooled data from four phase 2 trials reveal that patients with recent SSRI exposure were significantly more likely to continue to meet PTSD diagnostic criteria after methylenedioxymethamphetamine (MDMA)-assisted psychotherapy than their peers who had not recently taken SSRIs.
Although preliminary, the findings have implications for clinical practice if MDMA-assisted psychotherapy is approved by the Food and Drug Administration, Allison Feduccia, PhD, study coauthor and founder of the education platform Psychedelic.Support, said in an interview.
“As psychedelic medicines become available, it’s going to be important that we try to understand what factors impact the response rate and if there are ways that we can improve the treatment outcomes. Allowing for a longer period for tapering completely off SSRIs before initiating MDMA sessions might increase the effectiveness of MDMA,” Dr. Feduccia said.
The study was published online Nov. 20, 2020, in Psychopharmacology (doi: 10.1007/s00213-020-05710-w).
Reduced response
The primary mechanism of action of MDMA involves the same reuptake transporters that are targeted by antidepressant medications commonly prescribed for PTSD. These medications include SSRIs, serotonin-norepinephrine reuptake inhibitors (SNRIs), NRIs, and norepinephrine-dopamine reuptake inhibitors (NDRIs).
Prior research shows that, when MDMA is coadministered with a reuptake inhibitor, subjective and psychological effects of the therapy are attenuated.
The researchers sought to determine whether or not recent tapering off of an antidepressant that targets the same primary binding sites as MDMA would affect treatment response. They analyzed data on 50 adults who underwent two sessions of MDMA-assisted psychotherapy in phase 2 clinical trials.
For 16 of these patients, SSRI therapy was tapered off prior to the MDMA sessions. For 34 patients, SSRI therapy was not tapered off, because the patients had not been taking the medication at the time of initial study screening (nontaper group).
The taper protocols specified that medications be tapered gradually over a period of weeks to minimize withdrawal symptoms and for them to be discontinued at least five half-lives of each drug prior to MDMA administration. Most participants were tapered off one drug, but some were tapered off multiple drugs.
Demographics, baseline PTSD, and depression severity were similar between the taper and the nontaper groups. Participants in the studies had chronic PTSD (symptoms lasting >6 months). Severity scores on the Clinician-Administered PTSD Scale for DSM IV (CAPS-IV) were at least 50.
After MDMA-assisted psychotherapy, the nontaper group had significantly lower (better) CAPS-IV total scores, compared with the taper group (mean, 45.7 vs. 70.3; P = .009).
About two-thirds (63.6%) of the nontaper group no longer met PTSD criteria after MDMA-assisted therapy, compared with only 25% of those in the taper group.
The nontaper group also had lower depression symptom severity scores on the Beck Depression Inventory–II, compared with the taper group (mean, 12.7 vs. 22.6; P = .010).
“Another really interesting” observation, said Dr. Feduccia, is that the expected increases in systolic and diastolic blood pressure following MDMA administration were reduced in the taper group, compared with the nontaper group.
“This suggests that MDMA didn’t have the same physiological response in individuals who tapered SSRIs. This should be followed up,” she said.
The investigators offerred several potential mechanisms for the negative effect of recent SSRI use on MDMA-assisted psychotherapy for PTSD.
These include the down-regulation of binding sites (serotonin, dopamine, and/or norepinephrine) related to SSRI use, reduced MDMA treatment-relevant increases in blood pressure in patients with recent SSRI use, and the possibility that withdrawal symptoms from SSRIs may reduce the effectiveness of MDMA psychotherapy.
Important clinical implications
In a comment, Steven R. Thorp, PhD, professor at Alliant International University, San Diego, said the findings are “very interesting” and likely “not well known.”
“There has been great interest in MDMA-assisted psychotherapy in recent years, and if this finding is replicated, it will have important implications for that research,” Dr. Thorp said.
“Although psychotherapy is often preferred by clients with PTSD, compared to medications, and typically shows efficacy that is as strong or stronger (and longer lasting) than medications, many individuals with PTSD are provided with medication only,” Dr. Thorp noted.
“This study suggests that, in addition to the other potential disadvantages of medications (e.g., cost, side effects, potential for addiction), those who take SSRIs, SNRIs, NRIs, and NDRIs for PTSD may also benefit less from MDMA-assisted psychotherapy,” Dr. Thorp added.
The four phase 2 studies used in the analysis were sponsored by the Multidisciplinary Association for Psychedelic Studies, a nonprofit organization. Dr. Feduccia received salary support for full-time employment with MAPS Public Benefit Corporation. Dr. Thorp disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Looking back on his experience of being stalked by a former patient for nearly 1 year, William J. Newman, MD, regrets not reaching out to colleagues about the patient boundary violations earlier than he did.
Dr. William J. Newman
“My mindset was: ‘Maybe I did something wrong that created this,’ ” Dr. Newman, professor and interim chair of psychiatry at Saint Louis University, said during an annual psychopharmacology update held by the Nevada Psychiatric Association. “That’s a common theme among victims of stalking, being kind of embarrassed and not wanting to share it with other people.”
Dr. Newman’s ordeal began in August 2014, when the first of several threatening emails messages were sent to his account at the University of California, Davis, where he held a faculty post and worked on the teaching service at the Sacramento Mental Health Treatment Center, a county hospital that serves mainly uninsured or underinsured populations. The messages always contained a nonspecific email recipient name and the first wasn’t terribly worrisome, Dr. Newman said. It basically read (profanities excluded): “What is wrong with you? Leave me alone. All I want is some privacy.”
About 3 months later, he received another message in a similar writing pattern, but the name of the sender was “god devil,” which raised a red flag to him. “Once you start to get religious concepts, people are compelled to commit acts when they believe they’re doing so beyond the laws of the land and are doing so for a religious purpose,” said Dr. Newman, who is immediate past president of the American Academy of Psychiatry and the Law.
The content of the message contained the first name of a coworker and phrasing inferring suicide, which gave Dr. Newman a hint that it was someone he had cared for at the mental health treatment center, “but as anybody who has worked on a busy inpatient service can tell you, you encounter several suicidal patients, and this didn’t really narrow it down,” he said. “This told me the person had presented after a suicide attempt. In some ways, that made me a little more concerned, because when you’re looking at risk assessment, people who are at or past the breaking point are incredibly dangerous, because they don’t really worry about the consequences of being shot by law enforcement or dying in an attack.”
Dr. Newman contacted the university’s information technology team, which was able to trace all messages to an IP address from a computer located at a downtown branch of the public library, which had surveillance video. Armed with this information, he contacted the Sacramento Police Department to see if they would help. He had “what I can only describe as an unsatisfying and somewhat condescending conversation with an officer, who said: ‘Sir, we can’t just go around asking people questions without knowing they did something wrong. There’s nothing we’re going to do.’ ”
Between November 2014 and May 2015, Dr. Newman continued to receive periodic messages from the individual of varied length and intensity.
“Some messages were more disorganized and difficult to follow, while others were very intense and pointed about my imminent death,” he recalled. “I started to ignore these messages as much as possible, tried to put my head in the sand and move forward.”
However, one phrase contained in a message read “you won’t even recognize me,” which gave Dr. Newman pause. “It highlighted the idea that because I don’t know who this is, they could walk up to me on the sidewalk, and I would have no idea, which in its own right is somewhat terrorizing.”
At this point, he contacted the police again, telling them he was fearful for his imminent safety. He also met with his department chair and administrators, who helped Dr. Newman develop a plan to enter and exit the hospital at different times. Then, in May 2015, the stalker sent Dr. Newman another email message threatening not only his life, but the lives of his colleagues at the hospital.
“This was viewed as a terroristic threat, because [it inferred that] other people were going to be shot other than just me,” he said.
After this, Dr. Newman’s administrators contacted the police about the threat, who identified the individual through video surveillance footage at the public library and began to search for him. It was a patient who had been on testosterone and previously had sent similar messages to another mental health provider in town and wound up showing up at that person’s office with a loaded firearm.
“At that point, the police were called to the scene, picked the individual up, and took him to a local emergency room where he was placed on an involuntary 5150 psychiatric hold,” he said. “It was frustrating to me that this was very much minimized and kind of put to the side.”
Once he learned the stalker’s name, Dr. Newman had no recollection of the individual. “The patient had presented after a carbon monoxide overdose, had been sent to a local emergency room and came to my service,” he said. “It was a very nonconfrontational hospitalization, nothing out of the ordinary.”
At this point, the stalker was still at large, so Dr. Newman wrote farewell notes to his wife, children, and loved ones, “just in case,” he said. “I had those tucked away. That wasn’t an overly pleasant experience.” He also lived away from his family outside of Sacramento while police searched for his stalker.
In late May 2015, police located and arrested the individual, and Dr. Newman began a series of conversations with the District Attorney’s office. “They told me there were seven terroristic threat charges that had been levied. They said they were taking this very seriously and [that the case] would be going to trial.” About 1 year later, after Dr. Newman’s move to Missouri, the District Attorney indicated that there would be a court trial and that Dr. Newman would be asked to serve as a fact witness. “I gave them all the information I had, talked to investigators, and the process was moving along for about a year to the point that they had an anticipated trial date,” he said. About 1 year later, he received an automated phone message which stated that the individual had been released from jail. He called the District Attorney to ask what happened.
“He said the judge didn’t really want to deal with this [case] anymore, and accepted a plea with time served and released him,” Dr. Newman said. “That was the outcome of the situation.”
According to a 1997 study of 100 stalking victims, 94% made major lifestyle changes after their ordeal, 82% modified usual activities, 73% increased security measures, 70% curtailed social outings, 53% decreased/stopped work or school, and 39% relocated. “You do change a lot of what you do and how you do it in your life when you’ve had this experience, especially when it’s been a chronic experience for months or years,” said Dr. Newman, who is also medical director of adult psychiatric inpatient services for Saint Louis University. “To this day I get antsy any time I think about the story or prepare to talk about it. It remains uncomfortable even 6 years later, even without an ongoing direct threat at this point.”
The physiological impact of chronic stalking also takes its toll. The body releases adrenaline and cortisol as part of the fight or flight response, while chronic stress “is when you feel an increased stress response and have adrenaline and cortisol elevated for an extended period of time,” he said. “There are negative impacts in terms of increased inflammation in the body and in the brain. I have spoken to several professionals who have been stalked by former patients. Commonly, they have been diagnosed in the period after that with an autoimmune illness or a cancer. Less than a year after my stalking situation ended, I was diagnosed with a metastatic cancer and had to start chemotherapy. I would not at all be surprised that those things are highly related to one another.”
When patient boundary violations start to become problematic or worrisome, Dr. Newman advised reaching out to colleagues and law enforcement for help. “Don’t let it go on insidiously for an extended period of time,” he said. “I think that was the biggest lesson I learned.”
Looking back on his experience of being stalked by a former patient for nearly 1 year, William J. Newman, MD, regrets not reaching out to colleagues about the patient boundary violations earlier than he did.
Dr. William J. Newman
“My mindset was: ‘Maybe I did something wrong that created this,’ ” Dr. Newman, professor and interim chair of psychiatry at Saint Louis University, said during an annual psychopharmacology update held by the Nevada Psychiatric Association. “That’s a common theme among victims of stalking, being kind of embarrassed and not wanting to share it with other people.”
Dr. Newman’s ordeal began in August 2014, when the first of several threatening emails messages were sent to his account at the University of California, Davis, where he held a faculty post and worked on the teaching service at the Sacramento Mental Health Treatment Center, a county hospital that serves mainly uninsured or underinsured populations. The messages always contained a nonspecific email recipient name and the first wasn’t terribly worrisome, Dr. Newman said. It basically read (profanities excluded): “What is wrong with you? Leave me alone. All I want is some privacy.”
About 3 months later, he received another message in a similar writing pattern, but the name of the sender was “god devil,” which raised a red flag to him. “Once you start to get religious concepts, people are compelled to commit acts when they believe they’re doing so beyond the laws of the land and are doing so for a religious purpose,” said Dr. Newman, who is immediate past president of the American Academy of Psychiatry and the Law.
The content of the message contained the first name of a coworker and phrasing inferring suicide, which gave Dr. Newman a hint that it was someone he had cared for at the mental health treatment center, “but as anybody who has worked on a busy inpatient service can tell you, you encounter several suicidal patients, and this didn’t really narrow it down,” he said. “This told me the person had presented after a suicide attempt. In some ways, that made me a little more concerned, because when you’re looking at risk assessment, people who are at or past the breaking point are incredibly dangerous, because they don’t really worry about the consequences of being shot by law enforcement or dying in an attack.”
Dr. Newman contacted the university’s information technology team, which was able to trace all messages to an IP address from a computer located at a downtown branch of the public library, which had surveillance video. Armed with this information, he contacted the Sacramento Police Department to see if they would help. He had “what I can only describe as an unsatisfying and somewhat condescending conversation with an officer, who said: ‘Sir, we can’t just go around asking people questions without knowing they did something wrong. There’s nothing we’re going to do.’ ”
Between November 2014 and May 2015, Dr. Newman continued to receive periodic messages from the individual of varied length and intensity.
“Some messages were more disorganized and difficult to follow, while others were very intense and pointed about my imminent death,” he recalled. “I started to ignore these messages as much as possible, tried to put my head in the sand and move forward.”
However, one phrase contained in a message read “you won’t even recognize me,” which gave Dr. Newman pause. “It highlighted the idea that because I don’t know who this is, they could walk up to me on the sidewalk, and I would have no idea, which in its own right is somewhat terrorizing.”
At this point, he contacted the police again, telling them he was fearful for his imminent safety. He also met with his department chair and administrators, who helped Dr. Newman develop a plan to enter and exit the hospital at different times. Then, in May 2015, the stalker sent Dr. Newman another email message threatening not only his life, but the lives of his colleagues at the hospital.
“This was viewed as a terroristic threat, because [it inferred that] other people were going to be shot other than just me,” he said.
After this, Dr. Newman’s administrators contacted the police about the threat, who identified the individual through video surveillance footage at the public library and began to search for him. It was a patient who had been on testosterone and previously had sent similar messages to another mental health provider in town and wound up showing up at that person’s office with a loaded firearm.
“At that point, the police were called to the scene, picked the individual up, and took him to a local emergency room where he was placed on an involuntary 5150 psychiatric hold,” he said. “It was frustrating to me that this was very much minimized and kind of put to the side.”
Once he learned the stalker’s name, Dr. Newman had no recollection of the individual. “The patient had presented after a carbon monoxide overdose, had been sent to a local emergency room and came to my service,” he said. “It was a very nonconfrontational hospitalization, nothing out of the ordinary.”
At this point, the stalker was still at large, so Dr. Newman wrote farewell notes to his wife, children, and loved ones, “just in case,” he said. “I had those tucked away. That wasn’t an overly pleasant experience.” He also lived away from his family outside of Sacramento while police searched for his stalker.
In late May 2015, police located and arrested the individual, and Dr. Newman began a series of conversations with the District Attorney’s office. “They told me there were seven terroristic threat charges that had been levied. They said they were taking this very seriously and [that the case] would be going to trial.” About 1 year later, after Dr. Newman’s move to Missouri, the District Attorney indicated that there would be a court trial and that Dr. Newman would be asked to serve as a fact witness. “I gave them all the information I had, talked to investigators, and the process was moving along for about a year to the point that they had an anticipated trial date,” he said. About 1 year later, he received an automated phone message which stated that the individual had been released from jail. He called the District Attorney to ask what happened.
“He said the judge didn’t really want to deal with this [case] anymore, and accepted a plea with time served and released him,” Dr. Newman said. “That was the outcome of the situation.”
According to a 1997 study of 100 stalking victims, 94% made major lifestyle changes after their ordeal, 82% modified usual activities, 73% increased security measures, 70% curtailed social outings, 53% decreased/stopped work or school, and 39% relocated. “You do change a lot of what you do and how you do it in your life when you’ve had this experience, especially when it’s been a chronic experience for months or years,” said Dr. Newman, who is also medical director of adult psychiatric inpatient services for Saint Louis University. “To this day I get antsy any time I think about the story or prepare to talk about it. It remains uncomfortable even 6 years later, even without an ongoing direct threat at this point.”
The physiological impact of chronic stalking also takes its toll. The body releases adrenaline and cortisol as part of the fight or flight response, while chronic stress “is when you feel an increased stress response and have adrenaline and cortisol elevated for an extended period of time,” he said. “There are negative impacts in terms of increased inflammation in the body and in the brain. I have spoken to several professionals who have been stalked by former patients. Commonly, they have been diagnosed in the period after that with an autoimmune illness or a cancer. Less than a year after my stalking situation ended, I was diagnosed with a metastatic cancer and had to start chemotherapy. I would not at all be surprised that those things are highly related to one another.”
When patient boundary violations start to become problematic or worrisome, Dr. Newman advised reaching out to colleagues and law enforcement for help. “Don’t let it go on insidiously for an extended period of time,” he said. “I think that was the biggest lesson I learned.”
Looking back on his experience of being stalked by a former patient for nearly 1 year, William J. Newman, MD, regrets not reaching out to colleagues about the patient boundary violations earlier than he did.
Dr. William J. Newman
“My mindset was: ‘Maybe I did something wrong that created this,’ ” Dr. Newman, professor and interim chair of psychiatry at Saint Louis University, said during an annual psychopharmacology update held by the Nevada Psychiatric Association. “That’s a common theme among victims of stalking, being kind of embarrassed and not wanting to share it with other people.”
Dr. Newman’s ordeal began in August 2014, when the first of several threatening emails messages were sent to his account at the University of California, Davis, where he held a faculty post and worked on the teaching service at the Sacramento Mental Health Treatment Center, a county hospital that serves mainly uninsured or underinsured populations. The messages always contained a nonspecific email recipient name and the first wasn’t terribly worrisome, Dr. Newman said. It basically read (profanities excluded): “What is wrong with you? Leave me alone. All I want is some privacy.”
About 3 months later, he received another message in a similar writing pattern, but the name of the sender was “god devil,” which raised a red flag to him. “Once you start to get religious concepts, people are compelled to commit acts when they believe they’re doing so beyond the laws of the land and are doing so for a religious purpose,” said Dr. Newman, who is immediate past president of the American Academy of Psychiatry and the Law.
The content of the message contained the first name of a coworker and phrasing inferring suicide, which gave Dr. Newman a hint that it was someone he had cared for at the mental health treatment center, “but as anybody who has worked on a busy inpatient service can tell you, you encounter several suicidal patients, and this didn’t really narrow it down,” he said. “This told me the person had presented after a suicide attempt. In some ways, that made me a little more concerned, because when you’re looking at risk assessment, people who are at or past the breaking point are incredibly dangerous, because they don’t really worry about the consequences of being shot by law enforcement or dying in an attack.”
Dr. Newman contacted the university’s information technology team, which was able to trace all messages to an IP address from a computer located at a downtown branch of the public library, which had surveillance video. Armed with this information, he contacted the Sacramento Police Department to see if they would help. He had “what I can only describe as an unsatisfying and somewhat condescending conversation with an officer, who said: ‘Sir, we can’t just go around asking people questions without knowing they did something wrong. There’s nothing we’re going to do.’ ”
Between November 2014 and May 2015, Dr. Newman continued to receive periodic messages from the individual of varied length and intensity.
“Some messages were more disorganized and difficult to follow, while others were very intense and pointed about my imminent death,” he recalled. “I started to ignore these messages as much as possible, tried to put my head in the sand and move forward.”
However, one phrase contained in a message read “you won’t even recognize me,” which gave Dr. Newman pause. “It highlighted the idea that because I don’t know who this is, they could walk up to me on the sidewalk, and I would have no idea, which in its own right is somewhat terrorizing.”
At this point, he contacted the police again, telling them he was fearful for his imminent safety. He also met with his department chair and administrators, who helped Dr. Newman develop a plan to enter and exit the hospital at different times. Then, in May 2015, the stalker sent Dr. Newman another email message threatening not only his life, but the lives of his colleagues at the hospital.
“This was viewed as a terroristic threat, because [it inferred that] other people were going to be shot other than just me,” he said.
After this, Dr. Newman’s administrators contacted the police about the threat, who identified the individual through video surveillance footage at the public library and began to search for him. It was a patient who had been on testosterone and previously had sent similar messages to another mental health provider in town and wound up showing up at that person’s office with a loaded firearm.
“At that point, the police were called to the scene, picked the individual up, and took him to a local emergency room where he was placed on an involuntary 5150 psychiatric hold,” he said. “It was frustrating to me that this was very much minimized and kind of put to the side.”
Once he learned the stalker’s name, Dr. Newman had no recollection of the individual. “The patient had presented after a carbon monoxide overdose, had been sent to a local emergency room and came to my service,” he said. “It was a very nonconfrontational hospitalization, nothing out of the ordinary.”
At this point, the stalker was still at large, so Dr. Newman wrote farewell notes to his wife, children, and loved ones, “just in case,” he said. “I had those tucked away. That wasn’t an overly pleasant experience.” He also lived away from his family outside of Sacramento while police searched for his stalker.
In late May 2015, police located and arrested the individual, and Dr. Newman began a series of conversations with the District Attorney’s office. “They told me there were seven terroristic threat charges that had been levied. They said they were taking this very seriously and [that the case] would be going to trial.” About 1 year later, after Dr. Newman’s move to Missouri, the District Attorney indicated that there would be a court trial and that Dr. Newman would be asked to serve as a fact witness. “I gave them all the information I had, talked to investigators, and the process was moving along for about a year to the point that they had an anticipated trial date,” he said. About 1 year later, he received an automated phone message which stated that the individual had been released from jail. He called the District Attorney to ask what happened.
“He said the judge didn’t really want to deal with this [case] anymore, and accepted a plea with time served and released him,” Dr. Newman said. “That was the outcome of the situation.”
According to a 1997 study of 100 stalking victims, 94% made major lifestyle changes after their ordeal, 82% modified usual activities, 73% increased security measures, 70% curtailed social outings, 53% decreased/stopped work or school, and 39% relocated. “You do change a lot of what you do and how you do it in your life when you’ve had this experience, especially when it’s been a chronic experience for months or years,” said Dr. Newman, who is also medical director of adult psychiatric inpatient services for Saint Louis University. “To this day I get antsy any time I think about the story or prepare to talk about it. It remains uncomfortable even 6 years later, even without an ongoing direct threat at this point.”
The physiological impact of chronic stalking also takes its toll. The body releases adrenaline and cortisol as part of the fight or flight response, while chronic stress “is when you feel an increased stress response and have adrenaline and cortisol elevated for an extended period of time,” he said. “There are negative impacts in terms of increased inflammation in the body and in the brain. I have spoken to several professionals who have been stalked by former patients. Commonly, they have been diagnosed in the period after that with an autoimmune illness or a cancer. Less than a year after my stalking situation ended, I was diagnosed with a metastatic cancer and had to start chemotherapy. I would not at all be surprised that those things are highly related to one another.”
When patient boundary violations start to become problematic or worrisome, Dr. Newman advised reaching out to colleagues and law enforcement for help. “Don’t let it go on insidiously for an extended period of time,” he said. “I think that was the biggest lesson I learned.”
When the pandemic hit, health officials in Montana’s Beaverhead County had barely begun to fill a hole left by the 2017 closure of the local public assistance office, mental health clinic, chemical dependency center and job placement office after the state’s last budget shortfall.
Now, those health officials worry more cuts are coming, even as they brace for a spike in demand for substance abuse and mental health services. That would be no small challenge in a poor farming and ranching region where stigma often prevents people from admitting they need help, said Katherine Buckley-Patton, who chairs the county’s Mental Health Local Advisory Council.
“I find it very challenging to find the words that will not make one of my hard-nosed cowboys turn around and walk away,” Ms. Buckley-Patton said. “They’re lonely, they’re isolated, they’re depressed, but they’re not going to call a suicide hotline.”
States across the U.S. are still stinging after businesses closed and millions of people lost jobs because of COVID-related shutdowns and restrictions. Meanwhile, the pandemic has led to a dramatic increase in the number of people who say their mental health has suffered, rising from one in three people in March to more than half of people polled by KFF in July. (KHN is an editorially independent program of KFF.)
The full extent of the mental health crisis and the demand for behavioral health services may not be known until after the pandemic is over, mental health experts said. That could add costs that budget writers haven’t anticipated.
Chuck Ingoglia
“It usually takes a while before people feel comfortable seeking care from a specialty behavioral health organization,” said Chuck Ingoglia, president and CEO of the nonprofit National Council for Behavioral Health in Washington, D.C. “We are not likely to see the results of that either in terms of people seeking care – or suicide rates going up – until we’re on the other side of the pandemic.”
Last year, states slashed agency budgets, froze pay, furloughed workers, borrowed money, and tapped into rainy-day funds to make ends meet. Health programs, often among the most expensive part of a state’s budget, were targeted for cuts in several states even as health officials led efforts to stem the spread of the coronavirus.
This year, the outlook doesn’t seem quite so bleak, partly because of relief packages passed by Congress last spring and in December that buoyed state economies. Another major advantage was that income increased or held steady for people with well-paying jobs and investment income, which boosted states’ tax revenues even as millions of lower-income workers were laid off.
“It has turned out to be not as bad as it might have been in terms of state budgets,” said Mike Leachman, vice president for state fiscal policy for the nonpartisan Center on Budget and Policy Priorities.
But many states still face cash shortfalls that will be made worse if additional federal aid doesn’t come, Mr. Leachman said. President Joe Biden has pledged to push through Congress a $1.9 billion relief package that includes aid to states, while congressional Republicans are proposing a package worth about a third of that amount. States are banking on federal help.
Michael Leachman
New York Gov. Andrew Cuomo, a Democrat, predicted his state would have to plug a $15 billion deficit with spending cuts and tax increases if a fresh round of aid doesn’t materialize. Some states, such as New Jersey, borrowed to make their budgets whole, and they’re going to have to start paying that money back. Tourism states such as Hawaii and energy-producing states such as Alaska and Wyoming continue to face grim economic outlooks with oil, gas, and coal prices down and tourists cutting back on travel, Mr. Leachman said.
Even states with a relatively rosy economic outlook are being cautious. In Colorado, for example, Democratic Gov. Jared Polis proposed a budget that restores the cuts made last year to Medicaid and substance abuse programs. But health providers are doubtful the legislature will approve any significant spending increases in this economy.
“Everybody right now is just trying to protect and make sure we don’t have additional cuts,” said Doyle Forrestal, CEO of the Colorado Behavioral Healthcare Council.
That’s also what Ms. Buckley-Patton wants for Montana’s Beaverhead County, where most of the 9,400 residents live in poverty or earn low incomes.
She led the county’s effort to recover from the loss in 2017 of a wide range of behavioral health services, along with offices to help poor people receive Medicaid health services, plus cash and food assistance.
Through persuasive grant writing and donations coaxed from elected officials, Ms. Buckley-Patton and her team secured office space, equipment, and a part-time employee for a resource center that’s open once a week in the county in the southwestern corner of the state, she said. They also convinced the state health department to send two people every other week on a 120-mile round trip from the Butte office to help county residents with their Medicaid and public assistance applications.
But now Ms. Buckley-Patton worries even those modest gains will be threatened in this year’s budget. Montana is one of the few states with a budget on a 2-year cycle, so this is the first time lawmakers have had to craft a spending plan since the pandemic began.
Revenue forecasts predict healthy tax collections over the next 2 years.
In January, at the start of the legislative session, the panel in charge of building the state health department’s budget proposed starting with nearly $1 billion in cuts. The panel’s chairperson, Republican Rep. Matt Regier, pledged to add back programs and services on their merits during the months-long budget process.
It’s a strategy Ms. Buckley-Patton worries will lead to a net loss of funding for Beaverhead County, which covers more land than Connecticut.
“I have grave concerns about this legislative session,” she said. “We’re not digging out of the hole; we’re only going deeper.”
Republicans, who are in control of the Montana House, Senate, and governor’s office for the first time in 16 years, are considering reducing the income tax level for the state’s top earners. Such a measure that could affect state revenue in an uncertain economy has some observers concerned, particularly when an increased need for health services is expected.
“Are legislators committed to building back up that budget in a way that works for communities and for health providers, or are we going to see tax cuts that reduce revenue that put us yet again in another really tight budget?” asked Heather O’Loughlin, codirector of the Montana Budget and Policy Center.
Mary Windecker, executive director of the Behavioral Health Alliance of Montana, said that health providers across the state are still clawing back from more than $100 million in budget cuts in 2017, and that she worries more cuts are on the horizon.
Mary Windecker
But one bright spot, she said, is a proposal by new Gov. Greg Gianforte to create a fund that would put $23 million a year toward community substance abuse prevention and treatment programs. It would be partially funded by tax revenue the state will receive from recreational marijuana, which voters approved in November, with sales to begin next year.
Ms. Windecker cautioned, though, that mental health and substance use are linked, and the governor and lawmakers should plan with that in mind.
“In the public’s mind, there’s drug addicts and there’s the mentally ill,” she said. “Quite often, the same people who have a substance use disorder are using it to treat a mental health issue that is underlying that substance use. So, you can never split the two out.”
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.
When the pandemic hit, health officials in Montana’s Beaverhead County had barely begun to fill a hole left by the 2017 closure of the local public assistance office, mental health clinic, chemical dependency center and job placement office after the state’s last budget shortfall.
Now, those health officials worry more cuts are coming, even as they brace for a spike in demand for substance abuse and mental health services. That would be no small challenge in a poor farming and ranching region where stigma often prevents people from admitting they need help, said Katherine Buckley-Patton, who chairs the county’s Mental Health Local Advisory Council.
“I find it very challenging to find the words that will not make one of my hard-nosed cowboys turn around and walk away,” Ms. Buckley-Patton said. “They’re lonely, they’re isolated, they’re depressed, but they’re not going to call a suicide hotline.”
States across the U.S. are still stinging after businesses closed and millions of people lost jobs because of COVID-related shutdowns and restrictions. Meanwhile, the pandemic has led to a dramatic increase in the number of people who say their mental health has suffered, rising from one in three people in March to more than half of people polled by KFF in July. (KHN is an editorially independent program of KFF.)
The full extent of the mental health crisis and the demand for behavioral health services may not be known until after the pandemic is over, mental health experts said. That could add costs that budget writers haven’t anticipated.
Chuck Ingoglia
“It usually takes a while before people feel comfortable seeking care from a specialty behavioral health organization,” said Chuck Ingoglia, president and CEO of the nonprofit National Council for Behavioral Health in Washington, D.C. “We are not likely to see the results of that either in terms of people seeking care – or suicide rates going up – until we’re on the other side of the pandemic.”
Last year, states slashed agency budgets, froze pay, furloughed workers, borrowed money, and tapped into rainy-day funds to make ends meet. Health programs, often among the most expensive part of a state’s budget, were targeted for cuts in several states even as health officials led efforts to stem the spread of the coronavirus.
This year, the outlook doesn’t seem quite so bleak, partly because of relief packages passed by Congress last spring and in December that buoyed state economies. Another major advantage was that income increased or held steady for people with well-paying jobs and investment income, which boosted states’ tax revenues even as millions of lower-income workers were laid off.
“It has turned out to be not as bad as it might have been in terms of state budgets,” said Mike Leachman, vice president for state fiscal policy for the nonpartisan Center on Budget and Policy Priorities.
But many states still face cash shortfalls that will be made worse if additional federal aid doesn’t come, Mr. Leachman said. President Joe Biden has pledged to push through Congress a $1.9 billion relief package that includes aid to states, while congressional Republicans are proposing a package worth about a third of that amount. States are banking on federal help.
Michael Leachman
New York Gov. Andrew Cuomo, a Democrat, predicted his state would have to plug a $15 billion deficit with spending cuts and tax increases if a fresh round of aid doesn’t materialize. Some states, such as New Jersey, borrowed to make their budgets whole, and they’re going to have to start paying that money back. Tourism states such as Hawaii and energy-producing states such as Alaska and Wyoming continue to face grim economic outlooks with oil, gas, and coal prices down and tourists cutting back on travel, Mr. Leachman said.
Even states with a relatively rosy economic outlook are being cautious. In Colorado, for example, Democratic Gov. Jared Polis proposed a budget that restores the cuts made last year to Medicaid and substance abuse programs. But health providers are doubtful the legislature will approve any significant spending increases in this economy.
“Everybody right now is just trying to protect and make sure we don’t have additional cuts,” said Doyle Forrestal, CEO of the Colorado Behavioral Healthcare Council.
That’s also what Ms. Buckley-Patton wants for Montana’s Beaverhead County, where most of the 9,400 residents live in poverty or earn low incomes.
She led the county’s effort to recover from the loss in 2017 of a wide range of behavioral health services, along with offices to help poor people receive Medicaid health services, plus cash and food assistance.
Through persuasive grant writing and donations coaxed from elected officials, Ms. Buckley-Patton and her team secured office space, equipment, and a part-time employee for a resource center that’s open once a week in the county in the southwestern corner of the state, she said. They also convinced the state health department to send two people every other week on a 120-mile round trip from the Butte office to help county residents with their Medicaid and public assistance applications.
But now Ms. Buckley-Patton worries even those modest gains will be threatened in this year’s budget. Montana is one of the few states with a budget on a 2-year cycle, so this is the first time lawmakers have had to craft a spending plan since the pandemic began.
Revenue forecasts predict healthy tax collections over the next 2 years.
In January, at the start of the legislative session, the panel in charge of building the state health department’s budget proposed starting with nearly $1 billion in cuts. The panel’s chairperson, Republican Rep. Matt Regier, pledged to add back programs and services on their merits during the months-long budget process.
It’s a strategy Ms. Buckley-Patton worries will lead to a net loss of funding for Beaverhead County, which covers more land than Connecticut.
“I have grave concerns about this legislative session,” she said. “We’re not digging out of the hole; we’re only going deeper.”
Republicans, who are in control of the Montana House, Senate, and governor’s office for the first time in 16 years, are considering reducing the income tax level for the state’s top earners. Such a measure that could affect state revenue in an uncertain economy has some observers concerned, particularly when an increased need for health services is expected.
“Are legislators committed to building back up that budget in a way that works for communities and for health providers, or are we going to see tax cuts that reduce revenue that put us yet again in another really tight budget?” asked Heather O’Loughlin, codirector of the Montana Budget and Policy Center.
Mary Windecker, executive director of the Behavioral Health Alliance of Montana, said that health providers across the state are still clawing back from more than $100 million in budget cuts in 2017, and that she worries more cuts are on the horizon.
Mary Windecker
But one bright spot, she said, is a proposal by new Gov. Greg Gianforte to create a fund that would put $23 million a year toward community substance abuse prevention and treatment programs. It would be partially funded by tax revenue the state will receive from recreational marijuana, which voters approved in November, with sales to begin next year.
Ms. Windecker cautioned, though, that mental health and substance use are linked, and the governor and lawmakers should plan with that in mind.
“In the public’s mind, there’s drug addicts and there’s the mentally ill,” she said. “Quite often, the same people who have a substance use disorder are using it to treat a mental health issue that is underlying that substance use. So, you can never split the two out.”
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.
When the pandemic hit, health officials in Montana’s Beaverhead County had barely begun to fill a hole left by the 2017 closure of the local public assistance office, mental health clinic, chemical dependency center and job placement office after the state’s last budget shortfall.
Now, those health officials worry more cuts are coming, even as they brace for a spike in demand for substance abuse and mental health services. That would be no small challenge in a poor farming and ranching region where stigma often prevents people from admitting they need help, said Katherine Buckley-Patton, who chairs the county’s Mental Health Local Advisory Council.
“I find it very challenging to find the words that will not make one of my hard-nosed cowboys turn around and walk away,” Ms. Buckley-Patton said. “They’re lonely, they’re isolated, they’re depressed, but they’re not going to call a suicide hotline.”
States across the U.S. are still stinging after businesses closed and millions of people lost jobs because of COVID-related shutdowns and restrictions. Meanwhile, the pandemic has led to a dramatic increase in the number of people who say their mental health has suffered, rising from one in three people in March to more than half of people polled by KFF in July. (KHN is an editorially independent program of KFF.)
The full extent of the mental health crisis and the demand for behavioral health services may not be known until after the pandemic is over, mental health experts said. That could add costs that budget writers haven’t anticipated.
Chuck Ingoglia
“It usually takes a while before people feel comfortable seeking care from a specialty behavioral health organization,” said Chuck Ingoglia, president and CEO of the nonprofit National Council for Behavioral Health in Washington, D.C. “We are not likely to see the results of that either in terms of people seeking care – or suicide rates going up – until we’re on the other side of the pandemic.”
Last year, states slashed agency budgets, froze pay, furloughed workers, borrowed money, and tapped into rainy-day funds to make ends meet. Health programs, often among the most expensive part of a state’s budget, were targeted for cuts in several states even as health officials led efforts to stem the spread of the coronavirus.
This year, the outlook doesn’t seem quite so bleak, partly because of relief packages passed by Congress last spring and in December that buoyed state economies. Another major advantage was that income increased or held steady for people with well-paying jobs and investment income, which boosted states’ tax revenues even as millions of lower-income workers were laid off.
“It has turned out to be not as bad as it might have been in terms of state budgets,” said Mike Leachman, vice president for state fiscal policy for the nonpartisan Center on Budget and Policy Priorities.
But many states still face cash shortfalls that will be made worse if additional federal aid doesn’t come, Mr. Leachman said. President Joe Biden has pledged to push through Congress a $1.9 billion relief package that includes aid to states, while congressional Republicans are proposing a package worth about a third of that amount. States are banking on federal help.
Michael Leachman
New York Gov. Andrew Cuomo, a Democrat, predicted his state would have to plug a $15 billion deficit with spending cuts and tax increases if a fresh round of aid doesn’t materialize. Some states, such as New Jersey, borrowed to make their budgets whole, and they’re going to have to start paying that money back. Tourism states such as Hawaii and energy-producing states such as Alaska and Wyoming continue to face grim economic outlooks with oil, gas, and coal prices down and tourists cutting back on travel, Mr. Leachman said.
Even states with a relatively rosy economic outlook are being cautious. In Colorado, for example, Democratic Gov. Jared Polis proposed a budget that restores the cuts made last year to Medicaid and substance abuse programs. But health providers are doubtful the legislature will approve any significant spending increases in this economy.
“Everybody right now is just trying to protect and make sure we don’t have additional cuts,” said Doyle Forrestal, CEO of the Colorado Behavioral Healthcare Council.
That’s also what Ms. Buckley-Patton wants for Montana’s Beaverhead County, where most of the 9,400 residents live in poverty or earn low incomes.
She led the county’s effort to recover from the loss in 2017 of a wide range of behavioral health services, along with offices to help poor people receive Medicaid health services, plus cash and food assistance.
Through persuasive grant writing and donations coaxed from elected officials, Ms. Buckley-Patton and her team secured office space, equipment, and a part-time employee for a resource center that’s open once a week in the county in the southwestern corner of the state, she said. They also convinced the state health department to send two people every other week on a 120-mile round trip from the Butte office to help county residents with their Medicaid and public assistance applications.
But now Ms. Buckley-Patton worries even those modest gains will be threatened in this year’s budget. Montana is one of the few states with a budget on a 2-year cycle, so this is the first time lawmakers have had to craft a spending plan since the pandemic began.
Revenue forecasts predict healthy tax collections over the next 2 years.
In January, at the start of the legislative session, the panel in charge of building the state health department’s budget proposed starting with nearly $1 billion in cuts. The panel’s chairperson, Republican Rep. Matt Regier, pledged to add back programs and services on their merits during the months-long budget process.
It’s a strategy Ms. Buckley-Patton worries will lead to a net loss of funding for Beaverhead County, which covers more land than Connecticut.
“I have grave concerns about this legislative session,” she said. “We’re not digging out of the hole; we’re only going deeper.”
Republicans, who are in control of the Montana House, Senate, and governor’s office for the first time in 16 years, are considering reducing the income tax level for the state’s top earners. Such a measure that could affect state revenue in an uncertain economy has some observers concerned, particularly when an increased need for health services is expected.
“Are legislators committed to building back up that budget in a way that works for communities and for health providers, or are we going to see tax cuts that reduce revenue that put us yet again in another really tight budget?” asked Heather O’Loughlin, codirector of the Montana Budget and Policy Center.
Mary Windecker, executive director of the Behavioral Health Alliance of Montana, said that health providers across the state are still clawing back from more than $100 million in budget cuts in 2017, and that she worries more cuts are on the horizon.
Mary Windecker
But one bright spot, she said, is a proposal by new Gov. Greg Gianforte to create a fund that would put $23 million a year toward community substance abuse prevention and treatment programs. It would be partially funded by tax revenue the state will receive from recreational marijuana, which voters approved in November, with sales to begin next year.
Ms. Windecker cautioned, though, that mental health and substance use are linked, and the governor and lawmakers should plan with that in mind.
“In the public’s mind, there’s drug addicts and there’s the mentally ill,” she said. “Quite often, the same people who have a substance use disorder are using it to treat a mental health issue that is underlying that substance use. So, you can never split the two out.”
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.
Higher fiber intake may be associated with decreased risk of depression in premenopausal women, new research suggests.
Nic_Ol/Thinkstock
Investigators analyzed data from close to 6,000 pre- and postmenopausal women. They found that, in premenopausal women, dietary fiber intake was higher among those without depression versus their counterparts with the disorder in a dose-dependent manner. However, there appeared to be no relationship between higher fiber intake and depression risk in postmenopausal women.
“We think the most important finding of our study is that dietary fiber intake was inversely associated with depression in premenopausal but not postmenopausal women,” lead author Yunsun Kim, MD, resident, department of family medicine, Chung-Ang University Hospital, Seoul, South Korea, said in an interview.
“We hope that the findings of this study could form the basis of future investigations to determine the causal relationship between dietary fiber intake and depression,” she added.
The prevalence of depression is twice as high in women, compared with men, which may be attributable to a number of factors, including hormonal status – especially during menstruation and menopause, the authors wrote.
Previous research suggests a potential association between dietary fiber and depression in premenopausal women and between estrogen and gut microbiota. Fiber intake has an impact on gut microbiota, Dr. Kim said.
“We are motivated by the fact that depression provokes disease burden internationally and we would like to find modifiable factors that could prevent depression, especially in women, who are more vulnerable to depression,” she noted.
To investigate, the researchers drew on data from the Korea National Health and Nutrition Examination Survey for 2014, 2016, and 2018. Of the total number of women who met inclusion criteria (n = 5807; mean age, 47.11), roughly half were premenopausal and half were postmenopausal (n = 2,949 [mean age, 36.23 years] and n = 2,868 [mean age, 62.73], respectively).
Dietary fiber intake was assessed using the 24-hour dietary recall method, while depression was assessed using the Patient Health Questionnaire-9. The researchers used the Dietary Reference Intakes for Koreans to define a sufficient intake of dietary fiber (i.e., 12 g/1,000 kcal).
Covariates included chronic diseases, body mass index, medications, smoking status, alcohol use, physical activity, and sociodemographic factors.
When the researchers looked at all participants, they found that the estimated mean dietary fiber intake was significantly higher in women without depression, compared with those with depression (14.07 g/1,000 kcal/d; 95% confidence interval, 13.85-14.29 vs. 12.67 g/1,000 kcal/d; 95% CI, 11.79-13.55; P = .003).
Although the relationship remained significant in premenopausal women, it lost significance in postmenopausal women.
A 5% decrease in the prevalence of depression in premenopausal (but not postmenopausal) women was found in those with an increased intake of dietary fiber – i..e, there was a 1-g increase for every 1,000 kcal of daily energy intake, after adjusting for potential confounders in premenopausal women (OR, 0.949; 95% CI, 0.906-0.993]).
“The inverse relationship between dietary fiber intake and depression could be explained by the gut-brain interactions,” said Dr. Kim.
“Changes in the gut microbiota composition may affect neurotransmission and various neuropsychiatric phenomena in the brain,” she said, noting that previous studies have suggested that dietary fiber intake “may modulate the richness and diversity of the gut microbiota, and this change may promote brain health by affecting neurotransmission.”
Because postmenopausal women experience estrogen depletion, “the decreased interaction between estrogen and the gut microbiota may be related to the insignificant association between dietary fiber intake and depression in postmenopausal women,” she said.
Despite the lack of a significant association between postmenopausal depression and fiber intake, Dr. Kim said she “advises middle-aged women to have dietary fiber–rich diets, regardless of their menopausal status.”
Link between food and mood
In a comment, Stephanie S. Faubion, MD, MBA, a professor and chair of the department of medicine and the Penny and Bill George director of the Mayo Clinic’s Center for Women’s Health in Rochester, Minn., noted the study was cross-sectional and therefore the direction of the association could not be determined and “causality cannot be assumed.”
It is possible that “depressed women are less likely to eat fiber than women without depression. For example, a depressed woman may be more likely to sit on the couch eating Cheetos than shopping for and preparing a healthy meal,” said Dr. Faubion, who is also the medical director of the North American Menopause Society and was not involved with the study.
She noted that other potential confounders, including access to fresh fruits and vegetables or geographic locations could also “impact the findings and it is important that we do not somehow imply that eating a high-fiber diet can in any way treat a major depression.”
Nevertheless, the study does “add to the body of evidence suggesting a link between diet and overall health, including brain health,” Dr. Faubion said.
One take-home message for practicing clinicians is that a healthy diet that includes fiber may benefit women (and men) for a number of reasons and “appears to be linked to mood.”
More research is needed “to determine the pathophysiologic mechanisms (such as potential brain-gut connection that involves the microbiome) that may explain this association,” Dr. Faubion added.
No source of funding listed. Dr. Kim and coauthors, as well as Dr. Faubion, disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Higher fiber intake may be associated with decreased risk of depression in premenopausal women, new research suggests.
Nic_Ol/Thinkstock
Investigators analyzed data from close to 6,000 pre- and postmenopausal women. They found that, in premenopausal women, dietary fiber intake was higher among those without depression versus their counterparts with the disorder in a dose-dependent manner. However, there appeared to be no relationship between higher fiber intake and depression risk in postmenopausal women.
“We think the most important finding of our study is that dietary fiber intake was inversely associated with depression in premenopausal but not postmenopausal women,” lead author Yunsun Kim, MD, resident, department of family medicine, Chung-Ang University Hospital, Seoul, South Korea, said in an interview.
“We hope that the findings of this study could form the basis of future investigations to determine the causal relationship between dietary fiber intake and depression,” she added.
The prevalence of depression is twice as high in women, compared with men, which may be attributable to a number of factors, including hormonal status – especially during menstruation and menopause, the authors wrote.
Previous research suggests a potential association between dietary fiber and depression in premenopausal women and between estrogen and gut microbiota. Fiber intake has an impact on gut microbiota, Dr. Kim said.
“We are motivated by the fact that depression provokes disease burden internationally and we would like to find modifiable factors that could prevent depression, especially in women, who are more vulnerable to depression,” she noted.
To investigate, the researchers drew on data from the Korea National Health and Nutrition Examination Survey for 2014, 2016, and 2018. Of the total number of women who met inclusion criteria (n = 5807; mean age, 47.11), roughly half were premenopausal and half were postmenopausal (n = 2,949 [mean age, 36.23 years] and n = 2,868 [mean age, 62.73], respectively).
Dietary fiber intake was assessed using the 24-hour dietary recall method, while depression was assessed using the Patient Health Questionnaire-9. The researchers used the Dietary Reference Intakes for Koreans to define a sufficient intake of dietary fiber (i.e., 12 g/1,000 kcal).
Covariates included chronic diseases, body mass index, medications, smoking status, alcohol use, physical activity, and sociodemographic factors.
When the researchers looked at all participants, they found that the estimated mean dietary fiber intake was significantly higher in women without depression, compared with those with depression (14.07 g/1,000 kcal/d; 95% confidence interval, 13.85-14.29 vs. 12.67 g/1,000 kcal/d; 95% CI, 11.79-13.55; P = .003).
Although the relationship remained significant in premenopausal women, it lost significance in postmenopausal women.
A 5% decrease in the prevalence of depression in premenopausal (but not postmenopausal) women was found in those with an increased intake of dietary fiber – i..e, there was a 1-g increase for every 1,000 kcal of daily energy intake, after adjusting for potential confounders in premenopausal women (OR, 0.949; 95% CI, 0.906-0.993]).
“The inverse relationship between dietary fiber intake and depression could be explained by the gut-brain interactions,” said Dr. Kim.
“Changes in the gut microbiota composition may affect neurotransmission and various neuropsychiatric phenomena in the brain,” she said, noting that previous studies have suggested that dietary fiber intake “may modulate the richness and diversity of the gut microbiota, and this change may promote brain health by affecting neurotransmission.”
Because postmenopausal women experience estrogen depletion, “the decreased interaction between estrogen and the gut microbiota may be related to the insignificant association between dietary fiber intake and depression in postmenopausal women,” she said.
Despite the lack of a significant association between postmenopausal depression and fiber intake, Dr. Kim said she “advises middle-aged women to have dietary fiber–rich diets, regardless of their menopausal status.”
Link between food and mood
In a comment, Stephanie S. Faubion, MD, MBA, a professor and chair of the department of medicine and the Penny and Bill George director of the Mayo Clinic’s Center for Women’s Health in Rochester, Minn., noted the study was cross-sectional and therefore the direction of the association could not be determined and “causality cannot be assumed.”
It is possible that “depressed women are less likely to eat fiber than women without depression. For example, a depressed woman may be more likely to sit on the couch eating Cheetos than shopping for and preparing a healthy meal,” said Dr. Faubion, who is also the medical director of the North American Menopause Society and was not involved with the study.
She noted that other potential confounders, including access to fresh fruits and vegetables or geographic locations could also “impact the findings and it is important that we do not somehow imply that eating a high-fiber diet can in any way treat a major depression.”
Nevertheless, the study does “add to the body of evidence suggesting a link between diet and overall health, including brain health,” Dr. Faubion said.
One take-home message for practicing clinicians is that a healthy diet that includes fiber may benefit women (and men) for a number of reasons and “appears to be linked to mood.”
More research is needed “to determine the pathophysiologic mechanisms (such as potential brain-gut connection that involves the microbiome) that may explain this association,” Dr. Faubion added.
No source of funding listed. Dr. Kim and coauthors, as well as Dr. Faubion, disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Higher fiber intake may be associated with decreased risk of depression in premenopausal women, new research suggests.
Nic_Ol/Thinkstock
Investigators analyzed data from close to 6,000 pre- and postmenopausal women. They found that, in premenopausal women, dietary fiber intake was higher among those without depression versus their counterparts with the disorder in a dose-dependent manner. However, there appeared to be no relationship between higher fiber intake and depression risk in postmenopausal women.
“We think the most important finding of our study is that dietary fiber intake was inversely associated with depression in premenopausal but not postmenopausal women,” lead author Yunsun Kim, MD, resident, department of family medicine, Chung-Ang University Hospital, Seoul, South Korea, said in an interview.
“We hope that the findings of this study could form the basis of future investigations to determine the causal relationship between dietary fiber intake and depression,” she added.
The prevalence of depression is twice as high in women, compared with men, which may be attributable to a number of factors, including hormonal status – especially during menstruation and menopause, the authors wrote.
Previous research suggests a potential association between dietary fiber and depression in premenopausal women and between estrogen and gut microbiota. Fiber intake has an impact on gut microbiota, Dr. Kim said.
“We are motivated by the fact that depression provokes disease burden internationally and we would like to find modifiable factors that could prevent depression, especially in women, who are more vulnerable to depression,” she noted.
To investigate, the researchers drew on data from the Korea National Health and Nutrition Examination Survey for 2014, 2016, and 2018. Of the total number of women who met inclusion criteria (n = 5807; mean age, 47.11), roughly half were premenopausal and half were postmenopausal (n = 2,949 [mean age, 36.23 years] and n = 2,868 [mean age, 62.73], respectively).
Dietary fiber intake was assessed using the 24-hour dietary recall method, while depression was assessed using the Patient Health Questionnaire-9. The researchers used the Dietary Reference Intakes for Koreans to define a sufficient intake of dietary fiber (i.e., 12 g/1,000 kcal).
Covariates included chronic diseases, body mass index, medications, smoking status, alcohol use, physical activity, and sociodemographic factors.
When the researchers looked at all participants, they found that the estimated mean dietary fiber intake was significantly higher in women without depression, compared with those with depression (14.07 g/1,000 kcal/d; 95% confidence interval, 13.85-14.29 vs. 12.67 g/1,000 kcal/d; 95% CI, 11.79-13.55; P = .003).
Although the relationship remained significant in premenopausal women, it lost significance in postmenopausal women.
A 5% decrease in the prevalence of depression in premenopausal (but not postmenopausal) women was found in those with an increased intake of dietary fiber – i..e, there was a 1-g increase for every 1,000 kcal of daily energy intake, after adjusting for potential confounders in premenopausal women (OR, 0.949; 95% CI, 0.906-0.993]).
“The inverse relationship between dietary fiber intake and depression could be explained by the gut-brain interactions,” said Dr. Kim.
“Changes in the gut microbiota composition may affect neurotransmission and various neuropsychiatric phenomena in the brain,” she said, noting that previous studies have suggested that dietary fiber intake “may modulate the richness and diversity of the gut microbiota, and this change may promote brain health by affecting neurotransmission.”
Because postmenopausal women experience estrogen depletion, “the decreased interaction between estrogen and the gut microbiota may be related to the insignificant association between dietary fiber intake and depression in postmenopausal women,” she said.
Despite the lack of a significant association between postmenopausal depression and fiber intake, Dr. Kim said she “advises middle-aged women to have dietary fiber–rich diets, regardless of their menopausal status.”
Link between food and mood
In a comment, Stephanie S. Faubion, MD, MBA, a professor and chair of the department of medicine and the Penny and Bill George director of the Mayo Clinic’s Center for Women’s Health in Rochester, Minn., noted the study was cross-sectional and therefore the direction of the association could not be determined and “causality cannot be assumed.”
It is possible that “depressed women are less likely to eat fiber than women without depression. For example, a depressed woman may be more likely to sit on the couch eating Cheetos than shopping for and preparing a healthy meal,” said Dr. Faubion, who is also the medical director of the North American Menopause Society and was not involved with the study.
She noted that other potential confounders, including access to fresh fruits and vegetables or geographic locations could also “impact the findings and it is important that we do not somehow imply that eating a high-fiber diet can in any way treat a major depression.”
Nevertheless, the study does “add to the body of evidence suggesting a link between diet and overall health, including brain health,” Dr. Faubion said.
One take-home message for practicing clinicians is that a healthy diet that includes fiber may benefit women (and men) for a number of reasons and “appears to be linked to mood.”
More research is needed “to determine the pathophysiologic mechanisms (such as potential brain-gut connection that involves the microbiome) that may explain this association,” Dr. Faubion added.
No source of funding listed. Dr. Kim and coauthors, as well as Dr. Faubion, disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Psychiatrists with expertise in delusional infestation have some advice for dermatologists, infectious disease specialists, and primary care physicians who encounter affected patients: If you want to try to help them, initiate treatment yourself.
Dr. Peter Lepping
“If you see it, try and treat it. These patients are unlikely to agree to see a psychiatrist,” Peter Lepping, MD, said at the Entomology 2020 annual meeting.
Indeed, one of the hallmarks of delusional infestation (DI) is a refusal to even consider referral to a mental health professional, noted Dr. Lepping, a consultation-liaison psychiatrist at Bangor (Wales) University who, together with an infectious disease specialist, codirects one of the world’s few DI multispecialty referral clinics, located at the University of Liverpool School of Tropical Medicine.
That being said, he offered another piece of advice: “Accept that it is not easy to help these patients.”
Dr. Lepping was among a group of distinguished psychiatrists, dermatologists, entomologists, and a neurologist at the annual meeting who participated in a comprehensive session devoted to DI. The experts shared tips on making the diagnosis, establishing the rapport necessary to persuade affected patients to try taking a very-low-dose antipsychotic agent for their delusion, and how to achieve a high rate of therapeutic success. They also highlighted recent research advances in the field, including brain MRI evidence suggesting that impaired somatosensory neural networks mediate symptoms in DI, but not in nonsomatic delusional disorders.
COVID-19 pandemic triggers surge in DI
Entomologist Gail E. Ridge, PhD, has taken notes on all of her thousands of consultations with individuals with suspected DI since the late 1990s. A sharp jump in such contacts occurred during the Great Recession of 2008 in conjunction with the widespread social distress of job loss and threatened economic ruin. Now the same thing is happening as the catastrophic COVID-19 pandemic stretches on. Indeed, during the first 8 months of the pandemic she documented 500 interactions involving people with suspected DI. She’s learned to identify the clues, including a chattering mind, defensiveness, physician avoidance, and rigid body tension.
Courtesy Dr. Gale E. Ridge
Dr. Gale E. Ridge
“They’re fearful of judgment and suggestions of madness. And they’ll pounce on any perceived negativity. I never debunk beliefs; that can immediately backfire. If the medical profession was educated about DI, then many cases could be caught early. I, as the entomologist, and the mental health professionals are often last in line to be seen,” said Dr. Ridge, director of the Insect Information Office at the Connecticut Agricultural Experiment Station in New Haven.
She has noticed a recurring theme in her interactions with these patients: DI often starts with a real underlying medical condition, such as, for example, a cutaneous drug reaction, which over time, progresses to gain a psychiatric component. And she has found that a tipping point often occurs after roughly 6 months of unrelieved symptoms and sensations. Prior to that, affected individuals are concerned about their condition and will seek medical help in a genuine effort to understand what’s going on. They can be redirected. After about 6 months, however, Dr. Ridge has observed “they slide into the rabbit hole of fanaticism and despair.”
Arriving at the diagnosis
In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), DI is classified as a “delusional disorder, somatic type 297.1 F22.” The diagnosis requires that the delusion be present for at least 1 month, criteria for schizophrenia are not met, and the condition cannot be attributed to other medical or neuropsychiatric conditions.
“Many of these people are very high-functioning. I have corporate CEOs who fly in to see me in their private jets. At work, they’re king of their domain. At home, their family is falling apart because of their delusion,” said Dirk M. Elston, MD, professor and chair of the department of dermatology and dermatologic surgery at the Medical University of South Carolina, Charleston.
Dr. Dirk M. Elston
“These people suffer, and the people around them suffer,” he emphasized.
Dozens of medical conditions can cause intractable itching or biting sensations. Far and away at the top of the medical differential diagnosis is thyroid disease, given its high incidence and frequent presentation with anxiety and itch. Other possibilities that can readily be ruled out via lab tests include substance use – especially involving amphetamine/methamphetamine, cocaine, or opioids – liver or kidney disease, diabetes and other sources of peripheral neuropathy, polycythemia, dermatitis herpetiformis, and pemphigus, Dr. Elston said.
Scott A. Norton, MD, MPH, MSc, a dermatologist and preventive medicine specialist at the Uniformed Services University of the Health Sciences in Bethesda, Md., noted that a diagnosis of DI requires three elements: The presence of abnormal sensations in the skin, a patient’s tenacious conviction that the sensations are caused by an infestation, and a lack of supporting evidence for that conviction.
Dr. Scott A. Norton
Taking an accurate medical history can be a challenge in these patients because they are often so guarded. They won’t disclose that they’ve already seen other health care providers, or that they’ve been self-treating with OTC veterinary medicine products, such as high-dose topical or oral ivermectin. They’ll often even deny repeated scratching despite clear evidence to the contrary from the skin exam.
As a dermatologist, Dr. Norton considers his first task to be a search for evidence of an infestation. Scabies is usually the first diagnosis proposed to account for the uncomfortable skin sensations. The presentation can be subtle. While the classic teaching is that the telltale signs of infestation by Sarcoptes scabiei are burrows in the skin and a rash in the web spaces between the fingers, he finds these features are often absent or equivocal.
“I think there are two more reliable presentations of scabies: Check to see if there’s symmetric involvement of the volar or palm side of the wrists; if there isn’t, I’m skeptical of the diagnosis. And every male older than 1 year of age with scabies will have scabies nodules on their genitalia. If the penis, the glans, or the scrotum aren’t involved with the nodules, I discard scabies as a possible diagnosis and look for evidence of other skin conditions that can plausibly explain the sensations and skin lesions, like eczema, contact dermatitis, scalp folliculitis, or dry skin,” he said.
If he can’t find evidence of infestation, he next systematically looks for another dermatologic cause of the patient’s sensations. When that proves fruitless, he tries to determine if there might be a biomedical or neuropsychiatric cause, such as depression, anxiety, schizophrenia, or dementia.
Taking a personal hygiene history is helpful. Patients who believe they have an infestation may bathe or shower three to five times daily with harsh soaps, causing dry, inflamed, itchy and uncomfortable skin.
“Many patients are thrilled to hear the good news that the history, physical examination, and lab tests do not show an infestation and that we have another explanation to account for their unwanted sensations. However, there are some patients who vehemently reject that idea and immediately return to their unwavering, unalterable belief that they are in fact infested. At this point, the possible diagnosis of DI looms large,” the dermatologist said.
Clues suggestive of DI include a patient’s obsessive focus on collecting “specimens” of the offending pathogen in Ziplock bags for assessment during the office visit – “usually a mix of unhelpful household debris and environmental detritus” – and eager presentation of a lengthy and detailed infestation diary, Dr. Norton said.
“Among the most distinctive signs that the patient is detached from reality are the biologically implausible descriptions and explanations of the supposed attacking organism. It’s a fanciful amalgamation of mutable features, behaviors, and life cycles composed of a composite of taxonomically unrelated organisms – for example, fungal hyphae with wings – that shapeshift at will to evade detection,” he said.
Dr. Elston observed that DI skin lesions are typically excoriated, sometimes because of a patient’s systematic use of a sharp object in an effort to dig out the infestation.
“One of the clues is the angularity of the lesion,” the dermatologist noted. “We always say round-to-oval lesions suggest an inside job; angulated lesions suggest an outside job, like fingernail work. There’s often a row of good healing border showing there’s really nothing wrong with wound healing, but a fibrinoid base where the excoriations have occurred. And the lesions are often in various stages of healing.”
Don’t forget neuropathic itch in nondelusional individuals as a potential cause of sensations of infestation and self-injury due to relentless scratching, urged Anne Louise Oaklander, MD, PhD, associate professor of neurology, Harvard Medical School, Boston, who is director of the nerve unit and the neurodiagnostic skin biopsy lab at Massachusetts General Hospital, Boston.
Dr. Anne Louise Oaklander
“There’s no one cause of patients’ impressions that they may have insects. Let’s be sympathetic: It is a normal assumption that insects may be present if the skin itches. One problem is that when patients don’t get good medical diagnoses they make up their own explanations, and sometimes these include persistent ideas of infestation. Many of them don’t realize that their scratching is a cause, not a result, of their skin lesions,” said Dr. Oaklander, who has conducted pioneering research on unintentional self-injury due to neuropathic itch accompanied by loss of pain signaling.
“Rapport first, medication later”
“The office visits are typically difficult to conclude, but skills can be learned and make it much easier to help these people,” Dr. Elston said.
John Koo, MD, emphasized that establishing rapport is “by far” the most important part of managing patients with DI.
Dr. John Koo
“Rapport first, medication later. This may require multiple visits,” said Dr. Koo, professor of dermatology at the University of California, San Francisco, who is a board-certified psychiatrist.
He makes sure he walks into the examination room all smiles and positivity. Patients with DI are eager to expound on their ailment; he lets them talk for a while, then when the timing is right, he actively encourages them to shift their focus away from etiology to treatment.
Dr. Koo and coworkers have described a spectrum of mental fixation in DI ranging from having only crawling and biting sensations, progressing to holding an overvalued idea as to their cause, then on to DSM-5 somatic preoccupation, followed by becoming truly delusional, and finally terminal delusion, where the patient doesn’t care about getting better, but only wants the physician to agree there is an infestation (J Clin Exp Dermatol Res. 2014 Oct. 3. doi: 10.4172/2155-9554.1000241).
“You cannot argue with people with delusions. How you talk to them as a clinician depends on whether they are entirely delusional or not,” he advised. “I cannot agree with their ideation, but I can agree with their misery – and that’s how I make a connection.”
Declining a DI patient’s request for a skin biopsy when it’s obvious there is no infestation can lead to a counterproductive power struggle. Instead, Dr. Koo turns the patient request into an opportunity to form a verbal contract: “I ask, ‘If the result comes back negative, can you be open-minded about the possibility of other etiologies besides parasites?’ ”
As for Dr. Norton, when his schedule shows a patient is coming in for a first visit for a supposed skin infestation, he tells his staff to expect a lengthy session as he works at establishing a good relationship.
“When my patients arrive with bags of specimens, I ask them to select two or three that they’re most confident will have a creature in them. Then I bring a two-headed microscope into the exam room and ask the patient to join me in examining the material. It helps with rapport by showing that I genuinely want to determine if there’s an infestation,” he explained.
He then sends the specimens to a laboratory, which provides a full report of the findings.
In performing a skin biopsy in a patient with suspected DI, Dr. Norton routinely biopsies two sites so the patient can’t claim sampling error when the pathology report comes back with no pathogens or parasites found. Also, he asks the patient to choose biopsy sites with intact skin where he or she believes the infestation exists. There is no point in biopsying excoriated lesions because they often contain snagged textile fibers.
Another rapport-building strategy: “I try to design a treatment regimen that will palliate the uncomfortable sensations and help relieve the patient’s misery while we continue working towards treating those delusions,” Dr. Norton said.
This might entail cutting back to one lukewarm shower per day with gentle or no soap, coupled with moisturizing, oral antihistamines or doxepin for itch, topical corticosteroids for the associated inflammation, and oral or topical antibiotics for any secondary bacterial skin infection.
What he doesn’t recommend as a rapport-building strategy or simply in order to get the patient out of the office is offering a therapeutic trial of an antiparasitic agent. That’s counterproductive. It may reinforce the false belief of infestation, and when the medication doesn’t bring lasting belief, the patient may conclude the infestation is resistant to conventional treatment.
Dr. Koo tells affected patients that he suspects they have Morgellons syndrome. He doesn’t call it DI in their presence.
“These people would not like their condition to be called delusional,” he explained. “Morgellons is a more neutral term. I tell them it’s a mysterious condition, and that what I’m really interested in is in trying to get them out of their misery.”
Treatment tips
Dr. Koo’s first-line medication for DI is pimozide (Orap), which in the United States has the advantage of being approved only for Tourette syndrome; it’s an antipsychotic without the perceived stigma of a psychiatric indication.
“Many of these patients will not consider taking any medication that has any psychiatric indication,” he noted.
Low-dose pimozide is highly effective, according to Dr. Koo, who recommends starting at 0.5 mg to 1 mg/day, increasing by 0.5 mg/day every 2-4 weeks. The drug is usually effective at a dose of 3 mg/day or less. Once a patient’s symptoms become clear or almost clear, the patient is maintained on that dose for another 3-4 months, then tapered by 0.5 mg/day every 2-4 weeks.
“In 35 years of seeing a new patient on average every week or two, I’ve had only five patients with one recurrence and one patient with two recurrences. All six responded to repeat therapy,” Dr. Koo said.
Side effects at these low doses are “very rare,” he added. Diphenhydramine (Benadryl) at 25 mg up to four times daily is effective for complaints of stiffness or restlessness. Prolongation of the QT interval is a potential concern, but Dr. Koo has never encountered it despite routinely ordering ECGs for patients on pimozide with known heart disease or who are over age 50.
When a patient can’t tolerate pimozide, Dr. Koo’s second-line antipsychotic for DI is low-dose risperidone (Risperdal), which is also highly effective.
Dr. Lepping noted that the European situation is different. There, unlike in the United States, pimozide has regulatory approval as an antipsychotic, so it loses the advantage of being an under-the-radar neuroleptic. His go-to medication is the first-generation antipsychotic sulpiride (Dogmatil), which he finds has a more favorable side effect profile than pimozide, particularly in the elderly. (Sulpiride is not approved in the United States.)
In treating DI, he prefers more dopaminergic-focused antipsychotics over those covering a broader spectrum of receptors. His alternatives to sulpiride include risperidone and olanzapine, atypical antipsychotics. He explains to patients that just as aspirin is used in low doses for its antiplatelet effect and in higher doses for pain relief, these medications can help them feel better at much lower doses than for schizophrenia.
“Once we get some rapport and a trusting relationship going, we normally try to persuade people to basically try something against their better judgment. We know that they don’t believe in it, but you try to get them to at least try something because everything else has failed,” Dr. Lepping explained. “We tell them it’s a condition we have seen before, and we have seen these medications to be useful because they are good for their distress, they help with making them calmer, and they might help with their symptoms. We say, ‘What do you have to lose if you trust us?’
“About 60% of our patients take the medication and almost invariably they all get better,” the psychiatrist said. “The others we either lose to follow-up or they just refuse to take the medication.”
A patient’s first visit to the Liverpool multispecialty DI referral clinic is 1 hour long. “They know that in advance, and we very much stick to that hour. We say to people up front, ‘We have an hour – that’s a lot, but we don’t have more,’ ” he said.
The initial visit is typically followed by two to four 30-minute follow-up visits. Dr. Lepping recommends that when possible, patients with DI should be seen jointly by a psychiatrist and a nonpsychiatrist physician. He finds this approach leads to substantially better clinical outcomes than with a single health care provider.
“If you have two people in the clinic with the patient, when you get really annoyed and your amygdala really starts going, that’s the time when you can then turn to your colleague and say, ‘Oh yes, and Professor Squire, what do you have to say to that?’ So as you see the red mist rising in yourself because you’re getting so exasperated, you have the other person there to take over so you can calm down. And then the other person does the same. That can be really important to deescalate a heated situation,” Dr. Lepping explained.
Roughly 10% of patients with DI have what is termed folie à deux, where the delusion of infestation is shared by another person.
“Anecdotally, I would say those are much more difficult to treat,” said Jason S. Reichenberg, MD, MBA, professor of medicine (dermatology) at the University of Texas at Austin and president of the Ascension Medical Group Texas.
Dr. Jason S. Reichenberg
“It’s like getting somebody to quit smoking when everybody else in the house is still smoking. It’s very hard to convince a single family member that they’re wrong when everybody else in their family keeps telling them they’re right,” he said.
Recent advances in DI research
Dr. Lepping and coinvestigators at multispecialist DI clinics in London, Italy, and Moscow reported in an unusually large observational study of 236 affected patients that longer duration of untreated psychosis was associated with significantly worse clinical outcome. It’s a finding consistent with Dr. Koo’s construct of progressive stages of delusionality, and it underscores the need for early treatment.
“Having said that, improvement is still possible, even if people have had quite a long time of untreated psychosis,” Dr. Lepping said. The same study also showed that older age at illness onset was inversely associated with good outcome.
In another study, Dr. Lepping and colleagues reported that substance use involving amphetamines, cocaine, opioids, and other drugs that can cause itch was roughly twice as common in a group of patients with DI compared to the general population. “I highly recommend, if at all possible, a drug screen in suspected DI,” he said.
In a large survey of U.S. and Canadian veterinarians, Dr. Lepping and coinvestigators found that these practitioners not infrequently encountered delusional infestation among pet owners who claimed their dog or cat is infested when it’s not. This is called “delusion by proxy,” and it often leads to unwarranted animal euthanasia. Some of these pet owners claim they, too, are infested, which the investigators termed “double delusional infestation.”
MRI studies
Recent structural brain MRI studies support the concept that impaired somatosensory neural networks mediate the delusional symptoms of DI, but not in delusional disorders without somatic content. This was demonstrated in an MRI study by Dr. Lepping and others conducted in 18 patients with DI, 19 others with nonsomatic delusional disorders centered on themes of persecution or jealousy, and 20 healthy volunteers. The DI group had lower gray matter volume in prefrontal, thalamic, striatal, and insular regions of the brain compared to the other two groups.
Of note, mapping of the insula and dorsal striatum indicates they are part of the peripersonal space network, which integrates tactile and visual perceptions involving the area near the body surface. The insula also mediates feelings of pain and disgust.
Some of the same investigators have also recently reported brain MRI evidence specifically of cerebellar dysfunction in patients with DI, who displayed decreased gray matter volume in left lobule VIIa of the cerebellum and increased gray matter volume in bilateral lobule VIIa/crus II compared to patients with non-somatic delusions. This points to a role for impaired cerebellar neural networks related to somatosensory perception in patients with DI but not in those with non-somatic delusions.
Delusional infestation: What’s in a name?
Ekbom syndrome. Delusional parasitosis. Morgellons syndrome. These and other terms are increasingly giving way to ‘delusional infestation’ as the preferred moniker for the disorder. That’s in part because the delusional focus in patients with this condition has shifted over time. In the 19th century, for example, affected patients often attributed their infestation to typhus.
In contemporary practice, roughly one-quarter of affected patients think they are infested by small inanimate objects, most commonly fibers or threads emerging from the skin, rather than by parasites, insects, or worms. In a study of 148 consecutive European patients with suspected DI, Dr. Lepping and coinvestigators reported only 35% believed they were infested by parasites.
“The name ‘delusional infestation’ emphasizes the constantly changing pathogens and covers all present and future variations of the theme that are bound to occur,” Dr. Lepping observed.
All speakers reported having no conflicts of interest.
Psychiatrists with expertise in delusional infestation have some advice for dermatologists, infectious disease specialists, and primary care physicians who encounter affected patients: If you want to try to help them, initiate treatment yourself.
Dr. Peter Lepping
“If you see it, try and treat it. These patients are unlikely to agree to see a psychiatrist,” Peter Lepping, MD, said at the Entomology 2020 annual meeting.
Indeed, one of the hallmarks of delusional infestation (DI) is a refusal to even consider referral to a mental health professional, noted Dr. Lepping, a consultation-liaison psychiatrist at Bangor (Wales) University who, together with an infectious disease specialist, codirects one of the world’s few DI multispecialty referral clinics, located at the University of Liverpool School of Tropical Medicine.
That being said, he offered another piece of advice: “Accept that it is not easy to help these patients.”
Dr. Lepping was among a group of distinguished psychiatrists, dermatologists, entomologists, and a neurologist at the annual meeting who participated in a comprehensive session devoted to DI. The experts shared tips on making the diagnosis, establishing the rapport necessary to persuade affected patients to try taking a very-low-dose antipsychotic agent for their delusion, and how to achieve a high rate of therapeutic success. They also highlighted recent research advances in the field, including brain MRI evidence suggesting that impaired somatosensory neural networks mediate symptoms in DI, but not in nonsomatic delusional disorders.
COVID-19 pandemic triggers surge in DI
Entomologist Gail E. Ridge, PhD, has taken notes on all of her thousands of consultations with individuals with suspected DI since the late 1990s. A sharp jump in such contacts occurred during the Great Recession of 2008 in conjunction with the widespread social distress of job loss and threatened economic ruin. Now the same thing is happening as the catastrophic COVID-19 pandemic stretches on. Indeed, during the first 8 months of the pandemic she documented 500 interactions involving people with suspected DI. She’s learned to identify the clues, including a chattering mind, defensiveness, physician avoidance, and rigid body tension.
Courtesy Dr. Gale E. Ridge
Dr. Gale E. Ridge
“They’re fearful of judgment and suggestions of madness. And they’ll pounce on any perceived negativity. I never debunk beliefs; that can immediately backfire. If the medical profession was educated about DI, then many cases could be caught early. I, as the entomologist, and the mental health professionals are often last in line to be seen,” said Dr. Ridge, director of the Insect Information Office at the Connecticut Agricultural Experiment Station in New Haven.
She has noticed a recurring theme in her interactions with these patients: DI often starts with a real underlying medical condition, such as, for example, a cutaneous drug reaction, which over time, progresses to gain a psychiatric component. And she has found that a tipping point often occurs after roughly 6 months of unrelieved symptoms and sensations. Prior to that, affected individuals are concerned about their condition and will seek medical help in a genuine effort to understand what’s going on. They can be redirected. After about 6 months, however, Dr. Ridge has observed “they slide into the rabbit hole of fanaticism and despair.”
Arriving at the diagnosis
In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), DI is classified as a “delusional disorder, somatic type 297.1 F22.” The diagnosis requires that the delusion be present for at least 1 month, criteria for schizophrenia are not met, and the condition cannot be attributed to other medical or neuropsychiatric conditions.
“Many of these people are very high-functioning. I have corporate CEOs who fly in to see me in their private jets. At work, they’re king of their domain. At home, their family is falling apart because of their delusion,” said Dirk M. Elston, MD, professor and chair of the department of dermatology and dermatologic surgery at the Medical University of South Carolina, Charleston.
Dr. Dirk M. Elston
“These people suffer, and the people around them suffer,” he emphasized.
Dozens of medical conditions can cause intractable itching or biting sensations. Far and away at the top of the medical differential diagnosis is thyroid disease, given its high incidence and frequent presentation with anxiety and itch. Other possibilities that can readily be ruled out via lab tests include substance use – especially involving amphetamine/methamphetamine, cocaine, or opioids – liver or kidney disease, diabetes and other sources of peripheral neuropathy, polycythemia, dermatitis herpetiformis, and pemphigus, Dr. Elston said.
Scott A. Norton, MD, MPH, MSc, a dermatologist and preventive medicine specialist at the Uniformed Services University of the Health Sciences in Bethesda, Md., noted that a diagnosis of DI requires three elements: The presence of abnormal sensations in the skin, a patient’s tenacious conviction that the sensations are caused by an infestation, and a lack of supporting evidence for that conviction.
Dr. Scott A. Norton
Taking an accurate medical history can be a challenge in these patients because they are often so guarded. They won’t disclose that they’ve already seen other health care providers, or that they’ve been self-treating with OTC veterinary medicine products, such as high-dose topical or oral ivermectin. They’ll often even deny repeated scratching despite clear evidence to the contrary from the skin exam.
As a dermatologist, Dr. Norton considers his first task to be a search for evidence of an infestation. Scabies is usually the first diagnosis proposed to account for the uncomfortable skin sensations. The presentation can be subtle. While the classic teaching is that the telltale signs of infestation by Sarcoptes scabiei are burrows in the skin and a rash in the web spaces between the fingers, he finds these features are often absent or equivocal.
“I think there are two more reliable presentations of scabies: Check to see if there’s symmetric involvement of the volar or palm side of the wrists; if there isn’t, I’m skeptical of the diagnosis. And every male older than 1 year of age with scabies will have scabies nodules on their genitalia. If the penis, the glans, or the scrotum aren’t involved with the nodules, I discard scabies as a possible diagnosis and look for evidence of other skin conditions that can plausibly explain the sensations and skin lesions, like eczema, contact dermatitis, scalp folliculitis, or dry skin,” he said.
If he can’t find evidence of infestation, he next systematically looks for another dermatologic cause of the patient’s sensations. When that proves fruitless, he tries to determine if there might be a biomedical or neuropsychiatric cause, such as depression, anxiety, schizophrenia, or dementia.
Taking a personal hygiene history is helpful. Patients who believe they have an infestation may bathe or shower three to five times daily with harsh soaps, causing dry, inflamed, itchy and uncomfortable skin.
“Many patients are thrilled to hear the good news that the history, physical examination, and lab tests do not show an infestation and that we have another explanation to account for their unwanted sensations. However, there are some patients who vehemently reject that idea and immediately return to their unwavering, unalterable belief that they are in fact infested. At this point, the possible diagnosis of DI looms large,” the dermatologist said.
Clues suggestive of DI include a patient’s obsessive focus on collecting “specimens” of the offending pathogen in Ziplock bags for assessment during the office visit – “usually a mix of unhelpful household debris and environmental detritus” – and eager presentation of a lengthy and detailed infestation diary, Dr. Norton said.
“Among the most distinctive signs that the patient is detached from reality are the biologically implausible descriptions and explanations of the supposed attacking organism. It’s a fanciful amalgamation of mutable features, behaviors, and life cycles composed of a composite of taxonomically unrelated organisms – for example, fungal hyphae with wings – that shapeshift at will to evade detection,” he said.
Dr. Elston observed that DI skin lesions are typically excoriated, sometimes because of a patient’s systematic use of a sharp object in an effort to dig out the infestation.
“One of the clues is the angularity of the lesion,” the dermatologist noted. “We always say round-to-oval lesions suggest an inside job; angulated lesions suggest an outside job, like fingernail work. There’s often a row of good healing border showing there’s really nothing wrong with wound healing, but a fibrinoid base where the excoriations have occurred. And the lesions are often in various stages of healing.”
Don’t forget neuropathic itch in nondelusional individuals as a potential cause of sensations of infestation and self-injury due to relentless scratching, urged Anne Louise Oaklander, MD, PhD, associate professor of neurology, Harvard Medical School, Boston, who is director of the nerve unit and the neurodiagnostic skin biopsy lab at Massachusetts General Hospital, Boston.
Dr. Anne Louise Oaklander
“There’s no one cause of patients’ impressions that they may have insects. Let’s be sympathetic: It is a normal assumption that insects may be present if the skin itches. One problem is that when patients don’t get good medical diagnoses they make up their own explanations, and sometimes these include persistent ideas of infestation. Many of them don’t realize that their scratching is a cause, not a result, of their skin lesions,” said Dr. Oaklander, who has conducted pioneering research on unintentional self-injury due to neuropathic itch accompanied by loss of pain signaling.
“Rapport first, medication later”
“The office visits are typically difficult to conclude, but skills can be learned and make it much easier to help these people,” Dr. Elston said.
John Koo, MD, emphasized that establishing rapport is “by far” the most important part of managing patients with DI.
Dr. John Koo
“Rapport first, medication later. This may require multiple visits,” said Dr. Koo, professor of dermatology at the University of California, San Francisco, who is a board-certified psychiatrist.
He makes sure he walks into the examination room all smiles and positivity. Patients with DI are eager to expound on their ailment; he lets them talk for a while, then when the timing is right, he actively encourages them to shift their focus away from etiology to treatment.
Dr. Koo and coworkers have described a spectrum of mental fixation in DI ranging from having only crawling and biting sensations, progressing to holding an overvalued idea as to their cause, then on to DSM-5 somatic preoccupation, followed by becoming truly delusional, and finally terminal delusion, where the patient doesn’t care about getting better, but only wants the physician to agree there is an infestation (J Clin Exp Dermatol Res. 2014 Oct. 3. doi: 10.4172/2155-9554.1000241).
“You cannot argue with people with delusions. How you talk to them as a clinician depends on whether they are entirely delusional or not,” he advised. “I cannot agree with their ideation, but I can agree with their misery – and that’s how I make a connection.”
Declining a DI patient’s request for a skin biopsy when it’s obvious there is no infestation can lead to a counterproductive power struggle. Instead, Dr. Koo turns the patient request into an opportunity to form a verbal contract: “I ask, ‘If the result comes back negative, can you be open-minded about the possibility of other etiologies besides parasites?’ ”
As for Dr. Norton, when his schedule shows a patient is coming in for a first visit for a supposed skin infestation, he tells his staff to expect a lengthy session as he works at establishing a good relationship.
“When my patients arrive with bags of specimens, I ask them to select two or three that they’re most confident will have a creature in them. Then I bring a two-headed microscope into the exam room and ask the patient to join me in examining the material. It helps with rapport by showing that I genuinely want to determine if there’s an infestation,” he explained.
He then sends the specimens to a laboratory, which provides a full report of the findings.
In performing a skin biopsy in a patient with suspected DI, Dr. Norton routinely biopsies two sites so the patient can’t claim sampling error when the pathology report comes back with no pathogens or parasites found. Also, he asks the patient to choose biopsy sites with intact skin where he or she believes the infestation exists. There is no point in biopsying excoriated lesions because they often contain snagged textile fibers.
Another rapport-building strategy: “I try to design a treatment regimen that will palliate the uncomfortable sensations and help relieve the patient’s misery while we continue working towards treating those delusions,” Dr. Norton said.
This might entail cutting back to one lukewarm shower per day with gentle or no soap, coupled with moisturizing, oral antihistamines or doxepin for itch, topical corticosteroids for the associated inflammation, and oral or topical antibiotics for any secondary bacterial skin infection.
What he doesn’t recommend as a rapport-building strategy or simply in order to get the patient out of the office is offering a therapeutic trial of an antiparasitic agent. That’s counterproductive. It may reinforce the false belief of infestation, and when the medication doesn’t bring lasting belief, the patient may conclude the infestation is resistant to conventional treatment.
Dr. Koo tells affected patients that he suspects they have Morgellons syndrome. He doesn’t call it DI in their presence.
“These people would not like their condition to be called delusional,” he explained. “Morgellons is a more neutral term. I tell them it’s a mysterious condition, and that what I’m really interested in is in trying to get them out of their misery.”
Treatment tips
Dr. Koo’s first-line medication for DI is pimozide (Orap), which in the United States has the advantage of being approved only for Tourette syndrome; it’s an antipsychotic without the perceived stigma of a psychiatric indication.
“Many of these patients will not consider taking any medication that has any psychiatric indication,” he noted.
Low-dose pimozide is highly effective, according to Dr. Koo, who recommends starting at 0.5 mg to 1 mg/day, increasing by 0.5 mg/day every 2-4 weeks. The drug is usually effective at a dose of 3 mg/day or less. Once a patient’s symptoms become clear or almost clear, the patient is maintained on that dose for another 3-4 months, then tapered by 0.5 mg/day every 2-4 weeks.
“In 35 years of seeing a new patient on average every week or two, I’ve had only five patients with one recurrence and one patient with two recurrences. All six responded to repeat therapy,” Dr. Koo said.
Side effects at these low doses are “very rare,” he added. Diphenhydramine (Benadryl) at 25 mg up to four times daily is effective for complaints of stiffness or restlessness. Prolongation of the QT interval is a potential concern, but Dr. Koo has never encountered it despite routinely ordering ECGs for patients on pimozide with known heart disease or who are over age 50.
When a patient can’t tolerate pimozide, Dr. Koo’s second-line antipsychotic for DI is low-dose risperidone (Risperdal), which is also highly effective.
Dr. Lepping noted that the European situation is different. There, unlike in the United States, pimozide has regulatory approval as an antipsychotic, so it loses the advantage of being an under-the-radar neuroleptic. His go-to medication is the first-generation antipsychotic sulpiride (Dogmatil), which he finds has a more favorable side effect profile than pimozide, particularly in the elderly. (Sulpiride is not approved in the United States.)
In treating DI, he prefers more dopaminergic-focused antipsychotics over those covering a broader spectrum of receptors. His alternatives to sulpiride include risperidone and olanzapine, atypical antipsychotics. He explains to patients that just as aspirin is used in low doses for its antiplatelet effect and in higher doses for pain relief, these medications can help them feel better at much lower doses than for schizophrenia.
“Once we get some rapport and a trusting relationship going, we normally try to persuade people to basically try something against their better judgment. We know that they don’t believe in it, but you try to get them to at least try something because everything else has failed,” Dr. Lepping explained. “We tell them it’s a condition we have seen before, and we have seen these medications to be useful because they are good for their distress, they help with making them calmer, and they might help with their symptoms. We say, ‘What do you have to lose if you trust us?’
“About 60% of our patients take the medication and almost invariably they all get better,” the psychiatrist said. “The others we either lose to follow-up or they just refuse to take the medication.”
A patient’s first visit to the Liverpool multispecialty DI referral clinic is 1 hour long. “They know that in advance, and we very much stick to that hour. We say to people up front, ‘We have an hour – that’s a lot, but we don’t have more,’ ” he said.
The initial visit is typically followed by two to four 30-minute follow-up visits. Dr. Lepping recommends that when possible, patients with DI should be seen jointly by a psychiatrist and a nonpsychiatrist physician. He finds this approach leads to substantially better clinical outcomes than with a single health care provider.
“If you have two people in the clinic with the patient, when you get really annoyed and your amygdala really starts going, that’s the time when you can then turn to your colleague and say, ‘Oh yes, and Professor Squire, what do you have to say to that?’ So as you see the red mist rising in yourself because you’re getting so exasperated, you have the other person there to take over so you can calm down. And then the other person does the same. That can be really important to deescalate a heated situation,” Dr. Lepping explained.
Roughly 10% of patients with DI have what is termed folie à deux, where the delusion of infestation is shared by another person.
“Anecdotally, I would say those are much more difficult to treat,” said Jason S. Reichenberg, MD, MBA, professor of medicine (dermatology) at the University of Texas at Austin and president of the Ascension Medical Group Texas.
Dr. Jason S. Reichenberg
“It’s like getting somebody to quit smoking when everybody else in the house is still smoking. It’s very hard to convince a single family member that they’re wrong when everybody else in their family keeps telling them they’re right,” he said.
Recent advances in DI research
Dr. Lepping and coinvestigators at multispecialist DI clinics in London, Italy, and Moscow reported in an unusually large observational study of 236 affected patients that longer duration of untreated psychosis was associated with significantly worse clinical outcome. It’s a finding consistent with Dr. Koo’s construct of progressive stages of delusionality, and it underscores the need for early treatment.
“Having said that, improvement is still possible, even if people have had quite a long time of untreated psychosis,” Dr. Lepping said. The same study also showed that older age at illness onset was inversely associated with good outcome.
In another study, Dr. Lepping and colleagues reported that substance use involving amphetamines, cocaine, opioids, and other drugs that can cause itch was roughly twice as common in a group of patients with DI compared to the general population. “I highly recommend, if at all possible, a drug screen in suspected DI,” he said.
In a large survey of U.S. and Canadian veterinarians, Dr. Lepping and coinvestigators found that these practitioners not infrequently encountered delusional infestation among pet owners who claimed their dog or cat is infested when it’s not. This is called “delusion by proxy,” and it often leads to unwarranted animal euthanasia. Some of these pet owners claim they, too, are infested, which the investigators termed “double delusional infestation.”
MRI studies
Recent structural brain MRI studies support the concept that impaired somatosensory neural networks mediate the delusional symptoms of DI, but not in delusional disorders without somatic content. This was demonstrated in an MRI study by Dr. Lepping and others conducted in 18 patients with DI, 19 others with nonsomatic delusional disorders centered on themes of persecution or jealousy, and 20 healthy volunteers. The DI group had lower gray matter volume in prefrontal, thalamic, striatal, and insular regions of the brain compared to the other two groups.
Of note, mapping of the insula and dorsal striatum indicates they are part of the peripersonal space network, which integrates tactile and visual perceptions involving the area near the body surface. The insula also mediates feelings of pain and disgust.
Some of the same investigators have also recently reported brain MRI evidence specifically of cerebellar dysfunction in patients with DI, who displayed decreased gray matter volume in left lobule VIIa of the cerebellum and increased gray matter volume in bilateral lobule VIIa/crus II compared to patients with non-somatic delusions. This points to a role for impaired cerebellar neural networks related to somatosensory perception in patients with DI but not in those with non-somatic delusions.
Delusional infestation: What’s in a name?
Ekbom syndrome. Delusional parasitosis. Morgellons syndrome. These and other terms are increasingly giving way to ‘delusional infestation’ as the preferred moniker for the disorder. That’s in part because the delusional focus in patients with this condition has shifted over time. In the 19th century, for example, affected patients often attributed their infestation to typhus.
In contemporary practice, roughly one-quarter of affected patients think they are infested by small inanimate objects, most commonly fibers or threads emerging from the skin, rather than by parasites, insects, or worms. In a study of 148 consecutive European patients with suspected DI, Dr. Lepping and coinvestigators reported only 35% believed they were infested by parasites.
“The name ‘delusional infestation’ emphasizes the constantly changing pathogens and covers all present and future variations of the theme that are bound to occur,” Dr. Lepping observed.
All speakers reported having no conflicts of interest.
Psychiatrists with expertise in delusional infestation have some advice for dermatologists, infectious disease specialists, and primary care physicians who encounter affected patients: If you want to try to help them, initiate treatment yourself.
Dr. Peter Lepping
“If you see it, try and treat it. These patients are unlikely to agree to see a psychiatrist,” Peter Lepping, MD, said at the Entomology 2020 annual meeting.
Indeed, one of the hallmarks of delusional infestation (DI) is a refusal to even consider referral to a mental health professional, noted Dr. Lepping, a consultation-liaison psychiatrist at Bangor (Wales) University who, together with an infectious disease specialist, codirects one of the world’s few DI multispecialty referral clinics, located at the University of Liverpool School of Tropical Medicine.
That being said, he offered another piece of advice: “Accept that it is not easy to help these patients.”
Dr. Lepping was among a group of distinguished psychiatrists, dermatologists, entomologists, and a neurologist at the annual meeting who participated in a comprehensive session devoted to DI. The experts shared tips on making the diagnosis, establishing the rapport necessary to persuade affected patients to try taking a very-low-dose antipsychotic agent for their delusion, and how to achieve a high rate of therapeutic success. They also highlighted recent research advances in the field, including brain MRI evidence suggesting that impaired somatosensory neural networks mediate symptoms in DI, but not in nonsomatic delusional disorders.
COVID-19 pandemic triggers surge in DI
Entomologist Gail E. Ridge, PhD, has taken notes on all of her thousands of consultations with individuals with suspected DI since the late 1990s. A sharp jump in such contacts occurred during the Great Recession of 2008 in conjunction with the widespread social distress of job loss and threatened economic ruin. Now the same thing is happening as the catastrophic COVID-19 pandemic stretches on. Indeed, during the first 8 months of the pandemic she documented 500 interactions involving people with suspected DI. She’s learned to identify the clues, including a chattering mind, defensiveness, physician avoidance, and rigid body tension.
Courtesy Dr. Gale E. Ridge
Dr. Gale E. Ridge
“They’re fearful of judgment and suggestions of madness. And they’ll pounce on any perceived negativity. I never debunk beliefs; that can immediately backfire. If the medical profession was educated about DI, then many cases could be caught early. I, as the entomologist, and the mental health professionals are often last in line to be seen,” said Dr. Ridge, director of the Insect Information Office at the Connecticut Agricultural Experiment Station in New Haven.
She has noticed a recurring theme in her interactions with these patients: DI often starts with a real underlying medical condition, such as, for example, a cutaneous drug reaction, which over time, progresses to gain a psychiatric component. And she has found that a tipping point often occurs after roughly 6 months of unrelieved symptoms and sensations. Prior to that, affected individuals are concerned about their condition and will seek medical help in a genuine effort to understand what’s going on. They can be redirected. After about 6 months, however, Dr. Ridge has observed “they slide into the rabbit hole of fanaticism and despair.”
Arriving at the diagnosis
In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), DI is classified as a “delusional disorder, somatic type 297.1 F22.” The diagnosis requires that the delusion be present for at least 1 month, criteria for schizophrenia are not met, and the condition cannot be attributed to other medical or neuropsychiatric conditions.
“Many of these people are very high-functioning. I have corporate CEOs who fly in to see me in their private jets. At work, they’re king of their domain. At home, their family is falling apart because of their delusion,” said Dirk M. Elston, MD, professor and chair of the department of dermatology and dermatologic surgery at the Medical University of South Carolina, Charleston.
Dr. Dirk M. Elston
“These people suffer, and the people around them suffer,” he emphasized.
Dozens of medical conditions can cause intractable itching or biting sensations. Far and away at the top of the medical differential diagnosis is thyroid disease, given its high incidence and frequent presentation with anxiety and itch. Other possibilities that can readily be ruled out via lab tests include substance use – especially involving amphetamine/methamphetamine, cocaine, or opioids – liver or kidney disease, diabetes and other sources of peripheral neuropathy, polycythemia, dermatitis herpetiformis, and pemphigus, Dr. Elston said.
Scott A. Norton, MD, MPH, MSc, a dermatologist and preventive medicine specialist at the Uniformed Services University of the Health Sciences in Bethesda, Md., noted that a diagnosis of DI requires three elements: The presence of abnormal sensations in the skin, a patient’s tenacious conviction that the sensations are caused by an infestation, and a lack of supporting evidence for that conviction.
Dr. Scott A. Norton
Taking an accurate medical history can be a challenge in these patients because they are often so guarded. They won’t disclose that they’ve already seen other health care providers, or that they’ve been self-treating with OTC veterinary medicine products, such as high-dose topical or oral ivermectin. They’ll often even deny repeated scratching despite clear evidence to the contrary from the skin exam.
As a dermatologist, Dr. Norton considers his first task to be a search for evidence of an infestation. Scabies is usually the first diagnosis proposed to account for the uncomfortable skin sensations. The presentation can be subtle. While the classic teaching is that the telltale signs of infestation by Sarcoptes scabiei are burrows in the skin and a rash in the web spaces between the fingers, he finds these features are often absent or equivocal.
“I think there are two more reliable presentations of scabies: Check to see if there’s symmetric involvement of the volar or palm side of the wrists; if there isn’t, I’m skeptical of the diagnosis. And every male older than 1 year of age with scabies will have scabies nodules on their genitalia. If the penis, the glans, or the scrotum aren’t involved with the nodules, I discard scabies as a possible diagnosis and look for evidence of other skin conditions that can plausibly explain the sensations and skin lesions, like eczema, contact dermatitis, scalp folliculitis, or dry skin,” he said.
If he can’t find evidence of infestation, he next systematically looks for another dermatologic cause of the patient’s sensations. When that proves fruitless, he tries to determine if there might be a biomedical or neuropsychiatric cause, such as depression, anxiety, schizophrenia, or dementia.
Taking a personal hygiene history is helpful. Patients who believe they have an infestation may bathe or shower three to five times daily with harsh soaps, causing dry, inflamed, itchy and uncomfortable skin.
“Many patients are thrilled to hear the good news that the history, physical examination, and lab tests do not show an infestation and that we have another explanation to account for their unwanted sensations. However, there are some patients who vehemently reject that idea and immediately return to their unwavering, unalterable belief that they are in fact infested. At this point, the possible diagnosis of DI looms large,” the dermatologist said.
Clues suggestive of DI include a patient’s obsessive focus on collecting “specimens” of the offending pathogen in Ziplock bags for assessment during the office visit – “usually a mix of unhelpful household debris and environmental detritus” – and eager presentation of a lengthy and detailed infestation diary, Dr. Norton said.
“Among the most distinctive signs that the patient is detached from reality are the biologically implausible descriptions and explanations of the supposed attacking organism. It’s a fanciful amalgamation of mutable features, behaviors, and life cycles composed of a composite of taxonomically unrelated organisms – for example, fungal hyphae with wings – that shapeshift at will to evade detection,” he said.
Dr. Elston observed that DI skin lesions are typically excoriated, sometimes because of a patient’s systematic use of a sharp object in an effort to dig out the infestation.
“One of the clues is the angularity of the lesion,” the dermatologist noted. “We always say round-to-oval lesions suggest an inside job; angulated lesions suggest an outside job, like fingernail work. There’s often a row of good healing border showing there’s really nothing wrong with wound healing, but a fibrinoid base where the excoriations have occurred. And the lesions are often in various stages of healing.”
Don’t forget neuropathic itch in nondelusional individuals as a potential cause of sensations of infestation and self-injury due to relentless scratching, urged Anne Louise Oaklander, MD, PhD, associate professor of neurology, Harvard Medical School, Boston, who is director of the nerve unit and the neurodiagnostic skin biopsy lab at Massachusetts General Hospital, Boston.
Dr. Anne Louise Oaklander
“There’s no one cause of patients’ impressions that they may have insects. Let’s be sympathetic: It is a normal assumption that insects may be present if the skin itches. One problem is that when patients don’t get good medical diagnoses they make up their own explanations, and sometimes these include persistent ideas of infestation. Many of them don’t realize that their scratching is a cause, not a result, of their skin lesions,” said Dr. Oaklander, who has conducted pioneering research on unintentional self-injury due to neuropathic itch accompanied by loss of pain signaling.
“Rapport first, medication later”
“The office visits are typically difficult to conclude, but skills can be learned and make it much easier to help these people,” Dr. Elston said.
John Koo, MD, emphasized that establishing rapport is “by far” the most important part of managing patients with DI.
Dr. John Koo
“Rapport first, medication later. This may require multiple visits,” said Dr. Koo, professor of dermatology at the University of California, San Francisco, who is a board-certified psychiatrist.
He makes sure he walks into the examination room all smiles and positivity. Patients with DI are eager to expound on their ailment; he lets them talk for a while, then when the timing is right, he actively encourages them to shift their focus away from etiology to treatment.
Dr. Koo and coworkers have described a spectrum of mental fixation in DI ranging from having only crawling and biting sensations, progressing to holding an overvalued idea as to their cause, then on to DSM-5 somatic preoccupation, followed by becoming truly delusional, and finally terminal delusion, where the patient doesn’t care about getting better, but only wants the physician to agree there is an infestation (J Clin Exp Dermatol Res. 2014 Oct. 3. doi: 10.4172/2155-9554.1000241).
“You cannot argue with people with delusions. How you talk to them as a clinician depends on whether they are entirely delusional or not,” he advised. “I cannot agree with their ideation, but I can agree with their misery – and that’s how I make a connection.”
Declining a DI patient’s request for a skin biopsy when it’s obvious there is no infestation can lead to a counterproductive power struggle. Instead, Dr. Koo turns the patient request into an opportunity to form a verbal contract: “I ask, ‘If the result comes back negative, can you be open-minded about the possibility of other etiologies besides parasites?’ ”
As for Dr. Norton, when his schedule shows a patient is coming in for a first visit for a supposed skin infestation, he tells his staff to expect a lengthy session as he works at establishing a good relationship.
“When my patients arrive with bags of specimens, I ask them to select two or three that they’re most confident will have a creature in them. Then I bring a two-headed microscope into the exam room and ask the patient to join me in examining the material. It helps with rapport by showing that I genuinely want to determine if there’s an infestation,” he explained.
He then sends the specimens to a laboratory, which provides a full report of the findings.
In performing a skin biopsy in a patient with suspected DI, Dr. Norton routinely biopsies two sites so the patient can’t claim sampling error when the pathology report comes back with no pathogens or parasites found. Also, he asks the patient to choose biopsy sites with intact skin where he or she believes the infestation exists. There is no point in biopsying excoriated lesions because they often contain snagged textile fibers.
Another rapport-building strategy: “I try to design a treatment regimen that will palliate the uncomfortable sensations and help relieve the patient’s misery while we continue working towards treating those delusions,” Dr. Norton said.
This might entail cutting back to one lukewarm shower per day with gentle or no soap, coupled with moisturizing, oral antihistamines or doxepin for itch, topical corticosteroids for the associated inflammation, and oral or topical antibiotics for any secondary bacterial skin infection.
What he doesn’t recommend as a rapport-building strategy or simply in order to get the patient out of the office is offering a therapeutic trial of an antiparasitic agent. That’s counterproductive. It may reinforce the false belief of infestation, and when the medication doesn’t bring lasting belief, the patient may conclude the infestation is resistant to conventional treatment.
Dr. Koo tells affected patients that he suspects they have Morgellons syndrome. He doesn’t call it DI in their presence.
“These people would not like their condition to be called delusional,” he explained. “Morgellons is a more neutral term. I tell them it’s a mysterious condition, and that what I’m really interested in is in trying to get them out of their misery.”
Treatment tips
Dr. Koo’s first-line medication for DI is pimozide (Orap), which in the United States has the advantage of being approved only for Tourette syndrome; it’s an antipsychotic without the perceived stigma of a psychiatric indication.
“Many of these patients will not consider taking any medication that has any psychiatric indication,” he noted.
Low-dose pimozide is highly effective, according to Dr. Koo, who recommends starting at 0.5 mg to 1 mg/day, increasing by 0.5 mg/day every 2-4 weeks. The drug is usually effective at a dose of 3 mg/day or less. Once a patient’s symptoms become clear or almost clear, the patient is maintained on that dose for another 3-4 months, then tapered by 0.5 mg/day every 2-4 weeks.
“In 35 years of seeing a new patient on average every week or two, I’ve had only five patients with one recurrence and one patient with two recurrences. All six responded to repeat therapy,” Dr. Koo said.
Side effects at these low doses are “very rare,” he added. Diphenhydramine (Benadryl) at 25 mg up to four times daily is effective for complaints of stiffness or restlessness. Prolongation of the QT interval is a potential concern, but Dr. Koo has never encountered it despite routinely ordering ECGs for patients on pimozide with known heart disease or who are over age 50.
When a patient can’t tolerate pimozide, Dr. Koo’s second-line antipsychotic for DI is low-dose risperidone (Risperdal), which is also highly effective.
Dr. Lepping noted that the European situation is different. There, unlike in the United States, pimozide has regulatory approval as an antipsychotic, so it loses the advantage of being an under-the-radar neuroleptic. His go-to medication is the first-generation antipsychotic sulpiride (Dogmatil), which he finds has a more favorable side effect profile than pimozide, particularly in the elderly. (Sulpiride is not approved in the United States.)
In treating DI, he prefers more dopaminergic-focused antipsychotics over those covering a broader spectrum of receptors. His alternatives to sulpiride include risperidone and olanzapine, atypical antipsychotics. He explains to patients that just as aspirin is used in low doses for its antiplatelet effect and in higher doses for pain relief, these medications can help them feel better at much lower doses than for schizophrenia.
“Once we get some rapport and a trusting relationship going, we normally try to persuade people to basically try something against their better judgment. We know that they don’t believe in it, but you try to get them to at least try something because everything else has failed,” Dr. Lepping explained. “We tell them it’s a condition we have seen before, and we have seen these medications to be useful because they are good for their distress, they help with making them calmer, and they might help with their symptoms. We say, ‘What do you have to lose if you trust us?’
“About 60% of our patients take the medication and almost invariably they all get better,” the psychiatrist said. “The others we either lose to follow-up or they just refuse to take the medication.”
A patient’s first visit to the Liverpool multispecialty DI referral clinic is 1 hour long. “They know that in advance, and we very much stick to that hour. We say to people up front, ‘We have an hour – that’s a lot, but we don’t have more,’ ” he said.
The initial visit is typically followed by two to four 30-minute follow-up visits. Dr. Lepping recommends that when possible, patients with DI should be seen jointly by a psychiatrist and a nonpsychiatrist physician. He finds this approach leads to substantially better clinical outcomes than with a single health care provider.
“If you have two people in the clinic with the patient, when you get really annoyed and your amygdala really starts going, that’s the time when you can then turn to your colleague and say, ‘Oh yes, and Professor Squire, what do you have to say to that?’ So as you see the red mist rising in yourself because you’re getting so exasperated, you have the other person there to take over so you can calm down. And then the other person does the same. That can be really important to deescalate a heated situation,” Dr. Lepping explained.
Roughly 10% of patients with DI have what is termed folie à deux, where the delusion of infestation is shared by another person.
“Anecdotally, I would say those are much more difficult to treat,” said Jason S. Reichenberg, MD, MBA, professor of medicine (dermatology) at the University of Texas at Austin and president of the Ascension Medical Group Texas.
Dr. Jason S. Reichenberg
“It’s like getting somebody to quit smoking when everybody else in the house is still smoking. It’s very hard to convince a single family member that they’re wrong when everybody else in their family keeps telling them they’re right,” he said.
Recent advances in DI research
Dr. Lepping and coinvestigators at multispecialist DI clinics in London, Italy, and Moscow reported in an unusually large observational study of 236 affected patients that longer duration of untreated psychosis was associated with significantly worse clinical outcome. It’s a finding consistent with Dr. Koo’s construct of progressive stages of delusionality, and it underscores the need for early treatment.
“Having said that, improvement is still possible, even if people have had quite a long time of untreated psychosis,” Dr. Lepping said. The same study also showed that older age at illness onset was inversely associated with good outcome.
In another study, Dr. Lepping and colleagues reported that substance use involving amphetamines, cocaine, opioids, and other drugs that can cause itch was roughly twice as common in a group of patients with DI compared to the general population. “I highly recommend, if at all possible, a drug screen in suspected DI,” he said.
In a large survey of U.S. and Canadian veterinarians, Dr. Lepping and coinvestigators found that these practitioners not infrequently encountered delusional infestation among pet owners who claimed their dog or cat is infested when it’s not. This is called “delusion by proxy,” and it often leads to unwarranted animal euthanasia. Some of these pet owners claim they, too, are infested, which the investigators termed “double delusional infestation.”
MRI studies
Recent structural brain MRI studies support the concept that impaired somatosensory neural networks mediate the delusional symptoms of DI, but not in delusional disorders without somatic content. This was demonstrated in an MRI study by Dr. Lepping and others conducted in 18 patients with DI, 19 others with nonsomatic delusional disorders centered on themes of persecution or jealousy, and 20 healthy volunteers. The DI group had lower gray matter volume in prefrontal, thalamic, striatal, and insular regions of the brain compared to the other two groups.
Of note, mapping of the insula and dorsal striatum indicates they are part of the peripersonal space network, which integrates tactile and visual perceptions involving the area near the body surface. The insula also mediates feelings of pain and disgust.
Some of the same investigators have also recently reported brain MRI evidence specifically of cerebellar dysfunction in patients with DI, who displayed decreased gray matter volume in left lobule VIIa of the cerebellum and increased gray matter volume in bilateral lobule VIIa/crus II compared to patients with non-somatic delusions. This points to a role for impaired cerebellar neural networks related to somatosensory perception in patients with DI but not in those with non-somatic delusions.
Delusional infestation: What’s in a name?
Ekbom syndrome. Delusional parasitosis. Morgellons syndrome. These and other terms are increasingly giving way to ‘delusional infestation’ as the preferred moniker for the disorder. That’s in part because the delusional focus in patients with this condition has shifted over time. In the 19th century, for example, affected patients often attributed their infestation to typhus.
In contemporary practice, roughly one-quarter of affected patients think they are infested by small inanimate objects, most commonly fibers or threads emerging from the skin, rather than by parasites, insects, or worms. In a study of 148 consecutive European patients with suspected DI, Dr. Lepping and coinvestigators reported only 35% believed they were infested by parasites.
“The name ‘delusional infestation’ emphasizes the constantly changing pathogens and covers all present and future variations of the theme that are bound to occur,” Dr. Lepping observed.
All speakers reported having no conflicts of interest.
Adolescents and young adults with mood disorders and cannabis use disorder (CUD) are at significantly increased risk for self-harm, all-cause mortality, homicide, and death by unintentional overdose, new research suggests.
Dr. Cynthia Fontanella
Investigators found the risk for self-harm was three times higher, all-cause mortality was 59% higher, unintentional overdose was 2.5 times higher, and homicide was more than three times higher in those with versus without CUD.
“The take-home message of these findings is that we need to be aware of the perception that cannabis use is harmless, when it’s actually not,” lead author Cynthia Fontanella, PhD, associate professor of psychiatry, Ohio State University Wexner Medical Center, Columbus, said in an interview.
“We need to educate parents and clinicians that there are risks associated with cannabis, including increased risk for self-harm and death, and we need to effectively treat both cannabis use disorder and mood disorders,” she said.
The study was published online Jan. 19, 2021, in JAMA Pediatrics.
Little research in youth
“There has been very little research conducted on CUD in the adolescent population, and most studies have been conducted with adults,” Dr. Fontanella said.
Research on adults has shown that, even in people without mood disorders, cannabis use is associated with the early onset of mood disorders, psychosis, and anxiety disorders and has also been linked with suicidal behavior and increased risk for motor vehicle accidents, Dr. Fontanella said.
iStock/ThinkStockPhotos.com
“We were motivated to conduct this study because we treat kids with depression and bipolar disorder and we noticed a high prevalence of CUD in this population, so we were curious about what its negative effects might be,” Dr. Fontanella recounted.
The researchers analyzed 7-year data drawn from Ohio Medicaid claims and linked to data from death certificates in 204,780 youths between the ages of 10 and 24 years (mean age was 17.2 years at the time of mood disorder diagnosis). Most were female, non-Hispanic White, enrolled in Medicaid because of poverty, and living in a metropolitan area (65.0%, 66.9%, 87.6%, and 77.1%, respectively).
Participants were followed up to 1 year from diagnosis until the end of enrollment, a self-harm event, or death.
Researchers included demographic, clinical, and treatment factors as covariates.
Close to three-quarters (72.7%) of the cohort had a depressive disorder, followed by unspecified/persistent mood disorder and bipolar disorder (14.9% and 12.4%, respectively). Comorbidities included ADHD (12.4%), anxiety disorder (12.3%), and other mental disorders (13.1%).
One -tenth of the cohort (10.3%) were diagnosed with CUD.
CUD treatment referrals
“Although CUD was associated with suicide in the unadjusted model, it was not significantly associated in adjusted models,” the authors reported.
Dr. Fontanella noted that the risk for these adverse outcomes is greater among those who engage in heavy, frequent use or who use cannabis that has higher-potency tetrahydrocannabinol (THC) content.
Reasons why CUD might be associated with these adverse outcomes are that it can increase impulsivity, poor judgment, and clouded thinking, which may in turn increase the risk for self-harm behaviors, she said.
She recommended that clinicians refer youth with CUD for “effective treatments,” including family-based models and individual approaches, such as cognitive behavioral therapy and motivational enhancement therapy.
Open dialogue
In a comment, Wilfrid Noel Raby, MD, PhD, adjunct clinical professor, Albert Einstein College of Medicine, New York, noted that psychosis can occur in patients with CUD and mood disorders – especially bipolar disorder – but was not included as a study outcome. “I would have liked to see more data about that,” he said.
However, a strength of the study was that it included children aged as young as 10 years. “The trend is that cannabis use is starting at younger and younger ages, which has all kinds of ramifications in terms of cerebral development.”
Christopher Hammond, MD, PhD, assistant professor of psychiatry, Johns Hopkins University, Baltimore, said: “Three major strengths of the study are the size of the sample, its longitudinal analysis, and that the authors controlled for a number of potential confounding variables.”
In light of the findings, Dr. Hammond recommended clinicians and other health professionals who work with young people “should screen for cannabis-related problems in youth with mood disorders.”
Dr. Hammond, who is the director of the Co-occurring Disorders in Adolescents and Young Adults Clinical and Research Program, Johns Hopkins Bayview Medical Center, Baltimore, and was not involved with the study, recommended counseling youth with mood disorders and their parents and families “regarding the potential adverse health effects related to cannabis use.”
He also recommended “open dialogue with youth with and without mental health conditions about misleading reports in the national media and advertising about cannabis’ health benefits.”
The study was funded by the National Institute of Mental Health. Dr. Fontanella reported receiving grants from the National Institute of Mental Health during the conduct of the study. Dr. Raby reported no relevant financial relationships. Dr. Hammond reported receiving research grant funding from the National Institutes of Health, the American Academy of Child & Adolescent Psychiatry, Substance Abuse Mental Health Services Administration, the National Network of Depression Centers, and the Armstrong Institute at Johns Hopkins Bayview and serves as a scientific adviser for the National Courts and Science Institute and as a subject matter expert for SAMHSA related to co-occurring substance use disorders and severe emotional disturbance in youth.
A version of this article first appeared on Medscape.com.
Adolescents and young adults with mood disorders and cannabis use disorder (CUD) are at significantly increased risk for self-harm, all-cause mortality, homicide, and death by unintentional overdose, new research suggests.
Dr. Cynthia Fontanella
Investigators found the risk for self-harm was three times higher, all-cause mortality was 59% higher, unintentional overdose was 2.5 times higher, and homicide was more than three times higher in those with versus without CUD.
“The take-home message of these findings is that we need to be aware of the perception that cannabis use is harmless, when it’s actually not,” lead author Cynthia Fontanella, PhD, associate professor of psychiatry, Ohio State University Wexner Medical Center, Columbus, said in an interview.
“We need to educate parents and clinicians that there are risks associated with cannabis, including increased risk for self-harm and death, and we need to effectively treat both cannabis use disorder and mood disorders,” she said.
The study was published online Jan. 19, 2021, in JAMA Pediatrics.
Little research in youth
“There has been very little research conducted on CUD in the adolescent population, and most studies have been conducted with adults,” Dr. Fontanella said.
Research on adults has shown that, even in people without mood disorders, cannabis use is associated with the early onset of mood disorders, psychosis, and anxiety disorders and has also been linked with suicidal behavior and increased risk for motor vehicle accidents, Dr. Fontanella said.
iStock/ThinkStockPhotos.com
“We were motivated to conduct this study because we treat kids with depression and bipolar disorder and we noticed a high prevalence of CUD in this population, so we were curious about what its negative effects might be,” Dr. Fontanella recounted.
The researchers analyzed 7-year data drawn from Ohio Medicaid claims and linked to data from death certificates in 204,780 youths between the ages of 10 and 24 years (mean age was 17.2 years at the time of mood disorder diagnosis). Most were female, non-Hispanic White, enrolled in Medicaid because of poverty, and living in a metropolitan area (65.0%, 66.9%, 87.6%, and 77.1%, respectively).
Participants were followed up to 1 year from diagnosis until the end of enrollment, a self-harm event, or death.
Researchers included demographic, clinical, and treatment factors as covariates.
Close to three-quarters (72.7%) of the cohort had a depressive disorder, followed by unspecified/persistent mood disorder and bipolar disorder (14.9% and 12.4%, respectively). Comorbidities included ADHD (12.4%), anxiety disorder (12.3%), and other mental disorders (13.1%).
One -tenth of the cohort (10.3%) were diagnosed with CUD.
CUD treatment referrals
“Although CUD was associated with suicide in the unadjusted model, it was not significantly associated in adjusted models,” the authors reported.
Dr. Fontanella noted that the risk for these adverse outcomes is greater among those who engage in heavy, frequent use or who use cannabis that has higher-potency tetrahydrocannabinol (THC) content.
Reasons why CUD might be associated with these adverse outcomes are that it can increase impulsivity, poor judgment, and clouded thinking, which may in turn increase the risk for self-harm behaviors, she said.
She recommended that clinicians refer youth with CUD for “effective treatments,” including family-based models and individual approaches, such as cognitive behavioral therapy and motivational enhancement therapy.
Open dialogue
In a comment, Wilfrid Noel Raby, MD, PhD, adjunct clinical professor, Albert Einstein College of Medicine, New York, noted that psychosis can occur in patients with CUD and mood disorders – especially bipolar disorder – but was not included as a study outcome. “I would have liked to see more data about that,” he said.
However, a strength of the study was that it included children aged as young as 10 years. “The trend is that cannabis use is starting at younger and younger ages, which has all kinds of ramifications in terms of cerebral development.”
Christopher Hammond, MD, PhD, assistant professor of psychiatry, Johns Hopkins University, Baltimore, said: “Three major strengths of the study are the size of the sample, its longitudinal analysis, and that the authors controlled for a number of potential confounding variables.”
In light of the findings, Dr. Hammond recommended clinicians and other health professionals who work with young people “should screen for cannabis-related problems in youth with mood disorders.”
Dr. Hammond, who is the director of the Co-occurring Disorders in Adolescents and Young Adults Clinical and Research Program, Johns Hopkins Bayview Medical Center, Baltimore, and was not involved with the study, recommended counseling youth with mood disorders and their parents and families “regarding the potential adverse health effects related to cannabis use.”
He also recommended “open dialogue with youth with and without mental health conditions about misleading reports in the national media and advertising about cannabis’ health benefits.”
The study was funded by the National Institute of Mental Health. Dr. Fontanella reported receiving grants from the National Institute of Mental Health during the conduct of the study. Dr. Raby reported no relevant financial relationships. Dr. Hammond reported receiving research grant funding from the National Institutes of Health, the American Academy of Child & Adolescent Psychiatry, Substance Abuse Mental Health Services Administration, the National Network of Depression Centers, and the Armstrong Institute at Johns Hopkins Bayview and serves as a scientific adviser for the National Courts and Science Institute and as a subject matter expert for SAMHSA related to co-occurring substance use disorders and severe emotional disturbance in youth.
A version of this article first appeared on Medscape.com.
Adolescents and young adults with mood disorders and cannabis use disorder (CUD) are at significantly increased risk for self-harm, all-cause mortality, homicide, and death by unintentional overdose, new research suggests.
Dr. Cynthia Fontanella
Investigators found the risk for self-harm was three times higher, all-cause mortality was 59% higher, unintentional overdose was 2.5 times higher, and homicide was more than three times higher in those with versus without CUD.
“The take-home message of these findings is that we need to be aware of the perception that cannabis use is harmless, when it’s actually not,” lead author Cynthia Fontanella, PhD, associate professor of psychiatry, Ohio State University Wexner Medical Center, Columbus, said in an interview.
“We need to educate parents and clinicians that there are risks associated with cannabis, including increased risk for self-harm and death, and we need to effectively treat both cannabis use disorder and mood disorders,” she said.
The study was published online Jan. 19, 2021, in JAMA Pediatrics.
Little research in youth
“There has been very little research conducted on CUD in the adolescent population, and most studies have been conducted with adults,” Dr. Fontanella said.
Research on adults has shown that, even in people without mood disorders, cannabis use is associated with the early onset of mood disorders, psychosis, and anxiety disorders and has also been linked with suicidal behavior and increased risk for motor vehicle accidents, Dr. Fontanella said.
iStock/ThinkStockPhotos.com
“We were motivated to conduct this study because we treat kids with depression and bipolar disorder and we noticed a high prevalence of CUD in this population, so we were curious about what its negative effects might be,” Dr. Fontanella recounted.
The researchers analyzed 7-year data drawn from Ohio Medicaid claims and linked to data from death certificates in 204,780 youths between the ages of 10 and 24 years (mean age was 17.2 years at the time of mood disorder diagnosis). Most were female, non-Hispanic White, enrolled in Medicaid because of poverty, and living in a metropolitan area (65.0%, 66.9%, 87.6%, and 77.1%, respectively).
Participants were followed up to 1 year from diagnosis until the end of enrollment, a self-harm event, or death.
Researchers included demographic, clinical, and treatment factors as covariates.
Close to three-quarters (72.7%) of the cohort had a depressive disorder, followed by unspecified/persistent mood disorder and bipolar disorder (14.9% and 12.4%, respectively). Comorbidities included ADHD (12.4%), anxiety disorder (12.3%), and other mental disorders (13.1%).
One -tenth of the cohort (10.3%) were diagnosed with CUD.
CUD treatment referrals
“Although CUD was associated with suicide in the unadjusted model, it was not significantly associated in adjusted models,” the authors reported.
Dr. Fontanella noted that the risk for these adverse outcomes is greater among those who engage in heavy, frequent use or who use cannabis that has higher-potency tetrahydrocannabinol (THC) content.
Reasons why CUD might be associated with these adverse outcomes are that it can increase impulsivity, poor judgment, and clouded thinking, which may in turn increase the risk for self-harm behaviors, she said.
She recommended that clinicians refer youth with CUD for “effective treatments,” including family-based models and individual approaches, such as cognitive behavioral therapy and motivational enhancement therapy.
Open dialogue
In a comment, Wilfrid Noel Raby, MD, PhD, adjunct clinical professor, Albert Einstein College of Medicine, New York, noted that psychosis can occur in patients with CUD and mood disorders – especially bipolar disorder – but was not included as a study outcome. “I would have liked to see more data about that,” he said.
However, a strength of the study was that it included children aged as young as 10 years. “The trend is that cannabis use is starting at younger and younger ages, which has all kinds of ramifications in terms of cerebral development.”
Christopher Hammond, MD, PhD, assistant professor of psychiatry, Johns Hopkins University, Baltimore, said: “Three major strengths of the study are the size of the sample, its longitudinal analysis, and that the authors controlled for a number of potential confounding variables.”
In light of the findings, Dr. Hammond recommended clinicians and other health professionals who work with young people “should screen for cannabis-related problems in youth with mood disorders.”
Dr. Hammond, who is the director of the Co-occurring Disorders in Adolescents and Young Adults Clinical and Research Program, Johns Hopkins Bayview Medical Center, Baltimore, and was not involved with the study, recommended counseling youth with mood disorders and their parents and families “regarding the potential adverse health effects related to cannabis use.”
He also recommended “open dialogue with youth with and without mental health conditions about misleading reports in the national media and advertising about cannabis’ health benefits.”
The study was funded by the National Institute of Mental Health. Dr. Fontanella reported receiving grants from the National Institute of Mental Health during the conduct of the study. Dr. Raby reported no relevant financial relationships. Dr. Hammond reported receiving research grant funding from the National Institutes of Health, the American Academy of Child & Adolescent Psychiatry, Substance Abuse Mental Health Services Administration, the National Network of Depression Centers, and the Armstrong Institute at Johns Hopkins Bayview and serves as a scientific adviser for the National Courts and Science Institute and as a subject matter expert for SAMHSA related to co-occurring substance use disorders and severe emotional disturbance in youth.
A version of this article first appeared on Medscape.com.
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.
Dr. Susan Duffy
“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.
“Proportionally, the number of mental health visits is far more significant than it has been in the past,” said Dr. Duffy. “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.
Dr. Christopher Bellonci
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.
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.
Dr. Susan Duffy
“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.
“Proportionally, the number of mental health visits is far more significant than it has been in the past,” said Dr. Duffy. “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.
Dr. Christopher Bellonci
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.
StHelena/Getty Images
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.
Dr. Susan Duffy
“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.
“Proportionally, the number of mental health visits is far more significant than it has been in the past,” said Dr. Duffy. “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.
Dr. Christopher Bellonci
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.
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.
Dr. Michael F. Myers
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.
Dr. Dinah Miller
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.
Dr. Michael F. Myers
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.
Dr. Dinah Miller
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.
Dr. Michael F. Myers
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.
Dr. Dinah Miller
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.
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.
Dr. Richard Cohen and Ms. Nancy Cohen
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.
Dr. Richard Cohen and Ms. Nancy Cohen
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.
Dr. Richard Cohen and Ms. Nancy Cohen
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.
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. “I think the data are very strong.”
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.
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. “I think the data are very strong.”
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.
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. “I think the data are very strong.”
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.
