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Do Antipsychotic Overprescribing Warning Letters Work?
Warning letters to primary care physicians (PCPs) regarding overprescription of quetiapine were helpful in reducing overprescribing of this agent, new research suggested.
Investigators analyzed data from an earlier trial that compared prescribing patterns in 5055 PCPs who receive a placebo letter or three warning letters informing them that their prescribing of quetiapine was high and under review by Medicare. Patients in question all had dementia and were either living in nursing homes or in the community.
The intervention reduced quetiapine use among all patients with dementia, with no detectable adverse effects on cognitive function, behavioral symptoms, depression, metabolic diagnoses, hospitalization, or death.
“This study found that overprescribing warning letters to PCPs safely reduced quetiapine prescribing to their patients with dementia,” wrote investigators led by Adam Sacarny, PhD, of the Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York.
“This intervention and other[s] like it may be useful for future efforts to promote guideline-concordant care,” they added.
The study was published online in JAMA Network Open.
Off-Label Prescribing Common
The off-label use of antipsychotics in patients with dementia is fairly common, the investigators noted, affecting roughly one in seven nursing home residents and a similar number of community-dwelling older adults with dementia.
The agents are often prescribed to treat behavioral symptoms associated with dementia, including agitation and aggression. Although some evidence supports this use, antipsychotics in dementia patients can also cause an increased risk for weight gain, cognitive decline, falls and other injuries, cerebrovascular events, and mortality.
While some professional societies have called for “judicious use of antipsychotics in dementia care,” there is little evidence that reducing antipsychotic use in people with dementia might result in a benefit, investigators wrote.
The researchers analyzed data from a previous trial that focused on quetiapine, which is the most prescribed antipsychotic in the United States and is frequently used for patients with dementia.
In the original study, 2528 PCPs received a placebo letter and 2527 received three warning letters sent by the Centers for Medicare & Medicaid Services (CMS), which identified the highest-volume PCP prescribers of quetiapine.
The warning letters stated that the recipient’s quetiapine prescribing was high relative to their peers and was under review by Medicare. The placebo letter clarified an unrelated regulation.
The current secondary analysis followed the providers and a cohort of their patients from their first receipt of the letters in 2015 through April 2017. The current evaluation analyzes patients’ outcomes through December 2018, utilizing Medicare fee-for-service claims, Minimum Data Set nursing home assessment, and Medicare enrollment data.
Low-Cost, Effective Intervention
While the original study focused on total quetiapine prescribing by study PCPs, the current analysis focused on patients’ total quetiapine use per 90-day period. Additional secondary outcomes included measures of cognitive function and behavioral symptoms, indicators of depression, metabolic diagnoses, indicators of use of hospital and healthcare services, and death.
PCPs in the study had a total of 84,881 patients with dementia living in nursing homes and 261,288 living in the community. At baseline, there were 92,874 patients (mean age, 82 years; 69% female).
The warning letters were associated with reduced quetiapine use among both nursing home patients and community-dwelling patients (adjusted difference, –0.7 days; P = .02 and adjusted difference, −1.5 days; P < .001, respectively).
Among nursing home patients, there were no statistically significant adverse changes in cognitive of behavioral health measures that coincided with reduction in quetiapine use.
Although a higher percentage of treatment vs control patients reported weight loss, the difference was not significant, and rates of metabolic diagnoses were similar in both groups. There were also no significant differences between the groups in emergency department use, inpatient hospital admission, or use of restraints.
Results were similar for patients living in the community.
Additionally, no adverse effects on more severe health endpoints, including rates of hospital use or entry to nursing facilities, were detected. Importantly, the risk for death was statistically significantly lower for patients whose PCPs had received warning letters vs control patients (P = .04).
The analysis “provides evidence that a low-cost letter intervention informed by behavioral science can reduce prescribing of quetiapine to patients with dementia in nursing home and community settings,” the authors wrote.
Researchers did not directly observe the administration of the medication but instead used prescription drug fills as a proxy. Moreover, they could not observe results for patients enrolled in Medicare Advantage, and claims-based and assessment-based outcomes might have been subject to measurement errors and under-ascertainment of diagnoses.
The authors received support from the National Institute on Aging. They reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Warning letters to primary care physicians (PCPs) regarding overprescription of quetiapine were helpful in reducing overprescribing of this agent, new research suggested.
Investigators analyzed data from an earlier trial that compared prescribing patterns in 5055 PCPs who receive a placebo letter or three warning letters informing them that their prescribing of quetiapine was high and under review by Medicare. Patients in question all had dementia and were either living in nursing homes or in the community.
The intervention reduced quetiapine use among all patients with dementia, with no detectable adverse effects on cognitive function, behavioral symptoms, depression, metabolic diagnoses, hospitalization, or death.
“This study found that overprescribing warning letters to PCPs safely reduced quetiapine prescribing to their patients with dementia,” wrote investigators led by Adam Sacarny, PhD, of the Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York.
“This intervention and other[s] like it may be useful for future efforts to promote guideline-concordant care,” they added.
The study was published online in JAMA Network Open.
Off-Label Prescribing Common
The off-label use of antipsychotics in patients with dementia is fairly common, the investigators noted, affecting roughly one in seven nursing home residents and a similar number of community-dwelling older adults with dementia.
The agents are often prescribed to treat behavioral symptoms associated with dementia, including agitation and aggression. Although some evidence supports this use, antipsychotics in dementia patients can also cause an increased risk for weight gain, cognitive decline, falls and other injuries, cerebrovascular events, and mortality.
While some professional societies have called for “judicious use of antipsychotics in dementia care,” there is little evidence that reducing antipsychotic use in people with dementia might result in a benefit, investigators wrote.
The researchers analyzed data from a previous trial that focused on quetiapine, which is the most prescribed antipsychotic in the United States and is frequently used for patients with dementia.
In the original study, 2528 PCPs received a placebo letter and 2527 received three warning letters sent by the Centers for Medicare & Medicaid Services (CMS), which identified the highest-volume PCP prescribers of quetiapine.
The warning letters stated that the recipient’s quetiapine prescribing was high relative to their peers and was under review by Medicare. The placebo letter clarified an unrelated regulation.
The current secondary analysis followed the providers and a cohort of their patients from their first receipt of the letters in 2015 through April 2017. The current evaluation analyzes patients’ outcomes through December 2018, utilizing Medicare fee-for-service claims, Minimum Data Set nursing home assessment, and Medicare enrollment data.
Low-Cost, Effective Intervention
While the original study focused on total quetiapine prescribing by study PCPs, the current analysis focused on patients’ total quetiapine use per 90-day period. Additional secondary outcomes included measures of cognitive function and behavioral symptoms, indicators of depression, metabolic diagnoses, indicators of use of hospital and healthcare services, and death.
PCPs in the study had a total of 84,881 patients with dementia living in nursing homes and 261,288 living in the community. At baseline, there were 92,874 patients (mean age, 82 years; 69% female).
The warning letters were associated with reduced quetiapine use among both nursing home patients and community-dwelling patients (adjusted difference, –0.7 days; P = .02 and adjusted difference, −1.5 days; P < .001, respectively).
Among nursing home patients, there were no statistically significant adverse changes in cognitive of behavioral health measures that coincided with reduction in quetiapine use.
Although a higher percentage of treatment vs control patients reported weight loss, the difference was not significant, and rates of metabolic diagnoses were similar in both groups. There were also no significant differences between the groups in emergency department use, inpatient hospital admission, or use of restraints.
Results were similar for patients living in the community.
Additionally, no adverse effects on more severe health endpoints, including rates of hospital use or entry to nursing facilities, were detected. Importantly, the risk for death was statistically significantly lower for patients whose PCPs had received warning letters vs control patients (P = .04).
The analysis “provides evidence that a low-cost letter intervention informed by behavioral science can reduce prescribing of quetiapine to patients with dementia in nursing home and community settings,” the authors wrote.
Researchers did not directly observe the administration of the medication but instead used prescription drug fills as a proxy. Moreover, they could not observe results for patients enrolled in Medicare Advantage, and claims-based and assessment-based outcomes might have been subject to measurement errors and under-ascertainment of diagnoses.
The authors received support from the National Institute on Aging. They reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Warning letters to primary care physicians (PCPs) regarding overprescription of quetiapine were helpful in reducing overprescribing of this agent, new research suggested.
Investigators analyzed data from an earlier trial that compared prescribing patterns in 5055 PCPs who receive a placebo letter or three warning letters informing them that their prescribing of quetiapine was high and under review by Medicare. Patients in question all had dementia and were either living in nursing homes or in the community.
The intervention reduced quetiapine use among all patients with dementia, with no detectable adverse effects on cognitive function, behavioral symptoms, depression, metabolic diagnoses, hospitalization, or death.
“This study found that overprescribing warning letters to PCPs safely reduced quetiapine prescribing to their patients with dementia,” wrote investigators led by Adam Sacarny, PhD, of the Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York.
“This intervention and other[s] like it may be useful for future efforts to promote guideline-concordant care,” they added.
The study was published online in JAMA Network Open.
Off-Label Prescribing Common
The off-label use of antipsychotics in patients with dementia is fairly common, the investigators noted, affecting roughly one in seven nursing home residents and a similar number of community-dwelling older adults with dementia.
The agents are often prescribed to treat behavioral symptoms associated with dementia, including agitation and aggression. Although some evidence supports this use, antipsychotics in dementia patients can also cause an increased risk for weight gain, cognitive decline, falls and other injuries, cerebrovascular events, and mortality.
While some professional societies have called for “judicious use of antipsychotics in dementia care,” there is little evidence that reducing antipsychotic use in people with dementia might result in a benefit, investigators wrote.
The researchers analyzed data from a previous trial that focused on quetiapine, which is the most prescribed antipsychotic in the United States and is frequently used for patients with dementia.
In the original study, 2528 PCPs received a placebo letter and 2527 received three warning letters sent by the Centers for Medicare & Medicaid Services (CMS), which identified the highest-volume PCP prescribers of quetiapine.
The warning letters stated that the recipient’s quetiapine prescribing was high relative to their peers and was under review by Medicare. The placebo letter clarified an unrelated regulation.
The current secondary analysis followed the providers and a cohort of their patients from their first receipt of the letters in 2015 through April 2017. The current evaluation analyzes patients’ outcomes through December 2018, utilizing Medicare fee-for-service claims, Minimum Data Set nursing home assessment, and Medicare enrollment data.
Low-Cost, Effective Intervention
While the original study focused on total quetiapine prescribing by study PCPs, the current analysis focused on patients’ total quetiapine use per 90-day period. Additional secondary outcomes included measures of cognitive function and behavioral symptoms, indicators of depression, metabolic diagnoses, indicators of use of hospital and healthcare services, and death.
PCPs in the study had a total of 84,881 patients with dementia living in nursing homes and 261,288 living in the community. At baseline, there were 92,874 patients (mean age, 82 years; 69% female).
The warning letters were associated with reduced quetiapine use among both nursing home patients and community-dwelling patients (adjusted difference, –0.7 days; P = .02 and adjusted difference, −1.5 days; P < .001, respectively).
Among nursing home patients, there were no statistically significant adverse changes in cognitive of behavioral health measures that coincided with reduction in quetiapine use.
Although a higher percentage of treatment vs control patients reported weight loss, the difference was not significant, and rates of metabolic diagnoses were similar in both groups. There were also no significant differences between the groups in emergency department use, inpatient hospital admission, or use of restraints.
Results were similar for patients living in the community.
Additionally, no adverse effects on more severe health endpoints, including rates of hospital use or entry to nursing facilities, were detected. Importantly, the risk for death was statistically significantly lower for patients whose PCPs had received warning letters vs control patients (P = .04).
The analysis “provides evidence that a low-cost letter intervention informed by behavioral science can reduce prescribing of quetiapine to patients with dementia in nursing home and community settings,” the authors wrote.
Researchers did not directly observe the administration of the medication but instead used prescription drug fills as a proxy. Moreover, they could not observe results for patients enrolled in Medicare Advantage, and claims-based and assessment-based outcomes might have been subject to measurement errors and under-ascertainment of diagnoses.
The authors received support from the National Institute on Aging. They reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM JAMA NETWORK OPEN
Online, Self-Help Program May Curb Binge Eating
An online program aimed at helping those with binge-eating disorder (BED), based on completing cognitive-behavioral therapy (CBT) modules, showed positive results in a randomized, controlled trial. The findings were published in JAMA Network Open.
In the study, led by Luise Pruessner, MS, with the Department of Psychology at Heidelberg University in Germany, 154 patients (96% female; average age 35.9) who met the criteria for BED were randomized 1-to-1 to the intervention or control group.
12-Week CBT Program with 6 Modules
The intervention group had access to a 12-week CBT online program with a core curriculum of six mandatory modules of texts and videos, focused on self-monitoring of binge eating, psychoeducation, and regulating emotion. Each could be accessed only after the previous module was completed. Participants also chose six specialization areas to personalize the experience. Email reminders were sent to participants who delayed starting the program to boost initial and continuing engagement.
The control group had no access to the program and participants were told they were on a 12-week waiting list for it. They could explore other treatments during that time, an option that mimics real-world experiences. The design choice also helped navigate the ethics of withholding a potentially effective treatment.
Significant Improvement in Outcomes
The intervention group had a significant reduction in binge-eating episodes, the primary outcome, compared with the control group. In the intervention group, the average number of episodes decreased from 14.79 at baseline to 6.07 (95% confidence interval, −11.31 to −6.72; P < .001). The reduction surpassed the clinically meaningful threshold of 3.97 episodes. The control group, as expected, had no significant reductions in episodes.
The intervention group also showed improvement in outcomes including well-being, self-esteem, and emotional regulation and reductions in clinical impairment, depression, and anxiety. “However, there were no meaningful between-group differences regarding changes in work capacity,” the authors noted.
In an invited commentary, Andrea Graham, PhD, with the Center for Behavioral Intervention Technologies at the Feinberg School of Medicine, Northwestern University, Chicago, noted that BED “is a prevalent, serious, and impairing psychiatric illness.”
The study authors pointed out that BED is one of the most prevalent eating disorders, affecting “1.0% to 2.8% of the population over their lifetimes.”
Dr. Graham notes that while there are evidence-based, face-to-face psychological treatments, many patients have considerable barriers to accessing those services.
Digital Intervention Advantages
“Digital interventions, such as the one evaluated by Pruessner and colleagues, have the potential to curb the mental health crisis by reaching large numbers of people in need” in the moments they need help most, she wrote.
She added that with BED, eating decisions and signals for dysregulated eating occur frequently throughout the day, highlighting the need for on-demand and immediate access to self-help, like the solution Ms. Pruessner and colleagues describe.
“The importance of Pruessner and colleagues’ findings is strengthened because their digital intervention did not rely on human support for delivery,” she wrote. Relying on human intervention poses financial challenges for achieving scale.
“Therefore, self-help interventions that achieve clinically significant improvements in outcomes present an important opportunity for closing the treatment gap for binge eating. Given its effectiveness, the critical next step is to learn where and how to implement this intervention to broadly reach individuals in need,” Dr. Graham wrote.
Primary care clinicians don’t typically intervene in eating disorders and a self-help intervention might help address that gap, she added.
“However, a first step would require increasing screening for eating disorders in primary care,” Dr. Graham pointed out.
The authors report no relevant financial relationships. Dr. Graham reports grants from the National Institute of Mental Health, the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), and the Agency for Healthcare Research and Quality. She reports receiving a grant from the NIDDK-funded Chicago Center for Diabetes Translation Research, Dean’s Office of the Biological Sciences Division of the University of Chicago and Feinberg School of Medicine at Northwestern University; and being an adviser to Alavida Health.
An online program aimed at helping those with binge-eating disorder (BED), based on completing cognitive-behavioral therapy (CBT) modules, showed positive results in a randomized, controlled trial. The findings were published in JAMA Network Open.
In the study, led by Luise Pruessner, MS, with the Department of Psychology at Heidelberg University in Germany, 154 patients (96% female; average age 35.9) who met the criteria for BED were randomized 1-to-1 to the intervention or control group.
12-Week CBT Program with 6 Modules
The intervention group had access to a 12-week CBT online program with a core curriculum of six mandatory modules of texts and videos, focused on self-monitoring of binge eating, psychoeducation, and regulating emotion. Each could be accessed only after the previous module was completed. Participants also chose six specialization areas to personalize the experience. Email reminders were sent to participants who delayed starting the program to boost initial and continuing engagement.
The control group had no access to the program and participants were told they were on a 12-week waiting list for it. They could explore other treatments during that time, an option that mimics real-world experiences. The design choice also helped navigate the ethics of withholding a potentially effective treatment.
Significant Improvement in Outcomes
The intervention group had a significant reduction in binge-eating episodes, the primary outcome, compared with the control group. In the intervention group, the average number of episodes decreased from 14.79 at baseline to 6.07 (95% confidence interval, −11.31 to −6.72; P < .001). The reduction surpassed the clinically meaningful threshold of 3.97 episodes. The control group, as expected, had no significant reductions in episodes.
The intervention group also showed improvement in outcomes including well-being, self-esteem, and emotional regulation and reductions in clinical impairment, depression, and anxiety. “However, there were no meaningful between-group differences regarding changes in work capacity,” the authors noted.
In an invited commentary, Andrea Graham, PhD, with the Center for Behavioral Intervention Technologies at the Feinberg School of Medicine, Northwestern University, Chicago, noted that BED “is a prevalent, serious, and impairing psychiatric illness.”
The study authors pointed out that BED is one of the most prevalent eating disorders, affecting “1.0% to 2.8% of the population over their lifetimes.”
Dr. Graham notes that while there are evidence-based, face-to-face psychological treatments, many patients have considerable barriers to accessing those services.
Digital Intervention Advantages
“Digital interventions, such as the one evaluated by Pruessner and colleagues, have the potential to curb the mental health crisis by reaching large numbers of people in need” in the moments they need help most, she wrote.
She added that with BED, eating decisions and signals for dysregulated eating occur frequently throughout the day, highlighting the need for on-demand and immediate access to self-help, like the solution Ms. Pruessner and colleagues describe.
“The importance of Pruessner and colleagues’ findings is strengthened because their digital intervention did not rely on human support for delivery,” she wrote. Relying on human intervention poses financial challenges for achieving scale.
“Therefore, self-help interventions that achieve clinically significant improvements in outcomes present an important opportunity for closing the treatment gap for binge eating. Given its effectiveness, the critical next step is to learn where and how to implement this intervention to broadly reach individuals in need,” Dr. Graham wrote.
Primary care clinicians don’t typically intervene in eating disorders and a self-help intervention might help address that gap, she added.
“However, a first step would require increasing screening for eating disorders in primary care,” Dr. Graham pointed out.
The authors report no relevant financial relationships. Dr. Graham reports grants from the National Institute of Mental Health, the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), and the Agency for Healthcare Research and Quality. She reports receiving a grant from the NIDDK-funded Chicago Center for Diabetes Translation Research, Dean’s Office of the Biological Sciences Division of the University of Chicago and Feinberg School of Medicine at Northwestern University; and being an adviser to Alavida Health.
An online program aimed at helping those with binge-eating disorder (BED), based on completing cognitive-behavioral therapy (CBT) modules, showed positive results in a randomized, controlled trial. The findings were published in JAMA Network Open.
In the study, led by Luise Pruessner, MS, with the Department of Psychology at Heidelberg University in Germany, 154 patients (96% female; average age 35.9) who met the criteria for BED were randomized 1-to-1 to the intervention or control group.
12-Week CBT Program with 6 Modules
The intervention group had access to a 12-week CBT online program with a core curriculum of six mandatory modules of texts and videos, focused on self-monitoring of binge eating, psychoeducation, and regulating emotion. Each could be accessed only after the previous module was completed. Participants also chose six specialization areas to personalize the experience. Email reminders were sent to participants who delayed starting the program to boost initial and continuing engagement.
The control group had no access to the program and participants were told they were on a 12-week waiting list for it. They could explore other treatments during that time, an option that mimics real-world experiences. The design choice also helped navigate the ethics of withholding a potentially effective treatment.
Significant Improvement in Outcomes
The intervention group had a significant reduction in binge-eating episodes, the primary outcome, compared with the control group. In the intervention group, the average number of episodes decreased from 14.79 at baseline to 6.07 (95% confidence interval, −11.31 to −6.72; P < .001). The reduction surpassed the clinically meaningful threshold of 3.97 episodes. The control group, as expected, had no significant reductions in episodes.
The intervention group also showed improvement in outcomes including well-being, self-esteem, and emotional regulation and reductions in clinical impairment, depression, and anxiety. “However, there were no meaningful between-group differences regarding changes in work capacity,” the authors noted.
In an invited commentary, Andrea Graham, PhD, with the Center for Behavioral Intervention Technologies at the Feinberg School of Medicine, Northwestern University, Chicago, noted that BED “is a prevalent, serious, and impairing psychiatric illness.”
The study authors pointed out that BED is one of the most prevalent eating disorders, affecting “1.0% to 2.8% of the population over their lifetimes.”
Dr. Graham notes that while there are evidence-based, face-to-face psychological treatments, many patients have considerable barriers to accessing those services.
Digital Intervention Advantages
“Digital interventions, such as the one evaluated by Pruessner and colleagues, have the potential to curb the mental health crisis by reaching large numbers of people in need” in the moments they need help most, she wrote.
She added that with BED, eating decisions and signals for dysregulated eating occur frequently throughout the day, highlighting the need for on-demand and immediate access to self-help, like the solution Ms. Pruessner and colleagues describe.
“The importance of Pruessner and colleagues’ findings is strengthened because their digital intervention did not rely on human support for delivery,” she wrote. Relying on human intervention poses financial challenges for achieving scale.
“Therefore, self-help interventions that achieve clinically significant improvements in outcomes present an important opportunity for closing the treatment gap for binge eating. Given its effectiveness, the critical next step is to learn where and how to implement this intervention to broadly reach individuals in need,” Dr. Graham wrote.
Primary care clinicians don’t typically intervene in eating disorders and a self-help intervention might help address that gap, she added.
“However, a first step would require increasing screening for eating disorders in primary care,” Dr. Graham pointed out.
The authors report no relevant financial relationships. Dr. Graham reports grants from the National Institute of Mental Health, the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), and the Agency for Healthcare Research and Quality. She reports receiving a grant from the NIDDK-funded Chicago Center for Diabetes Translation Research, Dean’s Office of the Biological Sciences Division of the University of Chicago and Feinberg School of Medicine at Northwestern University; and being an adviser to Alavida Health.
FROM JAMA NETWORK OPEN
Smart Use of Smartphones
Amid the declarations about the current mental health crisis among youth, it has become increasingly common to link rising rates of anxiety and depression among youth to screen time, and more specifically to hours spent on social media. But in truth, this matter is far from settled. The evidence linking mood and anxiety disorders to social media use is inconsistent. And where the evidence is stronger, causality has not been established. Does screen time precipitate an episode of depression or does a preteen at risk for depression, in the midst of a divorce or burdened by learning problems, use screen time excessively as a solution to these problems? There is also substantial variation across age groups, genders, and other factors that suggests that time spent on smartphone apps may not be the primary factor creating risk. Indeed, there is growing uncertainty about whether the climbing rates of anxiety and mood disorders among youth reflect yet to be identified factors increasing the burden of mental illness or the altered screening and tracking landscape in the United States after COVID and the Affordable Care Act. This uncertainty does not mean that we cannot make recommendations about how to guide patients and their families. Smartphones (and watches, glasses, etc) are here to stay.
Start by asking your patients how much time they spend on screens of all sorts and on social media in particular. Find out if there are rules at school or at home limiting screen time or social media. Are there disagreements about screen time? Are patients frustrated with their parents’ use of screens? What are their favorite apps to use? How much time do they think they spend on them? If they don’t know, point out how they can track it on their phone directly. Is it painful to be separated from their phone? Do they have interests or hobbies that are not screen-based? What would they do if the power or Wi-Fi was out for a week? These questions can be the start of an ongoing project for screen time and social media literacy.
Recognize That Apps Are Designed to Be Addictive
Smartphones are useful tools designed to help people stay connected, manage their bank accounts, keep up with current events, access entertainment, and much more. It is easy to spend more time than one intended on them. The applications developed for smartphones promise, and often deliver, efficiency and ease, including staying connected to friends and families. But social media applications have been developed to make their parent companies profit from ad revenue or selling user data. They are designed to encourage more and more use, and for some may become addictive. Start the literacy course with a clear statement of this fact. Remind teenagers that they are often the target audience for the corporations making money from these apps. They are especially sensitive to the likes and followers that can be the currency of social media. For every minute they spend on the apps, a corporation is profiting. It can be helpful to remind teenagers to bring their healthy skepticism of authority to their use of these corporate products.
Develop Awareness of Their Time, Energy, and Mood
Time is our most precious commodity, and most teenagers are stressed by not having enough of it. Ask your patients about the variety of things they need to do and want to do each day. Do they have enough time to do the things they want beyond their smartphones? Is the time on their smartphones more or less than they want? How do they feel when they finish with different activities? Energized? Engaged? Exhilarated? Drained? Irritable? Sad? Do they feel connected? Lonely? Loved? Left out? Suggest that they pay attention to how they feel after engaging in all kinds of activities (including homework, sports, hobbies, and time with friends), as these are the types of choices they will make throughout their adult lives. Some tasks are simply required (homework), some are relaxing (leaving us feeling calm and even sleepy), and some are recharging (leaving us feeling focused and energized). If an activity consistently leaves them drained and irritable, sad, and lonely or discouraged and insecure, they need to step back and ask themselves why they are making this choice and if that is the choice they want to make. Support their developing self-awareness, activating their sense of agency and independence in making choices that will serve them.
Develop Awareness of Their Sense of Connection to Others
As your patients are paying attention to their mood, focus, interest, and energy, they can also pay attention to these components of their social life. How do they feel with individual friends? With different groups? In different settings? How does this compare with how they feel when engaged with social media? In general, when technology is supporting strong connections with friends, it can enhance their health and well-being. When it helps youth isolated by interests or identity to become connected to supportive youth who are physically far away, it can be a social lifeline. But sometimes, social media exploits youth sensitivity to peer opinions and social comparison to keep their attention without the payoff of deepened or new relationships. Do they know the youth they are chatting with or following? Could they spend 2 hours with them offline? How do they feel after spending 2 hours “with” them online? Once again, the goal is to develop teens’ awareness of the quality of their relationships and of their control over how to manage this.
Acknowledge Their Own Vulnerabilities
Does your patient have attention-deficit/hyperactivity disorder (ADHD)? Are they being treated for depression? An anxiety disorder? An eating disorder? While we cannot say whether excessive use of social media can cause these problems, we know that it can be counterproductive to their treatment. Youth with ADHD have great difficulty switching their cognitive focus away from something rewarding, so are particularly prone to spending excessive time in addictive apps. Those with depression often have low energy and initiative alongside feelings of worthlessness that can make engaging in physical, in-person activities challenging. Those with anxiety disorders are prone to rumination and avoidance. The possibility of escaping into virtual social activities or distractions can be very hard to resist and counter-therapeutic for these youth (and adults). Those with eating disorders are vulnerable to comparing themselves with idealized (airbrushed) images online, which can intensify the body image distortion and competitiveness that are common in eating disorders. While there may be helpful information about diagnoses, treatment, and support, there is also troubling information about self-injury, restrictive eating, and even suicide that can increase the risk for these behaviors in vulnerable youth. You can help your patients cultivate awareness of how to take good care of themselves.
Create Habits That Support Sleep, Exercise, and Relationships
Talk with your patients and their parents about strategies to set habits that will make it easier for them to be smart users of their smartphones. Can they explore new apps or games together? Can they talk together about how each of them relaxes and recharges? Then they can work together on how this tool (and toy) can fit into a healthy life. The task is to prioritize sleep, exercise, and live, in-person social time, so virtual activities don’t take over the time needed for them. This can be as simple as consistent bed and waking times and ensuring that smartphones are not at the dining table or in bedrooms at night. Having dinner together as a family most nights (an especially positive habit), going for walks, runs, or hikes together, or doing activities that everyone enjoys (playing music or board games, making cookies or art, gardening) are beneficial for every family member’s physical and mental health and ensure that screen time is not at the expense of real connection. Invite your patients to tell you how they practice putting their smartphones away, getting their homework done, or making time for activities that matter to them. And find out how they relax and recharge beyond using their smartphones. Healthy habits evolve over a lifetime, and there will surely be new technologies that require new limits in the coming years. Helping your patients to make good choices will serve them well as they enter adulthood and throughout their lives.
Dr. Swick is physician in chief at Ohana Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (California) Peninsula. Dr. Michael S. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].
Amid the declarations about the current mental health crisis among youth, it has become increasingly common to link rising rates of anxiety and depression among youth to screen time, and more specifically to hours spent on social media. But in truth, this matter is far from settled. The evidence linking mood and anxiety disorders to social media use is inconsistent. And where the evidence is stronger, causality has not been established. Does screen time precipitate an episode of depression or does a preteen at risk for depression, in the midst of a divorce or burdened by learning problems, use screen time excessively as a solution to these problems? There is also substantial variation across age groups, genders, and other factors that suggests that time spent on smartphone apps may not be the primary factor creating risk. Indeed, there is growing uncertainty about whether the climbing rates of anxiety and mood disorders among youth reflect yet to be identified factors increasing the burden of mental illness or the altered screening and tracking landscape in the United States after COVID and the Affordable Care Act. This uncertainty does not mean that we cannot make recommendations about how to guide patients and their families. Smartphones (and watches, glasses, etc) are here to stay.
Start by asking your patients how much time they spend on screens of all sorts and on social media in particular. Find out if there are rules at school or at home limiting screen time or social media. Are there disagreements about screen time? Are patients frustrated with their parents’ use of screens? What are their favorite apps to use? How much time do they think they spend on them? If they don’t know, point out how they can track it on their phone directly. Is it painful to be separated from their phone? Do they have interests or hobbies that are not screen-based? What would they do if the power or Wi-Fi was out for a week? These questions can be the start of an ongoing project for screen time and social media literacy.
Recognize That Apps Are Designed to Be Addictive
Smartphones are useful tools designed to help people stay connected, manage their bank accounts, keep up with current events, access entertainment, and much more. It is easy to spend more time than one intended on them. The applications developed for smartphones promise, and often deliver, efficiency and ease, including staying connected to friends and families. But social media applications have been developed to make their parent companies profit from ad revenue or selling user data. They are designed to encourage more and more use, and for some may become addictive. Start the literacy course with a clear statement of this fact. Remind teenagers that they are often the target audience for the corporations making money from these apps. They are especially sensitive to the likes and followers that can be the currency of social media. For every minute they spend on the apps, a corporation is profiting. It can be helpful to remind teenagers to bring their healthy skepticism of authority to their use of these corporate products.
Develop Awareness of Their Time, Energy, and Mood
Time is our most precious commodity, and most teenagers are stressed by not having enough of it. Ask your patients about the variety of things they need to do and want to do each day. Do they have enough time to do the things they want beyond their smartphones? Is the time on their smartphones more or less than they want? How do they feel when they finish with different activities? Energized? Engaged? Exhilarated? Drained? Irritable? Sad? Do they feel connected? Lonely? Loved? Left out? Suggest that they pay attention to how they feel after engaging in all kinds of activities (including homework, sports, hobbies, and time with friends), as these are the types of choices they will make throughout their adult lives. Some tasks are simply required (homework), some are relaxing (leaving us feeling calm and even sleepy), and some are recharging (leaving us feeling focused and energized). If an activity consistently leaves them drained and irritable, sad, and lonely or discouraged and insecure, they need to step back and ask themselves why they are making this choice and if that is the choice they want to make. Support their developing self-awareness, activating their sense of agency and independence in making choices that will serve them.
Develop Awareness of Their Sense of Connection to Others
As your patients are paying attention to their mood, focus, interest, and energy, they can also pay attention to these components of their social life. How do they feel with individual friends? With different groups? In different settings? How does this compare with how they feel when engaged with social media? In general, when technology is supporting strong connections with friends, it can enhance their health and well-being. When it helps youth isolated by interests or identity to become connected to supportive youth who are physically far away, it can be a social lifeline. But sometimes, social media exploits youth sensitivity to peer opinions and social comparison to keep their attention without the payoff of deepened or new relationships. Do they know the youth they are chatting with or following? Could they spend 2 hours with them offline? How do they feel after spending 2 hours “with” them online? Once again, the goal is to develop teens’ awareness of the quality of their relationships and of their control over how to manage this.
Acknowledge Their Own Vulnerabilities
Does your patient have attention-deficit/hyperactivity disorder (ADHD)? Are they being treated for depression? An anxiety disorder? An eating disorder? While we cannot say whether excessive use of social media can cause these problems, we know that it can be counterproductive to their treatment. Youth with ADHD have great difficulty switching their cognitive focus away from something rewarding, so are particularly prone to spending excessive time in addictive apps. Those with depression often have low energy and initiative alongside feelings of worthlessness that can make engaging in physical, in-person activities challenging. Those with anxiety disorders are prone to rumination and avoidance. The possibility of escaping into virtual social activities or distractions can be very hard to resist and counter-therapeutic for these youth (and adults). Those with eating disorders are vulnerable to comparing themselves with idealized (airbrushed) images online, which can intensify the body image distortion and competitiveness that are common in eating disorders. While there may be helpful information about diagnoses, treatment, and support, there is also troubling information about self-injury, restrictive eating, and even suicide that can increase the risk for these behaviors in vulnerable youth. You can help your patients cultivate awareness of how to take good care of themselves.
Create Habits That Support Sleep, Exercise, and Relationships
Talk with your patients and their parents about strategies to set habits that will make it easier for them to be smart users of their smartphones. Can they explore new apps or games together? Can they talk together about how each of them relaxes and recharges? Then they can work together on how this tool (and toy) can fit into a healthy life. The task is to prioritize sleep, exercise, and live, in-person social time, so virtual activities don’t take over the time needed for them. This can be as simple as consistent bed and waking times and ensuring that smartphones are not at the dining table or in bedrooms at night. Having dinner together as a family most nights (an especially positive habit), going for walks, runs, or hikes together, or doing activities that everyone enjoys (playing music or board games, making cookies or art, gardening) are beneficial for every family member’s physical and mental health and ensure that screen time is not at the expense of real connection. Invite your patients to tell you how they practice putting their smartphones away, getting their homework done, or making time for activities that matter to them. And find out how they relax and recharge beyond using their smartphones. Healthy habits evolve over a lifetime, and there will surely be new technologies that require new limits in the coming years. Helping your patients to make good choices will serve them well as they enter adulthood and throughout their lives.
Dr. Swick is physician in chief at Ohana Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (California) Peninsula. Dr. Michael S. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].
Amid the declarations about the current mental health crisis among youth, it has become increasingly common to link rising rates of anxiety and depression among youth to screen time, and more specifically to hours spent on social media. But in truth, this matter is far from settled. The evidence linking mood and anxiety disorders to social media use is inconsistent. And where the evidence is stronger, causality has not been established. Does screen time precipitate an episode of depression or does a preteen at risk for depression, in the midst of a divorce or burdened by learning problems, use screen time excessively as a solution to these problems? There is also substantial variation across age groups, genders, and other factors that suggests that time spent on smartphone apps may not be the primary factor creating risk. Indeed, there is growing uncertainty about whether the climbing rates of anxiety and mood disorders among youth reflect yet to be identified factors increasing the burden of mental illness or the altered screening and tracking landscape in the United States after COVID and the Affordable Care Act. This uncertainty does not mean that we cannot make recommendations about how to guide patients and their families. Smartphones (and watches, glasses, etc) are here to stay.
Start by asking your patients how much time they spend on screens of all sorts and on social media in particular. Find out if there are rules at school or at home limiting screen time or social media. Are there disagreements about screen time? Are patients frustrated with their parents’ use of screens? What are their favorite apps to use? How much time do they think they spend on them? If they don’t know, point out how they can track it on their phone directly. Is it painful to be separated from their phone? Do they have interests or hobbies that are not screen-based? What would they do if the power or Wi-Fi was out for a week? These questions can be the start of an ongoing project for screen time and social media literacy.
Recognize That Apps Are Designed to Be Addictive
Smartphones are useful tools designed to help people stay connected, manage their bank accounts, keep up with current events, access entertainment, and much more. It is easy to spend more time than one intended on them. The applications developed for smartphones promise, and often deliver, efficiency and ease, including staying connected to friends and families. But social media applications have been developed to make their parent companies profit from ad revenue or selling user data. They are designed to encourage more and more use, and for some may become addictive. Start the literacy course with a clear statement of this fact. Remind teenagers that they are often the target audience for the corporations making money from these apps. They are especially sensitive to the likes and followers that can be the currency of social media. For every minute they spend on the apps, a corporation is profiting. It can be helpful to remind teenagers to bring their healthy skepticism of authority to their use of these corporate products.
Develop Awareness of Their Time, Energy, and Mood
Time is our most precious commodity, and most teenagers are stressed by not having enough of it. Ask your patients about the variety of things they need to do and want to do each day. Do they have enough time to do the things they want beyond their smartphones? Is the time on their smartphones more or less than they want? How do they feel when they finish with different activities? Energized? Engaged? Exhilarated? Drained? Irritable? Sad? Do they feel connected? Lonely? Loved? Left out? Suggest that they pay attention to how they feel after engaging in all kinds of activities (including homework, sports, hobbies, and time with friends), as these are the types of choices they will make throughout their adult lives. Some tasks are simply required (homework), some are relaxing (leaving us feeling calm and even sleepy), and some are recharging (leaving us feeling focused and energized). If an activity consistently leaves them drained and irritable, sad, and lonely or discouraged and insecure, they need to step back and ask themselves why they are making this choice and if that is the choice they want to make. Support their developing self-awareness, activating their sense of agency and independence in making choices that will serve them.
Develop Awareness of Their Sense of Connection to Others
As your patients are paying attention to their mood, focus, interest, and energy, they can also pay attention to these components of their social life. How do they feel with individual friends? With different groups? In different settings? How does this compare with how they feel when engaged with social media? In general, when technology is supporting strong connections with friends, it can enhance their health and well-being. When it helps youth isolated by interests or identity to become connected to supportive youth who are physically far away, it can be a social lifeline. But sometimes, social media exploits youth sensitivity to peer opinions and social comparison to keep their attention without the payoff of deepened or new relationships. Do they know the youth they are chatting with or following? Could they spend 2 hours with them offline? How do they feel after spending 2 hours “with” them online? Once again, the goal is to develop teens’ awareness of the quality of their relationships and of their control over how to manage this.
Acknowledge Their Own Vulnerabilities
Does your patient have attention-deficit/hyperactivity disorder (ADHD)? Are they being treated for depression? An anxiety disorder? An eating disorder? While we cannot say whether excessive use of social media can cause these problems, we know that it can be counterproductive to their treatment. Youth with ADHD have great difficulty switching their cognitive focus away from something rewarding, so are particularly prone to spending excessive time in addictive apps. Those with depression often have low energy and initiative alongside feelings of worthlessness that can make engaging in physical, in-person activities challenging. Those with anxiety disorders are prone to rumination and avoidance. The possibility of escaping into virtual social activities or distractions can be very hard to resist and counter-therapeutic for these youth (and adults). Those with eating disorders are vulnerable to comparing themselves with idealized (airbrushed) images online, which can intensify the body image distortion and competitiveness that are common in eating disorders. While there may be helpful information about diagnoses, treatment, and support, there is also troubling information about self-injury, restrictive eating, and even suicide that can increase the risk for these behaviors in vulnerable youth. You can help your patients cultivate awareness of how to take good care of themselves.
Create Habits That Support Sleep, Exercise, and Relationships
Talk with your patients and their parents about strategies to set habits that will make it easier for them to be smart users of their smartphones. Can they explore new apps or games together? Can they talk together about how each of them relaxes and recharges? Then they can work together on how this tool (and toy) can fit into a healthy life. The task is to prioritize sleep, exercise, and live, in-person social time, so virtual activities don’t take over the time needed for them. This can be as simple as consistent bed and waking times and ensuring that smartphones are not at the dining table or in bedrooms at night. Having dinner together as a family most nights (an especially positive habit), going for walks, runs, or hikes together, or doing activities that everyone enjoys (playing music or board games, making cookies or art, gardening) are beneficial for every family member’s physical and mental health and ensure that screen time is not at the expense of real connection. Invite your patients to tell you how they practice putting their smartphones away, getting their homework done, or making time for activities that matter to them. And find out how they relax and recharge beyond using their smartphones. Healthy habits evolve over a lifetime, and there will surely be new technologies that require new limits in the coming years. Helping your patients to make good choices will serve them well as they enter adulthood and throughout their lives.
Dr. Swick is physician in chief at Ohana Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (California) Peninsula. Dr. Michael S. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].
Internet Use Good for Mental Well-Being?
Contrary to previous research that suggests internet use can have a deleterious effect on mental health, a new study of more than 2 million individuals suggested it can actually enhance well-being.
Between 2006 and 2021, investigators studied more than 2 million people between the ages of 15 and 99 years in 168 countries, focusing on their psychological well-being and their use of the internet. Many of the included countries have rarely or never been studied in this connection.
“We were surprised to find a positive correlation between well-being and internet use across the majority of the thousands of models we used for our analysis,” lead author Matti Vuorre, PhD, of Tilburg University, Tilburg, the Netherlands, and a research associate at Oxford Internet Institute in England, said in a news release.
The study was published online on May 13 in Technology, Mind, and Behavior.
A Global Phenomenon
Coauthor Andrew K. Przybylski, PhD, professor of human behavior and technology at Oxford Internet Institute, explained the motive for conducting the study.
“Whilst internet technologies and their platforms and their potential psychological consequences remain debated, research to date has been inconclusive and of limited geographic and demographic scope,” he said.
He noted that the “overwhelming majority” of studies have focused on the Global North and on younger people and “ignoring the fact that the penetration of the internet has been, and continues to be, a global phenomenon.”
The researchers set out to address this gap by analyzing “how internet access, mobility internet access, and active internet use might predict psychological well-being on a global level across the life stages,” Dr. Przybylski continued. “To our knowledge, no other research has directly grappled with these issues and addressed the worldwide scope of the debate.”
To study internet use, the investigators analyzed data from the 2022 Gallup World Poll, a nationally representative survey of each country’s civilian, non-institutionalized adult population (ie, aged ≥ 15 years), conducted between 2002 and 2022. The poll assessed well-being using face-to-face, as well as phone interviews, conducted by local interviewers in the respondents’ native languages.
The total sample size included 2,414,295 adults drawn from 186 countries (53.1% women), drawn from countries that included those located in Latin America, Asia, and Africa.
The researchers examined eight indicators of well-being: life satisfaction, daily negative and positive experiences, two indices of social well-being, physical well-being, community well-being, and experiences of purpose.
Covariates included respondents’ income, education, work, relationship status, the ability to meet basic needs (food and shelter), and whether they reported having health problems.
Greater Life Satisfaction
The researchers conducted a “multiverse” of 33,792 types of analyses, researching the average differences in well-being between individuals who had access to mobile internet or had used the internet in the past 7 days.
They found that for the average country, those who had access to the internet reported approximately 0.08 units greater life satisfaction, positive experiences, and social life satisfaction and 0.06 units lower negative experience than those without access.
They also reported approximately 0.08 units greater experiences of purpose and 0.1 unit greater physical, 0.02 units greater community, and 0.08 units greater social well-being than individuals without access.
Being an active internet user was associated with a 0.03- to 0.08-unit increase in life satisfaction, positive experiences, social well-being, and physical well-being and a 0.04-unit decrease in negative experiences. Access to a smartphone predicted increases of 0.06 and 0.07 units.
Although the standard deviations (SDs) of well-being outcomes were small (eg, the median life satisfaction difference was 0.36 SDs between individuals who did and did not have access to the internet), they were “not negligible.”
In fact, when the researchers examined the associations’ robustness across all analyses, they found that 84.9% resulted in positive and statistically significant associations between internet connectivity and well-being.
Of the 4.9% of associations between internet use and community well-being that were negative, most were observed among young women between the ages of 15 and 24 years.
While the researchers did not identify this as a causal relationship, they noted that this finding is consistent with previous reports of increased cyberbullying and negative associations between social media use and depressive symptoms in young women.
“Overall, we found that average associations were consistent across internet adoption predictors and well-being outcomes, with those who had access to or actively used the internet reporting meaningfully greater well-being than those who did not,” Dr. Przybylski said.
The study’s limitations included comparing individuals with each other, given that there “are likely myriad other feature of the human condition that are associated with both uptake of internet technologies and well-being in such a manner that they might case spurious associations or mask true associations,” the authors noted.
Moreover, longitudinal studies tracking participants over time can provide more information about the “contexts of how and why an individual might be affected by internet technologies and platforms.” In addition, the self-reported measures of technology might be “lacking.”
Dr. Przybylski hopes that the findings will “bring some greater context to the screen time debate; however, further work is still needed in this important area.”
He urged platform providers “to share their detailed data on user behavior with social scientists working in this field for transparent and independent scientific enquiry, to enable a more comprehensive understanding of internet technologies in our daily lives.”
A Starting Point
In a separate news release, Kevin McConway, PhD, MBA, emeritus professor of applied statistics, The Open University, Milton Keynes, England, noted that there has been “endless debate and considerable speculation on the possible effects of internet use on well-being, in general across all ages, but more specifically in relation to children and young people.”
The current study “certainly extends the available information beyond simple speculation and beyond previous studies that used participants mostly in relatively rich Northern countries,” noted Dr. McConway, who was not involved in the study.
However, he cautioned, the study is only “a starting point, and if nothing else, it casts very serious doubt on the view, held by some people, that the internet is bad for us all.”
In particular, the observational nature of the study meant that the positive associations between internet use and measure of well-being could have been caused by other factors and are not causative.
“It’s important to understand that none of the well-being measures used in this research has been properly validated by experts in psychological measurement,” said Dr. McConway.
No source of study funding was listed. Dr. Przybylski’s research is supported by the Huo Family Foundation and the Economic and Social Research Council. In the preceding 5 years, Dr. Przybylski has worked on research grants provided by the John Fell Fund, The Diana Award, and the children’s charity Barnardo’s. These research grants were paid to Dr. Przybylski’s employer, the Oxford Internet Institute. During this period, Dr. Przybylski has engaged unpaid consultations with several organizations including UNICEF, the Organization for Economic Co-operation and Development, Meta Inc., UKIE, UK Research and Innovation, The UK’s DCMS, The Office of the UK’s Chief Medical Officer, the Office of the US Surgeon General, The UK’s Academy of Medical Sciences, and the UK Parliament. There were no financial products or benefits resulting from these consultations. Dr. Vuorre reported no relevant financial relationships. Neither author reported any conflicts of interest. Dr. McConway is a trustee of the Science Media Center. However, his remarks are in the capacity of an independent professional statistician.
A version of this article appeared on Medscape.com.
Contrary to previous research that suggests internet use can have a deleterious effect on mental health, a new study of more than 2 million individuals suggested it can actually enhance well-being.
Between 2006 and 2021, investigators studied more than 2 million people between the ages of 15 and 99 years in 168 countries, focusing on their psychological well-being and their use of the internet. Many of the included countries have rarely or never been studied in this connection.
“We were surprised to find a positive correlation between well-being and internet use across the majority of the thousands of models we used for our analysis,” lead author Matti Vuorre, PhD, of Tilburg University, Tilburg, the Netherlands, and a research associate at Oxford Internet Institute in England, said in a news release.
The study was published online on May 13 in Technology, Mind, and Behavior.
A Global Phenomenon
Coauthor Andrew K. Przybylski, PhD, professor of human behavior and technology at Oxford Internet Institute, explained the motive for conducting the study.
“Whilst internet technologies and their platforms and their potential psychological consequences remain debated, research to date has been inconclusive and of limited geographic and demographic scope,” he said.
He noted that the “overwhelming majority” of studies have focused on the Global North and on younger people and “ignoring the fact that the penetration of the internet has been, and continues to be, a global phenomenon.”
The researchers set out to address this gap by analyzing “how internet access, mobility internet access, and active internet use might predict psychological well-being on a global level across the life stages,” Dr. Przybylski continued. “To our knowledge, no other research has directly grappled with these issues and addressed the worldwide scope of the debate.”
To study internet use, the investigators analyzed data from the 2022 Gallup World Poll, a nationally representative survey of each country’s civilian, non-institutionalized adult population (ie, aged ≥ 15 years), conducted between 2002 and 2022. The poll assessed well-being using face-to-face, as well as phone interviews, conducted by local interviewers in the respondents’ native languages.
The total sample size included 2,414,295 adults drawn from 186 countries (53.1% women), drawn from countries that included those located in Latin America, Asia, and Africa.
The researchers examined eight indicators of well-being: life satisfaction, daily negative and positive experiences, two indices of social well-being, physical well-being, community well-being, and experiences of purpose.
Covariates included respondents’ income, education, work, relationship status, the ability to meet basic needs (food and shelter), and whether they reported having health problems.
Greater Life Satisfaction
The researchers conducted a “multiverse” of 33,792 types of analyses, researching the average differences in well-being between individuals who had access to mobile internet or had used the internet in the past 7 days.
They found that for the average country, those who had access to the internet reported approximately 0.08 units greater life satisfaction, positive experiences, and social life satisfaction and 0.06 units lower negative experience than those without access.
They also reported approximately 0.08 units greater experiences of purpose and 0.1 unit greater physical, 0.02 units greater community, and 0.08 units greater social well-being than individuals without access.
Being an active internet user was associated with a 0.03- to 0.08-unit increase in life satisfaction, positive experiences, social well-being, and physical well-being and a 0.04-unit decrease in negative experiences. Access to a smartphone predicted increases of 0.06 and 0.07 units.
Although the standard deviations (SDs) of well-being outcomes were small (eg, the median life satisfaction difference was 0.36 SDs between individuals who did and did not have access to the internet), they were “not negligible.”
In fact, when the researchers examined the associations’ robustness across all analyses, they found that 84.9% resulted in positive and statistically significant associations between internet connectivity and well-being.
Of the 4.9% of associations between internet use and community well-being that were negative, most were observed among young women between the ages of 15 and 24 years.
While the researchers did not identify this as a causal relationship, they noted that this finding is consistent with previous reports of increased cyberbullying and negative associations between social media use and depressive symptoms in young women.
“Overall, we found that average associations were consistent across internet adoption predictors and well-being outcomes, with those who had access to or actively used the internet reporting meaningfully greater well-being than those who did not,” Dr. Przybylski said.
The study’s limitations included comparing individuals with each other, given that there “are likely myriad other feature of the human condition that are associated with both uptake of internet technologies and well-being in such a manner that they might case spurious associations or mask true associations,” the authors noted.
Moreover, longitudinal studies tracking participants over time can provide more information about the “contexts of how and why an individual might be affected by internet technologies and platforms.” In addition, the self-reported measures of technology might be “lacking.”
Dr. Przybylski hopes that the findings will “bring some greater context to the screen time debate; however, further work is still needed in this important area.”
He urged platform providers “to share their detailed data on user behavior with social scientists working in this field for transparent and independent scientific enquiry, to enable a more comprehensive understanding of internet technologies in our daily lives.”
A Starting Point
In a separate news release, Kevin McConway, PhD, MBA, emeritus professor of applied statistics, The Open University, Milton Keynes, England, noted that there has been “endless debate and considerable speculation on the possible effects of internet use on well-being, in general across all ages, but more specifically in relation to children and young people.”
The current study “certainly extends the available information beyond simple speculation and beyond previous studies that used participants mostly in relatively rich Northern countries,” noted Dr. McConway, who was not involved in the study.
However, he cautioned, the study is only “a starting point, and if nothing else, it casts very serious doubt on the view, held by some people, that the internet is bad for us all.”
In particular, the observational nature of the study meant that the positive associations between internet use and measure of well-being could have been caused by other factors and are not causative.
“It’s important to understand that none of the well-being measures used in this research has been properly validated by experts in psychological measurement,” said Dr. McConway.
No source of study funding was listed. Dr. Przybylski’s research is supported by the Huo Family Foundation and the Economic and Social Research Council. In the preceding 5 years, Dr. Przybylski has worked on research grants provided by the John Fell Fund, The Diana Award, and the children’s charity Barnardo’s. These research grants were paid to Dr. Przybylski’s employer, the Oxford Internet Institute. During this period, Dr. Przybylski has engaged unpaid consultations with several organizations including UNICEF, the Organization for Economic Co-operation and Development, Meta Inc., UKIE, UK Research and Innovation, The UK’s DCMS, The Office of the UK’s Chief Medical Officer, the Office of the US Surgeon General, The UK’s Academy of Medical Sciences, and the UK Parliament. There were no financial products or benefits resulting from these consultations. Dr. Vuorre reported no relevant financial relationships. Neither author reported any conflicts of interest. Dr. McConway is a trustee of the Science Media Center. However, his remarks are in the capacity of an independent professional statistician.
A version of this article appeared on Medscape.com.
Contrary to previous research that suggests internet use can have a deleterious effect on mental health, a new study of more than 2 million individuals suggested it can actually enhance well-being.
Between 2006 and 2021, investigators studied more than 2 million people between the ages of 15 and 99 years in 168 countries, focusing on their psychological well-being and their use of the internet. Many of the included countries have rarely or never been studied in this connection.
“We were surprised to find a positive correlation between well-being and internet use across the majority of the thousands of models we used for our analysis,” lead author Matti Vuorre, PhD, of Tilburg University, Tilburg, the Netherlands, and a research associate at Oxford Internet Institute in England, said in a news release.
The study was published online on May 13 in Technology, Mind, and Behavior.
A Global Phenomenon
Coauthor Andrew K. Przybylski, PhD, professor of human behavior and technology at Oxford Internet Institute, explained the motive for conducting the study.
“Whilst internet technologies and their platforms and their potential psychological consequences remain debated, research to date has been inconclusive and of limited geographic and demographic scope,” he said.
He noted that the “overwhelming majority” of studies have focused on the Global North and on younger people and “ignoring the fact that the penetration of the internet has been, and continues to be, a global phenomenon.”
The researchers set out to address this gap by analyzing “how internet access, mobility internet access, and active internet use might predict psychological well-being on a global level across the life stages,” Dr. Przybylski continued. “To our knowledge, no other research has directly grappled with these issues and addressed the worldwide scope of the debate.”
To study internet use, the investigators analyzed data from the 2022 Gallup World Poll, a nationally representative survey of each country’s civilian, non-institutionalized adult population (ie, aged ≥ 15 years), conducted between 2002 and 2022. The poll assessed well-being using face-to-face, as well as phone interviews, conducted by local interviewers in the respondents’ native languages.
The total sample size included 2,414,295 adults drawn from 186 countries (53.1% women), drawn from countries that included those located in Latin America, Asia, and Africa.
The researchers examined eight indicators of well-being: life satisfaction, daily negative and positive experiences, two indices of social well-being, physical well-being, community well-being, and experiences of purpose.
Covariates included respondents’ income, education, work, relationship status, the ability to meet basic needs (food and shelter), and whether they reported having health problems.
Greater Life Satisfaction
The researchers conducted a “multiverse” of 33,792 types of analyses, researching the average differences in well-being between individuals who had access to mobile internet or had used the internet in the past 7 days.
They found that for the average country, those who had access to the internet reported approximately 0.08 units greater life satisfaction, positive experiences, and social life satisfaction and 0.06 units lower negative experience than those without access.
They also reported approximately 0.08 units greater experiences of purpose and 0.1 unit greater physical, 0.02 units greater community, and 0.08 units greater social well-being than individuals without access.
Being an active internet user was associated with a 0.03- to 0.08-unit increase in life satisfaction, positive experiences, social well-being, and physical well-being and a 0.04-unit decrease in negative experiences. Access to a smartphone predicted increases of 0.06 and 0.07 units.
Although the standard deviations (SDs) of well-being outcomes were small (eg, the median life satisfaction difference was 0.36 SDs between individuals who did and did not have access to the internet), they were “not negligible.”
In fact, when the researchers examined the associations’ robustness across all analyses, they found that 84.9% resulted in positive and statistically significant associations between internet connectivity and well-being.
Of the 4.9% of associations between internet use and community well-being that were negative, most were observed among young women between the ages of 15 and 24 years.
While the researchers did not identify this as a causal relationship, they noted that this finding is consistent with previous reports of increased cyberbullying and negative associations between social media use and depressive symptoms in young women.
“Overall, we found that average associations were consistent across internet adoption predictors and well-being outcomes, with those who had access to or actively used the internet reporting meaningfully greater well-being than those who did not,” Dr. Przybylski said.
The study’s limitations included comparing individuals with each other, given that there “are likely myriad other feature of the human condition that are associated with both uptake of internet technologies and well-being in such a manner that they might case spurious associations or mask true associations,” the authors noted.
Moreover, longitudinal studies tracking participants over time can provide more information about the “contexts of how and why an individual might be affected by internet technologies and platforms.” In addition, the self-reported measures of technology might be “lacking.”
Dr. Przybylski hopes that the findings will “bring some greater context to the screen time debate; however, further work is still needed in this important area.”
He urged platform providers “to share their detailed data on user behavior with social scientists working in this field for transparent and independent scientific enquiry, to enable a more comprehensive understanding of internet technologies in our daily lives.”
A Starting Point
In a separate news release, Kevin McConway, PhD, MBA, emeritus professor of applied statistics, The Open University, Milton Keynes, England, noted that there has been “endless debate and considerable speculation on the possible effects of internet use on well-being, in general across all ages, but more specifically in relation to children and young people.”
The current study “certainly extends the available information beyond simple speculation and beyond previous studies that used participants mostly in relatively rich Northern countries,” noted Dr. McConway, who was not involved in the study.
However, he cautioned, the study is only “a starting point, and if nothing else, it casts very serious doubt on the view, held by some people, that the internet is bad for us all.”
In particular, the observational nature of the study meant that the positive associations between internet use and measure of well-being could have been caused by other factors and are not causative.
“It’s important to understand that none of the well-being measures used in this research has been properly validated by experts in psychological measurement,” said Dr. McConway.
No source of study funding was listed. Dr. Przybylski’s research is supported by the Huo Family Foundation and the Economic and Social Research Council. In the preceding 5 years, Dr. Przybylski has worked on research grants provided by the John Fell Fund, The Diana Award, and the children’s charity Barnardo’s. These research grants were paid to Dr. Przybylski’s employer, the Oxford Internet Institute. During this period, Dr. Przybylski has engaged unpaid consultations with several organizations including UNICEF, the Organization for Economic Co-operation and Development, Meta Inc., UKIE, UK Research and Innovation, The UK’s DCMS, The Office of the UK’s Chief Medical Officer, the Office of the US Surgeon General, The UK’s Academy of Medical Sciences, and the UK Parliament. There were no financial products or benefits resulting from these consultations. Dr. Vuorre reported no relevant financial relationships. Neither author reported any conflicts of interest. Dr. McConway is a trustee of the Science Media Center. However, his remarks are in the capacity of an independent professional statistician.
A version of this article appeared on Medscape.com.
Does Racism in Black Americans Boost Alzheimer’s Risk?
Racial discrimination in Black Americans is associated with an increased risk of developing Alzheimer’s disease (AD) in later life, new findings showed.
Researchers found that Black Americans who experience racism in their 40s and 50s are more likely to have increased serum levels of AD biomarkers p-tau181 and neurofilament light (NfL) more than a decade later.
“We know that Black Americans are at an elevated risk of Alzheimer’s disease and other dementias compared to non-Hispanic White Americans, but we don’t fully understand all the factors that contribute to this disproportionate risk,” Michelle Mielke, PhD, co-author and professor of epidemiology and prevention at Wake Forest University School of Medicine, Winston-Salem, North Carolina, said in a press release.
Recent data show AD is twice as prevalent in Black Americans as in Whites, at 18.6% and 10%, respectively. Dr. Mielke said this level of disparity cannot be attributed solely to genetic differences, and evidence suggests that racism and its related stress may play a role.
The findings were published online in Alzheimer’s and Dementia.
AD Biomarker Testing
To further explore a possible link between exposure to racism and AD risk, investigators analyzed data from the Family and Community Health Study, a multisite, longitudinal investigation that included more than 800 families in the United States.
Blood samples and information on racial discrimination were collected from 255 middle-aged Black Americans between 2002 and 2005.
Blood samples were tested for serum phosphorylated tau181 (p-Tau181), a marker of AD pathology; NfL, a nonspecific marker of neurodegeneration; and glial fibrillary acidic protein (GFAP), a marker of brain inflammation.
Participants answered questions about racial discrimination, which included whether they have been subjected to disrespectful treatment including racial slurs, harassment from law enforcement, or if they had ever been excluded from social activities because of their race.
The sample included 212 females and 43 males with a mean age of 46. Most participants (70%) lived in urban areas.
Stress-Related?
Investigators found no correlation between racial discrimination and increased levels of AD blood biomarkers in 2008 when participants were a mean age of 46 years. However, 11 years later, when participants were roughly 57 years old, investigators found experiencing racism in middle age was significantly correlated with higher levels of both p-Tau181 (r = 0.158; P ≤ .012) and NfL (r = 0.143; P ≤ .023). There was no significant association between reported discrimination and GFAP.
“These findings support the hypothesis that unique life stressors encountered by Black Americans in midlife become biologically embedded and contribute to AD pathology and neurodegeneration later in life,” the authors wrote.
Investigators speculated based on previous research that the stress related to discrimination may be associated with reductions in hippocampal and prefrontal cortex volumes and neurodegeneration in general.
Dr. Mielke also said it’s clear that future studies should focus on racism experienced by Black Americans to further understand their risk for dementia.
“This research can help inform policies and interventions to reduce racial disparities and reduce dementia risk,” she said.
Study limitations include the absence of amyloid biomarkers. Investigators noted that participants had non-detectable levels of amyloid, likely due to the use of serum vs cerebrospinal fluid.
The study was funded by the National Institute on Aging and the National Heart, Lung, and Blood Institute. Mielke reported serving on scientific advisory boards and/or having consulted for Acadia, Biogen, Eisai, LabCorp, Lilly, Merck, PeerView Institute, Roche, Siemens Healthineers, and Sunbird Bio.
A version of this article appeared on Medscape.com.
Racial discrimination in Black Americans is associated with an increased risk of developing Alzheimer’s disease (AD) in later life, new findings showed.
Researchers found that Black Americans who experience racism in their 40s and 50s are more likely to have increased serum levels of AD biomarkers p-tau181 and neurofilament light (NfL) more than a decade later.
“We know that Black Americans are at an elevated risk of Alzheimer’s disease and other dementias compared to non-Hispanic White Americans, but we don’t fully understand all the factors that contribute to this disproportionate risk,” Michelle Mielke, PhD, co-author and professor of epidemiology and prevention at Wake Forest University School of Medicine, Winston-Salem, North Carolina, said in a press release.
Recent data show AD is twice as prevalent in Black Americans as in Whites, at 18.6% and 10%, respectively. Dr. Mielke said this level of disparity cannot be attributed solely to genetic differences, and evidence suggests that racism and its related stress may play a role.
The findings were published online in Alzheimer’s and Dementia.
AD Biomarker Testing
To further explore a possible link between exposure to racism and AD risk, investigators analyzed data from the Family and Community Health Study, a multisite, longitudinal investigation that included more than 800 families in the United States.
Blood samples and information on racial discrimination were collected from 255 middle-aged Black Americans between 2002 and 2005.
Blood samples were tested for serum phosphorylated tau181 (p-Tau181), a marker of AD pathology; NfL, a nonspecific marker of neurodegeneration; and glial fibrillary acidic protein (GFAP), a marker of brain inflammation.
Participants answered questions about racial discrimination, which included whether they have been subjected to disrespectful treatment including racial slurs, harassment from law enforcement, or if they had ever been excluded from social activities because of their race.
The sample included 212 females and 43 males with a mean age of 46. Most participants (70%) lived in urban areas.
Stress-Related?
Investigators found no correlation between racial discrimination and increased levels of AD blood biomarkers in 2008 when participants were a mean age of 46 years. However, 11 years later, when participants were roughly 57 years old, investigators found experiencing racism in middle age was significantly correlated with higher levels of both p-Tau181 (r = 0.158; P ≤ .012) and NfL (r = 0.143; P ≤ .023). There was no significant association between reported discrimination and GFAP.
“These findings support the hypothesis that unique life stressors encountered by Black Americans in midlife become biologically embedded and contribute to AD pathology and neurodegeneration later in life,” the authors wrote.
Investigators speculated based on previous research that the stress related to discrimination may be associated with reductions in hippocampal and prefrontal cortex volumes and neurodegeneration in general.
Dr. Mielke also said it’s clear that future studies should focus on racism experienced by Black Americans to further understand their risk for dementia.
“This research can help inform policies and interventions to reduce racial disparities and reduce dementia risk,” she said.
Study limitations include the absence of amyloid biomarkers. Investigators noted that participants had non-detectable levels of amyloid, likely due to the use of serum vs cerebrospinal fluid.
The study was funded by the National Institute on Aging and the National Heart, Lung, and Blood Institute. Mielke reported serving on scientific advisory boards and/or having consulted for Acadia, Biogen, Eisai, LabCorp, Lilly, Merck, PeerView Institute, Roche, Siemens Healthineers, and Sunbird Bio.
A version of this article appeared on Medscape.com.
Racial discrimination in Black Americans is associated with an increased risk of developing Alzheimer’s disease (AD) in later life, new findings showed.
Researchers found that Black Americans who experience racism in their 40s and 50s are more likely to have increased serum levels of AD biomarkers p-tau181 and neurofilament light (NfL) more than a decade later.
“We know that Black Americans are at an elevated risk of Alzheimer’s disease and other dementias compared to non-Hispanic White Americans, but we don’t fully understand all the factors that contribute to this disproportionate risk,” Michelle Mielke, PhD, co-author and professor of epidemiology and prevention at Wake Forest University School of Medicine, Winston-Salem, North Carolina, said in a press release.
Recent data show AD is twice as prevalent in Black Americans as in Whites, at 18.6% and 10%, respectively. Dr. Mielke said this level of disparity cannot be attributed solely to genetic differences, and evidence suggests that racism and its related stress may play a role.
The findings were published online in Alzheimer’s and Dementia.
AD Biomarker Testing
To further explore a possible link between exposure to racism and AD risk, investigators analyzed data from the Family and Community Health Study, a multisite, longitudinal investigation that included more than 800 families in the United States.
Blood samples and information on racial discrimination were collected from 255 middle-aged Black Americans between 2002 and 2005.
Blood samples were tested for serum phosphorylated tau181 (p-Tau181), a marker of AD pathology; NfL, a nonspecific marker of neurodegeneration; and glial fibrillary acidic protein (GFAP), a marker of brain inflammation.
Participants answered questions about racial discrimination, which included whether they have been subjected to disrespectful treatment including racial slurs, harassment from law enforcement, or if they had ever been excluded from social activities because of their race.
The sample included 212 females and 43 males with a mean age of 46. Most participants (70%) lived in urban areas.
Stress-Related?
Investigators found no correlation between racial discrimination and increased levels of AD blood biomarkers in 2008 when participants were a mean age of 46 years. However, 11 years later, when participants were roughly 57 years old, investigators found experiencing racism in middle age was significantly correlated with higher levels of both p-Tau181 (r = 0.158; P ≤ .012) and NfL (r = 0.143; P ≤ .023). There was no significant association between reported discrimination and GFAP.
“These findings support the hypothesis that unique life stressors encountered by Black Americans in midlife become biologically embedded and contribute to AD pathology and neurodegeneration later in life,” the authors wrote.
Investigators speculated based on previous research that the stress related to discrimination may be associated with reductions in hippocampal and prefrontal cortex volumes and neurodegeneration in general.
Dr. Mielke also said it’s clear that future studies should focus on racism experienced by Black Americans to further understand their risk for dementia.
“This research can help inform policies and interventions to reduce racial disparities and reduce dementia risk,” she said.
Study limitations include the absence of amyloid biomarkers. Investigators noted that participants had non-detectable levels of amyloid, likely due to the use of serum vs cerebrospinal fluid.
The study was funded by the National Institute on Aging and the National Heart, Lung, and Blood Institute. Mielke reported serving on scientific advisory boards and/or having consulted for Acadia, Biogen, Eisai, LabCorp, Lilly, Merck, PeerView Institute, Roche, Siemens Healthineers, and Sunbird Bio.
A version of this article appeared on Medscape.com.
CBT Tops Mindfulness Therapy for Prolonged Grief Disorder
Cognitive-behavioral therapy (CBT) is superior to mindfulness-based cognitive therapy (MT) for reducing symptom severity in patients with prolonged grief disorder, results from a randomized trial showed.
While patients receiving grief-focused CBT had a superior response compared with those receiving MT, participants in both groups experienced a significant reduction in symptoms 6 months after treatment.
“We emphasize that these results do not suggest that mindfulness-based therapy was not effective in treating grief-focused CBT, but rather that grief-focused CBT was relatively more effective in reducing prolonged grief disorder, depression, and grief-related cognitions than mindfulness-based cognitive therapy,” investigators, led by Richard Bryant, PhD, of the University of New South Wales, Sydney, Australia, wrote.
The findings were published online in JAMA Psychiatry.
Barrier to Treatment
Prolonged grief disorder can affect up to 10% of bereaved individuals and is associated with increased suicide risk, cancer, immunological dysfunction, cardiac events, and functional impairment.
One barrier to treatment for individuals with prolonged grief disorder is that the treatment process can be emotionally painful. Between 15% and 25% of patients with prolonged grief offered grief-focused CBT decline to participate because they are reluctant to focus on painful emotions surrounding the death of their loved one.
To compare grief-focused CBT with mindfulness-based CT, another psychotherapeutic treatment, investigators recruited 100 adults aged 18-70 years between 2012 and 2022.
Participants who met the criteria for prolonged grief disorder were randomized on a 1:1 basis to receive either grief-focused CBT (n = 50) or CT (n = 50). All assessors were blinded to the treatment condition.
Therapy in both groups included 11 weekly 90-minute individual sessions.
Participants were assessed posttreatment at the 6-month mark for prolonged grief disorder symptom severity with the Prolonged Grief (PG)-13 Scale. They were also assessed for symptoms of depression, anxiety, and self-reported quality of life.
Grief-focused CBT entailed education on prolonged grief disorder, monitoring of daily thoughts, revisiting the death memory for several sessions, reframing maladaptive grief-related thoughts, writing a letter to the deceased loved one, relapse prevention strategies, and goal setting.
Mindfulness-based CT was adapted to problematic grief and began with psychoeducation about prolonged grief disorder. The additional sessions entailed mindfulness-orienting exercises, meditation, body scans, and how mindfulness practices can be used to tolerate aversive emotions and thoughts or to manage grief reactions.
Participants were assessed at the end of their treatment and had a mean age of 47 years, and 87% were female. The majority (71%) were White, and 21% were African, Indigenous Australian, and Pacific Islander.
While participants in both groups had similar outcomes posttreatment, at the 6-month follow-up, grief-focused CBT led to more significant reductions in scores on the PG-13 scale compared with mindfulness-based CT (mean difference, 7.1 points; 95% CI, 1.6-12.5; P = .01) with a large between-group effect size (0.8; 95% CI, 0.2-1.3).
PG-13 scores range from 11 to 55, with higher scores indicating greater prolonged grief disorder severity.
Of note, both treatment groups had a significant reduction in prolonged grief disorder symptoms (mean difference, 11.3; 95% CI, 8.6-14.1; P < .001), with a large effect size (1.2; 95% CI, 0.9-1.5).
Grief-focused CBT also led to greater reductions in depression at 6 months as measured by the Beck Depression Inventory (mean difference, 6.6; 95% CI, 0.5-12.9; P = .04). Investigators noted that this finding was unexpected and “suggests that the greater reduction of depression in participants receiving grief-focused cognitive behavior therapy may be attributed to the superior reductions in prolonged grief disorder severity, thereby leading to downstream decreases in depression.”
The investigators noted several study limitations. Most participants were White, which limits the generalizability of the results to other races and ethnicities. Therapists were not blinded to treatment conditions, and investigators did not monitor participants’ therapeutic exercises that were to be practiced posttreatment until the 6-month mark.
The study was funded by the National Health and Medical Research Council. Dr. Bryant served on the ICD Eleventh Revision Working Group on the Classification of Stress-Related Disorders. No other disclosures were reported.
A version of this article appeared on Medscape.com .
Cognitive-behavioral therapy (CBT) is superior to mindfulness-based cognitive therapy (MT) for reducing symptom severity in patients with prolonged grief disorder, results from a randomized trial showed.
While patients receiving grief-focused CBT had a superior response compared with those receiving MT, participants in both groups experienced a significant reduction in symptoms 6 months after treatment.
“We emphasize that these results do not suggest that mindfulness-based therapy was not effective in treating grief-focused CBT, but rather that grief-focused CBT was relatively more effective in reducing prolonged grief disorder, depression, and grief-related cognitions than mindfulness-based cognitive therapy,” investigators, led by Richard Bryant, PhD, of the University of New South Wales, Sydney, Australia, wrote.
The findings were published online in JAMA Psychiatry.
Barrier to Treatment
Prolonged grief disorder can affect up to 10% of bereaved individuals and is associated with increased suicide risk, cancer, immunological dysfunction, cardiac events, and functional impairment.
One barrier to treatment for individuals with prolonged grief disorder is that the treatment process can be emotionally painful. Between 15% and 25% of patients with prolonged grief offered grief-focused CBT decline to participate because they are reluctant to focus on painful emotions surrounding the death of their loved one.
To compare grief-focused CBT with mindfulness-based CT, another psychotherapeutic treatment, investigators recruited 100 adults aged 18-70 years between 2012 and 2022.
Participants who met the criteria for prolonged grief disorder were randomized on a 1:1 basis to receive either grief-focused CBT (n = 50) or CT (n = 50). All assessors were blinded to the treatment condition.
Therapy in both groups included 11 weekly 90-minute individual sessions.
Participants were assessed posttreatment at the 6-month mark for prolonged grief disorder symptom severity with the Prolonged Grief (PG)-13 Scale. They were also assessed for symptoms of depression, anxiety, and self-reported quality of life.
Grief-focused CBT entailed education on prolonged grief disorder, monitoring of daily thoughts, revisiting the death memory for several sessions, reframing maladaptive grief-related thoughts, writing a letter to the deceased loved one, relapse prevention strategies, and goal setting.
Mindfulness-based CT was adapted to problematic grief and began with psychoeducation about prolonged grief disorder. The additional sessions entailed mindfulness-orienting exercises, meditation, body scans, and how mindfulness practices can be used to tolerate aversive emotions and thoughts or to manage grief reactions.
Participants were assessed at the end of their treatment and had a mean age of 47 years, and 87% were female. The majority (71%) were White, and 21% were African, Indigenous Australian, and Pacific Islander.
While participants in both groups had similar outcomes posttreatment, at the 6-month follow-up, grief-focused CBT led to more significant reductions in scores on the PG-13 scale compared with mindfulness-based CT (mean difference, 7.1 points; 95% CI, 1.6-12.5; P = .01) with a large between-group effect size (0.8; 95% CI, 0.2-1.3).
PG-13 scores range from 11 to 55, with higher scores indicating greater prolonged grief disorder severity.
Of note, both treatment groups had a significant reduction in prolonged grief disorder symptoms (mean difference, 11.3; 95% CI, 8.6-14.1; P < .001), with a large effect size (1.2; 95% CI, 0.9-1.5).
Grief-focused CBT also led to greater reductions in depression at 6 months as measured by the Beck Depression Inventory (mean difference, 6.6; 95% CI, 0.5-12.9; P = .04). Investigators noted that this finding was unexpected and “suggests that the greater reduction of depression in participants receiving grief-focused cognitive behavior therapy may be attributed to the superior reductions in prolonged grief disorder severity, thereby leading to downstream decreases in depression.”
The investigators noted several study limitations. Most participants were White, which limits the generalizability of the results to other races and ethnicities. Therapists were not blinded to treatment conditions, and investigators did not monitor participants’ therapeutic exercises that were to be practiced posttreatment until the 6-month mark.
The study was funded by the National Health and Medical Research Council. Dr. Bryant served on the ICD Eleventh Revision Working Group on the Classification of Stress-Related Disorders. No other disclosures were reported.
A version of this article appeared on Medscape.com .
Cognitive-behavioral therapy (CBT) is superior to mindfulness-based cognitive therapy (MT) for reducing symptom severity in patients with prolonged grief disorder, results from a randomized trial showed.
While patients receiving grief-focused CBT had a superior response compared with those receiving MT, participants in both groups experienced a significant reduction in symptoms 6 months after treatment.
“We emphasize that these results do not suggest that mindfulness-based therapy was not effective in treating grief-focused CBT, but rather that grief-focused CBT was relatively more effective in reducing prolonged grief disorder, depression, and grief-related cognitions than mindfulness-based cognitive therapy,” investigators, led by Richard Bryant, PhD, of the University of New South Wales, Sydney, Australia, wrote.
The findings were published online in JAMA Psychiatry.
Barrier to Treatment
Prolonged grief disorder can affect up to 10% of bereaved individuals and is associated with increased suicide risk, cancer, immunological dysfunction, cardiac events, and functional impairment.
One barrier to treatment for individuals with prolonged grief disorder is that the treatment process can be emotionally painful. Between 15% and 25% of patients with prolonged grief offered grief-focused CBT decline to participate because they are reluctant to focus on painful emotions surrounding the death of their loved one.
To compare grief-focused CBT with mindfulness-based CT, another psychotherapeutic treatment, investigators recruited 100 adults aged 18-70 years between 2012 and 2022.
Participants who met the criteria for prolonged grief disorder were randomized on a 1:1 basis to receive either grief-focused CBT (n = 50) or CT (n = 50). All assessors were blinded to the treatment condition.
Therapy in both groups included 11 weekly 90-minute individual sessions.
Participants were assessed posttreatment at the 6-month mark for prolonged grief disorder symptom severity with the Prolonged Grief (PG)-13 Scale. They were also assessed for symptoms of depression, anxiety, and self-reported quality of life.
Grief-focused CBT entailed education on prolonged grief disorder, monitoring of daily thoughts, revisiting the death memory for several sessions, reframing maladaptive grief-related thoughts, writing a letter to the deceased loved one, relapse prevention strategies, and goal setting.
Mindfulness-based CT was adapted to problematic grief and began with psychoeducation about prolonged grief disorder. The additional sessions entailed mindfulness-orienting exercises, meditation, body scans, and how mindfulness practices can be used to tolerate aversive emotions and thoughts or to manage grief reactions.
Participants were assessed at the end of their treatment and had a mean age of 47 years, and 87% were female. The majority (71%) were White, and 21% were African, Indigenous Australian, and Pacific Islander.
While participants in both groups had similar outcomes posttreatment, at the 6-month follow-up, grief-focused CBT led to more significant reductions in scores on the PG-13 scale compared with mindfulness-based CT (mean difference, 7.1 points; 95% CI, 1.6-12.5; P = .01) with a large between-group effect size (0.8; 95% CI, 0.2-1.3).
PG-13 scores range from 11 to 55, with higher scores indicating greater prolonged grief disorder severity.
Of note, both treatment groups had a significant reduction in prolonged grief disorder symptoms (mean difference, 11.3; 95% CI, 8.6-14.1; P < .001), with a large effect size (1.2; 95% CI, 0.9-1.5).
Grief-focused CBT also led to greater reductions in depression at 6 months as measured by the Beck Depression Inventory (mean difference, 6.6; 95% CI, 0.5-12.9; P = .04). Investigators noted that this finding was unexpected and “suggests that the greater reduction of depression in participants receiving grief-focused cognitive behavior therapy may be attributed to the superior reductions in prolonged grief disorder severity, thereby leading to downstream decreases in depression.”
The investigators noted several study limitations. Most participants were White, which limits the generalizability of the results to other races and ethnicities. Therapists were not blinded to treatment conditions, and investigators did not monitor participants’ therapeutic exercises that were to be practiced posttreatment until the 6-month mark.
The study was funded by the National Health and Medical Research Council. Dr. Bryant served on the ICD Eleventh Revision Working Group on the Classification of Stress-Related Disorders. No other disclosures were reported.
A version of this article appeared on Medscape.com .
More Rapid Confirmation of an Autism Diagnosis Is Coming to Primary Care
TORONTO — , according to a series of studies presented at the Pediatric Academic Societies annual meeting.
Accelerated Diagnosis
In one study, 80% of the evaluations were conducted within 6 weeks of patient enrollment, according to Corinna Rea, MD, a clinician in the primary care center at Boston Children’s Hospital as well as an assistant professor at Harvard Medical School, Boston, Massachusetts.
This outcome was drawn from a pilot study with 179 children suspected of autism spectrum disorder (ASD) by clinicians in a pediatric clinic. All were under the age of 3 years. In the first step, families completed the Bayley-4 Social-Emotional and Adaptive Behavior Scale.
The next step was a virtual assessment by a trained clinician using the TELE-ADS-PEDs (TAP) tool developed by Vanderbilt University, Nashville, Tennessee. Patients and families participated from their homes. The diagnosis of ASD was made by a psychologist using the patient’s history and data provided by the two assessment tools.
Through this approach, the median time to diagnosis was 30 days, according to Dr. Rea. Relative to a median time of 168 days to diagnosis among patients considered likely to have ASD at Dr. Rea’s center in the year prior to this pilot study, the time was reduced significantly (P < .001).
All patients in the study were subsequently evaluated by traditional methods. One hundred percent of the ASD diagnoses were confirmed with traditional assessment.
On the basis of these data, the accelerated approach “seems efficient and quite accurate,” Dr. Rea reported. When family members were surveyed at the end of the pilot study, 60% were satisfied and 28% were moderately satisfied. Although 59% reported that they would have preferred an in-person assessment, approximately 90% agreed the child’s development was mostly or completely captured in the accelerated assessment.
Dr. Rea pointed out that the psychologists participating in this study offered the opinion that home-based assessments are in their experience better than in-person evaluations due to the more natural behavior of the child in their own environment. However, she said that the diagnostic approach in the pilot study is still being modified, and one of the goals is to make virtual assessment more acceptable to the families.
A Commercialized Diagnostic Approach
A similar approach has been commercialized by a firm called As You Are, according to Steven D. Hicks, MD, PhD, who is an associate professor of pediatrics at Pennsylvania State University College of Medicine, Hershey, Pennsylvania. Dr. Hicks is a principal in the enterprise, which is also assessing ASD virtually.
Trained pediatricians are evaluating patients with multiple tools in addition to TAP, including the Childhood Autism Rating Scale (CARS) and the Diagnostic and Statistical Manual (DSM-V) checklist for ASD. The company, which began offering this diagnostic service in 2022, now employs more than 30 pediatricians who participated in a 1-month training program.
At the 2024 PAS meeting, quality assurance data were presented on 215 (2.2%) of the 9632 children evaluated between February 2023 and March 2024. The diagnostic assessments of these randomly selected children were reviewed by one of three randomly assigned experts (a developmental pediatrician, a child psychologist, or a pediatrician with 7 years’ diagnostic experience) blinded to the initial scoring.
The diagnostic agreement was 94%, according to the data presented, providing a specificity of 90% and a sensitivity of 90% for ASD. The commercialized diagnostic approach is providing a diagnosis in a mean time of 29 days from initial contact, compared with delays that typically exceed 1 year for many children with suspected ASD, according to Dr. Hicks.
Additional Studies Aim at Streamlining Diagnosis
Two additional studies also evaluated strategies to streamline the diagnosis of ASD. Both were positive. In one, the accuracy and time to diagnosis among pediatricians trained in TAP and CARS were compared with those of ASD specialists in a dedicated autism clinic. Both were located at Nemours Children’s Health Center, Wilmington, Delaware.
In this study, presented by Meghan Harrison, DO, an attending pediatrician at Nemours Children’s Health, time to diagnosis among the 39 patients evaluated by pediatricians relative to the 349 patients evaluated at the dedicated ASD center (2.0 vs 5.1 months; P = .001) was significantly shorter. The age at diagnosis in the pediatrician-assessed population (27.5 vs 36.5 months; P < .001) was also significantly younger.
In another study, led by Ashely L. Early, MSW, a clinical social worker at the Medical University of South Carolina, Charleston, South Carolina, switching to a screening tool called the Rapid Interactive Screening Test for Autism in Toddlers (RITA-1) reduced the wait time to evaluation by approximately 5 months relative to previous practice with a more cumbersome screening method.
An ‘Urgent Need’ to Accelerate Diagnosis
In most places in the United States, children suspected of ASD are referred to specialists for confirmation of the diagnosis, which is needed to quality for ASD services, according to Katherine Zuckerman, MD, a professor of pediatrics the Oregon Health and Science University, Portland, Oregon. Dr. Zuckerman, who was moderator of the session in which all four of these abstracts were presented, explained that there is an urgent need to accelerate the time to diagnosis, which involves long delays for many if not most children with ASD. This is important because treatment and supportive services for ASD are almost always dependent on a diagnosis.
“There are tons of data to show that earlier access to ASD services has important patient benefits, including higher IQs,” she said. Other benefits she listed include a better quality of life for the child and the family.
“It can provide a huge reduction in family stress,” she added, suggesting that early interventions favorably modify the trajectory of the disability over time with accruing benefits.
“The lifetime costs of ASD exceed cancer and most other disease, so there are major implications for the cumulative cost of ASD management,” Dr. Zuckerman said. She suggested that the studies presented at the meeting reflect a likely evolution in who evaluates children for ASD and how quickly the evaluation is performed.
Dr. Rea, Dr. Harrison, Dr. Zuckerman, and Ms. Early reported no potential conflicts of interest. In addition to his executive role in As You Are, Dr. Hicks has financial relationships with Quadrant Biosciences and Spectrum Solutions.
TORONTO — , according to a series of studies presented at the Pediatric Academic Societies annual meeting.
Accelerated Diagnosis
In one study, 80% of the evaluations were conducted within 6 weeks of patient enrollment, according to Corinna Rea, MD, a clinician in the primary care center at Boston Children’s Hospital as well as an assistant professor at Harvard Medical School, Boston, Massachusetts.
This outcome was drawn from a pilot study with 179 children suspected of autism spectrum disorder (ASD) by clinicians in a pediatric clinic. All were under the age of 3 years. In the first step, families completed the Bayley-4 Social-Emotional and Adaptive Behavior Scale.
The next step was a virtual assessment by a trained clinician using the TELE-ADS-PEDs (TAP) tool developed by Vanderbilt University, Nashville, Tennessee. Patients and families participated from their homes. The diagnosis of ASD was made by a psychologist using the patient’s history and data provided by the two assessment tools.
Through this approach, the median time to diagnosis was 30 days, according to Dr. Rea. Relative to a median time of 168 days to diagnosis among patients considered likely to have ASD at Dr. Rea’s center in the year prior to this pilot study, the time was reduced significantly (P < .001).
All patients in the study were subsequently evaluated by traditional methods. One hundred percent of the ASD diagnoses were confirmed with traditional assessment.
On the basis of these data, the accelerated approach “seems efficient and quite accurate,” Dr. Rea reported. When family members were surveyed at the end of the pilot study, 60% were satisfied and 28% were moderately satisfied. Although 59% reported that they would have preferred an in-person assessment, approximately 90% agreed the child’s development was mostly or completely captured in the accelerated assessment.
Dr. Rea pointed out that the psychologists participating in this study offered the opinion that home-based assessments are in their experience better than in-person evaluations due to the more natural behavior of the child in their own environment. However, she said that the diagnostic approach in the pilot study is still being modified, and one of the goals is to make virtual assessment more acceptable to the families.
A Commercialized Diagnostic Approach
A similar approach has been commercialized by a firm called As You Are, according to Steven D. Hicks, MD, PhD, who is an associate professor of pediatrics at Pennsylvania State University College of Medicine, Hershey, Pennsylvania. Dr. Hicks is a principal in the enterprise, which is also assessing ASD virtually.
Trained pediatricians are evaluating patients with multiple tools in addition to TAP, including the Childhood Autism Rating Scale (CARS) and the Diagnostic and Statistical Manual (DSM-V) checklist for ASD. The company, which began offering this diagnostic service in 2022, now employs more than 30 pediatricians who participated in a 1-month training program.
At the 2024 PAS meeting, quality assurance data were presented on 215 (2.2%) of the 9632 children evaluated between February 2023 and March 2024. The diagnostic assessments of these randomly selected children were reviewed by one of three randomly assigned experts (a developmental pediatrician, a child psychologist, or a pediatrician with 7 years’ diagnostic experience) blinded to the initial scoring.
The diagnostic agreement was 94%, according to the data presented, providing a specificity of 90% and a sensitivity of 90% for ASD. The commercialized diagnostic approach is providing a diagnosis in a mean time of 29 days from initial contact, compared with delays that typically exceed 1 year for many children with suspected ASD, according to Dr. Hicks.
Additional Studies Aim at Streamlining Diagnosis
Two additional studies also evaluated strategies to streamline the diagnosis of ASD. Both were positive. In one, the accuracy and time to diagnosis among pediatricians trained in TAP and CARS were compared with those of ASD specialists in a dedicated autism clinic. Both were located at Nemours Children’s Health Center, Wilmington, Delaware.
In this study, presented by Meghan Harrison, DO, an attending pediatrician at Nemours Children’s Health, time to diagnosis among the 39 patients evaluated by pediatricians relative to the 349 patients evaluated at the dedicated ASD center (2.0 vs 5.1 months; P = .001) was significantly shorter. The age at diagnosis in the pediatrician-assessed population (27.5 vs 36.5 months; P < .001) was also significantly younger.
In another study, led by Ashely L. Early, MSW, a clinical social worker at the Medical University of South Carolina, Charleston, South Carolina, switching to a screening tool called the Rapid Interactive Screening Test for Autism in Toddlers (RITA-1) reduced the wait time to evaluation by approximately 5 months relative to previous practice with a more cumbersome screening method.
An ‘Urgent Need’ to Accelerate Diagnosis
In most places in the United States, children suspected of ASD are referred to specialists for confirmation of the diagnosis, which is needed to quality for ASD services, according to Katherine Zuckerman, MD, a professor of pediatrics the Oregon Health and Science University, Portland, Oregon. Dr. Zuckerman, who was moderator of the session in which all four of these abstracts were presented, explained that there is an urgent need to accelerate the time to diagnosis, which involves long delays for many if not most children with ASD. This is important because treatment and supportive services for ASD are almost always dependent on a diagnosis.
“There are tons of data to show that earlier access to ASD services has important patient benefits, including higher IQs,” she said. Other benefits she listed include a better quality of life for the child and the family.
“It can provide a huge reduction in family stress,” she added, suggesting that early interventions favorably modify the trajectory of the disability over time with accruing benefits.
“The lifetime costs of ASD exceed cancer and most other disease, so there are major implications for the cumulative cost of ASD management,” Dr. Zuckerman said. She suggested that the studies presented at the meeting reflect a likely evolution in who evaluates children for ASD and how quickly the evaluation is performed.
Dr. Rea, Dr. Harrison, Dr. Zuckerman, and Ms. Early reported no potential conflicts of interest. In addition to his executive role in As You Are, Dr. Hicks has financial relationships with Quadrant Biosciences and Spectrum Solutions.
TORONTO — , according to a series of studies presented at the Pediatric Academic Societies annual meeting.
Accelerated Diagnosis
In one study, 80% of the evaluations were conducted within 6 weeks of patient enrollment, according to Corinna Rea, MD, a clinician in the primary care center at Boston Children’s Hospital as well as an assistant professor at Harvard Medical School, Boston, Massachusetts.
This outcome was drawn from a pilot study with 179 children suspected of autism spectrum disorder (ASD) by clinicians in a pediatric clinic. All were under the age of 3 years. In the first step, families completed the Bayley-4 Social-Emotional and Adaptive Behavior Scale.
The next step was a virtual assessment by a trained clinician using the TELE-ADS-PEDs (TAP) tool developed by Vanderbilt University, Nashville, Tennessee. Patients and families participated from their homes. The diagnosis of ASD was made by a psychologist using the patient’s history and data provided by the two assessment tools.
Through this approach, the median time to diagnosis was 30 days, according to Dr. Rea. Relative to a median time of 168 days to diagnosis among patients considered likely to have ASD at Dr. Rea’s center in the year prior to this pilot study, the time was reduced significantly (P < .001).
All patients in the study were subsequently evaluated by traditional methods. One hundred percent of the ASD diagnoses were confirmed with traditional assessment.
On the basis of these data, the accelerated approach “seems efficient and quite accurate,” Dr. Rea reported. When family members were surveyed at the end of the pilot study, 60% were satisfied and 28% were moderately satisfied. Although 59% reported that they would have preferred an in-person assessment, approximately 90% agreed the child’s development was mostly or completely captured in the accelerated assessment.
Dr. Rea pointed out that the psychologists participating in this study offered the opinion that home-based assessments are in their experience better than in-person evaluations due to the more natural behavior of the child in their own environment. However, she said that the diagnostic approach in the pilot study is still being modified, and one of the goals is to make virtual assessment more acceptable to the families.
A Commercialized Diagnostic Approach
A similar approach has been commercialized by a firm called As You Are, according to Steven D. Hicks, MD, PhD, who is an associate professor of pediatrics at Pennsylvania State University College of Medicine, Hershey, Pennsylvania. Dr. Hicks is a principal in the enterprise, which is also assessing ASD virtually.
Trained pediatricians are evaluating patients with multiple tools in addition to TAP, including the Childhood Autism Rating Scale (CARS) and the Diagnostic and Statistical Manual (DSM-V) checklist for ASD. The company, which began offering this diagnostic service in 2022, now employs more than 30 pediatricians who participated in a 1-month training program.
At the 2024 PAS meeting, quality assurance data were presented on 215 (2.2%) of the 9632 children evaluated between February 2023 and March 2024. The diagnostic assessments of these randomly selected children were reviewed by one of three randomly assigned experts (a developmental pediatrician, a child psychologist, or a pediatrician with 7 years’ diagnostic experience) blinded to the initial scoring.
The diagnostic agreement was 94%, according to the data presented, providing a specificity of 90% and a sensitivity of 90% for ASD. The commercialized diagnostic approach is providing a diagnosis in a mean time of 29 days from initial contact, compared with delays that typically exceed 1 year for many children with suspected ASD, according to Dr. Hicks.
Additional Studies Aim at Streamlining Diagnosis
Two additional studies also evaluated strategies to streamline the diagnosis of ASD. Both were positive. In one, the accuracy and time to diagnosis among pediatricians trained in TAP and CARS were compared with those of ASD specialists in a dedicated autism clinic. Both were located at Nemours Children’s Health Center, Wilmington, Delaware.
In this study, presented by Meghan Harrison, DO, an attending pediatrician at Nemours Children’s Health, time to diagnosis among the 39 patients evaluated by pediatricians relative to the 349 patients evaluated at the dedicated ASD center (2.0 vs 5.1 months; P = .001) was significantly shorter. The age at diagnosis in the pediatrician-assessed population (27.5 vs 36.5 months; P < .001) was also significantly younger.
In another study, led by Ashely L. Early, MSW, a clinical social worker at the Medical University of South Carolina, Charleston, South Carolina, switching to a screening tool called the Rapid Interactive Screening Test for Autism in Toddlers (RITA-1) reduced the wait time to evaluation by approximately 5 months relative to previous practice with a more cumbersome screening method.
An ‘Urgent Need’ to Accelerate Diagnosis
In most places in the United States, children suspected of ASD are referred to specialists for confirmation of the diagnosis, which is needed to quality for ASD services, according to Katherine Zuckerman, MD, a professor of pediatrics the Oregon Health and Science University, Portland, Oregon. Dr. Zuckerman, who was moderator of the session in which all four of these abstracts were presented, explained that there is an urgent need to accelerate the time to diagnosis, which involves long delays for many if not most children with ASD. This is important because treatment and supportive services for ASD are almost always dependent on a diagnosis.
“There are tons of data to show that earlier access to ASD services has important patient benefits, including higher IQs,” she said. Other benefits she listed include a better quality of life for the child and the family.
“It can provide a huge reduction in family stress,” she added, suggesting that early interventions favorably modify the trajectory of the disability over time with accruing benefits.
“The lifetime costs of ASD exceed cancer and most other disease, so there are major implications for the cumulative cost of ASD management,” Dr. Zuckerman said. She suggested that the studies presented at the meeting reflect a likely evolution in who evaluates children for ASD and how quickly the evaluation is performed.
Dr. Rea, Dr. Harrison, Dr. Zuckerman, and Ms. Early reported no potential conflicts of interest. In addition to his executive role in As You Are, Dr. Hicks has financial relationships with Quadrant Biosciences and Spectrum Solutions.
FROM PAS 2024
Post-COVID Mental Health Risks Linger for Veterans
Not surprisingly, anxiety, depression, posttraumatic stress disorder, and other mental health issues became more prevalent during the COVID-19 pandemic—and after. Studies have found that neurologic and psychiatric sequelae may last up to 6 months following COVID-19 infection.
It appears that COVID-19 infection—even past the acute stage—could put hospitalized patients at risk of exacerbating existing mental health conditions or even developing new conditions. Researchers from Salem Veterans Affairs Health Care System conducted a retrospective observational study from January 1, 2020, through January 1, 2022, of 50,805 veterans hospitalized with COVID-19 and 50,805 patients hospitalized for other reasons.
The researchers found that veterans with COVID-19 group had significantly higher rates of psychiatry-related hospitalization at both 90 and 180 days, as well as a significant increase in the incidence of outpatient mental health visits at 180 days. They also noted a significantly higher risk of new-onset depression and new-onset dementia in the COVID-19 patients at 180 days compared with the non-COVID-19 cohort.
The exact mechanism of the impact of COVID-19 hospitalization on new or worsening depression has yet to be uncovered, the researchers say, but it is known to be complex and interrelated. They point to post-COVID-19 follow-up studies that have found that even mild and asymptomatic infection may lead to cognitive impairment, delirium, extreme fatigue, and clinically relevant mood symptoms. The residual effects of COVID-19 appear to span multiple organ systems.
The researchers also cite current hypotheses about the psychiatric sequelae of COVID-19 that suggest sustained neuroinflammatory processes disrupt the blood-brain barrier, leading to damaged neurons and glia in the brain. In a systematic review, roughly one-third of patients developed neurologic symptoms in the acute phase of the disease, with brain abnormalities “suggestive of COVID-19 etiology.” What’s more, multiple studies have found that anxiety and depression worsen the clinical course of chronic disease, indicating that this mechanism is bidirectional.
Future studies should, among other things include outcomes assessed by COVID-19 disease severity, as well as various psychiatric adverse effects, to enhance provider vigilance and promote closer monitoring.
Not surprisingly, anxiety, depression, posttraumatic stress disorder, and other mental health issues became more prevalent during the COVID-19 pandemic—and after. Studies have found that neurologic and psychiatric sequelae may last up to 6 months following COVID-19 infection.
It appears that COVID-19 infection—even past the acute stage—could put hospitalized patients at risk of exacerbating existing mental health conditions or even developing new conditions. Researchers from Salem Veterans Affairs Health Care System conducted a retrospective observational study from January 1, 2020, through January 1, 2022, of 50,805 veterans hospitalized with COVID-19 and 50,805 patients hospitalized for other reasons.
The researchers found that veterans with COVID-19 group had significantly higher rates of psychiatry-related hospitalization at both 90 and 180 days, as well as a significant increase in the incidence of outpatient mental health visits at 180 days. They also noted a significantly higher risk of new-onset depression and new-onset dementia in the COVID-19 patients at 180 days compared with the non-COVID-19 cohort.
The exact mechanism of the impact of COVID-19 hospitalization on new or worsening depression has yet to be uncovered, the researchers say, but it is known to be complex and interrelated. They point to post-COVID-19 follow-up studies that have found that even mild and asymptomatic infection may lead to cognitive impairment, delirium, extreme fatigue, and clinically relevant mood symptoms. The residual effects of COVID-19 appear to span multiple organ systems.
The researchers also cite current hypotheses about the psychiatric sequelae of COVID-19 that suggest sustained neuroinflammatory processes disrupt the blood-brain barrier, leading to damaged neurons and glia in the brain. In a systematic review, roughly one-third of patients developed neurologic symptoms in the acute phase of the disease, with brain abnormalities “suggestive of COVID-19 etiology.” What’s more, multiple studies have found that anxiety and depression worsen the clinical course of chronic disease, indicating that this mechanism is bidirectional.
Future studies should, among other things include outcomes assessed by COVID-19 disease severity, as well as various psychiatric adverse effects, to enhance provider vigilance and promote closer monitoring.
Not surprisingly, anxiety, depression, posttraumatic stress disorder, and other mental health issues became more prevalent during the COVID-19 pandemic—and after. Studies have found that neurologic and psychiatric sequelae may last up to 6 months following COVID-19 infection.
It appears that COVID-19 infection—even past the acute stage—could put hospitalized patients at risk of exacerbating existing mental health conditions or even developing new conditions. Researchers from Salem Veterans Affairs Health Care System conducted a retrospective observational study from January 1, 2020, through January 1, 2022, of 50,805 veterans hospitalized with COVID-19 and 50,805 patients hospitalized for other reasons.
The researchers found that veterans with COVID-19 group had significantly higher rates of psychiatry-related hospitalization at both 90 and 180 days, as well as a significant increase in the incidence of outpatient mental health visits at 180 days. They also noted a significantly higher risk of new-onset depression and new-onset dementia in the COVID-19 patients at 180 days compared with the non-COVID-19 cohort.
The exact mechanism of the impact of COVID-19 hospitalization on new or worsening depression has yet to be uncovered, the researchers say, but it is known to be complex and interrelated. They point to post-COVID-19 follow-up studies that have found that even mild and asymptomatic infection may lead to cognitive impairment, delirium, extreme fatigue, and clinically relevant mood symptoms. The residual effects of COVID-19 appear to span multiple organ systems.
The researchers also cite current hypotheses about the psychiatric sequelae of COVID-19 that suggest sustained neuroinflammatory processes disrupt the blood-brain barrier, leading to damaged neurons and glia in the brain. In a systematic review, roughly one-third of patients developed neurologic symptoms in the acute phase of the disease, with brain abnormalities “suggestive of COVID-19 etiology.” What’s more, multiple studies have found that anxiety and depression worsen the clinical course of chronic disease, indicating that this mechanism is bidirectional.
Future studies should, among other things include outcomes assessed by COVID-19 disease severity, as well as various psychiatric adverse effects, to enhance provider vigilance and promote closer monitoring.
High-Potency Cannabis Tied to Impaired Brain Development, Psychosis, Cannabis-Use Disorder
It’s becoming clear that (CUD).
That was the message delivered by Yasmin Hurd, PhD, director of the Addiction Institute at Mount Sinai in New York, during a press briefing at the American Psychiatric Association (APA) 2024 annual meeting.
“We’re actually in historic times in that we now have highly concentrated, highly potent cannabis products that are administered in various routes,” Dr. Hurd told reporters.
Tetrahydrocannabinol (THC) concentrations in cannabis products have increased over the years, from around 2%-4% to 15%-24% now, Dr. Hurd noted.
Dr. Hurd and colleagues wrote in a commentary on the developmental trajectory of CUD published simultaneously in the American Journal of Psychiatry.
Dramatic Increase in Teen Cannabis Use
A recent study from Oregon Health & Science University showed that adolescent cannabis abuse in the United States has increased dramatically, by about 245%, since 2000.
“Drug abuse is often driven by what is in front of you,” Nora Volkow, MD, director of the National Institute on Drug Abuse, noted in an interview.
“Right now, cannabis is widely available. So, guess what? Cannabis becomes the drug that people take. Nicotine is much harder to get. It is regulated to a much greater extent than cannabis, so fewer teenagers are consuming nicotine than are consuming cannabis,” Dr. Volkow said.
Cannabis exposure during neurodevelopment has the potential to alter the endocannabinoid system, which in turn, can affect the development of neural pathways that mediate reward; emotional regulation; and multiple cognitive domains including executive functioning and decision-making, learning, abstraction, and attention — all processes central to substance use disorder and other psychiatric disorders, Dr. Hurd said at the briefing.
Dr. Volkow said that cannabis use in adolescence and young adulthood is “very concerning because that’s also the age of risk for psychosis, particularly schizophrenia, with one study showing that use of cannabis in high doses can trigger psychotic episodes, particularly among young males.”
Dr. Hurd noted that not all young people who use cannabis develop CUD, “but a significant number do,” and large-scale studies have consistently reported two main factors associated with CUD risk.
The first is age, both for the onset and frequency of use at younger age. Those who start using cannabis before age 16 years are at the highest risk for CUD. The risk for CUD also increases significantly among youth who use cannabis at least weekly, with the highest prevalence among youth who use cannabis daily. One large study linked increased frequency of use with up to a 17-fold increased risk for CUD.
The second factor consistently associated with the risk for CUD is biologic sex, with CUD rates typically higher in male individuals.
Treatment Challenges
For young people who develop CUD, access to and uptake of treatment can be challenging.
“Given that the increased potency of cannabis and cannabinoid products is expected to increase CUD risk, it is disturbing that less than 10% of youth who meet the criteria for a substance use disorder, including CUD, receive treatment,” Dr. Hurd and colleagues point out in their commentary.
Another challenge is that treatment strategies for CUD are currently limited and consist mainly of motivational enhancement and cognitive-behavioral therapies.
“Clearly new treatment strategies are needed to address the mounting challenge of CUD risk in teens and young adults,” Dr. Hurd and colleagues wrote.
Summing up, Dr. Hurd told reporters, “We now know that most psychiatric disorders have a developmental origin, and the adolescent time period is a critical window for cannabis use disorder risk.”
Yet, on a positive note, the “plasticity of the developing brain that makes it vulnerable to cannabis use disorder and psychiatric comorbidities also provides an opportunity for prevention and early intervention to change that trajectory,” Dr. Hurd said.
The changing legal landscape of cannabis — the US Drug Enforcement Agency is moving forward with plans to move marijuana from a Schedule I to a Schedule III controlled substance under the Controlled Substance Act — makes addressing these risks all the timelier.
“As states vie to leverage tax dollars from the growing cannabis industry, a significant portion of such funds must be used for early intervention/prevention strategies to reduce the impact of cannabis on the developing brain,” Dr. Hurd and colleagues wrote.
This research was supported in part by the National Institute on Drug Abuse and the National Institutes of Health. Dr. Hurd and Dr. Volkow have no relevant disclosures.
A version of this article appeared on Medscape.com.
It’s becoming clear that (CUD).
That was the message delivered by Yasmin Hurd, PhD, director of the Addiction Institute at Mount Sinai in New York, during a press briefing at the American Psychiatric Association (APA) 2024 annual meeting.
“We’re actually in historic times in that we now have highly concentrated, highly potent cannabis products that are administered in various routes,” Dr. Hurd told reporters.
Tetrahydrocannabinol (THC) concentrations in cannabis products have increased over the years, from around 2%-4% to 15%-24% now, Dr. Hurd noted.
Dr. Hurd and colleagues wrote in a commentary on the developmental trajectory of CUD published simultaneously in the American Journal of Psychiatry.
Dramatic Increase in Teen Cannabis Use
A recent study from Oregon Health & Science University showed that adolescent cannabis abuse in the United States has increased dramatically, by about 245%, since 2000.
“Drug abuse is often driven by what is in front of you,” Nora Volkow, MD, director of the National Institute on Drug Abuse, noted in an interview.
“Right now, cannabis is widely available. So, guess what? Cannabis becomes the drug that people take. Nicotine is much harder to get. It is regulated to a much greater extent than cannabis, so fewer teenagers are consuming nicotine than are consuming cannabis,” Dr. Volkow said.
Cannabis exposure during neurodevelopment has the potential to alter the endocannabinoid system, which in turn, can affect the development of neural pathways that mediate reward; emotional regulation; and multiple cognitive domains including executive functioning and decision-making, learning, abstraction, and attention — all processes central to substance use disorder and other psychiatric disorders, Dr. Hurd said at the briefing.
Dr. Volkow said that cannabis use in adolescence and young adulthood is “very concerning because that’s also the age of risk for psychosis, particularly schizophrenia, with one study showing that use of cannabis in high doses can trigger psychotic episodes, particularly among young males.”
Dr. Hurd noted that not all young people who use cannabis develop CUD, “but a significant number do,” and large-scale studies have consistently reported two main factors associated with CUD risk.
The first is age, both for the onset and frequency of use at younger age. Those who start using cannabis before age 16 years are at the highest risk for CUD. The risk for CUD also increases significantly among youth who use cannabis at least weekly, with the highest prevalence among youth who use cannabis daily. One large study linked increased frequency of use with up to a 17-fold increased risk for CUD.
The second factor consistently associated with the risk for CUD is biologic sex, with CUD rates typically higher in male individuals.
Treatment Challenges
For young people who develop CUD, access to and uptake of treatment can be challenging.
“Given that the increased potency of cannabis and cannabinoid products is expected to increase CUD risk, it is disturbing that less than 10% of youth who meet the criteria for a substance use disorder, including CUD, receive treatment,” Dr. Hurd and colleagues point out in their commentary.
Another challenge is that treatment strategies for CUD are currently limited and consist mainly of motivational enhancement and cognitive-behavioral therapies.
“Clearly new treatment strategies are needed to address the mounting challenge of CUD risk in teens and young adults,” Dr. Hurd and colleagues wrote.
Summing up, Dr. Hurd told reporters, “We now know that most psychiatric disorders have a developmental origin, and the adolescent time period is a critical window for cannabis use disorder risk.”
Yet, on a positive note, the “plasticity of the developing brain that makes it vulnerable to cannabis use disorder and psychiatric comorbidities also provides an opportunity for prevention and early intervention to change that trajectory,” Dr. Hurd said.
The changing legal landscape of cannabis — the US Drug Enforcement Agency is moving forward with plans to move marijuana from a Schedule I to a Schedule III controlled substance under the Controlled Substance Act — makes addressing these risks all the timelier.
“As states vie to leverage tax dollars from the growing cannabis industry, a significant portion of such funds must be used for early intervention/prevention strategies to reduce the impact of cannabis on the developing brain,” Dr. Hurd and colleagues wrote.
This research was supported in part by the National Institute on Drug Abuse and the National Institutes of Health. Dr. Hurd and Dr. Volkow have no relevant disclosures.
A version of this article appeared on Medscape.com.
It’s becoming clear that (CUD).
That was the message delivered by Yasmin Hurd, PhD, director of the Addiction Institute at Mount Sinai in New York, during a press briefing at the American Psychiatric Association (APA) 2024 annual meeting.
“We’re actually in historic times in that we now have highly concentrated, highly potent cannabis products that are administered in various routes,” Dr. Hurd told reporters.
Tetrahydrocannabinol (THC) concentrations in cannabis products have increased over the years, from around 2%-4% to 15%-24% now, Dr. Hurd noted.
Dr. Hurd and colleagues wrote in a commentary on the developmental trajectory of CUD published simultaneously in the American Journal of Psychiatry.
Dramatic Increase in Teen Cannabis Use
A recent study from Oregon Health & Science University showed that adolescent cannabis abuse in the United States has increased dramatically, by about 245%, since 2000.
“Drug abuse is often driven by what is in front of you,” Nora Volkow, MD, director of the National Institute on Drug Abuse, noted in an interview.
“Right now, cannabis is widely available. So, guess what? Cannabis becomes the drug that people take. Nicotine is much harder to get. It is regulated to a much greater extent than cannabis, so fewer teenagers are consuming nicotine than are consuming cannabis,” Dr. Volkow said.
Cannabis exposure during neurodevelopment has the potential to alter the endocannabinoid system, which in turn, can affect the development of neural pathways that mediate reward; emotional regulation; and multiple cognitive domains including executive functioning and decision-making, learning, abstraction, and attention — all processes central to substance use disorder and other psychiatric disorders, Dr. Hurd said at the briefing.
Dr. Volkow said that cannabis use in adolescence and young adulthood is “very concerning because that’s also the age of risk for psychosis, particularly schizophrenia, with one study showing that use of cannabis in high doses can trigger psychotic episodes, particularly among young males.”
Dr. Hurd noted that not all young people who use cannabis develop CUD, “but a significant number do,” and large-scale studies have consistently reported two main factors associated with CUD risk.
The first is age, both for the onset and frequency of use at younger age. Those who start using cannabis before age 16 years are at the highest risk for CUD. The risk for CUD also increases significantly among youth who use cannabis at least weekly, with the highest prevalence among youth who use cannabis daily. One large study linked increased frequency of use with up to a 17-fold increased risk for CUD.
The second factor consistently associated with the risk for CUD is biologic sex, with CUD rates typically higher in male individuals.
Treatment Challenges
For young people who develop CUD, access to and uptake of treatment can be challenging.
“Given that the increased potency of cannabis and cannabinoid products is expected to increase CUD risk, it is disturbing that less than 10% of youth who meet the criteria for a substance use disorder, including CUD, receive treatment,” Dr. Hurd and colleagues point out in their commentary.
Another challenge is that treatment strategies for CUD are currently limited and consist mainly of motivational enhancement and cognitive-behavioral therapies.
“Clearly new treatment strategies are needed to address the mounting challenge of CUD risk in teens and young adults,” Dr. Hurd and colleagues wrote.
Summing up, Dr. Hurd told reporters, “We now know that most psychiatric disorders have a developmental origin, and the adolescent time period is a critical window for cannabis use disorder risk.”
Yet, on a positive note, the “plasticity of the developing brain that makes it vulnerable to cannabis use disorder and psychiatric comorbidities also provides an opportunity for prevention and early intervention to change that trajectory,” Dr. Hurd said.
The changing legal landscape of cannabis — the US Drug Enforcement Agency is moving forward with plans to move marijuana from a Schedule I to a Schedule III controlled substance under the Controlled Substance Act — makes addressing these risks all the timelier.
“As states vie to leverage tax dollars from the growing cannabis industry, a significant portion of such funds must be used for early intervention/prevention strategies to reduce the impact of cannabis on the developing brain,” Dr. Hurd and colleagues wrote.
This research was supported in part by the National Institute on Drug Abuse and the National Institutes of Health. Dr. Hurd and Dr. Volkow have no relevant disclosures.
A version of this article appeared on Medscape.com.
FROM APA 2024
Follow-Up for Pediatric Depression Doubles With New Quality Initiative
TORONTO — An ambitious effort at a busy pediatrics clinic to improve follow-up in children and adolescents with a positive depression screen improved this quality metric, and it produced a fundamental change in approach.
“It was a big culture shift,” reported Landon B. Krantz, MD, a clinical fellow in the Division of General and Community Pediatrics at Cincinnati Children’s Hospital in Ohio. From a baseline position of screening, risk identification, and then referral, “we are now taking ownership of the process.”
Based on the substantial risk posed by significant levels of depression, guidelines recommend follow-up for any patient 12 years or older who has a positive screen, according to Dr. Krantz. At his center, they found only 19% had a documented follow-up within 30 days, even though timely intervention is important.
“Nearly half of suicide events in adolescents occur within 30 days after a positive PHQ-9 [9-question Patient Health Questionnaire] is completed,” said Dr. Krantz when presenting his data at the Pediatric Academic Societies annual meeting.
The issue has gained more urgency because of the substantial increase over the past several years in children presenting with depression and suicidal thoughts, according to Dr. Krantz. He said many are characterizing the upsurge as a mental health crisis in the pediatric age group.
Improving Follow-Up
. The goal at the outset was to increase the proportion to 35%.
“We know that a lot of children would receive follow-up at centers outside of our system,” said Dr. Krantz, explaining why the goal was relatively modest. Based on the likelihood that many follow-up visits would not be captured, he expected the final data would represent an underestimate.
Depression at baseline was defined as a score of 10 or higher on the PHQ-9 or any positive answer to item 9 on this screening tool, which asks specifically about thoughts of self-harm.
To be counted, follow-up had to be a documented encounter, whether by phone call, in-person visit, or telehealth visit.
“We needed patients to be checked. We did not count a prescription refill as a true follow-up,” Dr. Krantz specified.
There were numerous strategies implemented to improve follow-up, not least of which was an educational program to reinforce the importance and value of follow-up that was disseminated to clinicians in all of the participating clinics. Medical assistants were instructed to schedule a follow-up appointment for all patients who tested positive before they left the office. A target of 3 weeks was a strategy of overcorrection when so many patients were missing the initial 30-day window by just a few days.
The approach also involved an enhanced collaboration with psychologists to which patients were referred. Asking for expedited appointments when appropriate ensured that those at highest risk were prioritized, although Dr. Krantz said that this step was planned carefully to avoid overwhelming the mental health team.
“We monitored this and made sure it was not increasing the burden for psychologists from a capacity standpoint,” he said.
Other steps, like a depression action plan, which Dr. Krantz compared to an asthma action plan, were also implemented to reduce the risk of losing symptomatic patients before the chance for an effective treatment.
When compared with the 19% 30-day follow-up rate in the preintervention sample of 589 children, the 43.8% 30-day follow-up rate achieved in the 764 patients identified after implementation beat the original goal.
The improvement in follow-up was relatively consistent across all six clinics, which Dr. Krantz believes reflected a broad and shared change in a sense of responsibility for confirming that symptoms of depression were being addressed. Patients were still referred for psychological help, but referral was no longer considered enough.
“Children with mental health issues are still our patients in primary care,” said Dr. Krantz, who considers this an important change in orientation.
While the goal was to schedule patients for a follow-up at the time of a positive depression screen, Dr. Krantz described one important accommodation.
“The screen for depression was being performed in most cases during well visits, so patients and their families were not expecting to be discussing this issue,” he said. The diagnosis might be a particular surprise to parents who were not aware of any symptoms. In this case, Dr. Krantz said patients and families were given time to process the information and were contacted after a week to discuss further workup.
It is also notable that about one third of patients met the criteria for depression by answering positively to the PHQ-9 item on self-harm when they did not meet the 10 or more threshold depression score overall. In other words, these patients would have been missed without this criterion.
In the participating Cincinnati pediatric clinics, about 12%-13% of adolescents met the criteria for depression, which Dr. Krantz said is consistent with reports in the literature. He said the range is about 6%-24%.
Although outcomes were not tracked, there is evidence that early intervention for depression yields better outcomes than delayed intervention, according to Dr. Krantz. Based on approximately 600 positive screens for depression per year at his pediatric clinics, he estimated that his data predict at least 25% more patients will receive timely follow-up.
Seeking Solutions to a Growing Problem
There are several studies documenting the growing problem of adolescent depression and suicide and, for this reason, the topic is attracting a lot of attention, according to Corinna Rea, MD, MPH, a pediatrician working in the primary care center at Boston Children’s Hospital in Massachusetts.
Dr. Rea was not involved with the study, but when asked to comment, she said: “The results of this study were encouraging because we know that getting patients to care quickly is probably important.” She also agreed that referring patients with depression for care might not be enough, noting that a lot of patients do not follow up on recommendations to pursue a consultation or treatment.
“I am now involved in a project with the American Academy of Pediatrics to address this issue,” Dr. Rae said. She thinks that more work in this area is needed and agreed with Dr. Krantz that pediatricians should verify that children with depression are getting help even when other specialists are providing the treatment.
Dr. Krantz and Dr. Rae report no potential conflicts of interest.
TORONTO — An ambitious effort at a busy pediatrics clinic to improve follow-up in children and adolescents with a positive depression screen improved this quality metric, and it produced a fundamental change in approach.
“It was a big culture shift,” reported Landon B. Krantz, MD, a clinical fellow in the Division of General and Community Pediatrics at Cincinnati Children’s Hospital in Ohio. From a baseline position of screening, risk identification, and then referral, “we are now taking ownership of the process.”
Based on the substantial risk posed by significant levels of depression, guidelines recommend follow-up for any patient 12 years or older who has a positive screen, according to Dr. Krantz. At his center, they found only 19% had a documented follow-up within 30 days, even though timely intervention is important.
“Nearly half of suicide events in adolescents occur within 30 days after a positive PHQ-9 [9-question Patient Health Questionnaire] is completed,” said Dr. Krantz when presenting his data at the Pediatric Academic Societies annual meeting.
The issue has gained more urgency because of the substantial increase over the past several years in children presenting with depression and suicidal thoughts, according to Dr. Krantz. He said many are characterizing the upsurge as a mental health crisis in the pediatric age group.
Improving Follow-Up
. The goal at the outset was to increase the proportion to 35%.
“We know that a lot of children would receive follow-up at centers outside of our system,” said Dr. Krantz, explaining why the goal was relatively modest. Based on the likelihood that many follow-up visits would not be captured, he expected the final data would represent an underestimate.
Depression at baseline was defined as a score of 10 or higher on the PHQ-9 or any positive answer to item 9 on this screening tool, which asks specifically about thoughts of self-harm.
To be counted, follow-up had to be a documented encounter, whether by phone call, in-person visit, or telehealth visit.
“We needed patients to be checked. We did not count a prescription refill as a true follow-up,” Dr. Krantz specified.
There were numerous strategies implemented to improve follow-up, not least of which was an educational program to reinforce the importance and value of follow-up that was disseminated to clinicians in all of the participating clinics. Medical assistants were instructed to schedule a follow-up appointment for all patients who tested positive before they left the office. A target of 3 weeks was a strategy of overcorrection when so many patients were missing the initial 30-day window by just a few days.
The approach also involved an enhanced collaboration with psychologists to which patients were referred. Asking for expedited appointments when appropriate ensured that those at highest risk were prioritized, although Dr. Krantz said that this step was planned carefully to avoid overwhelming the mental health team.
“We monitored this and made sure it was not increasing the burden for psychologists from a capacity standpoint,” he said.
Other steps, like a depression action plan, which Dr. Krantz compared to an asthma action plan, were also implemented to reduce the risk of losing symptomatic patients before the chance for an effective treatment.
When compared with the 19% 30-day follow-up rate in the preintervention sample of 589 children, the 43.8% 30-day follow-up rate achieved in the 764 patients identified after implementation beat the original goal.
The improvement in follow-up was relatively consistent across all six clinics, which Dr. Krantz believes reflected a broad and shared change in a sense of responsibility for confirming that symptoms of depression were being addressed. Patients were still referred for psychological help, but referral was no longer considered enough.
“Children with mental health issues are still our patients in primary care,” said Dr. Krantz, who considers this an important change in orientation.
While the goal was to schedule patients for a follow-up at the time of a positive depression screen, Dr. Krantz described one important accommodation.
“The screen for depression was being performed in most cases during well visits, so patients and their families were not expecting to be discussing this issue,” he said. The diagnosis might be a particular surprise to parents who were not aware of any symptoms. In this case, Dr. Krantz said patients and families were given time to process the information and were contacted after a week to discuss further workup.
It is also notable that about one third of patients met the criteria for depression by answering positively to the PHQ-9 item on self-harm when they did not meet the 10 or more threshold depression score overall. In other words, these patients would have been missed without this criterion.
In the participating Cincinnati pediatric clinics, about 12%-13% of adolescents met the criteria for depression, which Dr. Krantz said is consistent with reports in the literature. He said the range is about 6%-24%.
Although outcomes were not tracked, there is evidence that early intervention for depression yields better outcomes than delayed intervention, according to Dr. Krantz. Based on approximately 600 positive screens for depression per year at his pediatric clinics, he estimated that his data predict at least 25% more patients will receive timely follow-up.
Seeking Solutions to a Growing Problem
There are several studies documenting the growing problem of adolescent depression and suicide and, for this reason, the topic is attracting a lot of attention, according to Corinna Rea, MD, MPH, a pediatrician working in the primary care center at Boston Children’s Hospital in Massachusetts.
Dr. Rea was not involved with the study, but when asked to comment, she said: “The results of this study were encouraging because we know that getting patients to care quickly is probably important.” She also agreed that referring patients with depression for care might not be enough, noting that a lot of patients do not follow up on recommendations to pursue a consultation or treatment.
“I am now involved in a project with the American Academy of Pediatrics to address this issue,” Dr. Rae said. She thinks that more work in this area is needed and agreed with Dr. Krantz that pediatricians should verify that children with depression are getting help even when other specialists are providing the treatment.
Dr. Krantz and Dr. Rae report no potential conflicts of interest.
TORONTO — An ambitious effort at a busy pediatrics clinic to improve follow-up in children and adolescents with a positive depression screen improved this quality metric, and it produced a fundamental change in approach.
“It was a big culture shift,” reported Landon B. Krantz, MD, a clinical fellow in the Division of General and Community Pediatrics at Cincinnati Children’s Hospital in Ohio. From a baseline position of screening, risk identification, and then referral, “we are now taking ownership of the process.”
Based on the substantial risk posed by significant levels of depression, guidelines recommend follow-up for any patient 12 years or older who has a positive screen, according to Dr. Krantz. At his center, they found only 19% had a documented follow-up within 30 days, even though timely intervention is important.
“Nearly half of suicide events in adolescents occur within 30 days after a positive PHQ-9 [9-question Patient Health Questionnaire] is completed,” said Dr. Krantz when presenting his data at the Pediatric Academic Societies annual meeting.
The issue has gained more urgency because of the substantial increase over the past several years in children presenting with depression and suicidal thoughts, according to Dr. Krantz. He said many are characterizing the upsurge as a mental health crisis in the pediatric age group.
Improving Follow-Up
. The goal at the outset was to increase the proportion to 35%.
“We know that a lot of children would receive follow-up at centers outside of our system,” said Dr. Krantz, explaining why the goal was relatively modest. Based on the likelihood that many follow-up visits would not be captured, he expected the final data would represent an underestimate.
Depression at baseline was defined as a score of 10 or higher on the PHQ-9 or any positive answer to item 9 on this screening tool, which asks specifically about thoughts of self-harm.
To be counted, follow-up had to be a documented encounter, whether by phone call, in-person visit, or telehealth visit.
“We needed patients to be checked. We did not count a prescription refill as a true follow-up,” Dr. Krantz specified.
There were numerous strategies implemented to improve follow-up, not least of which was an educational program to reinforce the importance and value of follow-up that was disseminated to clinicians in all of the participating clinics. Medical assistants were instructed to schedule a follow-up appointment for all patients who tested positive before they left the office. A target of 3 weeks was a strategy of overcorrection when so many patients were missing the initial 30-day window by just a few days.
The approach also involved an enhanced collaboration with psychologists to which patients were referred. Asking for expedited appointments when appropriate ensured that those at highest risk were prioritized, although Dr. Krantz said that this step was planned carefully to avoid overwhelming the mental health team.
“We monitored this and made sure it was not increasing the burden for psychologists from a capacity standpoint,” he said.
Other steps, like a depression action plan, which Dr. Krantz compared to an asthma action plan, were also implemented to reduce the risk of losing symptomatic patients before the chance for an effective treatment.
When compared with the 19% 30-day follow-up rate in the preintervention sample of 589 children, the 43.8% 30-day follow-up rate achieved in the 764 patients identified after implementation beat the original goal.
The improvement in follow-up was relatively consistent across all six clinics, which Dr. Krantz believes reflected a broad and shared change in a sense of responsibility for confirming that symptoms of depression were being addressed. Patients were still referred for psychological help, but referral was no longer considered enough.
“Children with mental health issues are still our patients in primary care,” said Dr. Krantz, who considers this an important change in orientation.
While the goal was to schedule patients for a follow-up at the time of a positive depression screen, Dr. Krantz described one important accommodation.
“The screen for depression was being performed in most cases during well visits, so patients and their families were not expecting to be discussing this issue,” he said. The diagnosis might be a particular surprise to parents who were not aware of any symptoms. In this case, Dr. Krantz said patients and families were given time to process the information and were contacted after a week to discuss further workup.
It is also notable that about one third of patients met the criteria for depression by answering positively to the PHQ-9 item on self-harm when they did not meet the 10 or more threshold depression score overall. In other words, these patients would have been missed without this criterion.
In the participating Cincinnati pediatric clinics, about 12%-13% of adolescents met the criteria for depression, which Dr. Krantz said is consistent with reports in the literature. He said the range is about 6%-24%.
Although outcomes were not tracked, there is evidence that early intervention for depression yields better outcomes than delayed intervention, according to Dr. Krantz. Based on approximately 600 positive screens for depression per year at his pediatric clinics, he estimated that his data predict at least 25% more patients will receive timely follow-up.
Seeking Solutions to a Growing Problem
There are several studies documenting the growing problem of adolescent depression and suicide and, for this reason, the topic is attracting a lot of attention, according to Corinna Rea, MD, MPH, a pediatrician working in the primary care center at Boston Children’s Hospital in Massachusetts.
Dr. Rea was not involved with the study, but when asked to comment, she said: “The results of this study were encouraging because we know that getting patients to care quickly is probably important.” She also agreed that referring patients with depression for care might not be enough, noting that a lot of patients do not follow up on recommendations to pursue a consultation or treatment.
“I am now involved in a project with the American Academy of Pediatrics to address this issue,” Dr. Rae said. She thinks that more work in this area is needed and agreed with Dr. Krantz that pediatricians should verify that children with depression are getting help even when other specialists are providing the treatment.
Dr. Krantz and Dr. Rae report no potential conflicts of interest.
FROM PAS 2024