Mental Health

Most adults in the United States (70%) are anxious or extremely anxious about keeping themselves or their families safe, with 42% very anxious about gun violence, results of a national mental health poll conducted by the American Psychiatric Association (APA) show.

“There is a lot of worry in the world right now about economic uncertainty, about violence, about how we’re going to come out of this period of time,” APA President Rebecca W. Brendel, MD, JD, said during an APA press briefing announcing the latest poll results.

Brendel said the results are an important reminder and opportunity for psychiatrists to put their finger on the pulse of Americans’ mental health.

“If 70% of people are feeling unsafe, we need to come up with individual and also society-based solutions to help people move forward so that we can see a brighter future and not experience so much anxiety,” she added.

The poll was conducted between April 20 and 22, 2023, among a nationally representative sample of 2,201 adults. The analysis also tracks data from a poll conducted between April 23 and 24, 2022, among a sample of 2,210 adults.

Overall, nearly two in five adults (37%) reported feeling more anxious than they were at this time last year, which is higher than in 2022 (32%) but lower than in 2021 (41%) and 2020 (62%).

About one-third (30%) of adults said they have consulted a mental health care professional, a slight uptick from 2022.

Other issues keeping Americans up at night include keeping their identity safe (68%), their health (66%), paying bills or expenses (65%), climate change (59%), the opioid epidemic (50%) and the impact of emerging technology on day-to-day life (45%).

Half of respondents reported they would be likely to consider a mental health treatment involving cannabis or marijuana, while most said they would be unlikely to consider a treatment involving psychedelics (59%) or ketamine (56%).

Two-thirds (68%) of American adults reported that their children and teenagers have more mental health problems than they did a decade ago.

More than 50% of parents are concerned about their children’s technology use (59%) and mental state (55%), and 31% have encountered difficulty scheduling appointments with mental health professionals for their children.

More than three-quarters (78%) of U.S. adults believe mental health affects physical health and that untreated mental illness has a significant negative effect on families (78%). About two-thirds (64%) believe untreated mental illness harms the economy.

One in three adults (34%) would not vote for a candidate for elected office who has a mental illness – up 7% from 2022.

“The majority of the public understands something we’ve been saying for a long time: Your mental health is about your health,” Saul Levin, MD, MPA, chief executive officer and medical director at the American Psychiatric Association, said in the release.

“It’s contingent upon us as a field to continue to spread that message, and that those who are experiencing mental health concerns aren’t alone and that there are ways to receive help,” Dr. Levin added.
 

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

Most adults in the United States (70%) are anxious or extremely anxious about keeping themselves or their families safe, with 42% very anxious about gun violence, results of a national mental health poll conducted by the American Psychiatric Association (APA) show.

“There is a lot of worry in the world right now about economic uncertainty, about violence, about how we’re going to come out of this period of time,” APA President Rebecca W. Brendel, MD, JD, said during an APA press briefing announcing the latest poll results.

Brendel said the results are an important reminder and opportunity for psychiatrists to put their finger on the pulse of Americans’ mental health.

“If 70% of people are feeling unsafe, we need to come up with individual and also society-based solutions to help people move forward so that we can see a brighter future and not experience so much anxiety,” she added.

The poll was conducted between April 20 and 22, 2023, among a nationally representative sample of 2,201 adults. The analysis also tracks data from a poll conducted between April 23 and 24, 2022, among a sample of 2,210 adults.

Overall, nearly two in five adults (37%) reported feeling more anxious than they were at this time last year, which is higher than in 2022 (32%) but lower than in 2021 (41%) and 2020 (62%).

About one-third (30%) of adults said they have consulted a mental health care professional, a slight uptick from 2022.

Other issues keeping Americans up at night include keeping their identity safe (68%), their health (66%), paying bills or expenses (65%), climate change (59%), the opioid epidemic (50%) and the impact of emerging technology on day-to-day life (45%).

Half of respondents reported they would be likely to consider a mental health treatment involving cannabis or marijuana, while most said they would be unlikely to consider a treatment involving psychedelics (59%) or ketamine (56%).

Two-thirds (68%) of American adults reported that their children and teenagers have more mental health problems than they did a decade ago.

More than 50% of parents are concerned about their children’s technology use (59%) and mental state (55%), and 31% have encountered difficulty scheduling appointments with mental health professionals for their children.

More than three-quarters (78%) of U.S. adults believe mental health affects physical health and that untreated mental illness has a significant negative effect on families (78%). About two-thirds (64%) believe untreated mental illness harms the economy.

One in three adults (34%) would not vote for a candidate for elected office who has a mental illness – up 7% from 2022.

“The majority of the public understands something we’ve been saying for a long time: Your mental health is about your health,” Saul Levin, MD, MPA, chief executive officer and medical director at the American Psychiatric Association, said in the release.

“It’s contingent upon us as a field to continue to spread that message, and that those who are experiencing mental health concerns aren’t alone and that there are ways to receive help,” Dr. Levin added.
 

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

Most adults in the United States (70%) are anxious or extremely anxious about keeping themselves or their families safe, with 42% very anxious about gun violence, results of a national mental health poll conducted by the American Psychiatric Association (APA) show.

“There is a lot of worry in the world right now about economic uncertainty, about violence, about how we’re going to come out of this period of time,” APA President Rebecca W. Brendel, MD, JD, said during an APA press briefing announcing the latest poll results.

Brendel said the results are an important reminder and opportunity for psychiatrists to put their finger on the pulse of Americans’ mental health.

“If 70% of people are feeling unsafe, we need to come up with individual and also society-based solutions to help people move forward so that we can see a brighter future and not experience so much anxiety,” she added.

The poll was conducted between April 20 and 22, 2023, among a nationally representative sample of 2,201 adults. The analysis also tracks data from a poll conducted between April 23 and 24, 2022, among a sample of 2,210 adults.

Overall, nearly two in five adults (37%) reported feeling more anxious than they were at this time last year, which is higher than in 2022 (32%) but lower than in 2021 (41%) and 2020 (62%).

About one-third (30%) of adults said they have consulted a mental health care professional, a slight uptick from 2022.

Other issues keeping Americans up at night include keeping their identity safe (68%), their health (66%), paying bills or expenses (65%), climate change (59%), the opioid epidemic (50%) and the impact of emerging technology on day-to-day life (45%).

Half of respondents reported they would be likely to consider a mental health treatment involving cannabis or marijuana, while most said they would be unlikely to consider a treatment involving psychedelics (59%) or ketamine (56%).

Two-thirds (68%) of American adults reported that their children and teenagers have more mental health problems than they did a decade ago.

More than 50% of parents are concerned about their children’s technology use (59%) and mental state (55%), and 31% have encountered difficulty scheduling appointments with mental health professionals for their children.

More than three-quarters (78%) of U.S. adults believe mental health affects physical health and that untreated mental illness has a significant negative effect on families (78%). About two-thirds (64%) believe untreated mental illness harms the economy.

One in three adults (34%) would not vote for a candidate for elected office who has a mental illness – up 7% from 2022.

“The majority of the public understands something we’ve been saying for a long time: Your mental health is about your health,” Saul Levin, MD, MPA, chief executive officer and medical director at the American Psychiatric Association, said in the release.

“It’s contingent upon us as a field to continue to spread that message, and that those who are experiencing mental health concerns aren’t alone and that there are ways to receive help,” Dr. Levin added.
 

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

May is Mental Health Awareness Month, providing us a chance to go beyond discussing the screening, diagnosis, and evidence-based treatments for the mental illnesses of youth. Just as children are developing physical health, they are similarly establishing the foundations for their mental health. The World Health Organization defines good mental health as “a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her own community.” While the science of mental health promotion and disease prevention in childhood and adolescence is relatively young, there are several discrete domains in which you can follow and support your patient’s developing mental health. This begins with the well-being of new parents, and then moves into how parents are helping their children to develop skills to manage their basic daily needs and impulses, their thoughts and feelings, their stresses and their relationships. With a little support from you, parents can confidently help their children develop the foundations for good mental health.

First year of life: Parental mental health

Perhaps the strongest risk factor for serious mental illness in childhood and adulthood is parental neglect during the first year of life, and neglect in the first several months of life is the most commonly reported form of child abuse. Infant neglect is associated with parental depression (and other mental illnesses), parental substance use, and a parent’s own experience of childhood abuse or neglect. Neglect is more common with teenaged parents and parents living in poverty. Pediatricians are uniquely connected to families during the first year of a child’s life. The American Academy of Pediatrics recommends screening new mothers for depression at 1-, 2-, 4-, and 6-month infant check-ups with the Edinburgh Postnatal Depression Screen. Even without a positive screen, new parents may need the fortifications of extra community support to adapt to the changes parenthood brings.

At checkups, ask (both) parents how they are managing the stresses of a new baby. Are they getting restful sleep? Do they have social supports? Are they connected to a community (friends, extended family, faith) or isolated? Are they developing confidence as parents or feeling overwhelmed? Simple guidance, such as “sleep when the baby sleeps” and reassurance that taking good care of themselves is taking good care of the baby is always helpful. Sometimes you will need to refer for treatment or to community supports. Have your list of online and in-person resources at the ready to provide parents with these prescriptions. Supporting parental mental health and adjustment in the first year of life is possibly the most important building block for their child’s future mental health.
 

Toddlers and up: Emotional literacy

Emotional literacy (sometimes called “emotional intelligence”) is the capacity to recognize, identify, and manage feelings in oneself and in others. This skill begins to develop in infancy when parents respond to their baby’s cries with attunement, feeding or changing them if needed, and at other times simply reflecting their feelings and soothing them with movement, singing, or quiet talking. As children grow, so does their range of feelings, and their (cognitive) capacity to identify and manage them. Parents support this development by being available whenever their young children experience strong emotions, calmly listening, and acknowledging their discomfort. Parents can offer words for describing those feelings, and even be curious with their young children where in their bodies they are feeling them, how they can stay patient while the feeling passes or things they might be able to do to feel better. Parents may want to remove their child’s distress, but staying calm, curious, and present while helping their child to manage it will build their child’s emotional health. Parents can nurture this development in a less intense way by reading books about feelings together and noticing and identifying feelings in other children or in cartoon characters.

School-age children: Adding mindfulness

While a child’s cognitive development unfolds naturally, school-age children can cultivate awareness of their thoughts. This becomes possible after awareness of feelings and parents can help their older children consider whether something they are experiencing is a thought, a feeling, or a fact. They do so in the same way they helped their child develop emotional literacy: By responding with calm, curiosity, and confidence every time their child comes to them in distress (especially mild distress, like boredom!) or with a challenge or a question. With a difficult situation, parents start by helping their child to identify thoughts and feelings before impulsively acting on them. Parents can help children identify what’s in their control, try different approaches, and be flexible if their first efforts don’t work. Children need to learn that failing at things is how we learn and grow. Just like learning to ride a bike, it builds their frustration tolerance, their knowledge that they can do difficult things, and that distress subsides. These are critical building blocks for adolescence, when the challenges become greater and they manage them more independently.

Learning “mindfulness” (a practice that cultivates nonjudgmental awareness of one’s own thoughts, feelings, and sensations) can help children (and parents) to cultivate quiet self-awareness outside of moments of difficulty. “Stop, Breathe, and Think” and “Mindful gNATs” are two free apps that are recommended by the American Academy of Child and Adolescent Psychiatry for children (and their parents) to use to practice this awareness of thoughts and feelings.
 

Early and later adolescence: Stress management skills

Building on this awareness of thoughts and emotions, adolescents develop adaptive coping skills by facing challenges with the support of their parents nearby. Parents should still be ready to respond to charged emotional moments with calm and curiosity, validating their child’s distress while helping them to consider healthy responses. Helping their teenager to describe their experience, differentiating feelings from thoughts (and facts), and considering different choices within their control is foundational to resilience in adulthood. Parents also help their teenagers by reminding them of the need for good self-care (sleep, exercise, nutrition), nourishing social relationships, and protecting time for rest and recharging activities. Sometimes, parents will think with their teenager about why they are engaged in an activity that is stressful, whether it is authentically important to them, and why. Adolescents should be deepening their sense of identity, interests, talents, and even values, and stressful moments are rich opportunities to do so, with the support of caring adults. Without intentionally building these skills, adolescents will be more prone to managing stress with avoidance or unhealthy coping, such as excessive eating, video gaming, drugs, or alcohol.

Infancy and up: Behavioral healthy habits (sleep, physical activity, nutrition, and screen time)

Healthy habits sound simple, but establishing them is not always easy. The idea of a habit is that it makes managing something challenging or important more automatic, and thus easier and more reliable. Many of the same habits that promote physical health in adulthood also promote mental health: adequate, restful sleep; daily physical activity; a nutritious diet and a healthy relationship with food; and managing screen time in a developmentally appropriate way. Infants depend entirely on their parents for regulation of these behaviors. As their children grow, parents will adapt these routines so that their children are gradually regulating these needs and activities more independently. In each of these areas, children need clear expectations and routines, consistent consequences and positive feedback, and the modeling and patient support of their parents. Educate parents about what good sleep hygiene looks like at each age. Discuss ways to support regular physical activity, especially as a family. Ask the parents about nutrition, including how they manage picky eating; how many family meals they enjoy together; and whether food is ever used to manage boredom or distress. Finally, talk with parents about a developmentally appropriate approach to rules and expectations around screen time and the importance of using family-based rules. Establishing expectations and routines during early childhood means children learn how good it feels to have restful sleep, regular exercise, and happy, healthy family meals. In adolescence, parents can then focus on helping their children to manage temptation, challenge, disappointment, and frustration more independently.

Infancy and up: Relational health

Children develop the skills needed for healthy relationships at home, and they are connected to all of the skills described above. Children need attuned, responsive, and reliable parenting to build a capacity for trust of others, to learn how to communicate honestly and effectively, to learn to expect and offer compassion and respect, and to learn how to handle disagreement and conflict. They learn these skills by watching their parents and by developing the emotional, cognitive, and behavioral healthy habits with their parents’ help. They need a consistently safe and responsive environment at home. They need parents who are attuned and flexible, while maintaining routines and high expectations. They need parents who make time for them when they are sad or struggling, and make time for joy, play, and mindless fun. While a detailed assessment of how the family is functioning may go beyond a check-up, you can ask about those routines that build healthy habits (family mealtime, sleep routines, screen time rules), communication style, and what the family enjoys doing together. Learning about how a family is building these healthy habits and how connected they are to one another can give you a clear snapshot of how well a child may be doing on their mental health growth curve, and what areas might benefit from more active guidance and support.

Dr. Swick is physician in chief at Ohana Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].

May is Mental Health Awareness Month, providing us a chance to go beyond discussing the screening, diagnosis, and evidence-based treatments for the mental illnesses of youth. Just as children are developing physical health, they are similarly establishing the foundations for their mental health. The World Health Organization defines good mental health as “a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her own community.” While the science of mental health promotion and disease prevention in childhood and adolescence is relatively young, there are several discrete domains in which you can follow and support your patient’s developing mental health. This begins with the well-being of new parents, and then moves into how parents are helping their children to develop skills to manage their basic daily needs and impulses, their thoughts and feelings, their stresses and their relationships. With a little support from you, parents can confidently help their children develop the foundations for good mental health.

First year of life: Parental mental health

Perhaps the strongest risk factor for serious mental illness in childhood and adulthood is parental neglect during the first year of life, and neglect in the first several months of life is the most commonly reported form of child abuse. Infant neglect is associated with parental depression (and other mental illnesses), parental substance use, and a parent’s own experience of childhood abuse or neglect. Neglect is more common with teenaged parents and parents living in poverty. Pediatricians are uniquely connected to families during the first year of a child’s life. The American Academy of Pediatrics recommends screening new mothers for depression at 1-, 2-, 4-, and 6-month infant check-ups with the Edinburgh Postnatal Depression Screen. Even without a positive screen, new parents may need the fortifications of extra community support to adapt to the changes parenthood brings.

At checkups, ask (both) parents how they are managing the stresses of a new baby. Are they getting restful sleep? Do they have social supports? Are they connected to a community (friends, extended family, faith) or isolated? Are they developing confidence as parents or feeling overwhelmed? Simple guidance, such as “sleep when the baby sleeps” and reassurance that taking good care of themselves is taking good care of the baby is always helpful. Sometimes you will need to refer for treatment or to community supports. Have your list of online and in-person resources at the ready to provide parents with these prescriptions. Supporting parental mental health and adjustment in the first year of life is possibly the most important building block for their child’s future mental health.
 

Toddlers and up: Emotional literacy

Emotional literacy (sometimes called “emotional intelligence”) is the capacity to recognize, identify, and manage feelings in oneself and in others. This skill begins to develop in infancy when parents respond to their baby’s cries with attunement, feeding or changing them if needed, and at other times simply reflecting their feelings and soothing them with movement, singing, or quiet talking. As children grow, so does their range of feelings, and their (cognitive) capacity to identify and manage them. Parents support this development by being available whenever their young children experience strong emotions, calmly listening, and acknowledging their discomfort. Parents can offer words for describing those feelings, and even be curious with their young children where in their bodies they are feeling them, how they can stay patient while the feeling passes or things they might be able to do to feel better. Parents may want to remove their child’s distress, but staying calm, curious, and present while helping their child to manage it will build their child’s emotional health. Parents can nurture this development in a less intense way by reading books about feelings together and noticing and identifying feelings in other children or in cartoon characters.

School-age children: Adding mindfulness

While a child’s cognitive development unfolds naturally, school-age children can cultivate awareness of their thoughts. This becomes possible after awareness of feelings and parents can help their older children consider whether something they are experiencing is a thought, a feeling, or a fact. They do so in the same way they helped their child develop emotional literacy: By responding with calm, curiosity, and confidence every time their child comes to them in distress (especially mild distress, like boredom!) or with a challenge or a question. With a difficult situation, parents start by helping their child to identify thoughts and feelings before impulsively acting on them. Parents can help children identify what’s in their control, try different approaches, and be flexible if their first efforts don’t work. Children need to learn that failing at things is how we learn and grow. Just like learning to ride a bike, it builds their frustration tolerance, their knowledge that they can do difficult things, and that distress subsides. These are critical building blocks for adolescence, when the challenges become greater and they manage them more independently.

Learning “mindfulness” (a practice that cultivates nonjudgmental awareness of one’s own thoughts, feelings, and sensations) can help children (and parents) to cultivate quiet self-awareness outside of moments of difficulty. “Stop, Breathe, and Think” and “Mindful gNATs” are two free apps that are recommended by the American Academy of Child and Adolescent Psychiatry for children (and their parents) to use to practice this awareness of thoughts and feelings.
 

Early and later adolescence: Stress management skills

Building on this awareness of thoughts and emotions, adolescents develop adaptive coping skills by facing challenges with the support of their parents nearby. Parents should still be ready to respond to charged emotional moments with calm and curiosity, validating their child’s distress while helping them to consider healthy responses. Helping their teenager to describe their experience, differentiating feelings from thoughts (and facts), and considering different choices within their control is foundational to resilience in adulthood. Parents also help their teenagers by reminding them of the need for good self-care (sleep, exercise, nutrition), nourishing social relationships, and protecting time for rest and recharging activities. Sometimes, parents will think with their teenager about why they are engaged in an activity that is stressful, whether it is authentically important to them, and why. Adolescents should be deepening their sense of identity, interests, talents, and even values, and stressful moments are rich opportunities to do so, with the support of caring adults. Without intentionally building these skills, adolescents will be more prone to managing stress with avoidance or unhealthy coping, such as excessive eating, video gaming, drugs, or alcohol.

Infancy and up: Behavioral healthy habits (sleep, physical activity, nutrition, and screen time)

Healthy habits sound simple, but establishing them is not always easy. The idea of a habit is that it makes managing something challenging or important more automatic, and thus easier and more reliable. Many of the same habits that promote physical health in adulthood also promote mental health: adequate, restful sleep; daily physical activity; a nutritious diet and a healthy relationship with food; and managing screen time in a developmentally appropriate way. Infants depend entirely on their parents for regulation of these behaviors. As their children grow, parents will adapt these routines so that their children are gradually regulating these needs and activities more independently. In each of these areas, children need clear expectations and routines, consistent consequences and positive feedback, and the modeling and patient support of their parents. Educate parents about what good sleep hygiene looks like at each age. Discuss ways to support regular physical activity, especially as a family. Ask the parents about nutrition, including how they manage picky eating; how many family meals they enjoy together; and whether food is ever used to manage boredom or distress. Finally, talk with parents about a developmentally appropriate approach to rules and expectations around screen time and the importance of using family-based rules. Establishing expectations and routines during early childhood means children learn how good it feels to have restful sleep, regular exercise, and happy, healthy family meals. In adolescence, parents can then focus on helping their children to manage temptation, challenge, disappointment, and frustration more independently.

Infancy and up: Relational health

Children develop the skills needed for healthy relationships at home, and they are connected to all of the skills described above. Children need attuned, responsive, and reliable parenting to build a capacity for trust of others, to learn how to communicate honestly and effectively, to learn to expect and offer compassion and respect, and to learn how to handle disagreement and conflict. They learn these skills by watching their parents and by developing the emotional, cognitive, and behavioral healthy habits with their parents’ help. They need a consistently safe and responsive environment at home. They need parents who are attuned and flexible, while maintaining routines and high expectations. They need parents who make time for them when they are sad or struggling, and make time for joy, play, and mindless fun. While a detailed assessment of how the family is functioning may go beyond a check-up, you can ask about those routines that build healthy habits (family mealtime, sleep routines, screen time rules), communication style, and what the family enjoys doing together. Learning about how a family is building these healthy habits and how connected they are to one another can give you a clear snapshot of how well a child may be doing on their mental health growth curve, and what areas might benefit from more active guidance and support.

Dr. Swick is physician in chief at Ohana Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].

May is Mental Health Awareness Month, providing us a chance to go beyond discussing the screening, diagnosis, and evidence-based treatments for the mental illnesses of youth. Just as children are developing physical health, they are similarly establishing the foundations for their mental health. The World Health Organization defines good mental health as “a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her own community.” While the science of mental health promotion and disease prevention in childhood and adolescence is relatively young, there are several discrete domains in which you can follow and support your patient’s developing mental health. This begins with the well-being of new parents, and then moves into how parents are helping their children to develop skills to manage their basic daily needs and impulses, their thoughts and feelings, their stresses and their relationships. With a little support from you, parents can confidently help their children develop the foundations for good mental health.

First year of life: Parental mental health

Perhaps the strongest risk factor for serious mental illness in childhood and adulthood is parental neglect during the first year of life, and neglect in the first several months of life is the most commonly reported form of child abuse. Infant neglect is associated with parental depression (and other mental illnesses), parental substance use, and a parent’s own experience of childhood abuse or neglect. Neglect is more common with teenaged parents and parents living in poverty. Pediatricians are uniquely connected to families during the first year of a child’s life. The American Academy of Pediatrics recommends screening new mothers for depression at 1-, 2-, 4-, and 6-month infant check-ups with the Edinburgh Postnatal Depression Screen. Even without a positive screen, new parents may need the fortifications of extra community support to adapt to the changes parenthood brings.

At checkups, ask (both) parents how they are managing the stresses of a new baby. Are they getting restful sleep? Do they have social supports? Are they connected to a community (friends, extended family, faith) or isolated? Are they developing confidence as parents or feeling overwhelmed? Simple guidance, such as “sleep when the baby sleeps” and reassurance that taking good care of themselves is taking good care of the baby is always helpful. Sometimes you will need to refer for treatment or to community supports. Have your list of online and in-person resources at the ready to provide parents with these prescriptions. Supporting parental mental health and adjustment in the first year of life is possibly the most important building block for their child’s future mental health.
 

Toddlers and up: Emotional literacy

Emotional literacy (sometimes called “emotional intelligence”) is the capacity to recognize, identify, and manage feelings in oneself and in others. This skill begins to develop in infancy when parents respond to their baby’s cries with attunement, feeding or changing them if needed, and at other times simply reflecting their feelings and soothing them with movement, singing, or quiet talking. As children grow, so does their range of feelings, and their (cognitive) capacity to identify and manage them. Parents support this development by being available whenever their young children experience strong emotions, calmly listening, and acknowledging their discomfort. Parents can offer words for describing those feelings, and even be curious with their young children where in their bodies they are feeling them, how they can stay patient while the feeling passes or things they might be able to do to feel better. Parents may want to remove their child’s distress, but staying calm, curious, and present while helping their child to manage it will build their child’s emotional health. Parents can nurture this development in a less intense way by reading books about feelings together and noticing and identifying feelings in other children or in cartoon characters.

School-age children: Adding mindfulness

While a child’s cognitive development unfolds naturally, school-age children can cultivate awareness of their thoughts. This becomes possible after awareness of feelings and parents can help their older children consider whether something they are experiencing is a thought, a feeling, or a fact. They do so in the same way they helped their child develop emotional literacy: By responding with calm, curiosity, and confidence every time their child comes to them in distress (especially mild distress, like boredom!) or with a challenge or a question. With a difficult situation, parents start by helping their child to identify thoughts and feelings before impulsively acting on them. Parents can help children identify what’s in their control, try different approaches, and be flexible if their first efforts don’t work. Children need to learn that failing at things is how we learn and grow. Just like learning to ride a bike, it builds their frustration tolerance, their knowledge that they can do difficult things, and that distress subsides. These are critical building blocks for adolescence, when the challenges become greater and they manage them more independently.

Learning “mindfulness” (a practice that cultivates nonjudgmental awareness of one’s own thoughts, feelings, and sensations) can help children (and parents) to cultivate quiet self-awareness outside of moments of difficulty. “Stop, Breathe, and Think” and “Mindful gNATs” are two free apps that are recommended by the American Academy of Child and Adolescent Psychiatry for children (and their parents) to use to practice this awareness of thoughts and feelings.
 

Early and later adolescence: Stress management skills

Building on this awareness of thoughts and emotions, adolescents develop adaptive coping skills by facing challenges with the support of their parents nearby. Parents should still be ready to respond to charged emotional moments with calm and curiosity, validating their child’s distress while helping them to consider healthy responses. Helping their teenager to describe their experience, differentiating feelings from thoughts (and facts), and considering different choices within their control is foundational to resilience in adulthood. Parents also help their teenagers by reminding them of the need for good self-care (sleep, exercise, nutrition), nourishing social relationships, and protecting time for rest and recharging activities. Sometimes, parents will think with their teenager about why they are engaged in an activity that is stressful, whether it is authentically important to them, and why. Adolescents should be deepening their sense of identity, interests, talents, and even values, and stressful moments are rich opportunities to do so, with the support of caring adults. Without intentionally building these skills, adolescents will be more prone to managing stress with avoidance or unhealthy coping, such as excessive eating, video gaming, drugs, or alcohol.

Infancy and up: Behavioral healthy habits (sleep, physical activity, nutrition, and screen time)

Healthy habits sound simple, but establishing them is not always easy. The idea of a habit is that it makes managing something challenging or important more automatic, and thus easier and more reliable. Many of the same habits that promote physical health in adulthood also promote mental health: adequate, restful sleep; daily physical activity; a nutritious diet and a healthy relationship with food; and managing screen time in a developmentally appropriate way. Infants depend entirely on their parents for regulation of these behaviors. As their children grow, parents will adapt these routines so that their children are gradually regulating these needs and activities more independently. In each of these areas, children need clear expectations and routines, consistent consequences and positive feedback, and the modeling and patient support of their parents. Educate parents about what good sleep hygiene looks like at each age. Discuss ways to support regular physical activity, especially as a family. Ask the parents about nutrition, including how they manage picky eating; how many family meals they enjoy together; and whether food is ever used to manage boredom or distress. Finally, talk with parents about a developmentally appropriate approach to rules and expectations around screen time and the importance of using family-based rules. Establishing expectations and routines during early childhood means children learn how good it feels to have restful sleep, regular exercise, and happy, healthy family meals. In adolescence, parents can then focus on helping their children to manage temptation, challenge, disappointment, and frustration more independently.

Infancy and up: Relational health

Children develop the skills needed for healthy relationships at home, and they are connected to all of the skills described above. Children need attuned, responsive, and reliable parenting to build a capacity for trust of others, to learn how to communicate honestly and effectively, to learn to expect and offer compassion and respect, and to learn how to handle disagreement and conflict. They learn these skills by watching their parents and by developing the emotional, cognitive, and behavioral healthy habits with their parents’ help. They need a consistently safe and responsive environment at home. They need parents who are attuned and flexible, while maintaining routines and high expectations. They need parents who make time for them when they are sad or struggling, and make time for joy, play, and mindless fun. While a detailed assessment of how the family is functioning may go beyond a check-up, you can ask about those routines that build healthy habits (family mealtime, sleep routines, screen time rules), communication style, and what the family enjoys doing together. Learning about how a family is building these healthy habits and how connected they are to one another can give you a clear snapshot of how well a child may be doing on their mental health growth curve, and what areas might benefit from more active guidance and support.

Dr. Swick is physician in chief at Ohana Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].

A new study confirms the robust link between cannabis use and schizophrenia among men and women but suggests that young men may be especially susceptible to schizophrenia from cannabis abuse.

Of note, investigators estimate that roughly 15% of schizophrenia cases among young males may be preventable by avoiding cannabis use disorder (CUD).

“The entanglement of substance use disorders and mental illnesses is a major public health issue, requiring urgent action and support for people who need it,” study coauthor Nora Volkow, MD, director of the National Institute on Drug Abuse, said in a news release.

“As access to potent cannabis products continues to expand, it is crucial that we also expand prevention, screening, and treatment for people who may experience mental illnesses associated with cannabis use,” Dr. Volkow added.

The study was published online in Psychological Medicine.
 

A modifiable risk factor

The researchers analyzed Danish registry data spanning 5 decades and representing more than 6.9 million people in Denmark to estimate the population-level percentage of schizophrenia cases attributable to CUD.

A total of 60,563 participants were diagnosed with CUD. Three-quarters of cases were in men; there were 45,327 incident cases of schizophrenia during the study period.

The overall adjusted hazard ratio for CUD on schizophrenia was slightly higher among males than females (aHR, 2.42 vs. 2.02); however, among those aged 16 to 20 years, the adjusted incidence risk ratio for males was more than twice that for females (aIRR, 3.84 vs. 1.81).

The researchers estimate that, in 2021, about 15% of schizophrenia cases among males aged 16-49 could have been avoided by preventing CUD, compared with 4% among females in this age range.

For young men aged 21-30, the proportion of preventable schizophrenia cases related to CUD may be as high as 30%, the authors reported.

“Alongside the increasing evidence that CUD is a modifiable risk factor for schizophrenia, our findings underscore the importance of evidence-based strategies to regulate cannabis use and to effectively prevent, screen for, and treat CUD as well as schizophrenia,” the researchers wrote.
 

Legalization sends the wrong message

In a press statement, lead investigator Carsten Hjorthøj, PhD, with the University of Copenhagen, noted that “increases in the legalization of cannabis over the past few decades have made it one of the most frequently used psychoactive substances in the world, while also decreasing the public’s perception of its harm. This study adds to our growing understanding that cannabis use is not harmless, and that risks are not fixed at one point in time.”

In a prior study, Dr. Hjorthøj and colleagues found that the proportion of new schizophrenia cases attributable to CUD has consistently increased over the past 20 years.

“In my view, the association is most likely causative, at least to a large extent,” Dr. Hjorthøj said at the time this research was published.

“It is of course nearly impossible to use epidemiological studies to actually prove causation, but all the numbers behave exactly in the way that would be expected under the theory of causation,” Dr. Hjorthøj added.

The study received no specific funding. The authors disclosed no relevant financial relationships.

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

A new study confirms the robust link between cannabis use and schizophrenia among men and women but suggests that young men may be especially susceptible to schizophrenia from cannabis abuse.

Of note, investigators estimate that roughly 15% of schizophrenia cases among young males may be preventable by avoiding cannabis use disorder (CUD).

“The entanglement of substance use disorders and mental illnesses is a major public health issue, requiring urgent action and support for people who need it,” study coauthor Nora Volkow, MD, director of the National Institute on Drug Abuse, said in a news release.

“As access to potent cannabis products continues to expand, it is crucial that we also expand prevention, screening, and treatment for people who may experience mental illnesses associated with cannabis use,” Dr. Volkow added.

The study was published online in Psychological Medicine.
 

A modifiable risk factor

The researchers analyzed Danish registry data spanning 5 decades and representing more than 6.9 million people in Denmark to estimate the population-level percentage of schizophrenia cases attributable to CUD.

A total of 60,563 participants were diagnosed with CUD. Three-quarters of cases were in men; there were 45,327 incident cases of schizophrenia during the study period.

The overall adjusted hazard ratio for CUD on schizophrenia was slightly higher among males than females (aHR, 2.42 vs. 2.02); however, among those aged 16 to 20 years, the adjusted incidence risk ratio for males was more than twice that for females (aIRR, 3.84 vs. 1.81).

The researchers estimate that, in 2021, about 15% of schizophrenia cases among males aged 16-49 could have been avoided by preventing CUD, compared with 4% among females in this age range.

For young men aged 21-30, the proportion of preventable schizophrenia cases related to CUD may be as high as 30%, the authors reported.

“Alongside the increasing evidence that CUD is a modifiable risk factor for schizophrenia, our findings underscore the importance of evidence-based strategies to regulate cannabis use and to effectively prevent, screen for, and treat CUD as well as schizophrenia,” the researchers wrote.
 

Legalization sends the wrong message

In a press statement, lead investigator Carsten Hjorthøj, PhD, with the University of Copenhagen, noted that “increases in the legalization of cannabis over the past few decades have made it one of the most frequently used psychoactive substances in the world, while also decreasing the public’s perception of its harm. This study adds to our growing understanding that cannabis use is not harmless, and that risks are not fixed at one point in time.”

In a prior study, Dr. Hjorthøj and colleagues found that the proportion of new schizophrenia cases attributable to CUD has consistently increased over the past 20 years.

“In my view, the association is most likely causative, at least to a large extent,” Dr. Hjorthøj said at the time this research was published.

“It is of course nearly impossible to use epidemiological studies to actually prove causation, but all the numbers behave exactly in the way that would be expected under the theory of causation,” Dr. Hjorthøj added.

The study received no specific funding. The authors disclosed no relevant financial relationships.

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

A new study confirms the robust link between cannabis use and schizophrenia among men and women but suggests that young men may be especially susceptible to schizophrenia from cannabis abuse.

Of note, investigators estimate that roughly 15% of schizophrenia cases among young males may be preventable by avoiding cannabis use disorder (CUD).

“The entanglement of substance use disorders and mental illnesses is a major public health issue, requiring urgent action and support for people who need it,” study coauthor Nora Volkow, MD, director of the National Institute on Drug Abuse, said in a news release.

“As access to potent cannabis products continues to expand, it is crucial that we also expand prevention, screening, and treatment for people who may experience mental illnesses associated with cannabis use,” Dr. Volkow added.

The study was published online in Psychological Medicine.
 

A modifiable risk factor

The researchers analyzed Danish registry data spanning 5 decades and representing more than 6.9 million people in Denmark to estimate the population-level percentage of schizophrenia cases attributable to CUD.

A total of 60,563 participants were diagnosed with CUD. Three-quarters of cases were in men; there were 45,327 incident cases of schizophrenia during the study period.

The overall adjusted hazard ratio for CUD on schizophrenia was slightly higher among males than females (aHR, 2.42 vs. 2.02); however, among those aged 16 to 20 years, the adjusted incidence risk ratio for males was more than twice that for females (aIRR, 3.84 vs. 1.81).

The researchers estimate that, in 2021, about 15% of schizophrenia cases among males aged 16-49 could have been avoided by preventing CUD, compared with 4% among females in this age range.

For young men aged 21-30, the proportion of preventable schizophrenia cases related to CUD may be as high as 30%, the authors reported.

“Alongside the increasing evidence that CUD is a modifiable risk factor for schizophrenia, our findings underscore the importance of evidence-based strategies to regulate cannabis use and to effectively prevent, screen for, and treat CUD as well as schizophrenia,” the researchers wrote.
 

Legalization sends the wrong message

In a press statement, lead investigator Carsten Hjorthøj, PhD, with the University of Copenhagen, noted that “increases in the legalization of cannabis over the past few decades have made it one of the most frequently used psychoactive substances in the world, while also decreasing the public’s perception of its harm. This study adds to our growing understanding that cannabis use is not harmless, and that risks are not fixed at one point in time.”

In a prior study, Dr. Hjorthøj and colleagues found that the proportion of new schizophrenia cases attributable to CUD has consistently increased over the past 20 years.

“In my view, the association is most likely causative, at least to a large extent,” Dr. Hjorthøj said at the time this research was published.

“It is of course nearly impossible to use epidemiological studies to actually prove causation, but all the numbers behave exactly in the way that would be expected under the theory of causation,” Dr. Hjorthøj added.

The study received no specific funding. The authors disclosed no relevant financial relationships.

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

In case anybody hasn’t noticed, the good ole days are long gone in which pediatric patients with mental health challenges could be simply referred out to be promptly assessed and treated by specialists. Due to a shortage of psychiatrists coupled with large increases in the number of youth presenting with emotional-behavioral difficulties, primary care clinicians are now called upon to fill in much of this gap, with professional organizations like the AAP articulating that mental health treatment, within reason, is squarely in the primary care clinician’s “lane” and scope of treatment.¹

Dr. Rettew

To meet this need, new models of integrated or collaborative care between primary care and mental health clinicians have been attempted and tested. While these initiatives have certainly been a welcome advance to many pediatricians, the large numbers of different models and initiatives out there have made for a rather confusing landscape that many busy primary care clinicians have found difficult to navigate.

In an attempt to offer some guidance on the subject, the American Academy of Child and Adolescent Psychiatry recently published a clinical update on pediatric collaborative care.² The report is rich with resources and ideas. One of the main points of the document is that there are different levels of integration that exist. Kind of like the situation with recycling and household waste reduction, it is possible to make valuable improvements at any level of participation, although evidence suggests that more extensive efforts offer the most benefits. At one end of the spectrum, psychiatrists and primary care clinicians maintain separate practices and medical records and occasionally discuss mutual patients. Middle levels may include “colocation” with mental health and primary care professionals sharing a building and/or being part of the same overall system but continuing to work mainly independently. At the highest levels of integration, there is a coordinated and collaborative team that supports an intentional system of care with consistent communication about individual patients and general workflows. These approaches vary in the amount that the following four core areas of integrated care are incorporated.

• Direct service. Many integrated care initiatives heavily rely on the services of an on-site mental health care manager or behavioral health consultant who can provide a number of important functions such as overseeing of the integrated care program, conducting brief therapy with youth and parents, overseeing mental health screenings at the clinic, and providing general mental health promotion guidance.
• Care coordination. Helping patients and families find needed mental health, social services, and educational resources is a key component of integrated care. This task can fall to the practice’s behavioral health consultant, if there is one, but more general care coordinators can also be trained for this important role. The University of Washington’s Center for Advancing Integrated Mental Health Solutions has some published guidelines in this area.³
• Consultation. More advanced integrated care models often have established relationships to specific child psychiatric clinicians who are able to meet with the primary care team to discuss cases and general approaches to various problems. Alternatively, a number of states have implemented what are called Child Psychiatry Access Programs that give primary care clinicians a phone number to an organization (often affiliated with an academic medical center) that can provide quick and even immediate access to a child psychiatry provider for specific questions. Recent federal grants have led to many if not most states now having one of these programs in place, and a website listing these programs and their contact information is available.⁴
• Education. As mental health training was traditionally not part of a typical pediatrics residency, there have been a number of strategies introduced to help primary care clinicians increase their proficiency and comfort level when it comes to assessing and treating emotional-behavioral problems. These include specific conferences, online programs, and case-based training through mechanisms like the ECHO program.^5,6 The AAP itself has released a number of toolkits and training materials related to mental health care that are available.⁷

The report also outlines some obstacles that continue to get in the way of more extensive integrative care efforts. Chief among them are financial concerns, including how to pay for what often are traditionally nonbillable efforts, particularly those that involve the communication of two expensive health care professionals. Some improvements have been made, however, such as the creation of some relatively new codes (such as 99451 and 99452) that can be submitted by both a primary care and mental health professional when there is a consultation that occurs that does not involve an actual face-to-face encounter.

One area that, in my view, has not received the level of attention it deserves when it comes to integrated care is the degree to which these programs have the potential not only to improve the care of children and adolescents already struggling with mental health challenges but also to serve as a powerful prevention tool to lower the risk of being diagnosed with a psychiatric disorder in the future and generally to improve levels of well-being. Thus far, however, research on various integrated programs has shown promising results that indicate that overall care for patients with mental health challenges improves.⁸ Further, when it comes to costs, there is some evidence to suggest that some of the biggest financial gains associated with integrated care has to do with reduced nonpsychiatric medical expenses of patients.⁹ This, then, suggests that practices that participate in capitated or accountable care organization structures could particularly benefit both clinically and financially from these collaborations.

If your practice has been challenged with the level of mental health care you are now expected to provide and has been contemplating even some small moves toward integrated care, now may the time to put those thoughts into action.

References

1. Foy JM et al. American Academy of Pediatrics policy statement. Mental health competencies for pediatric practice. Pediatrics. 2019;144(5):e20192757.

2. AACAP Committee on Collaborative and Integrated Care and AACAP Committee on Quality Issues. Clinical update: Collaborative mental health care for children and adolescents in pediatric primary care. J Am Acad Child Adolesc Psychiatry. 2023;62(2):91-119.

3. Behavioral health care managers. AIMS Center, University of Washington. Accessed May 5, 2023. Available at https://aims.uw.edu/online-bhcm-modules.

4. National Network of Child Psychiatry Access Programs. Accessed May 5, 2023. Available at https://www.nncpap.org/.

5. Project Echo Programs. Accessed May 5, 2023. https://hsc.unm.edu/echo.

6. Project TEACH. Accessed May 5, 2023. https://projectteachny.org.

7. Earls MF et al. Addressing mental health concerns in pediatrics: A practical resource toolkit for clinicians, 2nd edition. Itasca, Ill.: American Academy of Pediatrics, 2021.

8. Asarnow JR et al. Integrated medical-behavioral care compared with usual primary care for child and adolescent behavioral health: A meta analysis. JAMA Pediatr. 2015;169(10):929-37.

9. Unutzer J et al. Long-term costs effects of collaborative care for late-life depression. Am J Manag Care. 2008.14(2):95-100.
 

Dr. Rettew is a child and adolescent psychiatrist with Lane County Behavioral Health in Eugene, Ore., and Oregon Health & Science University, Portland. His latest book is “Parenting Made Complicated: What Science Really Knows about the Greatest Debates of Early Childhood.” You can follow him on Twitter and Facebook @PediPsych.

In case anybody hasn’t noticed, the good ole days are long gone in which pediatric patients with mental health challenges could be simply referred out to be promptly assessed and treated by specialists. Due to a shortage of psychiatrists coupled with large increases in the number of youth presenting with emotional-behavioral difficulties, primary care clinicians are now called upon to fill in much of this gap, with professional organizations like the AAP articulating that mental health treatment, within reason, is squarely in the primary care clinician’s “lane” and scope of treatment.¹

Dr. Rettew

To meet this need, new models of integrated or collaborative care between primary care and mental health clinicians have been attempted and tested. While these initiatives have certainly been a welcome advance to many pediatricians, the large numbers of different models and initiatives out there have made for a rather confusing landscape that many busy primary care clinicians have found difficult to navigate.

In an attempt to offer some guidance on the subject, the American Academy of Child and Adolescent Psychiatry recently published a clinical update on pediatric collaborative care.² The report is rich with resources and ideas. One of the main points of the document is that there are different levels of integration that exist. Kind of like the situation with recycling and household waste reduction, it is possible to make valuable improvements at any level of participation, although evidence suggests that more extensive efforts offer the most benefits. At one end of the spectrum, psychiatrists and primary care clinicians maintain separate practices and medical records and occasionally discuss mutual patients. Middle levels may include “colocation” with mental health and primary care professionals sharing a building and/or being part of the same overall system but continuing to work mainly independently. At the highest levels of integration, there is a coordinated and collaborative team that supports an intentional system of care with consistent communication about individual patients and general workflows. These approaches vary in the amount that the following four core areas of integrated care are incorporated.

• Direct service. Many integrated care initiatives heavily rely on the services of an on-site mental health care manager or behavioral health consultant who can provide a number of important functions such as overseeing of the integrated care program, conducting brief therapy with youth and parents, overseeing mental health screenings at the clinic, and providing general mental health promotion guidance.
• Care coordination. Helping patients and families find needed mental health, social services, and educational resources is a key component of integrated care. This task can fall to the practice’s behavioral health consultant, if there is one, but more general care coordinators can also be trained for this important role. The University of Washington’s Center for Advancing Integrated Mental Health Solutions has some published guidelines in this area.³
• Consultation. More advanced integrated care models often have established relationships to specific child psychiatric clinicians who are able to meet with the primary care team to discuss cases and general approaches to various problems. Alternatively, a number of states have implemented what are called Child Psychiatry Access Programs that give primary care clinicians a phone number to an organization (often affiliated with an academic medical center) that can provide quick and even immediate access to a child psychiatry provider for specific questions. Recent federal grants have led to many if not most states now having one of these programs in place, and a website listing these programs and their contact information is available.⁴
• Education. As mental health training was traditionally not part of a typical pediatrics residency, there have been a number of strategies introduced to help primary care clinicians increase their proficiency and comfort level when it comes to assessing and treating emotional-behavioral problems. These include specific conferences, online programs, and case-based training through mechanisms like the ECHO program.^5,6 The AAP itself has released a number of toolkits and training materials related to mental health care that are available.⁷

The report also outlines some obstacles that continue to get in the way of more extensive integrative care efforts. Chief among them are financial concerns, including how to pay for what often are traditionally nonbillable efforts, particularly those that involve the communication of two expensive health care professionals. Some improvements have been made, however, such as the creation of some relatively new codes (such as 99451 and 99452) that can be submitted by both a primary care and mental health professional when there is a consultation that occurs that does not involve an actual face-to-face encounter.

One area that, in my view, has not received the level of attention it deserves when it comes to integrated care is the degree to which these programs have the potential not only to improve the care of children and adolescents already struggling with mental health challenges but also to serve as a powerful prevention tool to lower the risk of being diagnosed with a psychiatric disorder in the future and generally to improve levels of well-being. Thus far, however, research on various integrated programs has shown promising results that indicate that overall care for patients with mental health challenges improves.⁸ Further, when it comes to costs, there is some evidence to suggest that some of the biggest financial gains associated with integrated care has to do with reduced nonpsychiatric medical expenses of patients.⁹ This, then, suggests that practices that participate in capitated or accountable care organization structures could particularly benefit both clinically and financially from these collaborations.

If your practice has been challenged with the level of mental health care you are now expected to provide and has been contemplating even some small moves toward integrated care, now may the time to put those thoughts into action.

References

1. Foy JM et al. American Academy of Pediatrics policy statement. Mental health competencies for pediatric practice. Pediatrics. 2019;144(5):e20192757.

2. AACAP Committee on Collaborative and Integrated Care and AACAP Committee on Quality Issues. Clinical update: Collaborative mental health care for children and adolescents in pediatric primary care. J Am Acad Child Adolesc Psychiatry. 2023;62(2):91-119.

3. Behavioral health care managers. AIMS Center, University of Washington. Accessed May 5, 2023. Available at https://aims.uw.edu/online-bhcm-modules.

4. National Network of Child Psychiatry Access Programs. Accessed May 5, 2023. Available at https://www.nncpap.org/.

5. Project Echo Programs. Accessed May 5, 2023. https://hsc.unm.edu/echo.

6. Project TEACH. Accessed May 5, 2023. https://projectteachny.org.

7. Earls MF et al. Addressing mental health concerns in pediatrics: A practical resource toolkit for clinicians, 2nd edition. Itasca, Ill.: American Academy of Pediatrics, 2021.

8. Asarnow JR et al. Integrated medical-behavioral care compared with usual primary care for child and adolescent behavioral health: A meta analysis. JAMA Pediatr. 2015;169(10):929-37.

9. Unutzer J et al. Long-term costs effects of collaborative care for late-life depression. Am J Manag Care. 2008.14(2):95-100.
 

Dr. Rettew is a child and adolescent psychiatrist with Lane County Behavioral Health in Eugene, Ore., and Oregon Health & Science University, Portland. His latest book is “Parenting Made Complicated: What Science Really Knows about the Greatest Debates of Early Childhood.” You can follow him on Twitter and Facebook @PediPsych.

In case anybody hasn’t noticed, the good ole days are long gone in which pediatric patients with mental health challenges could be simply referred out to be promptly assessed and treated by specialists. Due to a shortage of psychiatrists coupled with large increases in the number of youth presenting with emotional-behavioral difficulties, primary care clinicians are now called upon to fill in much of this gap, with professional organizations like the AAP articulating that mental health treatment, within reason, is squarely in the primary care clinician’s “lane” and scope of treatment.¹

Dr. Rettew

To meet this need, new models of integrated or collaborative care between primary care and mental health clinicians have been attempted and tested. While these initiatives have certainly been a welcome advance to many pediatricians, the large numbers of different models and initiatives out there have made for a rather confusing landscape that many busy primary care clinicians have found difficult to navigate.

In an attempt to offer some guidance on the subject, the American Academy of Child and Adolescent Psychiatry recently published a clinical update on pediatric collaborative care.² The report is rich with resources and ideas. One of the main points of the document is that there are different levels of integration that exist. Kind of like the situation with recycling and household waste reduction, it is possible to make valuable improvements at any level of participation, although evidence suggests that more extensive efforts offer the most benefits. At one end of the spectrum, psychiatrists and primary care clinicians maintain separate practices and medical records and occasionally discuss mutual patients. Middle levels may include “colocation” with mental health and primary care professionals sharing a building and/or being part of the same overall system but continuing to work mainly independently. At the highest levels of integration, there is a coordinated and collaborative team that supports an intentional system of care with consistent communication about individual patients and general workflows. These approaches vary in the amount that the following four core areas of integrated care are incorporated.

• Direct service. Many integrated care initiatives heavily rely on the services of an on-site mental health care manager or behavioral health consultant who can provide a number of important functions such as overseeing of the integrated care program, conducting brief therapy with youth and parents, overseeing mental health screenings at the clinic, and providing general mental health promotion guidance.
• Care coordination. Helping patients and families find needed mental health, social services, and educational resources is a key component of integrated care. This task can fall to the practice’s behavioral health consultant, if there is one, but more general care coordinators can also be trained for this important role. The University of Washington’s Center for Advancing Integrated Mental Health Solutions has some published guidelines in this area.³
• Consultation. More advanced integrated care models often have established relationships to specific child psychiatric clinicians who are able to meet with the primary care team to discuss cases and general approaches to various problems. Alternatively, a number of states have implemented what are called Child Psychiatry Access Programs that give primary care clinicians a phone number to an organization (often affiliated with an academic medical center) that can provide quick and even immediate access to a child psychiatry provider for specific questions. Recent federal grants have led to many if not most states now having one of these programs in place, and a website listing these programs and their contact information is available.⁴
• Education. As mental health training was traditionally not part of a typical pediatrics residency, there have been a number of strategies introduced to help primary care clinicians increase their proficiency and comfort level when it comes to assessing and treating emotional-behavioral problems. These include specific conferences, online programs, and case-based training through mechanisms like the ECHO program.^5,6 The AAP itself has released a number of toolkits and training materials related to mental health care that are available.⁷

The report also outlines some obstacles that continue to get in the way of more extensive integrative care efforts. Chief among them are financial concerns, including how to pay for what often are traditionally nonbillable efforts, particularly those that involve the communication of two expensive health care professionals. Some improvements have been made, however, such as the creation of some relatively new codes (such as 99451 and 99452) that can be submitted by both a primary care and mental health professional when there is a consultation that occurs that does not involve an actual face-to-face encounter.

One area that, in my view, has not received the level of attention it deserves when it comes to integrated care is the degree to which these programs have the potential not only to improve the care of children and adolescents already struggling with mental health challenges but also to serve as a powerful prevention tool to lower the risk of being diagnosed with a psychiatric disorder in the future and generally to improve levels of well-being. Thus far, however, research on various integrated programs has shown promising results that indicate that overall care for patients with mental health challenges improves.⁸ Further, when it comes to costs, there is some evidence to suggest that some of the biggest financial gains associated with integrated care has to do with reduced nonpsychiatric medical expenses of patients.⁹ This, then, suggests that practices that participate in capitated or accountable care organization structures could particularly benefit both clinically and financially from these collaborations.

If your practice has been challenged with the level of mental health care you are now expected to provide and has been contemplating even some small moves toward integrated care, now may the time to put those thoughts into action.

References

1. Foy JM et al. American Academy of Pediatrics policy statement. Mental health competencies for pediatric practice. Pediatrics. 2019;144(5):e20192757.

2. AACAP Committee on Collaborative and Integrated Care and AACAP Committee on Quality Issues. Clinical update: Collaborative mental health care for children and adolescents in pediatric primary care. J Am Acad Child Adolesc Psychiatry. 2023;62(2):91-119.

3. Behavioral health care managers. AIMS Center, University of Washington. Accessed May 5, 2023. Available at https://aims.uw.edu/online-bhcm-modules.

4. National Network of Child Psychiatry Access Programs. Accessed May 5, 2023. Available at https://www.nncpap.org/.

5. Project Echo Programs. Accessed May 5, 2023. https://hsc.unm.edu/echo.

6. Project TEACH. Accessed May 5, 2023. https://projectteachny.org.

7. Earls MF et al. Addressing mental health concerns in pediatrics: A practical resource toolkit for clinicians, 2nd edition. Itasca, Ill.: American Academy of Pediatrics, 2021.

8. Asarnow JR et al. Integrated medical-behavioral care compared with usual primary care for child and adolescent behavioral health: A meta analysis. JAMA Pediatr. 2015;169(10):929-37.

9. Unutzer J et al. Long-term costs effects of collaborative care for late-life depression. Am J Manag Care. 2008.14(2):95-100.
 

Dr. Rettew is a child and adolescent psychiatrist with Lane County Behavioral Health in Eugene, Ore., and Oregon Health & Science University, Portland. His latest book is “Parenting Made Complicated: What Science Really Knows about the Greatest Debates of Early Childhood.” You can follow him on Twitter and Facebook @PediPsych.

A large proportion of U.S. adults who are prescribed schedule II stimulants are simultaneously receiving other CNS-active agents including benzodiazepines, opioids, and antidepressants – a potentially dangerous practice.

Investigators analyzed prescription drug claims for over 9.1 million U.S. adults over a 1-year period and found that 276,223 (3%) had used a schedule II stimulant, such as methylphenidate and amphetamines, during that time. Of these 276,223 patients, 45% combined these agents with one or more additional CNS-active drugs and almost 25% were simultaneously using two or more additional CNS-active drugs.

Close to half of the stimulant users were taking an antidepressant, while close to one-third filled prescriptions for anxiolytic/sedative/hypnotic meditations, and one-fifth received opioid prescriptions.

The widespread, often off-label use of these stimulants in combination therapy with antidepressants, anxiolytics, opioids, and other psychoactive drugs, “reveals new patterns of utilization beyond the approved use of stimulants as monotherapy for ADHD, but because there are so few studies of these kinds of combination therapy, both the advantages and additional risks [of this type of prescribing] remain unknown,” study investigator Thomas J. Moore, AB, faculty associate in epidemiology, Johns Hopkins Bloomberg School of Public Health and Johns Hopkins Medicine, Baltimore, told this news organization.

The study was published online in BMJ Open.
 

‘Dangerous’ substances

Amphetamines and methylphenidate are CNS stimulants that have been in use for almost a century. Like opioids and barbiturates, they’re considered “dangerous” and classified as schedule II Controlled Substances because of their high potential for abuse.

Over many years, these stimulants have been used for multiple purposes, including nasal congestion, narcolepsy, appetite suppression, binge eating, depression, senile behavior, lethargy, and ADHD, the researchers note.

Observational studies suggest medical use of these agents has been increasing in the United States. The investigators conducted previous research that revealed a 79% increase from 2013 to 2018 in the number of adults who self-report their use. The current study, said Mr. Moore, explores how these stimulants are being used.

For the study, data was extracted from the MarketScan 2019 and 2020 Commercial Claims and Encounters Databases, focusing on 9.1 million adults aged 19-64 years who were continuously enrolled in an included commercial benefit plan from Oct. 1, 2019 to Dec. 31, 2020.

The primary outcome consisted of an outpatient prescription claim, service date, and days’ supply for the CNS-active drugs.

The researchers defined “combination-2” therapy as 60 or more days of combination treatment with a schedule II stimulant and at least one additional CNS-active drug. “Combination-3” therapy was defined as the addition of at least two additional CNS-active drugs.

The researchers used service date and days’ supply to examine the number of stimulant and other CNS-active drugs for each of the days of 2020.

CNS-active drug classes included antidepressants, anxiolytics/sedatives/hypnotics, antipsychotics, opioids, anticonvulsants, and other CNS-active drugs.
 

Prescribing cascade

Of the total number of adults enrolled, 3% (n = 276,223) were taking schedule II stimulants during 2020, with a median of 8 (interquartile range, 4-11) prescriptions. These drugs provided 227 (IQR, 110-322) treatment days of exposure.

Among those taking stimulants 45.5% combined the use of at least one additional CNS-active drug for a median of 213 (IQR, 126-301) treatment days; and 24.3% used at least two additional CNS-active drugs for a median of 182 (IQR, 108-276) days.

“Clinicians should beware of the prescribing cascade. Sometimes it begins with an antidepressant that causes too much sedation, so a stimulant gets added, which leads to insomnia, so alprazolam gets added to the mix,” Mr. Moore said.

He cautioned that this “leaves a patient with multiple drugs, all with discontinuation effects of different kinds and clashing effects.”

These new findings, the investigators note, “add new public health concerns to those raised by our previous study. ... this more-detailed profile reveals several new patterns.”

Most patients become “long-term users” once treatment has started, with 75% continuing for a 1-year period.

“This underscores the possible risks of nonmedical use and dependence that have warranted the classification of these drugs as having high potential for psychological or physical dependence and their prominent appearance in toxicology drug rankings of fatal overdose cases,” they write.

They note that the data “do not indicate which intervention may have come first – a stimulant added to compensate for excess sedation from the benzodiazepine, or the alprazolam added to calm excessive CNS stimulation and/or insomnia from the stimulants or other drugs.”

Several limitations cited by the authors include the fact that, although the population encompassed 9.1 million people, it “may not represent all commercially insured adults,” and it doesn’t include people who aren’t covered by commercial insurance.

Moreover, the MarketScan dataset included up to four diagnosis codes for each outpatient and emergency department encounter; therefore, it was not possible to directly link the diagnoses to specific prescription drug claims, and thus the diagnoses were not evaluated.

“Since many providers will not accept a drug claim for a schedule II stimulant without an on-label diagnosis of ADHD,” the authors suspect that “large numbers of this diagnosis were present.”
 

Complex prescribing regimens

Mark Olfson, MD, MPH, professor of psychiatry, medicine, and law and professor of epidemiology, Columbia University Irving Medical Center, New York, said the report “highlights the pharmacological complexity of adults who are treated with stimulants.”

Columbia University

Dr. Olfson, who is a research psychiatrist at the New York State Psychiatric Institute, New York, and was not involved with the study, observed there is “evidence to support stimulants as an adjunctive therapy for treatment-resistant unipolar depression in older adults.”

However, he added, “this indication is unlikely to fully explain the high proportion of nonelderly, stimulant-treated adults who also receive antidepressants.”

These new findings “call for research to increase our understanding of the clinical contexts that motivate these complex prescribing regimens as well as their effectiveness and safety,” said Dr. Olfson.

The authors have not declared a specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors. Mr. Moore declares no relevant financial relationships. Coauthor G. Caleb Alexander, MD, is past chair and a current member of the Food and Drug Administration’s Peripheral and Central Nervous System Advisory Committee; is a cofounding principal and equity holder in Monument Analytics, a health care consultancy whose clients include the life sciences industry as well as plaintiffs in opioid litigation, for whom he has served as a paid expert witness; and is a past member of OptumRx’s National P&T Committee. Dr. Olfson declares no relevant financial relationships.

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

A large proportion of U.S. adults who are prescribed schedule II stimulants are simultaneously receiving other CNS-active agents including benzodiazepines, opioids, and antidepressants – a potentially dangerous practice.

Investigators analyzed prescription drug claims for over 9.1 million U.S. adults over a 1-year period and found that 276,223 (3%) had used a schedule II stimulant, such as methylphenidate and amphetamines, during that time. Of these 276,223 patients, 45% combined these agents with one or more additional CNS-active drugs and almost 25% were simultaneously using two or more additional CNS-active drugs.

Close to half of the stimulant users were taking an antidepressant, while close to one-third filled prescriptions for anxiolytic/sedative/hypnotic meditations, and one-fifth received opioid prescriptions.

The widespread, often off-label use of these stimulants in combination therapy with antidepressants, anxiolytics, opioids, and other psychoactive drugs, “reveals new patterns of utilization beyond the approved use of stimulants as monotherapy for ADHD, but because there are so few studies of these kinds of combination therapy, both the advantages and additional risks [of this type of prescribing] remain unknown,” study investigator Thomas J. Moore, AB, faculty associate in epidemiology, Johns Hopkins Bloomberg School of Public Health and Johns Hopkins Medicine, Baltimore, told this news organization.

The study was published online in BMJ Open.
 

‘Dangerous’ substances

Amphetamines and methylphenidate are CNS stimulants that have been in use for almost a century. Like opioids and barbiturates, they’re considered “dangerous” and classified as schedule II Controlled Substances because of their high potential for abuse.

Over many years, these stimulants have been used for multiple purposes, including nasal congestion, narcolepsy, appetite suppression, binge eating, depression, senile behavior, lethargy, and ADHD, the researchers note.

Observational studies suggest medical use of these agents has been increasing in the United States. The investigators conducted previous research that revealed a 79% increase from 2013 to 2018 in the number of adults who self-report their use. The current study, said Mr. Moore, explores how these stimulants are being used.

For the study, data was extracted from the MarketScan 2019 and 2020 Commercial Claims and Encounters Databases, focusing on 9.1 million adults aged 19-64 years who were continuously enrolled in an included commercial benefit plan from Oct. 1, 2019 to Dec. 31, 2020.

The primary outcome consisted of an outpatient prescription claim, service date, and days’ supply for the CNS-active drugs.

The researchers defined “combination-2” therapy as 60 or more days of combination treatment with a schedule II stimulant and at least one additional CNS-active drug. “Combination-3” therapy was defined as the addition of at least two additional CNS-active drugs.

The researchers used service date and days’ supply to examine the number of stimulant and other CNS-active drugs for each of the days of 2020.

CNS-active drug classes included antidepressants, anxiolytics/sedatives/hypnotics, antipsychotics, opioids, anticonvulsants, and other CNS-active drugs.
 

Prescribing cascade

Of the total number of adults enrolled, 3% (n = 276,223) were taking schedule II stimulants during 2020, with a median of 8 (interquartile range, 4-11) prescriptions. These drugs provided 227 (IQR, 110-322) treatment days of exposure.

Among those taking stimulants 45.5% combined the use of at least one additional CNS-active drug for a median of 213 (IQR, 126-301) treatment days; and 24.3% used at least two additional CNS-active drugs for a median of 182 (IQR, 108-276) days.

“Clinicians should beware of the prescribing cascade. Sometimes it begins with an antidepressant that causes too much sedation, so a stimulant gets added, which leads to insomnia, so alprazolam gets added to the mix,” Mr. Moore said.

He cautioned that this “leaves a patient with multiple drugs, all with discontinuation effects of different kinds and clashing effects.”

These new findings, the investigators note, “add new public health concerns to those raised by our previous study. ... this more-detailed profile reveals several new patterns.”

Most patients become “long-term users” once treatment has started, with 75% continuing for a 1-year period.

“This underscores the possible risks of nonmedical use and dependence that have warranted the classification of these drugs as having high potential for psychological or physical dependence and their prominent appearance in toxicology drug rankings of fatal overdose cases,” they write.

They note that the data “do not indicate which intervention may have come first – a stimulant added to compensate for excess sedation from the benzodiazepine, or the alprazolam added to calm excessive CNS stimulation and/or insomnia from the stimulants or other drugs.”

Several limitations cited by the authors include the fact that, although the population encompassed 9.1 million people, it “may not represent all commercially insured adults,” and it doesn’t include people who aren’t covered by commercial insurance.

Moreover, the MarketScan dataset included up to four diagnosis codes for each outpatient and emergency department encounter; therefore, it was not possible to directly link the diagnoses to specific prescription drug claims, and thus the diagnoses were not evaluated.

“Since many providers will not accept a drug claim for a schedule II stimulant without an on-label diagnosis of ADHD,” the authors suspect that “large numbers of this diagnosis were present.”
 

Complex prescribing regimens

Mark Olfson, MD, MPH, professor of psychiatry, medicine, and law and professor of epidemiology, Columbia University Irving Medical Center, New York, said the report “highlights the pharmacological complexity of adults who are treated with stimulants.”

Columbia University

Dr. Olfson, who is a research psychiatrist at the New York State Psychiatric Institute, New York, and was not involved with the study, observed there is “evidence to support stimulants as an adjunctive therapy for treatment-resistant unipolar depression in older adults.”

However, he added, “this indication is unlikely to fully explain the high proportion of nonelderly, stimulant-treated adults who also receive antidepressants.”

These new findings “call for research to increase our understanding of the clinical contexts that motivate these complex prescribing regimens as well as their effectiveness and safety,” said Dr. Olfson.

The authors have not declared a specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors. Mr. Moore declares no relevant financial relationships. Coauthor G. Caleb Alexander, MD, is past chair and a current member of the Food and Drug Administration’s Peripheral and Central Nervous System Advisory Committee; is a cofounding principal and equity holder in Monument Analytics, a health care consultancy whose clients include the life sciences industry as well as plaintiffs in opioid litigation, for whom he has served as a paid expert witness; and is a past member of OptumRx’s National P&T Committee. Dr. Olfson declares no relevant financial relationships.

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

A large proportion of U.S. adults who are prescribed schedule II stimulants are simultaneously receiving other CNS-active agents including benzodiazepines, opioids, and antidepressants – a potentially dangerous practice.

Investigators analyzed prescription drug claims for over 9.1 million U.S. adults over a 1-year period and found that 276,223 (3%) had used a schedule II stimulant, such as methylphenidate and amphetamines, during that time. Of these 276,223 patients, 45% combined these agents with one or more additional CNS-active drugs and almost 25% were simultaneously using two or more additional CNS-active drugs.

Close to half of the stimulant users were taking an antidepressant, while close to one-third filled prescriptions for anxiolytic/sedative/hypnotic meditations, and one-fifth received opioid prescriptions.

The widespread, often off-label use of these stimulants in combination therapy with antidepressants, anxiolytics, opioids, and other psychoactive drugs, “reveals new patterns of utilization beyond the approved use of stimulants as monotherapy for ADHD, but because there are so few studies of these kinds of combination therapy, both the advantages and additional risks [of this type of prescribing] remain unknown,” study investigator Thomas J. Moore, AB, faculty associate in epidemiology, Johns Hopkins Bloomberg School of Public Health and Johns Hopkins Medicine, Baltimore, told this news organization.

The study was published online in BMJ Open.
 

‘Dangerous’ substances

Amphetamines and methylphenidate are CNS stimulants that have been in use for almost a century. Like opioids and barbiturates, they’re considered “dangerous” and classified as schedule II Controlled Substances because of their high potential for abuse.

Over many years, these stimulants have been used for multiple purposes, including nasal congestion, narcolepsy, appetite suppression, binge eating, depression, senile behavior, lethargy, and ADHD, the researchers note.

Observational studies suggest medical use of these agents has been increasing in the United States. The investigators conducted previous research that revealed a 79% increase from 2013 to 2018 in the number of adults who self-report their use. The current study, said Mr. Moore, explores how these stimulants are being used.

For the study, data was extracted from the MarketScan 2019 and 2020 Commercial Claims and Encounters Databases, focusing on 9.1 million adults aged 19-64 years who were continuously enrolled in an included commercial benefit plan from Oct. 1, 2019 to Dec. 31, 2020.

The primary outcome consisted of an outpatient prescription claim, service date, and days’ supply for the CNS-active drugs.

The researchers defined “combination-2” therapy as 60 or more days of combination treatment with a schedule II stimulant and at least one additional CNS-active drug. “Combination-3” therapy was defined as the addition of at least two additional CNS-active drugs.

The researchers used service date and days’ supply to examine the number of stimulant and other CNS-active drugs for each of the days of 2020.

CNS-active drug classes included antidepressants, anxiolytics/sedatives/hypnotics, antipsychotics, opioids, anticonvulsants, and other CNS-active drugs.
 

Prescribing cascade

Of the total number of adults enrolled, 3% (n = 276,223) were taking schedule II stimulants during 2020, with a median of 8 (interquartile range, 4-11) prescriptions. These drugs provided 227 (IQR, 110-322) treatment days of exposure.

Among those taking stimulants 45.5% combined the use of at least one additional CNS-active drug for a median of 213 (IQR, 126-301) treatment days; and 24.3% used at least two additional CNS-active drugs for a median of 182 (IQR, 108-276) days.

“Clinicians should beware of the prescribing cascade. Sometimes it begins with an antidepressant that causes too much sedation, so a stimulant gets added, which leads to insomnia, so alprazolam gets added to the mix,” Mr. Moore said.

He cautioned that this “leaves a patient with multiple drugs, all with discontinuation effects of different kinds and clashing effects.”

These new findings, the investigators note, “add new public health concerns to those raised by our previous study. ... this more-detailed profile reveals several new patterns.”

Most patients become “long-term users” once treatment has started, with 75% continuing for a 1-year period.

“This underscores the possible risks of nonmedical use and dependence that have warranted the classification of these drugs as having high potential for psychological or physical dependence and their prominent appearance in toxicology drug rankings of fatal overdose cases,” they write.

They note that the data “do not indicate which intervention may have come first – a stimulant added to compensate for excess sedation from the benzodiazepine, or the alprazolam added to calm excessive CNS stimulation and/or insomnia from the stimulants or other drugs.”

Several limitations cited by the authors include the fact that, although the population encompassed 9.1 million people, it “may not represent all commercially insured adults,” and it doesn’t include people who aren’t covered by commercial insurance.

Moreover, the MarketScan dataset included up to four diagnosis codes for each outpatient and emergency department encounter; therefore, it was not possible to directly link the diagnoses to specific prescription drug claims, and thus the diagnoses were not evaluated.

“Since many providers will not accept a drug claim for a schedule II stimulant without an on-label diagnosis of ADHD,” the authors suspect that “large numbers of this diagnosis were present.”
 

Complex prescribing regimens

Mark Olfson, MD, MPH, professor of psychiatry, medicine, and law and professor of epidemiology, Columbia University Irving Medical Center, New York, said the report “highlights the pharmacological complexity of adults who are treated with stimulants.”

Columbia University

Dr. Olfson, who is a research psychiatrist at the New York State Psychiatric Institute, New York, and was not involved with the study, observed there is “evidence to support stimulants as an adjunctive therapy for treatment-resistant unipolar depression in older adults.”

However, he added, “this indication is unlikely to fully explain the high proportion of nonelderly, stimulant-treated adults who also receive antidepressants.”

These new findings “call for research to increase our understanding of the clinical contexts that motivate these complex prescribing regimens as well as their effectiveness and safety,” said Dr. Olfson.

The authors have not declared a specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors. Mr. Moore declares no relevant financial relationships. Coauthor G. Caleb Alexander, MD, is past chair and a current member of the Food and Drug Administration’s Peripheral and Central Nervous System Advisory Committee; is a cofounding principal and equity holder in Monument Analytics, a health care consultancy whose clients include the life sciences industry as well as plaintiffs in opioid litigation, for whom he has served as a paid expert witness; and is a past member of OptumRx’s National P&T Committee. Dr. Olfson declares no relevant financial relationships.

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

Investigators for a study of children with parent-reported attention deficit/hyperactivity disorder (ADHD) found that only 12.9% are receiving medications for the disorder and only 26.2% have ever received outpatient mental health care. Just more than one-third (34.8%) had received either treatment.

Researchers, led by Mark Olfson, MD, MPH, Elizabeth K. Dollard Professor of Psychiatry, Medicine and Law and professor of epidemiology at New York State Psychiatric Institute and Columbia University Department of Psychiatry, New York, also found that girls were much less likely to get medications.

Columbia University

In this cross-sectional sample taken from 11, 723 children in the Adolescent Brain and Cognitive Development Study, 1,206 children aged 9 and 10 years had parent-reported ADHD, and of those children, 15.7% of boys and 7% of girls were currently receiving ADHD medications. The parents reported the children met ADHD criteria according to the Diagnostic and Statistical Manual of Mental Disorders.

Findings were published online in JAMA Network Open.
 

Diagnoses have doubled but treatment numbers lag

Report authors noted that the percentage of U.S. children whose parents report their child has been diagnosed with ADHD has nearly doubled over 2 decades from 5.5% in 1999 to 9.8% in 2018. That has led to misperceptions among professionals and the public that the disorder is overdiagnosed and overtreated, the authors wrote.

However, they wrote, “a focus on the increasing numbers of children treated for ADHD does not give a sense of what fraction of children in the population with ADHD receive treatment.”
 

Higher uptake at lower income and education levels

Researchers also found that, contrary to popular belief, children with ADHD from families with lower educational levels and lower income were more likely than those with higher educational levels and higher incomes to have received outpatient mental health care.

Among children with ADHD whose parents did not have a high school education, 32.2% of children were receiving medications while among children of parents with a bachelor’s degree 11.5% received medications.

Among children from families with incomes of less than $25 000, 36.5% were receiving outpatient mental health care, compared with 20.1% of those from families with incomes of $75,000 or more.

“These patterns suggest that attitudinal rather than socioeconomic factors often impede the flow of children with ADHD into treatment,” they wrote.
 

Black children less likely to receive medications

The researchers found that substantially more White children (14.8% [104 of 759]) than Black children (9.4% [22 of 206]), received medication, a finding consistent with previous research.

“Population-based racial and ethnic gradients exist in prescriptions for stimulants and other controlled substances, with the highest rates in majority-White areas,” the authors wrote. “As a result of structural racism, Black parents’ perspectives might further influence ADHD management decisions through mistrust in clinicians and concerns over safety and efficacy of stimulants.”

“Physician efforts to recognize and manage their own implicit biases, together with patient-centered clinical approaches that promote shared decision-making,” might help narrow the treatment gap, the authors wrote. That includes talking with Black parents about their knowledge and beliefs concerning managing ADHD, they added.
 

Confirming diagnosis critical

The authors noted that not all children with parent-reported ADHD need treatment or would benefit from it.

Lenard Adler, MD, director of the adult ADHD program and professor of Psychiatry and Child and Adolescent Psychiatry at New York University Langone Health, who was not part of the current study, said this research emphasizes the urgency of clinical diagnosis.

Dr. Adler was part of a team of researchers that found similar low numbers for treatment among adults with ADHD.

The current results highlight that “we want to get the diagnosis correct so that people who receive a diagnosis actually have it and, if they do, that they have access to care. Because the consequences for not having treatment for ADHD are significant,” Dr. Adler said.

He urged physicians who diagnose ADHD to make follow-up part of the care plan or these treatment gaps will persist.

The authors wrote that the results suggest a need to increase availability for mental health services and better communicate symptoms among parents, teachers, and primary care providers.

The authors declare no relevant financial relationships. Dr. Adler has consulted with Supernus Pharmaceuticals and Otsuka Pharmaceuticals, has done research with Takeda, and has received royalty payments from NYU for licensing of ADHD training materials.

Investigators for a study of children with parent-reported attention deficit/hyperactivity disorder (ADHD) found that only 12.9% are receiving medications for the disorder and only 26.2% have ever received outpatient mental health care. Just more than one-third (34.8%) had received either treatment.

Researchers, led by Mark Olfson, MD, MPH, Elizabeth K. Dollard Professor of Psychiatry, Medicine and Law and professor of epidemiology at New York State Psychiatric Institute and Columbia University Department of Psychiatry, New York, also found that girls were much less likely to get medications.

Columbia University

In this cross-sectional sample taken from 11, 723 children in the Adolescent Brain and Cognitive Development Study, 1,206 children aged 9 and 10 years had parent-reported ADHD, and of those children, 15.7% of boys and 7% of girls were currently receiving ADHD medications. The parents reported the children met ADHD criteria according to the Diagnostic and Statistical Manual of Mental Disorders.

Findings were published online in JAMA Network Open.
 

Diagnoses have doubled but treatment numbers lag

Report authors noted that the percentage of U.S. children whose parents report their child has been diagnosed with ADHD has nearly doubled over 2 decades from 5.5% in 1999 to 9.8% in 2018. That has led to misperceptions among professionals and the public that the disorder is overdiagnosed and overtreated, the authors wrote.

However, they wrote, “a focus on the increasing numbers of children treated for ADHD does not give a sense of what fraction of children in the population with ADHD receive treatment.”
 

Higher uptake at lower income and education levels

Researchers also found that, contrary to popular belief, children with ADHD from families with lower educational levels and lower income were more likely than those with higher educational levels and higher incomes to have received outpatient mental health care.

Among children with ADHD whose parents did not have a high school education, 32.2% of children were receiving medications while among children of parents with a bachelor’s degree 11.5% received medications.

Among children from families with incomes of less than $25 000, 36.5% were receiving outpatient mental health care, compared with 20.1% of those from families with incomes of $75,000 or more.

“These patterns suggest that attitudinal rather than socioeconomic factors often impede the flow of children with ADHD into treatment,” they wrote.
 

Black children less likely to receive medications

The researchers found that substantially more White children (14.8% [104 of 759]) than Black children (9.4% [22 of 206]), received medication, a finding consistent with previous research.

“Population-based racial and ethnic gradients exist in prescriptions for stimulants and other controlled substances, with the highest rates in majority-White areas,” the authors wrote. “As a result of structural racism, Black parents’ perspectives might further influence ADHD management decisions through mistrust in clinicians and concerns over safety and efficacy of stimulants.”

“Physician efforts to recognize and manage their own implicit biases, together with patient-centered clinical approaches that promote shared decision-making,” might help narrow the treatment gap, the authors wrote. That includes talking with Black parents about their knowledge and beliefs concerning managing ADHD, they added.
 

Confirming diagnosis critical

The authors noted that not all children with parent-reported ADHD need treatment or would benefit from it.

Lenard Adler, MD, director of the adult ADHD program and professor of Psychiatry and Child and Adolescent Psychiatry at New York University Langone Health, who was not part of the current study, said this research emphasizes the urgency of clinical diagnosis.

Dr. Adler was part of a team of researchers that found similar low numbers for treatment among adults with ADHD.

The current results highlight that “we want to get the diagnosis correct so that people who receive a diagnosis actually have it and, if they do, that they have access to care. Because the consequences for not having treatment for ADHD are significant,” Dr. Adler said.

He urged physicians who diagnose ADHD to make follow-up part of the care plan or these treatment gaps will persist.

The authors wrote that the results suggest a need to increase availability for mental health services and better communicate symptoms among parents, teachers, and primary care providers.

The authors declare no relevant financial relationships. Dr. Adler has consulted with Supernus Pharmaceuticals and Otsuka Pharmaceuticals, has done research with Takeda, and has received royalty payments from NYU for licensing of ADHD training materials.

Investigators for a study of children with parent-reported attention deficit/hyperactivity disorder (ADHD) found that only 12.9% are receiving medications for the disorder and only 26.2% have ever received outpatient mental health care. Just more than one-third (34.8%) had received either treatment.

Researchers, led by Mark Olfson, MD, MPH, Elizabeth K. Dollard Professor of Psychiatry, Medicine and Law and professor of epidemiology at New York State Psychiatric Institute and Columbia University Department of Psychiatry, New York, also found that girls were much less likely to get medications.

Columbia University

In this cross-sectional sample taken from 11, 723 children in the Adolescent Brain and Cognitive Development Study, 1,206 children aged 9 and 10 years had parent-reported ADHD, and of those children, 15.7% of boys and 7% of girls were currently receiving ADHD medications. The parents reported the children met ADHD criteria according to the Diagnostic and Statistical Manual of Mental Disorders.

Findings were published online in JAMA Network Open.
 

Diagnoses have doubled but treatment numbers lag

Report authors noted that the percentage of U.S. children whose parents report their child has been diagnosed with ADHD has nearly doubled over 2 decades from 5.5% in 1999 to 9.8% in 2018. That has led to misperceptions among professionals and the public that the disorder is overdiagnosed and overtreated, the authors wrote.

However, they wrote, “a focus on the increasing numbers of children treated for ADHD does not give a sense of what fraction of children in the population with ADHD receive treatment.”
 

Higher uptake at lower income and education levels

Researchers also found that, contrary to popular belief, children with ADHD from families with lower educational levels and lower income were more likely than those with higher educational levels and higher incomes to have received outpatient mental health care.

Among children with ADHD whose parents did not have a high school education, 32.2% of children were receiving medications while among children of parents with a bachelor’s degree 11.5% received medications.

Among children from families with incomes of less than $25 000, 36.5% were receiving outpatient mental health care, compared with 20.1% of those from families with incomes of $75,000 or more.

“These patterns suggest that attitudinal rather than socioeconomic factors often impede the flow of children with ADHD into treatment,” they wrote.
 

Black children less likely to receive medications

The researchers found that substantially more White children (14.8% [104 of 759]) than Black children (9.4% [22 of 206]), received medication, a finding consistent with previous research.

“Population-based racial and ethnic gradients exist in prescriptions for stimulants and other controlled substances, with the highest rates in majority-White areas,” the authors wrote. “As a result of structural racism, Black parents’ perspectives might further influence ADHD management decisions through mistrust in clinicians and concerns over safety and efficacy of stimulants.”

“Physician efforts to recognize and manage their own implicit biases, together with patient-centered clinical approaches that promote shared decision-making,” might help narrow the treatment gap, the authors wrote. That includes talking with Black parents about their knowledge and beliefs concerning managing ADHD, they added.
 

Confirming diagnosis critical

The authors noted that not all children with parent-reported ADHD need treatment or would benefit from it.

Lenard Adler, MD, director of the adult ADHD program and professor of Psychiatry and Child and Adolescent Psychiatry at New York University Langone Health, who was not part of the current study, said this research emphasizes the urgency of clinical diagnosis.

Dr. Adler was part of a team of researchers that found similar low numbers for treatment among adults with ADHD.

The current results highlight that “we want to get the diagnosis correct so that people who receive a diagnosis actually have it and, if they do, that they have access to care. Because the consequences for not having treatment for ADHD are significant,” Dr. Adler said.

He urged physicians who diagnose ADHD to make follow-up part of the care plan or these treatment gaps will persist.

The authors wrote that the results suggest a need to increase availability for mental health services and better communicate symptoms among parents, teachers, and primary care providers.

The authors declare no relevant financial relationships. Dr. Adler has consulted with Supernus Pharmaceuticals and Otsuka Pharmaceuticals, has done research with Takeda, and has received royalty payments from NYU for licensing of ADHD training materials.

WASHINGTON – Dysregulated stress systems may help explain why childhood trauma has such a dramatic and enduring psychiatric impact, new research suggests.

“We already knew childhood trauma is associated with the later development of depressive and anxiety disorders, but it’s been unclear what makes sufferers of early trauma more likely to develop these psychiatric conditions,” study investigator Erika Kuzminskaite, PhD candidate, department of psychiatry, Amsterdam University Medical Center (UMC), the Netherlands, told this news organization.

Pauline Anderson

“The evidence now points to unbalanced stress systems as a possible cause of this vulnerability, and now the most important question is, how we can develop preventive interventions,” she added.

The findings were presented as part of the Anxiety and Depression Association of America Anxiety & Depression conference.
 

Elevated cortisol, inflammation

The study included 2,779 adults from the Netherlands Study of Depression and Anxiety (NESDA). Two thirds of participants were female.

Participants retrospectively reported childhood trauma, defined as emotional, physical, or sexual abuse or emotional or physical neglect, before the age of 18 years. Severe trauma was defined as multiple types or increased frequency of abuse.

Of the total cohort, 48% reported experiencing some childhood trauma – 21% reported severe trauma, 27% reported mild trauma, and 42% reported no childhood trauma.

Among those with trauma, 89% had a current or remitted anxiety or depressive disorder, and 11% had no psychiatric sequelae. Among participants who reported no trauma, 68% had a current or remitted disorder, and 32% had no psychiatric disorders.

At baseline, researchers assessed markers of major bodily stress systems, including the hypothalamic-pituitary-adrenal (HPA) axis, the immune-inflammatory system, and the autonomic nervous system (ANS). They examined these markers separately and cumulatively.

In one model, investigators found that levels of cortisol and inflammation were significantly elevated in those with severe childhood trauma compared to those with no childhood trauma. The effects were largest for the cumulative markers for HPA-axis, inflammation, and all stress system markers (Cohen’s d = 0.23, 0.12, and 0.25, respectively). There was no association with ANS markers.

The results were partially explained by lifestyle, said Ms. Kuzminskaite, who noted that people with severe childhood trauma tend to have a higher body mass index, smoke more, and have other unhealthy habits that may represent a “coping” mechanism for trauma.

Those who experienced childhood trauma also have higher rates of other disorders, including asthma, diabetes, and cardiovascular disease. Ms. Kuzminskaite noted that people with childhood trauma have at least double the risk of cancer in later life.

When researchers adjusted for lifestyle factors and chronic conditions, the association for cortisol was reduced and that for inflammation disappeared. However, the cumulative inflammatory markers remained significant.

Another model examined lipopolysaccharide-stimulated (LPS) immune-inflammatory markers by childhood trauma severity. This provides a more “dynamic” measure of stress systems than looking only at static circulating levels in the blood, as was done in the first model, said Ms. Kuzminskaite.

“These levels should theoretically be more affected by experiences such as childhood trauma and they are also less sensitive to lifestyle.”

Here, researchers found significant positive associations with childhood trauma, especially severe trauma, after adjusting for lifestyle and health-related covariates (cumulative index d = 0.19).

“Almost all people with childhood trauma, especially severe trauma, had LPS-stimulated cytokines upregulated,” said Ms. Kuzminskaite. “So again, there is this dysregulation of immune system functioning in these subjects.”

And again, the strongest effect was for the cumulative index of all cytokines, she said.
 

Personalized interventions

Ms. Kuzminskaite noted the importance of learning the impact of early trauma on stress responses. “The goal is to eventually have personalized interventions for people with depression or anxiety related to childhood trauma, or even preventative interventions. If we know, for example, something is going wrong with a patient’s stress systems, we can suggest some therapeutic targets.”

Investigators in Amsterdam are examining the efficacy of mifepristone, which blocks progesterone and is used along with misoprostol for medication abortions and to treat high blood sugar. “The drug is supposed to reset the stress system functioning,” said Ms. Kuzminskaite.

It’s still important to target unhealthy lifestyle habits “that are really impacting the functioning of the stress systems,” she said. Lifestyle interventions could improve the efficacy of treatments for depression, for example, she added.

Luana Marques, PhD, associate professor, department of psychiatry, Harvard Medical School, Boston, said such research is important.

“It reveals the potentially extensive and long-lasting impact of childhood trauma on functioning. The findings underscore the importance of equipping at-risk and trauma-exposed youth with evidence-based skills for managing stress,” she said.

No conflicts of interest were reported.

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

WASHINGTON – Dysregulated stress systems may help explain why childhood trauma has such a dramatic and enduring psychiatric impact, new research suggests.

“We already knew childhood trauma is associated with the later development of depressive and anxiety disorders, but it’s been unclear what makes sufferers of early trauma more likely to develop these psychiatric conditions,” study investigator Erika Kuzminskaite, PhD candidate, department of psychiatry, Amsterdam University Medical Center (UMC), the Netherlands, told this news organization.

Pauline Anderson

“The evidence now points to unbalanced stress systems as a possible cause of this vulnerability, and now the most important question is, how we can develop preventive interventions,” she added.

The findings were presented as part of the Anxiety and Depression Association of America Anxiety & Depression conference.
 

Elevated cortisol, inflammation

The study included 2,779 adults from the Netherlands Study of Depression and Anxiety (NESDA). Two thirds of participants were female.

Participants retrospectively reported childhood trauma, defined as emotional, physical, or sexual abuse or emotional or physical neglect, before the age of 18 years. Severe trauma was defined as multiple types or increased frequency of abuse.

Of the total cohort, 48% reported experiencing some childhood trauma – 21% reported severe trauma, 27% reported mild trauma, and 42% reported no childhood trauma.

Among those with trauma, 89% had a current or remitted anxiety or depressive disorder, and 11% had no psychiatric sequelae. Among participants who reported no trauma, 68% had a current or remitted disorder, and 32% had no psychiatric disorders.

At baseline, researchers assessed markers of major bodily stress systems, including the hypothalamic-pituitary-adrenal (HPA) axis, the immune-inflammatory system, and the autonomic nervous system (ANS). They examined these markers separately and cumulatively.

In one model, investigators found that levels of cortisol and inflammation were significantly elevated in those with severe childhood trauma compared to those with no childhood trauma. The effects were largest for the cumulative markers for HPA-axis, inflammation, and all stress system markers (Cohen’s d = 0.23, 0.12, and 0.25, respectively). There was no association with ANS markers.

The results were partially explained by lifestyle, said Ms. Kuzminskaite, who noted that people with severe childhood trauma tend to have a higher body mass index, smoke more, and have other unhealthy habits that may represent a “coping” mechanism for trauma.

Those who experienced childhood trauma also have higher rates of other disorders, including asthma, diabetes, and cardiovascular disease. Ms. Kuzminskaite noted that people with childhood trauma have at least double the risk of cancer in later life.

When researchers adjusted for lifestyle factors and chronic conditions, the association for cortisol was reduced and that for inflammation disappeared. However, the cumulative inflammatory markers remained significant.

Another model examined lipopolysaccharide-stimulated (LPS) immune-inflammatory markers by childhood trauma severity. This provides a more “dynamic” measure of stress systems than looking only at static circulating levels in the blood, as was done in the first model, said Ms. Kuzminskaite.

“These levels should theoretically be more affected by experiences such as childhood trauma and they are also less sensitive to lifestyle.”

Here, researchers found significant positive associations with childhood trauma, especially severe trauma, after adjusting for lifestyle and health-related covariates (cumulative index d = 0.19).

“Almost all people with childhood trauma, especially severe trauma, had LPS-stimulated cytokines upregulated,” said Ms. Kuzminskaite. “So again, there is this dysregulation of immune system functioning in these subjects.”

And again, the strongest effect was for the cumulative index of all cytokines, she said.
 

Personalized interventions

Ms. Kuzminskaite noted the importance of learning the impact of early trauma on stress responses. “The goal is to eventually have personalized interventions for people with depression or anxiety related to childhood trauma, or even preventative interventions. If we know, for example, something is going wrong with a patient’s stress systems, we can suggest some therapeutic targets.”

Investigators in Amsterdam are examining the efficacy of mifepristone, which blocks progesterone and is used along with misoprostol for medication abortions and to treat high blood sugar. “The drug is supposed to reset the stress system functioning,” said Ms. Kuzminskaite.

It’s still important to target unhealthy lifestyle habits “that are really impacting the functioning of the stress systems,” she said. Lifestyle interventions could improve the efficacy of treatments for depression, for example, she added.

Luana Marques, PhD, associate professor, department of psychiatry, Harvard Medical School, Boston, said such research is important.

“It reveals the potentially extensive and long-lasting impact of childhood trauma on functioning. The findings underscore the importance of equipping at-risk and trauma-exposed youth with evidence-based skills for managing stress,” she said.

No conflicts of interest were reported.

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

WASHINGTON – Dysregulated stress systems may help explain why childhood trauma has such a dramatic and enduring psychiatric impact, new research suggests.

“We already knew childhood trauma is associated with the later development of depressive and anxiety disorders, but it’s been unclear what makes sufferers of early trauma more likely to develop these psychiatric conditions,” study investigator Erika Kuzminskaite, PhD candidate, department of psychiatry, Amsterdam University Medical Center (UMC), the Netherlands, told this news organization.

Pauline Anderson

“The evidence now points to unbalanced stress systems as a possible cause of this vulnerability, and now the most important question is, how we can develop preventive interventions,” she added.

The findings were presented as part of the Anxiety and Depression Association of America Anxiety & Depression conference.
 

Elevated cortisol, inflammation

The study included 2,779 adults from the Netherlands Study of Depression and Anxiety (NESDA). Two thirds of participants were female.

Participants retrospectively reported childhood trauma, defined as emotional, physical, or sexual abuse or emotional or physical neglect, before the age of 18 years. Severe trauma was defined as multiple types or increased frequency of abuse.

Of the total cohort, 48% reported experiencing some childhood trauma – 21% reported severe trauma, 27% reported mild trauma, and 42% reported no childhood trauma.

Among those with trauma, 89% had a current or remitted anxiety or depressive disorder, and 11% had no psychiatric sequelae. Among participants who reported no trauma, 68% had a current or remitted disorder, and 32% had no psychiatric disorders.

At baseline, researchers assessed markers of major bodily stress systems, including the hypothalamic-pituitary-adrenal (HPA) axis, the immune-inflammatory system, and the autonomic nervous system (ANS). They examined these markers separately and cumulatively.

In one model, investigators found that levels of cortisol and inflammation were significantly elevated in those with severe childhood trauma compared to those with no childhood trauma. The effects were largest for the cumulative markers for HPA-axis, inflammation, and all stress system markers (Cohen’s d = 0.23, 0.12, and 0.25, respectively). There was no association with ANS markers.

The results were partially explained by lifestyle, said Ms. Kuzminskaite, who noted that people with severe childhood trauma tend to have a higher body mass index, smoke more, and have other unhealthy habits that may represent a “coping” mechanism for trauma.

Those who experienced childhood trauma also have higher rates of other disorders, including asthma, diabetes, and cardiovascular disease. Ms. Kuzminskaite noted that people with childhood trauma have at least double the risk of cancer in later life.

When researchers adjusted for lifestyle factors and chronic conditions, the association for cortisol was reduced and that for inflammation disappeared. However, the cumulative inflammatory markers remained significant.

Another model examined lipopolysaccharide-stimulated (LPS) immune-inflammatory markers by childhood trauma severity. This provides a more “dynamic” measure of stress systems than looking only at static circulating levels in the blood, as was done in the first model, said Ms. Kuzminskaite.

“These levels should theoretically be more affected by experiences such as childhood trauma and they are also less sensitive to lifestyle.”

Here, researchers found significant positive associations with childhood trauma, especially severe trauma, after adjusting for lifestyle and health-related covariates (cumulative index d = 0.19).

“Almost all people with childhood trauma, especially severe trauma, had LPS-stimulated cytokines upregulated,” said Ms. Kuzminskaite. “So again, there is this dysregulation of immune system functioning in these subjects.”

And again, the strongest effect was for the cumulative index of all cytokines, she said.
 

Personalized interventions

Ms. Kuzminskaite noted the importance of learning the impact of early trauma on stress responses. “The goal is to eventually have personalized interventions for people with depression or anxiety related to childhood trauma, or even preventative interventions. If we know, for example, something is going wrong with a patient’s stress systems, we can suggest some therapeutic targets.”

Investigators in Amsterdam are examining the efficacy of mifepristone, which blocks progesterone and is used along with misoprostol for medication abortions and to treat high blood sugar. “The drug is supposed to reset the stress system functioning,” said Ms. Kuzminskaite.

It’s still important to target unhealthy lifestyle habits “that are really impacting the functioning of the stress systems,” she said. Lifestyle interventions could improve the efficacy of treatments for depression, for example, she added.

Luana Marques, PhD, associate professor, department of psychiatry, Harvard Medical School, Boston, said such research is important.

“It reveals the potentially extensive and long-lasting impact of childhood trauma on functioning. The findings underscore the importance of equipping at-risk and trauma-exposed youth with evidence-based skills for managing stress,” she said.

No conflicts of interest were reported.

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

The American Society of Clinical Oncology has released updated guidelines for treating anxiety and depression in adult cancer survivors.

Since the last guidelines, published in 2014, screening and assessment for depression and anxiety have improved, and a large new evidence base has emerged. To ensure the most up-to-date recommendations, a group of experts spanning psychology, psychiatry, medical and surgical oncology, internal medicine, and nursing convened to review the current literature on managing depression and anxiety. The review included 61 studies – 16 meta-analyses, 44 randomized controlled trials, and one systematic review – published between 2013 and 2021.

“The purpose of this guideline update is to gather and examine the evidence published since the 2014 guideline ... [with a] focus on management and treatment only.” The overall goal is to provide “the most effective and least resource-intensive intervention based on symptom severity” for patients with cancer, the experts write.

The new clinical practice guideline addresses the following question: What are the recommended treatment approaches in the management of anxiety and/or depression in survivors of adult cancer?

After an extensive literature search and analysis, the study was published online in the Journal of Clinical Oncology.

The expert panel’s recommendations fell into three broad categories – general management principles, treatment and care options for depressive symptoms, and treatment and care options for anxiety symptoms – with the guidelines for managing depression and anxiety largely mirroring each other.

The authors caution, however, that the guidelines “were developed in the context of mental health care being available and may not be applicable within other resource settings.”
 

General management principals

All patients with cancer, along with their caregivers, family members, or trusted confidants, should be offered information and resources on depression and anxiety. The panel gave this a “strong” recommendation but provided the caveat that the “information should be culturally informed and linguistically appropriate and can include a conversation between clinician and patient.”

Clinicians should select the most effective and least intensive intervention based on symptom severity when selecting treatment – what the panelists referred to as a stepped-care model. History of psychiatric diagnoses or substance use as well as prior responses to mental health treatment are some of the factors that may inform treatment choice.

For patients experiencing both depression and anxiety symptoms, treatment of depressive symptoms should be prioritized.

When referring a patient for further evaluation or care, clinicians “should make every effort to reduce barriers and facilitate patient follow-through,” the authors write. And health care professionals should regularly assess the treatment responses for patients receiving psychological or pharmacological interventions.

Overall, the treatments should be “supervised by a psychiatrist, and primary care or oncology providers work collaboratively with a nurse care manager to provide psychological interventions and monitor treatment compliance and outcomes,” the panelists write. “This type of collaborative care is found to be superior to usual care and is more cost-effective than face-to-face and pharmacologic treatment for depression.”
 

Treatment and care options for depressive and anxiety symptoms

For patients with moderate to severe depression symptoms, the panelists again stressed that clinicians should provide “culturally informed and linguistically appropriate information.” This information may include the frequency and symptoms of depression as well as signs these symptoms may be getting worse, with contact information for the medical team provided.

Among patients with moderate symptoms, clinicians can offer patients a range of individual or group therapy options, including cognitive-behavioral therapy (CBT), behavioral activation, mindfulness-based stress reduction, or structured physical activity and exercise. For patients with severe symptoms of depression, clinicians should offer individual therapy with one of these four treatment options: CBT, behavioral activation, mindfulness-based stress reduction, or interpersonal therapy.

The panelists offered almost identical recommendations for patients with anxiety, except mindfulness-based stress reduction was an option for patients with severe symptoms.

Clinicians can also provide pharmacologic options to treat depression or anxiety in certain patients, though the panelists provided the caveat that evidence for pharmacologic management is weak.

“These guidelines make no recommendations about any specific pharmacologic regimen being better than another,” the experts wrote. And “patients should be warned of potential harm or adverse effects.”

Overall, the panelists noted that, as highlighted in the 2014 ASCO guideline, the updated version continues to stress the importance of providing education on coping with stress, anxiety, and depression.

And “for individuals with elevated symptoms, validation and normalizing patients’ experiences is crucial,” the panelists write.

Although the timing of screening is not the focus of this updated review, the experts recognized that “how and when patients with cancer and survivors are screened are important determinants of timely management of anxiety and depression.”

And unlike the prior guideline, “pharmacotherapy is not recommended as a first-line treatment, neither alone nor in combination,” the authors say.

Overall, the panelists emphasize how widespread the mental health care crisis is and that problems accessing mental health care remain. “The choice of intervention to offer patients facing such obstacles should be based on shared decision-making, taking into account availability, accessibility, patient preference, likelihood of adverse events, adherence, and cost,” the experts conclude.

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

The American Society of Clinical Oncology has released updated guidelines for treating anxiety and depression in adult cancer survivors.

Since the last guidelines, published in 2014, screening and assessment for depression and anxiety have improved, and a large new evidence base has emerged. To ensure the most up-to-date recommendations, a group of experts spanning psychology, psychiatry, medical and surgical oncology, internal medicine, and nursing convened to review the current literature on managing depression and anxiety. The review included 61 studies – 16 meta-analyses, 44 randomized controlled trials, and one systematic review – published between 2013 and 2021.

“The purpose of this guideline update is to gather and examine the evidence published since the 2014 guideline ... [with a] focus on management and treatment only.” The overall goal is to provide “the most effective and least resource-intensive intervention based on symptom severity” for patients with cancer, the experts write.

The new clinical practice guideline addresses the following question: What are the recommended treatment approaches in the management of anxiety and/or depression in survivors of adult cancer?

After an extensive literature search and analysis, the study was published online in the Journal of Clinical Oncology.

The expert panel’s recommendations fell into three broad categories – general management principles, treatment and care options for depressive symptoms, and treatment and care options for anxiety symptoms – with the guidelines for managing depression and anxiety largely mirroring each other.

The authors caution, however, that the guidelines “were developed in the context of mental health care being available and may not be applicable within other resource settings.”
 

General management principals

All patients with cancer, along with their caregivers, family members, or trusted confidants, should be offered information and resources on depression and anxiety. The panel gave this a “strong” recommendation but provided the caveat that the “information should be culturally informed and linguistically appropriate and can include a conversation between clinician and patient.”

Clinicians should select the most effective and least intensive intervention based on symptom severity when selecting treatment – what the panelists referred to as a stepped-care model. History of psychiatric diagnoses or substance use as well as prior responses to mental health treatment are some of the factors that may inform treatment choice.

For patients experiencing both depression and anxiety symptoms, treatment of depressive symptoms should be prioritized.

When referring a patient for further evaluation or care, clinicians “should make every effort to reduce barriers and facilitate patient follow-through,” the authors write. And health care professionals should regularly assess the treatment responses for patients receiving psychological or pharmacological interventions.

Overall, the treatments should be “supervised by a psychiatrist, and primary care or oncology providers work collaboratively with a nurse care manager to provide psychological interventions and monitor treatment compliance and outcomes,” the panelists write. “This type of collaborative care is found to be superior to usual care and is more cost-effective than face-to-face and pharmacologic treatment for depression.”
 

Treatment and care options for depressive and anxiety symptoms

For patients with moderate to severe depression symptoms, the panelists again stressed that clinicians should provide “culturally informed and linguistically appropriate information.” This information may include the frequency and symptoms of depression as well as signs these symptoms may be getting worse, with contact information for the medical team provided.

Among patients with moderate symptoms, clinicians can offer patients a range of individual or group therapy options, including cognitive-behavioral therapy (CBT), behavioral activation, mindfulness-based stress reduction, or structured physical activity and exercise. For patients with severe symptoms of depression, clinicians should offer individual therapy with one of these four treatment options: CBT, behavioral activation, mindfulness-based stress reduction, or interpersonal therapy.

The panelists offered almost identical recommendations for patients with anxiety, except mindfulness-based stress reduction was an option for patients with severe symptoms.

Clinicians can also provide pharmacologic options to treat depression or anxiety in certain patients, though the panelists provided the caveat that evidence for pharmacologic management is weak.

“These guidelines make no recommendations about any specific pharmacologic regimen being better than another,” the experts wrote. And “patients should be warned of potential harm or adverse effects.”

Overall, the panelists noted that, as highlighted in the 2014 ASCO guideline, the updated version continues to stress the importance of providing education on coping with stress, anxiety, and depression.

And “for individuals with elevated symptoms, validation and normalizing patients’ experiences is crucial,” the panelists write.

Although the timing of screening is not the focus of this updated review, the experts recognized that “how and when patients with cancer and survivors are screened are important determinants of timely management of anxiety and depression.”

And unlike the prior guideline, “pharmacotherapy is not recommended as a first-line treatment, neither alone nor in combination,” the authors say.

Overall, the panelists emphasize how widespread the mental health care crisis is and that problems accessing mental health care remain. “The choice of intervention to offer patients facing such obstacles should be based on shared decision-making, taking into account availability, accessibility, patient preference, likelihood of adverse events, adherence, and cost,” the experts conclude.

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

The American Society of Clinical Oncology has released updated guidelines for treating anxiety and depression in adult cancer survivors.

Since the last guidelines, published in 2014, screening and assessment for depression and anxiety have improved, and a large new evidence base has emerged. To ensure the most up-to-date recommendations, a group of experts spanning psychology, psychiatry, medical and surgical oncology, internal medicine, and nursing convened to review the current literature on managing depression and anxiety. The review included 61 studies – 16 meta-analyses, 44 randomized controlled trials, and one systematic review – published between 2013 and 2021.

“The purpose of this guideline update is to gather and examine the evidence published since the 2014 guideline ... [with a] focus on management and treatment only.” The overall goal is to provide “the most effective and least resource-intensive intervention based on symptom severity” for patients with cancer, the experts write.

The new clinical practice guideline addresses the following question: What are the recommended treatment approaches in the management of anxiety and/or depression in survivors of adult cancer?

After an extensive literature search and analysis, the study was published online in the Journal of Clinical Oncology.

The expert panel’s recommendations fell into three broad categories – general management principles, treatment and care options for depressive symptoms, and treatment and care options for anxiety symptoms – with the guidelines for managing depression and anxiety largely mirroring each other.

The authors caution, however, that the guidelines “were developed in the context of mental health care being available and may not be applicable within other resource settings.”
 

General management principals

All patients with cancer, along with their caregivers, family members, or trusted confidants, should be offered information and resources on depression and anxiety. The panel gave this a “strong” recommendation but provided the caveat that the “information should be culturally informed and linguistically appropriate and can include a conversation between clinician and patient.”

Clinicians should select the most effective and least intensive intervention based on symptom severity when selecting treatment – what the panelists referred to as a stepped-care model. History of psychiatric diagnoses or substance use as well as prior responses to mental health treatment are some of the factors that may inform treatment choice.

For patients experiencing both depression and anxiety symptoms, treatment of depressive symptoms should be prioritized.

When referring a patient for further evaluation or care, clinicians “should make every effort to reduce barriers and facilitate patient follow-through,” the authors write. And health care professionals should regularly assess the treatment responses for patients receiving psychological or pharmacological interventions.

Overall, the treatments should be “supervised by a psychiatrist, and primary care or oncology providers work collaboratively with a nurse care manager to provide psychological interventions and monitor treatment compliance and outcomes,” the panelists write. “This type of collaborative care is found to be superior to usual care and is more cost-effective than face-to-face and pharmacologic treatment for depression.”
 

Treatment and care options for depressive and anxiety symptoms

For patients with moderate to severe depression symptoms, the panelists again stressed that clinicians should provide “culturally informed and linguistically appropriate information.” This information may include the frequency and symptoms of depression as well as signs these symptoms may be getting worse, with contact information for the medical team provided.

Among patients with moderate symptoms, clinicians can offer patients a range of individual or group therapy options, including cognitive-behavioral therapy (CBT), behavioral activation, mindfulness-based stress reduction, or structured physical activity and exercise. For patients with severe symptoms of depression, clinicians should offer individual therapy with one of these four treatment options: CBT, behavioral activation, mindfulness-based stress reduction, or interpersonal therapy.

The panelists offered almost identical recommendations for patients with anxiety, except mindfulness-based stress reduction was an option for patients with severe symptoms.

Clinicians can also provide pharmacologic options to treat depression or anxiety in certain patients, though the panelists provided the caveat that evidence for pharmacologic management is weak.

“These guidelines make no recommendations about any specific pharmacologic regimen being better than another,” the experts wrote. And “patients should be warned of potential harm or adverse effects.”

Overall, the panelists noted that, as highlighted in the 2014 ASCO guideline, the updated version continues to stress the importance of providing education on coping with stress, anxiety, and depression.

And “for individuals with elevated symptoms, validation and normalizing patients’ experiences is crucial,” the panelists write.

Although the timing of screening is not the focus of this updated review, the experts recognized that “how and when patients with cancer and survivors are screened are important determinants of timely management of anxiety and depression.”

And unlike the prior guideline, “pharmacotherapy is not recommended as a first-line treatment, neither alone nor in combination,” the authors say.

Overall, the panelists emphasize how widespread the mental health care crisis is and that problems accessing mental health care remain. “The choice of intervention to offer patients facing such obstacles should be based on shared decision-making, taking into account availability, accessibility, patient preference, likelihood of adverse events, adherence, and cost,” the experts conclude.

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

A growing number of women ask about nonpharmacologic approaches for either the treatment of acute perinatal depression or for relapse prevention during pregnancy.

The last several decades have brought an increasing level of comfort with respect to antidepressant use during pregnancy, which derives from several factors.

First, it’s been well described that there’s an increased risk of relapse and morbidity associated with discontinuation of antidepressants proximate to pregnancy, particularly in women with histories of recurrent disease (JAMA Psychiatry. 2023;80[5]:441-50 and JAMA. 2006;295[5]:499-507).

Second, there’s an obvious increased confidence about using antidepressants during pregnancy given the robust reproductive safety data about antidepressants with respect to both teratogenesis and risk for organ malformation. Other studies also fail to demonstrate a relationship between fetal exposure to antidepressants and risk for subsequent development of attention-deficit/hyperactivity disorder (ADHD) and autism. These latter studies have been reviewed extensively in systematic reviews of meta-analyses addressing this question.

However, there are women who, as they approach the question of antidepressant use during pregnancy, would prefer a nonpharmacologic approach to managing depression in the setting of either a planned pregnancy, or sometimes in the setting of acute onset of depressive symptoms during pregnancy. Other women are more comfortable with the data in hand regarding the reproductive safety of antidepressants and continue antidepressants that have afforded emotional well-being, particularly if the road to well-being or euthymia has been a long one.

Still, we at Massachusetts General Hospital (MGH) Center for Women’s Mental Health along with multidisciplinary colleagues with whom we engage during our weekly Virtual Rounds community have observed a growing number of women asking about nonpharmacologic approaches for either the treatment of acute perinatal depression or for relapse prevention during pregnancy. They ask about these options for personal reasons, regardless of what we may know (and what we may not know) about existing pharmacologic interventions. In these scenarios, it is important to keep in mind that it is not about what we as clinicians necessarily know about these medicines per se that drives treatment, but rather about the private calculus that women and their partners apply about risk and benefit of pharmacologic treatment during pregnancy.
 

Nonpharmacologic treatment options

Mindfulness-based cognitive therapy (MBCT), cognitive behavioral therapy (CBT), and behavioral activation are therapies all of which have an evidence base with respect to their effectiveness for either the acute treatment of both depression (and perinatal depression specifically) or for mitigating risk for depressive relapse (MBCT). Several investigations are underway evaluating digital apps that utilize MBCT and CBT in these patient populations as well.

New treatments for which we have none or exceedingly sparse data to support use during pregnancy are neurosteroids. We are asked all the time about the use of neurosteroids such as brexanolone or zuranolone during pregnancy. Given the data on effectiveness of these agents for treatment of postpartum depression, the question about use during pregnancy is intuitive. But at this point in time, absent data, their use during pregnancy cannot be recommended.

With respect to newer nonpharmacologic approaches that have been looked at for treatment of major depressive disorder, the Food and Drug Administration has approved transcranial magnetic stimulation (TMS), a noninvasive form of neuromodulating therapy that use magnetic pulses to stimulate specific regions of the brain that have been implicated in psychiatric illness.

While there are no safety concerns that have been noted about use of TMS, the data regarding its use during pregnancy are still relatively limited, but it has been used to treat certain neurologic conditions during pregnancy. We now have a small randomized controlled study using TMS during pregnancy and multiple small case series suggesting a signal of efficacy in women with perinatal major depressive disorder. Side effects of TMS use during pregnancy have included hypotension, which has sometimes required repositioning of subjects, particularly later in pregnancy. Unlike electroconvulsive therapy, (ECT), often used when clinicians have exhausted other treatment options, TMS has no risk of seizure associated with its use.

TMS is now entering into the clinical arena in a more robust way. In certain settings, insurance companies are reimbursing for TMS treatment more often than was the case previously, making it a more viable option for a larger number of patients. There are also several exciting newer protocols, including theta burst stimulation, a new form of TMS treatment with less of a time commitment, and which may be more cost effective. However, data on this modality of treatment remain limited.
 

Where TMS fits in treating depression during pregnancy

The real question we are getting asked in clinic, both in person and during virtual rounds with multidisciplinary colleagues from across the world, is where TMS might fit into the algorithm for treating of depression during pregnancy. Where is it appropriate to be thinking about TMS in pregnancy, and where should it perhaps be deferred at this moment (and where is it not appropriate)?

It is probably of limited value (and possibly of potential harm) to switch to TMS in patients who have severe recurrent major depression and who are on maintenance antidepressant, and who believe that a switch to TMS will be effective for relapse prevention; there are simply no data currently suggesting that TMS can be used as a relapse prevention tool, unlike certain other nonpharmacologic interventions.

What about managing relapse of major depressive disorder during pregnancy in a patient who had responded to an antidepressant? We have seen patients with histories of severe recurrent disease who are managed well on antidepressants during pregnancy who then have breakthrough symptoms and inquire about using TMS as an augmentation strategy. Although we don’t have clear data supporting the use of TMS as an adjunct in that setting, in those patients, one could argue that a trial of TMS may be appropriate – as opposed to introducing multiple medicines to recapture euthymia during pregnancy where the benefit is unclear and where more exposure is implied by having to do potentially multiple trials.

Other patients with new onset of depression during pregnancy who, for personal reasons, will not take an antidepressant or pursue other nonpharmacologic interventions will frequently ask about TMS. It’s important to at least have a potential referral source in mind given the increased popularity of TMS and the increased availability of TMS in the community in various centers – as opposed to previously where it was more restricted to large academic medical centers.

I think it is a time of excitement in reproductive psychiatry where we have a growing number of tools to treat perinatal depression – from medications to digital tools. These tools – either alone or in combination with medicines that we’ve been using for years – are able to afford women a greater number of choices with respect to the treatment of perinatal depression than was available even 5 years ago. That takes us closer to an ability to use interventions that truly combine patient wishes and “precision perinatal psychiatry,” where we can match effective therapies with the individual clinical presentations and wishes with which patients come to us.

Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. Email Dr. Cohen at [email protected].

A growing number of women ask about nonpharmacologic approaches for either the treatment of acute perinatal depression or for relapse prevention during pregnancy.

The last several decades have brought an increasing level of comfort with respect to antidepressant use during pregnancy, which derives from several factors.

First, it’s been well described that there’s an increased risk of relapse and morbidity associated with discontinuation of antidepressants proximate to pregnancy, particularly in women with histories of recurrent disease (JAMA Psychiatry. 2023;80[5]:441-50 and JAMA. 2006;295[5]:499-507).

Second, there’s an obvious increased confidence about using antidepressants during pregnancy given the robust reproductive safety data about antidepressants with respect to both teratogenesis and risk for organ malformation. Other studies also fail to demonstrate a relationship between fetal exposure to antidepressants and risk for subsequent development of attention-deficit/hyperactivity disorder (ADHD) and autism. These latter studies have been reviewed extensively in systematic reviews of meta-analyses addressing this question.

However, there are women who, as they approach the question of antidepressant use during pregnancy, would prefer a nonpharmacologic approach to managing depression in the setting of either a planned pregnancy, or sometimes in the setting of acute onset of depressive symptoms during pregnancy. Other women are more comfortable with the data in hand regarding the reproductive safety of antidepressants and continue antidepressants that have afforded emotional well-being, particularly if the road to well-being or euthymia has been a long one.

Still, we at Massachusetts General Hospital (MGH) Center for Women’s Mental Health along with multidisciplinary colleagues with whom we engage during our weekly Virtual Rounds community have observed a growing number of women asking about nonpharmacologic approaches for either the treatment of acute perinatal depression or for relapse prevention during pregnancy. They ask about these options for personal reasons, regardless of what we may know (and what we may not know) about existing pharmacologic interventions. In these scenarios, it is important to keep in mind that it is not about what we as clinicians necessarily know about these medicines per se that drives treatment, but rather about the private calculus that women and their partners apply about risk and benefit of pharmacologic treatment during pregnancy.
 

Nonpharmacologic treatment options

Mindfulness-based cognitive therapy (MBCT), cognitive behavioral therapy (CBT), and behavioral activation are therapies all of which have an evidence base with respect to their effectiveness for either the acute treatment of both depression (and perinatal depression specifically) or for mitigating risk for depressive relapse (MBCT). Several investigations are underway evaluating digital apps that utilize MBCT and CBT in these patient populations as well.

New treatments for which we have none or exceedingly sparse data to support use during pregnancy are neurosteroids. We are asked all the time about the use of neurosteroids such as brexanolone or zuranolone during pregnancy. Given the data on effectiveness of these agents for treatment of postpartum depression, the question about use during pregnancy is intuitive. But at this point in time, absent data, their use during pregnancy cannot be recommended.

With respect to newer nonpharmacologic approaches that have been looked at for treatment of major depressive disorder, the Food and Drug Administration has approved transcranial magnetic stimulation (TMS), a noninvasive form of neuromodulating therapy that use magnetic pulses to stimulate specific regions of the brain that have been implicated in psychiatric illness.

While there are no safety concerns that have been noted about use of TMS, the data regarding its use during pregnancy are still relatively limited, but it has been used to treat certain neurologic conditions during pregnancy. We now have a small randomized controlled study using TMS during pregnancy and multiple small case series suggesting a signal of efficacy in women with perinatal major depressive disorder. Side effects of TMS use during pregnancy have included hypotension, which has sometimes required repositioning of subjects, particularly later in pregnancy. Unlike electroconvulsive therapy, (ECT), often used when clinicians have exhausted other treatment options, TMS has no risk of seizure associated with its use.

TMS is now entering into the clinical arena in a more robust way. In certain settings, insurance companies are reimbursing for TMS treatment more often than was the case previously, making it a more viable option for a larger number of patients. There are also several exciting newer protocols, including theta burst stimulation, a new form of TMS treatment with less of a time commitment, and which may be more cost effective. However, data on this modality of treatment remain limited.
 

Where TMS fits in treating depression during pregnancy

The real question we are getting asked in clinic, both in person and during virtual rounds with multidisciplinary colleagues from across the world, is where TMS might fit into the algorithm for treating of depression during pregnancy. Where is it appropriate to be thinking about TMS in pregnancy, and where should it perhaps be deferred at this moment (and where is it not appropriate)?

It is probably of limited value (and possibly of potential harm) to switch to TMS in patients who have severe recurrent major depression and who are on maintenance antidepressant, and who believe that a switch to TMS will be effective for relapse prevention; there are simply no data currently suggesting that TMS can be used as a relapse prevention tool, unlike certain other nonpharmacologic interventions.

What about managing relapse of major depressive disorder during pregnancy in a patient who had responded to an antidepressant? We have seen patients with histories of severe recurrent disease who are managed well on antidepressants during pregnancy who then have breakthrough symptoms and inquire about using TMS as an augmentation strategy. Although we don’t have clear data supporting the use of TMS as an adjunct in that setting, in those patients, one could argue that a trial of TMS may be appropriate – as opposed to introducing multiple medicines to recapture euthymia during pregnancy where the benefit is unclear and where more exposure is implied by having to do potentially multiple trials.

Other patients with new onset of depression during pregnancy who, for personal reasons, will not take an antidepressant or pursue other nonpharmacologic interventions will frequently ask about TMS. It’s important to at least have a potential referral source in mind given the increased popularity of TMS and the increased availability of TMS in the community in various centers – as opposed to previously where it was more restricted to large academic medical centers.

I think it is a time of excitement in reproductive psychiatry where we have a growing number of tools to treat perinatal depression – from medications to digital tools. These tools – either alone or in combination with medicines that we’ve been using for years – are able to afford women a greater number of choices with respect to the treatment of perinatal depression than was available even 5 years ago. That takes us closer to an ability to use interventions that truly combine patient wishes and “precision perinatal psychiatry,” where we can match effective therapies with the individual clinical presentations and wishes with which patients come to us.

Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. Email Dr. Cohen at [email protected].

A growing number of women ask about nonpharmacologic approaches for either the treatment of acute perinatal depression or for relapse prevention during pregnancy.

The last several decades have brought an increasing level of comfort with respect to antidepressant use during pregnancy, which derives from several factors.

First, it’s been well described that there’s an increased risk of relapse and morbidity associated with discontinuation of antidepressants proximate to pregnancy, particularly in women with histories of recurrent disease (JAMA Psychiatry. 2023;80[5]:441-50 and JAMA. 2006;295[5]:499-507).

Second, there’s an obvious increased confidence about using antidepressants during pregnancy given the robust reproductive safety data about antidepressants with respect to both teratogenesis and risk for organ malformation. Other studies also fail to demonstrate a relationship between fetal exposure to antidepressants and risk for subsequent development of attention-deficit/hyperactivity disorder (ADHD) and autism. These latter studies have been reviewed extensively in systematic reviews of meta-analyses addressing this question.

However, there are women who, as they approach the question of antidepressant use during pregnancy, would prefer a nonpharmacologic approach to managing depression in the setting of either a planned pregnancy, or sometimes in the setting of acute onset of depressive symptoms during pregnancy. Other women are more comfortable with the data in hand regarding the reproductive safety of antidepressants and continue antidepressants that have afforded emotional well-being, particularly if the road to well-being or euthymia has been a long one.

Still, we at Massachusetts General Hospital (MGH) Center for Women’s Mental Health along with multidisciplinary colleagues with whom we engage during our weekly Virtual Rounds community have observed a growing number of women asking about nonpharmacologic approaches for either the treatment of acute perinatal depression or for relapse prevention during pregnancy. They ask about these options for personal reasons, regardless of what we may know (and what we may not know) about existing pharmacologic interventions. In these scenarios, it is important to keep in mind that it is not about what we as clinicians necessarily know about these medicines per se that drives treatment, but rather about the private calculus that women and their partners apply about risk and benefit of pharmacologic treatment during pregnancy.
 

Nonpharmacologic treatment options

Mindfulness-based cognitive therapy (MBCT), cognitive behavioral therapy (CBT), and behavioral activation are therapies all of which have an evidence base with respect to their effectiveness for either the acute treatment of both depression (and perinatal depression specifically) or for mitigating risk for depressive relapse (MBCT). Several investigations are underway evaluating digital apps that utilize MBCT and CBT in these patient populations as well.

New treatments for which we have none or exceedingly sparse data to support use during pregnancy are neurosteroids. We are asked all the time about the use of neurosteroids such as brexanolone or zuranolone during pregnancy. Given the data on effectiveness of these agents for treatment of postpartum depression, the question about use during pregnancy is intuitive. But at this point in time, absent data, their use during pregnancy cannot be recommended.

With respect to newer nonpharmacologic approaches that have been looked at for treatment of major depressive disorder, the Food and Drug Administration has approved transcranial magnetic stimulation (TMS), a noninvasive form of neuromodulating therapy that use magnetic pulses to stimulate specific regions of the brain that have been implicated in psychiatric illness.

While there are no safety concerns that have been noted about use of TMS, the data regarding its use during pregnancy are still relatively limited, but it has been used to treat certain neurologic conditions during pregnancy. We now have a small randomized controlled study using TMS during pregnancy and multiple small case series suggesting a signal of efficacy in women with perinatal major depressive disorder. Side effects of TMS use during pregnancy have included hypotension, which has sometimes required repositioning of subjects, particularly later in pregnancy. Unlike electroconvulsive therapy, (ECT), often used when clinicians have exhausted other treatment options, TMS has no risk of seizure associated with its use.

TMS is now entering into the clinical arena in a more robust way. In certain settings, insurance companies are reimbursing for TMS treatment more often than was the case previously, making it a more viable option for a larger number of patients. There are also several exciting newer protocols, including theta burst stimulation, a new form of TMS treatment with less of a time commitment, and which may be more cost effective. However, data on this modality of treatment remain limited.
 

Where TMS fits in treating depression during pregnancy

The real question we are getting asked in clinic, both in person and during virtual rounds with multidisciplinary colleagues from across the world, is where TMS might fit into the algorithm for treating of depression during pregnancy. Where is it appropriate to be thinking about TMS in pregnancy, and where should it perhaps be deferred at this moment (and where is it not appropriate)?

It is probably of limited value (and possibly of potential harm) to switch to TMS in patients who have severe recurrent major depression and who are on maintenance antidepressant, and who believe that a switch to TMS will be effective for relapse prevention; there are simply no data currently suggesting that TMS can be used as a relapse prevention tool, unlike certain other nonpharmacologic interventions.

What about managing relapse of major depressive disorder during pregnancy in a patient who had responded to an antidepressant? We have seen patients with histories of severe recurrent disease who are managed well on antidepressants during pregnancy who then have breakthrough symptoms and inquire about using TMS as an augmentation strategy. Although we don’t have clear data supporting the use of TMS as an adjunct in that setting, in those patients, one could argue that a trial of TMS may be appropriate – as opposed to introducing multiple medicines to recapture euthymia during pregnancy where the benefit is unclear and where more exposure is implied by having to do potentially multiple trials.

Other patients with new onset of depression during pregnancy who, for personal reasons, will not take an antidepressant or pursue other nonpharmacologic interventions will frequently ask about TMS. It’s important to at least have a potential referral source in mind given the increased popularity of TMS and the increased availability of TMS in the community in various centers – as opposed to previously where it was more restricted to large academic medical centers.

I think it is a time of excitement in reproductive psychiatry where we have a growing number of tools to treat perinatal depression – from medications to digital tools. These tools – either alone or in combination with medicines that we’ve been using for years – are able to afford women a greater number of choices with respect to the treatment of perinatal depression than was available even 5 years ago. That takes us closer to an ability to use interventions that truly combine patient wishes and “precision perinatal psychiatry,” where we can match effective therapies with the individual clinical presentations and wishes with which patients come to us.

Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. Email Dr. Cohen at [email protected].

WASHINGTON – Six in 10 primary care pediatricians reported always screening adolescents for substance use, but less than half reported using a standardized instrument, Deepa Camenga, MD, said in a presentation at the 2023 Pediatric Academic Societies annual meeting.

Yale University

The American Academy of Pediatrics recommends universal screening for substance use in adolescents during annual health visits, but current screening rates and practices among primary care pediatricians in the United States are unknown, said Dr. Camenga, an associate professor at Yale University, New Haven, Conn.
 

Uniformity in screening is lacking

Dr. Camenga presented data from the 2021 AAP Periodic Survey, which included 1,683 nonretired AAP members in the United States. Residents were excluded. The current analysis included 471 pediatricians who reported providing health supervision to adolescents. Overall, 284 of the 471 included respondents (60%) reported always screening adolescent patients for substance use during a health supervision visit. Of these, 42% reported using a standardized screening instrument, Dr. Camenga said.

The majority (70%) of pediatricians who used a standardized screening tool opted for the CRAFFT tool (Car, Relax, Alone, Forget, Friends, Trouble) designed for ages 12-21 years. Another 21% reported using an unspecified screening tool, 4% used RAAPS (Rapid Assessment for Adolescent Preventive Services), 3% used S2BI (Screening to Brief Intervention), and 1% used BSTAD (Brief Screener for Tobacco, Alcohol, and other Drugs).

A total of 77% of respondents reported screening their adolescent patients for substance use without a parent or guardian present. Approximately half (52%) used paper-based screening, 22% used electronic screening, 21% used verbal screening, and 6% reported other methods.

A total of 68% and 70% of respondents, respectively, agreed or strongly agreed that top barriers to screening were the lack of an onsite provider for counseling and the lack of readily available treatment options. Other reported barriers included lack of knowledge or information, patient reluctance to discuss substance use, too many other priorities during the visit, and inadequate payment. Only 6% of respondents strongly agreed that lack of time was a barrier, said Dr. Camenga.

Screening frequency and screening practices varied by geographic region, Dr. Camenga said. Pediatricians in the South and Midwest were only half as likely as those in the Northeast to report always screening adolescents for substance use (adjusted odds ratio, 0.43 and 0.53, respectively; P < .05). Similarly, compared with pediatricians in the Northeast, those in the South, Midwest, and West were significantly less likely to report using a standardized instrument for substance use screening (aOR, 0.53, 0.24, and 0.52, respectively; P < 0.001 for all).

The disparities in screening by geographic region show that there is room for improvement in this area, said Dr. Camenga. Systems-level interventions such as treatment financing and access to telehealth services could improve primary care access to substance use treatment professionals, she said.

At the practice level, embedding screening and referral tools into electronic health records could potentially improve screening rates. Many primary care pediatricians do not receive training in identifying and assessing substance use in their patients, or in first-line treatment, Dr. Camenga said.

“We have to invest in a ‘train the trainer’ type of model,” she emphasized.
 

Data highlight regional resource gaps

The current study is important because it highlights potential missed opportunities to screen adolescents for substance use, said Sarah Yale, MD, assistant professor of pediatrics at the Medical College of Wisconsin, Milwaukee, in an interview. Dr. Yale said that the disparities in screening by region are interesting and should serve as a focus for resource investment because the lack of specialists for referral and treatment options in these areas is likely a contributing factor.

However, lack of training also plays a role, said Dr. Yale, who was not involved in the study but served as a moderator of the presentation session at the meeting. Many pediatricians in practice have not been trained in substance use screening, and the fact that many of those who did try to screen were not using a standardized screening tool indicates a need for provider education, she said. The take-home message for clinicians is to find ways to include substance use screening in the care of their adolescent patients. Additionally, more research is needed to assess how best to integrate screening tools into visits, whether on paper, electronically, or verbally, and to include training on substance use screening during pediatric medical training.

The survey was conducted by the American Academy of Pediatrics Research Division. This year’s survey was supported by the Conrad N. Hilton Foundation. Dr. Camenga had no financial conflicts to disclose. Dr. Yale had no financial conflicts to disclose.
 

WASHINGTON – Six in 10 primary care pediatricians reported always screening adolescents for substance use, but less than half reported using a standardized instrument, Deepa Camenga, MD, said in a presentation at the 2023 Pediatric Academic Societies annual meeting.

Yale University

The American Academy of Pediatrics recommends universal screening for substance use in adolescents during annual health visits, but current screening rates and practices among primary care pediatricians in the United States are unknown, said Dr. Camenga, an associate professor at Yale University, New Haven, Conn.
 

Uniformity in screening is lacking

Dr. Camenga presented data from the 2021 AAP Periodic Survey, which included 1,683 nonretired AAP members in the United States. Residents were excluded. The current analysis included 471 pediatricians who reported providing health supervision to adolescents. Overall, 284 of the 471 included respondents (60%) reported always screening adolescent patients for substance use during a health supervision visit. Of these, 42% reported using a standardized screening instrument, Dr. Camenga said.

The majority (70%) of pediatricians who used a standardized screening tool opted for the CRAFFT tool (Car, Relax, Alone, Forget, Friends, Trouble) designed for ages 12-21 years. Another 21% reported using an unspecified screening tool, 4% used RAAPS (Rapid Assessment for Adolescent Preventive Services), 3% used S2BI (Screening to Brief Intervention), and 1% used BSTAD (Brief Screener for Tobacco, Alcohol, and other Drugs).

A total of 77% of respondents reported screening their adolescent patients for substance use without a parent or guardian present. Approximately half (52%) used paper-based screening, 22% used electronic screening, 21% used verbal screening, and 6% reported other methods.

A total of 68% and 70% of respondents, respectively, agreed or strongly agreed that top barriers to screening were the lack of an onsite provider for counseling and the lack of readily available treatment options. Other reported barriers included lack of knowledge or information, patient reluctance to discuss substance use, too many other priorities during the visit, and inadequate payment. Only 6% of respondents strongly agreed that lack of time was a barrier, said Dr. Camenga.

Screening frequency and screening practices varied by geographic region, Dr. Camenga said. Pediatricians in the South and Midwest were only half as likely as those in the Northeast to report always screening adolescents for substance use (adjusted odds ratio, 0.43 and 0.53, respectively; P < .05). Similarly, compared with pediatricians in the Northeast, those in the South, Midwest, and West were significantly less likely to report using a standardized instrument for substance use screening (aOR, 0.53, 0.24, and 0.52, respectively; P < 0.001 for all).

The disparities in screening by geographic region show that there is room for improvement in this area, said Dr. Camenga. Systems-level interventions such as treatment financing and access to telehealth services could improve primary care access to substance use treatment professionals, she said.

At the practice level, embedding screening and referral tools into electronic health records could potentially improve screening rates. Many primary care pediatricians do not receive training in identifying and assessing substance use in their patients, or in first-line treatment, Dr. Camenga said.

“We have to invest in a ‘train the trainer’ type of model,” she emphasized.
 

Data highlight regional resource gaps

The current study is important because it highlights potential missed opportunities to screen adolescents for substance use, said Sarah Yale, MD, assistant professor of pediatrics at the Medical College of Wisconsin, Milwaukee, in an interview. Dr. Yale said that the disparities in screening by region are interesting and should serve as a focus for resource investment because the lack of specialists for referral and treatment options in these areas is likely a contributing factor.

However, lack of training also plays a role, said Dr. Yale, who was not involved in the study but served as a moderator of the presentation session at the meeting. Many pediatricians in practice have not been trained in substance use screening, and the fact that many of those who did try to screen were not using a standardized screening tool indicates a need for provider education, she said. The take-home message for clinicians is to find ways to include substance use screening in the care of their adolescent patients. Additionally, more research is needed to assess how best to integrate screening tools into visits, whether on paper, electronically, or verbally, and to include training on substance use screening during pediatric medical training.

The survey was conducted by the American Academy of Pediatrics Research Division. This year’s survey was supported by the Conrad N. Hilton Foundation. Dr. Camenga had no financial conflicts to disclose. Dr. Yale had no financial conflicts to disclose.
 

WASHINGTON – Six in 10 primary care pediatricians reported always screening adolescents for substance use, but less than half reported using a standardized instrument, Deepa Camenga, MD, said in a presentation at the 2023 Pediatric Academic Societies annual meeting.

Yale University

The American Academy of Pediatrics recommends universal screening for substance use in adolescents during annual health visits, but current screening rates and practices among primary care pediatricians in the United States are unknown, said Dr. Camenga, an associate professor at Yale University, New Haven, Conn.
 

Uniformity in screening is lacking

Dr. Camenga presented data from the 2021 AAP Periodic Survey, which included 1,683 nonretired AAP members in the United States. Residents were excluded. The current analysis included 471 pediatricians who reported providing health supervision to adolescents. Overall, 284 of the 471 included respondents (60%) reported always screening adolescent patients for substance use during a health supervision visit. Of these, 42% reported using a standardized screening instrument, Dr. Camenga said.

The majority (70%) of pediatricians who used a standardized screening tool opted for the CRAFFT tool (Car, Relax, Alone, Forget, Friends, Trouble) designed for ages 12-21 years. Another 21% reported using an unspecified screening tool, 4% used RAAPS (Rapid Assessment for Adolescent Preventive Services), 3% used S2BI (Screening to Brief Intervention), and 1% used BSTAD (Brief Screener for Tobacco, Alcohol, and other Drugs).

A total of 77% of respondents reported screening their adolescent patients for substance use without a parent or guardian present. Approximately half (52%) used paper-based screening, 22% used electronic screening, 21% used verbal screening, and 6% reported other methods.

A total of 68% and 70% of respondents, respectively, agreed or strongly agreed that top barriers to screening were the lack of an onsite provider for counseling and the lack of readily available treatment options. Other reported barriers included lack of knowledge or information, patient reluctance to discuss substance use, too many other priorities during the visit, and inadequate payment. Only 6% of respondents strongly agreed that lack of time was a barrier, said Dr. Camenga.

Screening frequency and screening practices varied by geographic region, Dr. Camenga said. Pediatricians in the South and Midwest were only half as likely as those in the Northeast to report always screening adolescents for substance use (adjusted odds ratio, 0.43 and 0.53, respectively; P < .05). Similarly, compared with pediatricians in the Northeast, those in the South, Midwest, and West were significantly less likely to report using a standardized instrument for substance use screening (aOR, 0.53, 0.24, and 0.52, respectively; P < 0.001 for all).

The disparities in screening by geographic region show that there is room for improvement in this area, said Dr. Camenga. Systems-level interventions such as treatment financing and access to telehealth services could improve primary care access to substance use treatment professionals, she said.

At the practice level, embedding screening and referral tools into electronic health records could potentially improve screening rates. Many primary care pediatricians do not receive training in identifying and assessing substance use in their patients, or in first-line treatment, Dr. Camenga said.

“We have to invest in a ‘train the trainer’ type of model,” she emphasized.
 

Data highlight regional resource gaps

The current study is important because it highlights potential missed opportunities to screen adolescents for substance use, said Sarah Yale, MD, assistant professor of pediatrics at the Medical College of Wisconsin, Milwaukee, in an interview. Dr. Yale said that the disparities in screening by region are interesting and should serve as a focus for resource investment because the lack of specialists for referral and treatment options in these areas is likely a contributing factor.

However, lack of training also plays a role, said Dr. Yale, who was not involved in the study but served as a moderator of the presentation session at the meeting. Many pediatricians in practice have not been trained in substance use screening, and the fact that many of those who did try to screen were not using a standardized screening tool indicates a need for provider education, she said. The take-home message for clinicians is to find ways to include substance use screening in the care of their adolescent patients. Additionally, more research is needed to assess how best to integrate screening tools into visits, whether on paper, electronically, or verbally, and to include training on substance use screening during pediatric medical training.

The survey was conducted by the American Academy of Pediatrics Research Division. This year’s survey was supported by the Conrad N. Hilton Foundation. Dr. Camenga had no financial conflicts to disclose. Dr. Yale had no financial conflicts to disclose.