Mental Health

Childhood exposure to leaded gasoline via car exhaust over the past 75 years is linked to 151 million excess cases of psychiatric disorders in the United States, new research suggested.

The data revealed that the group most heavily exposed to lead — individuals born between 1966 and 1986, commonly known as Generation X — experienced the biggest increases in mental health issues.

Within this cohort, those born between 1966 and 1970 were affected the most. This timeline, the investigators noted, aligns with the peak use of leaded gasoline during the mid-1960s and 1970s. Specifically for this group, overall mental health issues increase by 0.35 times the average, anxiety and depression by 1.75 times, and attention-deficit/hyperactivity disorder (ADHD) symptoms by 1.17 times.

“Lead exposure across the country has probably played a significant role in worsening mental health in ways that had previously been unappreciated and invisible,” study investigator Aaron Reuben, PhD, assistant professor of clinical neuropsychology at the University of Virginia, Charlottesville, said in an interview.

However, the investigators emphasized that the study only establishes an association and not a causal relationship between leaded gas exposure and subsequent psychopathology.

The findings were published online on December 4 in The Journal of Child Psychology and Psychiatry.

 

Lead Astray?

Leaded gasoline was first used in the 1920s to stop engine knocking and improve performance. Despite early evidence of neurotoxicity its use continued until 1996 when it was banned.

The investigators noted that over half of the current US population was exposed to adverse lead levels from gasoline in childhood. However, they added the total contribution of childhood lead exposure to the population’s mental health and personality has not previously been evaluated.

For the study, the researchers combined serial, cross-sectional data on blood lead levels (BLLs) from the National Health and Nutrition Examination Survey and integrated it with historical data on gasoline usage, allowing them to estimate childhood BLLs in the United States from 1940 to 2015.

They calculated the impact of lead exposure on mental health using general psychopathology factor points, also referred to as mental illness points, which function similarly to IQ points.

These measures used were based on a prior study led by Reuben in 2019 from a New Zealand cohort and a study by a different group that followed a longitudinal birth cohort in Chicago .

Using these data, the researchers calculated population-level elevations in mental health symptoms on the basis of lead exposure and five key psychiatric outcomes in the US population.

These included general psychopathology, which reflects an individual’s overall liability to mental disorders and was scaled to match IQ scores with a mean of 100 and an SD of 15.

They also evaluated symptoms of internalizing disorders including anxiety and depression and ADHD and standardized them to a mean of 0 and an SD of 1.

The researchers also looked at differences in the personality traits of neuroticism, which relate to emotional instability and conscientiousness and reflect organization and responsibility. Both of these were assessed using similar standardized scales.

 

151 Million Excess Cases of Mental Illness

Using this approach, the researchers were able to assess the historical and long-term implications of lead exposure on mental health and personality traits in the US population over time.

Results showed that during the peak era of leaded gasoline in the United States, children were routinely exposed to lead levels three to six times higher than the current reference point for clinical concern (3.5 μg/dL of blood), the authors noted.

While the United States banned leaded gasoline in 1996, lead can still be present in water pipes, old paint, and soil. The Centers for Disease Control and Prevention cautions that no BLLs are safe.

The investigators found that between 1940 and 2015, the US population gained 602 million general psychopathology points, which the investigators said equates to 151 million excess instances of mental disorders that are primarily, but not completely, attributable to early life exposure to leaded gasoline.

“Assuming that published lead-psychopathology associations are causal and not purely correlational, we estimate that by 2015, the US population had gained 602 million General Psychopathology factor points because of exposure arising from leaded gasoline, reflecting a 0.13 standard deviation increase in overall liability to mental illness in the population and an estimated 151 million excess mental disorders attributable to lead exposure,” the researchers wrote.

Specific effects included a 0.64 SD increase in anxiety and depression symptoms, a 0.42 SD increase in ADHD symptoms, a 0.14 SD increase in ADHD symptoms, a 0.14 SD increase in emotional instability (neuroticism), and a 0.20 SD decrease in traits like organization and responsibility (conscientiousness).

These mental health and personality changes were not distributed evenly among the generations, most significant in those born between 1966 and 1986, the investigators reported.

For example, children between 1966 and 1970, the period when leaded gasoline use was at its peak, had BLLs > 5 μg/dL and experienced a 1.75 SD increase in internalizing symptoms and a 1.17 SD increase in ADHD symptoms.

 

Assess Lead Risk

The study had several limitations. Causality could not be established, and the accuracy of the estimates relied on findings from the researchers’ two previous key studies.

However, the investigators noted that these findings have been replicated across multiple cohorts and settings. Additionally, the results may not be fully generalizable to the entire US population, as one study was based in New Zealand and the other in urban Chicago.

Reuben cautioned that even though gasoline and new paint no longer contain lead, exposure is still possible.

“We saw this most acutely in Flint, Michigan,” when aging water pipes exposed more than 100,000 residents to high lead levels in 2014. “This situation made us aware that thousands of communities are exposed to lead service lines.”

He recommended that physicians consider screening patients for lead exposure — both new and old. Experts estimate that 90% of lead in the body is stored in the skeleton and can be released back into the bloodstream over time, particularly in cases of calcium deficiency, pregnancy, or osteoporosis.

While reversing childhood lead exposure is not possible, Reuben noted that healthy lifestyle choices and multimodal interventions such as medication and therapy can effectively address and alleviate mental illness.

 

‘Legacy of Lead’

In a comment, Terrie Moffitt, PhD, who was not involved in the research, said the study “is important because it gives us a crystal ball to see into the future of children living with lead today.”

“It’s called the ‘legacy of lead,’ and what a legacy,” said Moffitt, professor in the Department of Psychology and Neuroscience, Nannerl O. Keohane University at Duke University in Durham, North Carolina.

Moffitt emphasized that children exposed to lead today often live in areas of poverty and disadvantage, making it difficult to disentangle the potential effects of lead exposure from those of childhood adversity that predispose individuals to mental illness.

“This study tells us about lead’s damage in an era when it was everywhere, not just in poor communities,” she said.

The study was funded by a fellowship from the National Institute of Environmental Health Sciences. Reuben and Moffitt reported no relevant financial relationships.

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

Childhood exposure to leaded gasoline via car exhaust over the past 75 years is linked to 151 million excess cases of psychiatric disorders in the United States, new research suggested.

The data revealed that the group most heavily exposed to lead — individuals born between 1966 and 1986, commonly known as Generation X — experienced the biggest increases in mental health issues.

Within this cohort, those born between 1966 and 1970 were affected the most. This timeline, the investigators noted, aligns with the peak use of leaded gasoline during the mid-1960s and 1970s. Specifically for this group, overall mental health issues increase by 0.35 times the average, anxiety and depression by 1.75 times, and attention-deficit/hyperactivity disorder (ADHD) symptoms by 1.17 times.

“Lead exposure across the country has probably played a significant role in worsening mental health in ways that had previously been unappreciated and invisible,” study investigator Aaron Reuben, PhD, assistant professor of clinical neuropsychology at the University of Virginia, Charlottesville, said in an interview.

However, the investigators emphasized that the study only establishes an association and not a causal relationship between leaded gas exposure and subsequent psychopathology.

The findings were published online on December 4 in The Journal of Child Psychology and Psychiatry.

 

Lead Astray?

Leaded gasoline was first used in the 1920s to stop engine knocking and improve performance. Despite early evidence of neurotoxicity its use continued until 1996 when it was banned.

The investigators noted that over half of the current US population was exposed to adverse lead levels from gasoline in childhood. However, they added the total contribution of childhood lead exposure to the population’s mental health and personality has not previously been evaluated.

For the study, the researchers combined serial, cross-sectional data on blood lead levels (BLLs) from the National Health and Nutrition Examination Survey and integrated it with historical data on gasoline usage, allowing them to estimate childhood BLLs in the United States from 1940 to 2015.

They calculated the impact of lead exposure on mental health using general psychopathology factor points, also referred to as mental illness points, which function similarly to IQ points.

These measures used were based on a prior study led by Reuben in 2019 from a New Zealand cohort and a study by a different group that followed a longitudinal birth cohort in Chicago .

Using these data, the researchers calculated population-level elevations in mental health symptoms on the basis of lead exposure and five key psychiatric outcomes in the US population.

These included general psychopathology, which reflects an individual’s overall liability to mental disorders and was scaled to match IQ scores with a mean of 100 and an SD of 15.

They also evaluated symptoms of internalizing disorders including anxiety and depression and ADHD and standardized them to a mean of 0 and an SD of 1.

The researchers also looked at differences in the personality traits of neuroticism, which relate to emotional instability and conscientiousness and reflect organization and responsibility. Both of these were assessed using similar standardized scales.

 

151 Million Excess Cases of Mental Illness

Using this approach, the researchers were able to assess the historical and long-term implications of lead exposure on mental health and personality traits in the US population over time.

Results showed that during the peak era of leaded gasoline in the United States, children were routinely exposed to lead levels three to six times higher than the current reference point for clinical concern (3.5 μg/dL of blood), the authors noted.

While the United States banned leaded gasoline in 1996, lead can still be present in water pipes, old paint, and soil. The Centers for Disease Control and Prevention cautions that no BLLs are safe.

The investigators found that between 1940 and 2015, the US population gained 602 million general psychopathology points, which the investigators said equates to 151 million excess instances of mental disorders that are primarily, but not completely, attributable to early life exposure to leaded gasoline.

“Assuming that published lead-psychopathology associations are causal and not purely correlational, we estimate that by 2015, the US population had gained 602 million General Psychopathology factor points because of exposure arising from leaded gasoline, reflecting a 0.13 standard deviation increase in overall liability to mental illness in the population and an estimated 151 million excess mental disorders attributable to lead exposure,” the researchers wrote.

Specific effects included a 0.64 SD increase in anxiety and depression symptoms, a 0.42 SD increase in ADHD symptoms, a 0.14 SD increase in ADHD symptoms, a 0.14 SD increase in emotional instability (neuroticism), and a 0.20 SD decrease in traits like organization and responsibility (conscientiousness).

These mental health and personality changes were not distributed evenly among the generations, most significant in those born between 1966 and 1986, the investigators reported.

For example, children between 1966 and 1970, the period when leaded gasoline use was at its peak, had BLLs > 5 μg/dL and experienced a 1.75 SD increase in internalizing symptoms and a 1.17 SD increase in ADHD symptoms.

 

Assess Lead Risk

The study had several limitations. Causality could not be established, and the accuracy of the estimates relied on findings from the researchers’ two previous key studies.

However, the investigators noted that these findings have been replicated across multiple cohorts and settings. Additionally, the results may not be fully generalizable to the entire US population, as one study was based in New Zealand and the other in urban Chicago.

Reuben cautioned that even though gasoline and new paint no longer contain lead, exposure is still possible.

“We saw this most acutely in Flint, Michigan,” when aging water pipes exposed more than 100,000 residents to high lead levels in 2014. “This situation made us aware that thousands of communities are exposed to lead service lines.”

He recommended that physicians consider screening patients for lead exposure — both new and old. Experts estimate that 90% of lead in the body is stored in the skeleton and can be released back into the bloodstream over time, particularly in cases of calcium deficiency, pregnancy, or osteoporosis.

While reversing childhood lead exposure is not possible, Reuben noted that healthy lifestyle choices and multimodal interventions such as medication and therapy can effectively address and alleviate mental illness.

 

‘Legacy of Lead’

In a comment, Terrie Moffitt, PhD, who was not involved in the research, said the study “is important because it gives us a crystal ball to see into the future of children living with lead today.”

“It’s called the ‘legacy of lead,’ and what a legacy,” said Moffitt, professor in the Department of Psychology and Neuroscience, Nannerl O. Keohane University at Duke University in Durham, North Carolina.

Moffitt emphasized that children exposed to lead today often live in areas of poverty and disadvantage, making it difficult to disentangle the potential effects of lead exposure from those of childhood adversity that predispose individuals to mental illness.

“This study tells us about lead’s damage in an era when it was everywhere, not just in poor communities,” she said.

The study was funded by a fellowship from the National Institute of Environmental Health Sciences. Reuben and Moffitt reported no relevant financial relationships.

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

Childhood exposure to leaded gasoline via car exhaust over the past 75 years is linked to 151 million excess cases of psychiatric disorders in the United States, new research suggested.

The data revealed that the group most heavily exposed to lead — individuals born between 1966 and 1986, commonly known as Generation X — experienced the biggest increases in mental health issues.

Within this cohort, those born between 1966 and 1970 were affected the most. This timeline, the investigators noted, aligns with the peak use of leaded gasoline during the mid-1960s and 1970s. Specifically for this group, overall mental health issues increase by 0.35 times the average, anxiety and depression by 1.75 times, and attention-deficit/hyperactivity disorder (ADHD) symptoms by 1.17 times.

“Lead exposure across the country has probably played a significant role in worsening mental health in ways that had previously been unappreciated and invisible,” study investigator Aaron Reuben, PhD, assistant professor of clinical neuropsychology at the University of Virginia, Charlottesville, said in an interview.

However, the investigators emphasized that the study only establishes an association and not a causal relationship between leaded gas exposure and subsequent psychopathology.

The findings were published online on December 4 in The Journal of Child Psychology and Psychiatry.

 

Lead Astray?

Leaded gasoline was first used in the 1920s to stop engine knocking and improve performance. Despite early evidence of neurotoxicity its use continued until 1996 when it was banned.

The investigators noted that over half of the current US population was exposed to adverse lead levels from gasoline in childhood. However, they added the total contribution of childhood lead exposure to the population’s mental health and personality has not previously been evaluated.

For the study, the researchers combined serial, cross-sectional data on blood lead levels (BLLs) from the National Health and Nutrition Examination Survey and integrated it with historical data on gasoline usage, allowing them to estimate childhood BLLs in the United States from 1940 to 2015.

They calculated the impact of lead exposure on mental health using general psychopathology factor points, also referred to as mental illness points, which function similarly to IQ points.

These measures used were based on a prior study led by Reuben in 2019 from a New Zealand cohort and a study by a different group that followed a longitudinal birth cohort in Chicago .

Using these data, the researchers calculated population-level elevations in mental health symptoms on the basis of lead exposure and five key psychiatric outcomes in the US population.

These included general psychopathology, which reflects an individual’s overall liability to mental disorders and was scaled to match IQ scores with a mean of 100 and an SD of 15.

They also evaluated symptoms of internalizing disorders including anxiety and depression and ADHD and standardized them to a mean of 0 and an SD of 1.

The researchers also looked at differences in the personality traits of neuroticism, which relate to emotional instability and conscientiousness and reflect organization and responsibility. Both of these were assessed using similar standardized scales.

 

151 Million Excess Cases of Mental Illness

Using this approach, the researchers were able to assess the historical and long-term implications of lead exposure on mental health and personality traits in the US population over time.

Results showed that during the peak era of leaded gasoline in the United States, children were routinely exposed to lead levels three to six times higher than the current reference point for clinical concern (3.5 μg/dL of blood), the authors noted.

While the United States banned leaded gasoline in 1996, lead can still be present in water pipes, old paint, and soil. The Centers for Disease Control and Prevention cautions that no BLLs are safe.

The investigators found that between 1940 and 2015, the US population gained 602 million general psychopathology points, which the investigators said equates to 151 million excess instances of mental disorders that are primarily, but not completely, attributable to early life exposure to leaded gasoline.

“Assuming that published lead-psychopathology associations are causal and not purely correlational, we estimate that by 2015, the US population had gained 602 million General Psychopathology factor points because of exposure arising from leaded gasoline, reflecting a 0.13 standard deviation increase in overall liability to mental illness in the population and an estimated 151 million excess mental disorders attributable to lead exposure,” the researchers wrote.

Specific effects included a 0.64 SD increase in anxiety and depression symptoms, a 0.42 SD increase in ADHD symptoms, a 0.14 SD increase in ADHD symptoms, a 0.14 SD increase in emotional instability (neuroticism), and a 0.20 SD decrease in traits like organization and responsibility (conscientiousness).

These mental health and personality changes were not distributed evenly among the generations, most significant in those born between 1966 and 1986, the investigators reported.

For example, children between 1966 and 1970, the period when leaded gasoline use was at its peak, had BLLs > 5 μg/dL and experienced a 1.75 SD increase in internalizing symptoms and a 1.17 SD increase in ADHD symptoms.

 

Assess Lead Risk

The study had several limitations. Causality could not be established, and the accuracy of the estimates relied on findings from the researchers’ two previous key studies.

However, the investigators noted that these findings have been replicated across multiple cohorts and settings. Additionally, the results may not be fully generalizable to the entire US population, as one study was based in New Zealand and the other in urban Chicago.

Reuben cautioned that even though gasoline and new paint no longer contain lead, exposure is still possible.

“We saw this most acutely in Flint, Michigan,” when aging water pipes exposed more than 100,000 residents to high lead levels in 2014. “This situation made us aware that thousands of communities are exposed to lead service lines.”

He recommended that physicians consider screening patients for lead exposure — both new and old. Experts estimate that 90% of lead in the body is stored in the skeleton and can be released back into the bloodstream over time, particularly in cases of calcium deficiency, pregnancy, or osteoporosis.

While reversing childhood lead exposure is not possible, Reuben noted that healthy lifestyle choices and multimodal interventions such as medication and therapy can effectively address and alleviate mental illness.

 

‘Legacy of Lead’

In a comment, Terrie Moffitt, PhD, who was not involved in the research, said the study “is important because it gives us a crystal ball to see into the future of children living with lead today.”

“It’s called the ‘legacy of lead,’ and what a legacy,” said Moffitt, professor in the Department of Psychology and Neuroscience, Nannerl O. Keohane University at Duke University in Durham, North Carolina.

Moffitt emphasized that children exposed to lead today often live in areas of poverty and disadvantage, making it difficult to disentangle the potential effects of lead exposure from those of childhood adversity that predispose individuals to mental illness.

“This study tells us about lead’s damage in an era when it was everywhere, not just in poor communities,” she said.

The study was funded by a fellowship from the National Institute of Environmental Health Sciences. Reuben and Moffitt reported no relevant financial relationships.

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

There has been a lot of talk about polarization in America in the past year and how hard it can be to talk with someone with a different world view. It also seems that the COVID pandemic and a move to non–face-to-face communication has eroded social skills, increased disinformation, and made people irritable. As pediatric providers dealing with all kinds of people we have to increasingly deal with difficult communications.

We pediatric providers tend to be a friendly bunch with a mission of helping the health and well-being of children whose problems are no fault of their own. What’s not to like about us? Hence, one of the most difficult situations is a parent approaching us in anger. [All that follows also applies generally to adults, teens, and children but I here focus on parents.]

 

Health problems are often very frustrating. Parents mainly want their child’s problem fixed, yet that is not easy. Frustration with the health condition is compounded by having to wait, costs for care, life interruption, and confusing information. Anger and aggression are natural results of frustration (remember the Frustration-Aggression paradigm in animals?). Frustration is cumulative — a health problem may be the last straw, especially when social stressors or past trauma, also out of their control, were already present. Individuals with mental disorders or substance use are especially vulnerable to anger reactions.

 

Allaying Anger

As providers, we don’t know how anger may have been reinforced in the individual’s past. Anger may have scared others into giving in to them and thus became a familiar weapon. Sometimes angry outbursts get people to the front of the line. Expressing anger is also a kind of relief valve for emotions. Acknowledging that their situation is “very upsetting” and “frustrating” and that you will try to get a solution is the first step in effective communication.

Anger also comes from anxiety or fear. Anxiety is often a missed cause of childhood aggressive behavior. Parents are scared about poor short-and long-term outcomes of health problems in their child. Asking “What worries you the most about this illness?” or “What have you heard about this illness?” can elicit reports of fears you may be able to debunk or put in perspective. 

Keeping their child healthy and safe are parents’ top priorities, so feeling helpless and out of control when an illness or injury occurs is very disturbing. Being a good parent is partly driven by guilt, which may be unrealistic, or from omission (eg, did not bring the child in sooner), or commission (eg, shouldn’t have taken her to that birthday party where she caught it). This is where you may normalize their actions such as saying “a child really can’t grow up in a bubble” or “symptoms can mean many things. I usually tell parents they don’t need to call unless the temperature is over 101,” for example. If appropriate, you might clarify what actions they should take in the future and provide a handout or instructions for sources of reliable information (and perhaps what is unreliable, such as TikTok!) to give them more power. 

Feeling helpless may also evoke memories from the past when, as a child themselves, they were not able to help a loved one suffering from an accident or a health or mental health issue. They may have been helpless in the face of bullying, domestic violence, or racism. Even a hint of helplessness now can tap into the previous emotions, accelerating their reactivity. Promising to “work on this together” lends them your agency. 

Of course, the main thing angry parents need is to have their child’s issue resolved. But this may not be a quick fix, especially if they are too incensed to cooperate. But what we can always do is address their need to be heard — both in content and emotion — and to help them regain a sense of control.

 

Pacing Can Help

One strategy that may seem counterintuitive is called “pacing.” Instead of begging the parent to calm down, which denigrates their strong feelings, we can echo their concerns while mirroring their emotions (within limits) to demonstrate that we understand them. Mirroring emotions may include your physical posture, volume and speed of speech, as well as use of similar sensory modalities. As for the modality component, you may notice that people tend to use visual, auditory or kinesthetic (feeling or action) words. So, for example, for an angry parent “screaming that no one has looked at the lab results yet” we might posture as they do, increase our volume, and use visual words such as saying “You are upset because you don’t see anyone looking over the labs in all this time.” As you hear more, you can continue to paraphrase and summarize what they are saying including their examples or wording. You can then change your own tone and posture progressively downshifting, bringing them along, and establishing rapport as they can tell that you are understanding them. Validating their emotions does not mean you have to agree with what they are saying; it demonstrates that you hear them.

Other strategies to demonstrate listening that can be helpful include sitting down side by side, and taking notes they can see, asking if you are getting the details correct. Using open-ended questions to elicit answers other than yes/no conveys openness to hear their story and may also reveal some of the causes for the upset. Sitting side by side conveys collaboration, whereas face to face implies more confrontation. Keep your arms down and arms and legs uncrossed and your head nodding and tilted somewhat down. These positions and verbal techniques demonstrate that you are listening to both their content and feelings. 

 

Next Steps

The other main component to communication with an angry parent is providing action on the issue, especially involving them in a way that gives them some sense of control. Once they can tell that you understand them, it is then key to stay focused on solutions, bringing the discussion back if it veers off. There may be things they can do or you can do together such as log in to their portal, get on the phone with a relevant staff person such as a referral coordinator, or set a time for a follow-up appointment or call. Any action step they can do, even asking that they record a temperature every 6 hours, reduces helplessness.

It is crucial to elicit the parents’ criteria for satisfaction of their complaint. You may try asking: “What would tell you that your child’s problem is being adequately addressed?” Write down these criteria as part of the overall plan, making sure they are detailed, measurable, feasible, time related, and relevant. Include actions for the parent to take, if possible. By setting criteria and times for follow-up you establish accountability that also gives them a sense of control. 

There are certain communications that can make things worse with an angry parent, some of which you may not even know occurred. Their anger may well have sparked a reaction in our staff, who are getting it full force before we even start our visit. Not only you but also your staff need to avoid making excuses for what happened (or didn’t happen) to the patient, blame the family for the child’s issue, imply that the parent’s feelings are invalid, or react as though their anger was a personal affront. 

 

Setting Boundaries

There are certainly times when a parent’s behavior is unacceptable or even dangerous. It is important to have policies about what action to take so that we can verbally refer to these, if needed. We should all avoid threatening expulsion from the practice or calling security. Instead, assertively state the boundaries and rules and tell them what will happen if the behavior continues or exceeds a limit, such as frightening other patients or damaging equipment. It is essential to use respectful language and address them by name and certainly not make comments about them personally or criticize them, as these raise defensiveness. Suggesting they or you “take a break,” give them “some space” for a few minutes in a safe private room, or leave and come back in 15 minutes allows the upset parent to save face and gather themselves. All these things also work with children and teens. 

Health care is stressful, especially with short staffing, and is often intensely personal and emotional. The human struggles we deal with may also be present in our own and our staff’s experiences. Mastering skills for interacting with angry parents can strengthen our relationships with them, our staff, and even our understanding of ourselves.

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at [email protected].

There has been a lot of talk about polarization in America in the past year and how hard it can be to talk with someone with a different world view. It also seems that the COVID pandemic and a move to non–face-to-face communication has eroded social skills, increased disinformation, and made people irritable. As pediatric providers dealing with all kinds of people we have to increasingly deal with difficult communications.

We pediatric providers tend to be a friendly bunch with a mission of helping the health and well-being of children whose problems are no fault of their own. What’s not to like about us? Hence, one of the most difficult situations is a parent approaching us in anger. [All that follows also applies generally to adults, teens, and children but I here focus on parents.]

 

Health problems are often very frustrating. Parents mainly want their child’s problem fixed, yet that is not easy. Frustration with the health condition is compounded by having to wait, costs for care, life interruption, and confusing information. Anger and aggression are natural results of frustration (remember the Frustration-Aggression paradigm in animals?). Frustration is cumulative — a health problem may be the last straw, especially when social stressors or past trauma, also out of their control, were already present. Individuals with mental disorders or substance use are especially vulnerable to anger reactions.

 

Allaying Anger

As providers, we don’t know how anger may have been reinforced in the individual’s past. Anger may have scared others into giving in to them and thus became a familiar weapon. Sometimes angry outbursts get people to the front of the line. Expressing anger is also a kind of relief valve for emotions. Acknowledging that their situation is “very upsetting” and “frustrating” and that you will try to get a solution is the first step in effective communication.

Anger also comes from anxiety or fear. Anxiety is often a missed cause of childhood aggressive behavior. Parents are scared about poor short-and long-term outcomes of health problems in their child. Asking “What worries you the most about this illness?” or “What have you heard about this illness?” can elicit reports of fears you may be able to debunk or put in perspective. 

Keeping their child healthy and safe are parents’ top priorities, so feeling helpless and out of control when an illness or injury occurs is very disturbing. Being a good parent is partly driven by guilt, which may be unrealistic, or from omission (eg, did not bring the child in sooner), or commission (eg, shouldn’t have taken her to that birthday party where she caught it). This is where you may normalize their actions such as saying “a child really can’t grow up in a bubble” or “symptoms can mean many things. I usually tell parents they don’t need to call unless the temperature is over 101,” for example. If appropriate, you might clarify what actions they should take in the future and provide a handout or instructions for sources of reliable information (and perhaps what is unreliable, such as TikTok!) to give them more power. 

Feeling helpless may also evoke memories from the past when, as a child themselves, they were not able to help a loved one suffering from an accident or a health or mental health issue. They may have been helpless in the face of bullying, domestic violence, or racism. Even a hint of helplessness now can tap into the previous emotions, accelerating their reactivity. Promising to “work on this together” lends them your agency. 

Of course, the main thing angry parents need is to have their child’s issue resolved. But this may not be a quick fix, especially if they are too incensed to cooperate. But what we can always do is address their need to be heard — both in content and emotion — and to help them regain a sense of control.

 

Pacing Can Help

One strategy that may seem counterintuitive is called “pacing.” Instead of begging the parent to calm down, which denigrates their strong feelings, we can echo their concerns while mirroring their emotions (within limits) to demonstrate that we understand them. Mirroring emotions may include your physical posture, volume and speed of speech, as well as use of similar sensory modalities. As for the modality component, you may notice that people tend to use visual, auditory or kinesthetic (feeling or action) words. So, for example, for an angry parent “screaming that no one has looked at the lab results yet” we might posture as they do, increase our volume, and use visual words such as saying “You are upset because you don’t see anyone looking over the labs in all this time.” As you hear more, you can continue to paraphrase and summarize what they are saying including their examples or wording. You can then change your own tone and posture progressively downshifting, bringing them along, and establishing rapport as they can tell that you are understanding them. Validating their emotions does not mean you have to agree with what they are saying; it demonstrates that you hear them.

Other strategies to demonstrate listening that can be helpful include sitting down side by side, and taking notes they can see, asking if you are getting the details correct. Using open-ended questions to elicit answers other than yes/no conveys openness to hear their story and may also reveal some of the causes for the upset. Sitting side by side conveys collaboration, whereas face to face implies more confrontation. Keep your arms down and arms and legs uncrossed and your head nodding and tilted somewhat down. These positions and verbal techniques demonstrate that you are listening to both their content and feelings. 

 

Next Steps

The other main component to communication with an angry parent is providing action on the issue, especially involving them in a way that gives them some sense of control. Once they can tell that you understand them, it is then key to stay focused on solutions, bringing the discussion back if it veers off. There may be things they can do or you can do together such as log in to their portal, get on the phone with a relevant staff person such as a referral coordinator, or set a time for a follow-up appointment or call. Any action step they can do, even asking that they record a temperature every 6 hours, reduces helplessness.

It is crucial to elicit the parents’ criteria for satisfaction of their complaint. You may try asking: “What would tell you that your child’s problem is being adequately addressed?” Write down these criteria as part of the overall plan, making sure they are detailed, measurable, feasible, time related, and relevant. Include actions for the parent to take, if possible. By setting criteria and times for follow-up you establish accountability that also gives them a sense of control. 

There are certain communications that can make things worse with an angry parent, some of which you may not even know occurred. Their anger may well have sparked a reaction in our staff, who are getting it full force before we even start our visit. Not only you but also your staff need to avoid making excuses for what happened (or didn’t happen) to the patient, blame the family for the child’s issue, imply that the parent’s feelings are invalid, or react as though their anger was a personal affront. 

 

Setting Boundaries

There are certainly times when a parent’s behavior is unacceptable or even dangerous. It is important to have policies about what action to take so that we can verbally refer to these, if needed. We should all avoid threatening expulsion from the practice or calling security. Instead, assertively state the boundaries and rules and tell them what will happen if the behavior continues or exceeds a limit, such as frightening other patients or damaging equipment. It is essential to use respectful language and address them by name and certainly not make comments about them personally or criticize them, as these raise defensiveness. Suggesting they or you “take a break,” give them “some space” for a few minutes in a safe private room, or leave and come back in 15 minutes allows the upset parent to save face and gather themselves. All these things also work with children and teens. 

Health care is stressful, especially with short staffing, and is often intensely personal and emotional. The human struggles we deal with may also be present in our own and our staff’s experiences. Mastering skills for interacting with angry parents can strengthen our relationships with them, our staff, and even our understanding of ourselves.

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at [email protected].

There has been a lot of talk about polarization in America in the past year and how hard it can be to talk with someone with a different world view. It also seems that the COVID pandemic and a move to non–face-to-face communication has eroded social skills, increased disinformation, and made people irritable. As pediatric providers dealing with all kinds of people we have to increasingly deal with difficult communications.

We pediatric providers tend to be a friendly bunch with a mission of helping the health and well-being of children whose problems are no fault of their own. What’s not to like about us? Hence, one of the most difficult situations is a parent approaching us in anger. [All that follows also applies generally to adults, teens, and children but I here focus on parents.]

 

Health problems are often very frustrating. Parents mainly want their child’s problem fixed, yet that is not easy. Frustration with the health condition is compounded by having to wait, costs for care, life interruption, and confusing information. Anger and aggression are natural results of frustration (remember the Frustration-Aggression paradigm in animals?). Frustration is cumulative — a health problem may be the last straw, especially when social stressors or past trauma, also out of their control, were already present. Individuals with mental disorders or substance use are especially vulnerable to anger reactions.

 

Allaying Anger

As providers, we don’t know how anger may have been reinforced in the individual’s past. Anger may have scared others into giving in to them and thus became a familiar weapon. Sometimes angry outbursts get people to the front of the line. Expressing anger is also a kind of relief valve for emotions. Acknowledging that their situation is “very upsetting” and “frustrating” and that you will try to get a solution is the first step in effective communication.

Anger also comes from anxiety or fear. Anxiety is often a missed cause of childhood aggressive behavior. Parents are scared about poor short-and long-term outcomes of health problems in their child. Asking “What worries you the most about this illness?” or “What have you heard about this illness?” can elicit reports of fears you may be able to debunk or put in perspective. 

Keeping their child healthy and safe are parents’ top priorities, so feeling helpless and out of control when an illness or injury occurs is very disturbing. Being a good parent is partly driven by guilt, which may be unrealistic, or from omission (eg, did not bring the child in sooner), or commission (eg, shouldn’t have taken her to that birthday party where she caught it). This is where you may normalize their actions such as saying “a child really can’t grow up in a bubble” or “symptoms can mean many things. I usually tell parents they don’t need to call unless the temperature is over 101,” for example. If appropriate, you might clarify what actions they should take in the future and provide a handout or instructions for sources of reliable information (and perhaps what is unreliable, such as TikTok!) to give them more power. 

Feeling helpless may also evoke memories from the past when, as a child themselves, they were not able to help a loved one suffering from an accident or a health or mental health issue. They may have been helpless in the face of bullying, domestic violence, or racism. Even a hint of helplessness now can tap into the previous emotions, accelerating their reactivity. Promising to “work on this together” lends them your agency. 

Of course, the main thing angry parents need is to have their child’s issue resolved. But this may not be a quick fix, especially if they are too incensed to cooperate. But what we can always do is address their need to be heard — both in content and emotion — and to help them regain a sense of control.

 

Pacing Can Help

One strategy that may seem counterintuitive is called “pacing.” Instead of begging the parent to calm down, which denigrates their strong feelings, we can echo their concerns while mirroring their emotions (within limits) to demonstrate that we understand them. Mirroring emotions may include your physical posture, volume and speed of speech, as well as use of similar sensory modalities. As for the modality component, you may notice that people tend to use visual, auditory or kinesthetic (feeling or action) words. So, for example, for an angry parent “screaming that no one has looked at the lab results yet” we might posture as they do, increase our volume, and use visual words such as saying “You are upset because you don’t see anyone looking over the labs in all this time.” As you hear more, you can continue to paraphrase and summarize what they are saying including their examples or wording. You can then change your own tone and posture progressively downshifting, bringing them along, and establishing rapport as they can tell that you are understanding them. Validating their emotions does not mean you have to agree with what they are saying; it demonstrates that you hear them.

Other strategies to demonstrate listening that can be helpful include sitting down side by side, and taking notes they can see, asking if you are getting the details correct. Using open-ended questions to elicit answers other than yes/no conveys openness to hear their story and may also reveal some of the causes for the upset. Sitting side by side conveys collaboration, whereas face to face implies more confrontation. Keep your arms down and arms and legs uncrossed and your head nodding and tilted somewhat down. These positions and verbal techniques demonstrate that you are listening to both their content and feelings. 

 

Next Steps

The other main component to communication with an angry parent is providing action on the issue, especially involving them in a way that gives them some sense of control. Once they can tell that you understand them, it is then key to stay focused on solutions, bringing the discussion back if it veers off. There may be things they can do or you can do together such as log in to their portal, get on the phone with a relevant staff person such as a referral coordinator, or set a time for a follow-up appointment or call. Any action step they can do, even asking that they record a temperature every 6 hours, reduces helplessness.

It is crucial to elicit the parents’ criteria for satisfaction of their complaint. You may try asking: “What would tell you that your child’s problem is being adequately addressed?” Write down these criteria as part of the overall plan, making sure they are detailed, measurable, feasible, time related, and relevant. Include actions for the parent to take, if possible. By setting criteria and times for follow-up you establish accountability that also gives them a sense of control. 

There are certain communications that can make things worse with an angry parent, some of which you may not even know occurred. Their anger may well have sparked a reaction in our staff, who are getting it full force before we even start our visit. Not only you but also your staff need to avoid making excuses for what happened (or didn’t happen) to the patient, blame the family for the child’s issue, imply that the parent’s feelings are invalid, or react as though their anger was a personal affront. 

 

Setting Boundaries

There are certainly times when a parent’s behavior is unacceptable or even dangerous. It is important to have policies about what action to take so that we can verbally refer to these, if needed. We should all avoid threatening expulsion from the practice or calling security. Instead, assertively state the boundaries and rules and tell them what will happen if the behavior continues or exceeds a limit, such as frightening other patients or damaging equipment. It is essential to use respectful language and address them by name and certainly not make comments about them personally or criticize them, as these raise defensiveness. Suggesting they or you “take a break,” give them “some space” for a few minutes in a safe private room, or leave and come back in 15 minutes allows the upset parent to save face and gather themselves. All these things also work with children and teens. 

Health care is stressful, especially with short staffing, and is often intensely personal and emotional. The human struggles we deal with may also be present in our own and our staff’s experiences. Mastering skills for interacting with angry parents can strengthen our relationships with them, our staff, and even our understanding of ourselves.

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at [email protected].

A 40-year-old woman presents for a wellness visit. She says that she feels well but admits to high levels of stress and occasional fatigue. She works about 60 hours per week as an executive in a finance company. In addition, she is married and has two children, ages 12 and 10 years. She says that she has no time for herself and has noticed that she gets frustrated faster than she used to, but she does not think she has depression. Her score on a Patient Health Questionnaire 9 (PHQ-9) is 5, indicating a low level of depression symptoms.

Regarding health habits, she has never used nicotine products. She reports having one to two alcoholic drinks per day, either wine or a cocktail, and has four drinks per day on a couple of weekend days per month (such as on “date night” with her spouse). She says she does not use any other drugs, including cannabis, and is not taking any medications.

Her vital signs and physical examination are unremarkable. You note that she had an evaluation with a complete blood count, comprehensive metabolic panel, and thyroid-stimulating hormone level performed 7 months ago, with normal results.

What would be the best next step in caring for this patient?

A. Ask her to consider talk therapy to address her fatigue and stress

B. Have her complete a tool (such as the AUDIT-C) to identify hazardous drinking

C. Consider prescribing a selective serotonin reuptake inhibitor

D. Repeat her previous labs, adding vitamin B12 and vitamin D levels

Dr. Vega’s Take

Although all of the answer choices above could apply to this patient, a more formal screening for problem drinking is the most important intervention to make now.

This patient’s story is not unique, particularly in the wake of the COVID-19 pandemic. According to data from the National Institute on Alcohol Abuse and Alcoholism, 64% and 61% of males and females, respectively, at least 12 years of age, reported consuming alcohol in 2023, and 21.7% of these individuals reported binge drinking. 

Alcohol consumption is taking an increasing toll on public health. Between 2016 and 2021, the number of US deaths caused by excessive alcohol use increased by 29%, to a total of 47.6 cases per 100,000 population. The death rate increased faster among females vs males.

The US Preventive Services Task Force (USPSTF) recommends screening for alcohol misuse among adults at least 18 years of age, with no specific interval for repeat screening. USPSTF does recommend two specific screening instruments because of their ease of use and accuracy: the Alcohol Use Disorders Identification Test–Consumption (AUDIT-C) and Single Alcohol Screening Question (SASQ): How many times in the past year have you had more than four drinks (for women) or five drinks (for men) in a day? 

The AUDIT-C features three questions about alcohol use, the amount of alcohol consumed, and the frequency of heavy alcohol use. The instrument is scored from 0 to 12, with a higher score indicating a high risk for problem drinking. Generally, an AUDIT-C score is considered a positive screen at a score of 4 for men and 3 for women. The SASQ focuses on the number of heavy drinking days in the past year, with a current cutoff of five drinks for men and four drinks for women and anyone age 65 years or older.

Both the AUDIT-C and SASQ should be followed up with a more extensive history to make the diagnosis of alcohol use disorder (AUD). The USPSTF also recommends at least brief follow-up counseling for adults with possible AUD, noting that the most common form of counseling is personalized normative feedback, which compares a patient’s alcohol use pattern with that of others. 

What is your practice in screening for AUD, and what have you found effective in counseling patients? I look forward to hearing your thoughts.

Dr. Vega is Health Sciences Clinical Professor, Family Medicine, University of California, Irvine. He reported a conflict of interest with McNeil Pharmaceuticals.

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

A 40-year-old woman presents for a wellness visit. She says that she feels well but admits to high levels of stress and occasional fatigue. She works about 60 hours per week as an executive in a finance company. In addition, she is married and has two children, ages 12 and 10 years. She says that she has no time for herself and has noticed that she gets frustrated faster than she used to, but she does not think she has depression. Her score on a Patient Health Questionnaire 9 (PHQ-9) is 5, indicating a low level of depression symptoms.

Regarding health habits, she has never used nicotine products. She reports having one to two alcoholic drinks per day, either wine or a cocktail, and has four drinks per day on a couple of weekend days per month (such as on “date night” with her spouse). She says she does not use any other drugs, including cannabis, and is not taking any medications.

Her vital signs and physical examination are unremarkable. You note that she had an evaluation with a complete blood count, comprehensive metabolic panel, and thyroid-stimulating hormone level performed 7 months ago, with normal results.

What would be the best next step in caring for this patient?

A. Ask her to consider talk therapy to address her fatigue and stress

B. Have her complete a tool (such as the AUDIT-C) to identify hazardous drinking

C. Consider prescribing a selective serotonin reuptake inhibitor

D. Repeat her previous labs, adding vitamin B12 and vitamin D levels

Dr. Vega’s Take

Although all of the answer choices above could apply to this patient, a more formal screening for problem drinking is the most important intervention to make now.

This patient’s story is not unique, particularly in the wake of the COVID-19 pandemic. According to data from the National Institute on Alcohol Abuse and Alcoholism, 64% and 61% of males and females, respectively, at least 12 years of age, reported consuming alcohol in 2023, and 21.7% of these individuals reported binge drinking. 

Alcohol consumption is taking an increasing toll on public health. Between 2016 and 2021, the number of US deaths caused by excessive alcohol use increased by 29%, to a total of 47.6 cases per 100,000 population. The death rate increased faster among females vs males.

The US Preventive Services Task Force (USPSTF) recommends screening for alcohol misuse among adults at least 18 years of age, with no specific interval for repeat screening. USPSTF does recommend two specific screening instruments because of their ease of use and accuracy: the Alcohol Use Disorders Identification Test–Consumption (AUDIT-C) and Single Alcohol Screening Question (SASQ): How many times in the past year have you had more than four drinks (for women) or five drinks (for men) in a day? 

The AUDIT-C features three questions about alcohol use, the amount of alcohol consumed, and the frequency of heavy alcohol use. The instrument is scored from 0 to 12, with a higher score indicating a high risk for problem drinking. Generally, an AUDIT-C score is considered a positive screen at a score of 4 for men and 3 for women. The SASQ focuses on the number of heavy drinking days in the past year, with a current cutoff of five drinks for men and four drinks for women and anyone age 65 years or older.

Both the AUDIT-C and SASQ should be followed up with a more extensive history to make the diagnosis of alcohol use disorder (AUD). The USPSTF also recommends at least brief follow-up counseling for adults with possible AUD, noting that the most common form of counseling is personalized normative feedback, which compares a patient’s alcohol use pattern with that of others. 

What is your practice in screening for AUD, and what have you found effective in counseling patients? I look forward to hearing your thoughts.

Dr. Vega is Health Sciences Clinical Professor, Family Medicine, University of California, Irvine. He reported a conflict of interest with McNeil Pharmaceuticals.

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

A 40-year-old woman presents for a wellness visit. She says that she feels well but admits to high levels of stress and occasional fatigue. She works about 60 hours per week as an executive in a finance company. In addition, she is married and has two children, ages 12 and 10 years. She says that she has no time for herself and has noticed that she gets frustrated faster than she used to, but she does not think she has depression. Her score on a Patient Health Questionnaire 9 (PHQ-9) is 5, indicating a low level of depression symptoms.

Regarding health habits, she has never used nicotine products. She reports having one to two alcoholic drinks per day, either wine or a cocktail, and has four drinks per day on a couple of weekend days per month (such as on “date night” with her spouse). She says she does not use any other drugs, including cannabis, and is not taking any medications.

Her vital signs and physical examination are unremarkable. You note that she had an evaluation with a complete blood count, comprehensive metabolic panel, and thyroid-stimulating hormone level performed 7 months ago, with normal results.

What would be the best next step in caring for this patient?

A. Ask her to consider talk therapy to address her fatigue and stress

B. Have her complete a tool (such as the AUDIT-C) to identify hazardous drinking

C. Consider prescribing a selective serotonin reuptake inhibitor

D. Repeat her previous labs, adding vitamin B12 and vitamin D levels

Dr. Vega’s Take

Although all of the answer choices above could apply to this patient, a more formal screening for problem drinking is the most important intervention to make now.

This patient’s story is not unique, particularly in the wake of the COVID-19 pandemic. According to data from the National Institute on Alcohol Abuse and Alcoholism, 64% and 61% of males and females, respectively, at least 12 years of age, reported consuming alcohol in 2023, and 21.7% of these individuals reported binge drinking. 

Alcohol consumption is taking an increasing toll on public health. Between 2016 and 2021, the number of US deaths caused by excessive alcohol use increased by 29%, to a total of 47.6 cases per 100,000 population. The death rate increased faster among females vs males.

The US Preventive Services Task Force (USPSTF) recommends screening for alcohol misuse among adults at least 18 years of age, with no specific interval for repeat screening. USPSTF does recommend two specific screening instruments because of their ease of use and accuracy: the Alcohol Use Disorders Identification Test–Consumption (AUDIT-C) and Single Alcohol Screening Question (SASQ): How many times in the past year have you had more than four drinks (for women) or five drinks (for men) in a day? 

The AUDIT-C features three questions about alcohol use, the amount of alcohol consumed, and the frequency of heavy alcohol use. The instrument is scored from 0 to 12, with a higher score indicating a high risk for problem drinking. Generally, an AUDIT-C score is considered a positive screen at a score of 4 for men and 3 for women. The SASQ focuses on the number of heavy drinking days in the past year, with a current cutoff of five drinks for men and four drinks for women and anyone age 65 years or older.

Both the AUDIT-C and SASQ should be followed up with a more extensive history to make the diagnosis of alcohol use disorder (AUD). The USPSTF also recommends at least brief follow-up counseling for adults with possible AUD, noting that the most common form of counseling is personalized normative feedback, which compares a patient’s alcohol use pattern with that of others. 

What is your practice in screening for AUD, and what have you found effective in counseling patients? I look forward to hearing your thoughts.

Dr. Vega is Health Sciences Clinical Professor, Family Medicine, University of California, Irvine. He reported a conflict of interest with McNeil Pharmaceuticals.

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

Outpatient psychotherapy use in the United States rose sharply between 2018 and 2021, an increase that was driven primarily by young, urban professionals with higher family incomes, new data exposed significant disparities in access to this treatment type.

Results of a large population-based repeated cross-sectional study revealed that psychotherapy use increased significantly faster for women vs men, younger individuals vs their older counterparts, college graduates than those without a high school diploma, and privately insured vs publicly insured individuals.

Overall, psychotherapy use increased significantly faster among several socioeconomically advantaged groups, and inequalities were evident in teletherapy access. These trends and patterns highlight a need for clinical interventions and healthcare policies to broaden access to psychotherapy, including teletherapy, the authors noted.

“While psychotherapy access has expanded in the US, there’s concern that recent gains may not be equally distributed, despite or maybe because of the growth of teletherapy,” study author Mark Olfson, MD, MPH, Department of Psychiatry, Mailman School of Public Health, Columbia University, New York City, said in a press release.

“This increase in psychotherapy use, driven by the rise of teletherapy, has largely benefited socioeconomically advantaged adults with mild to moderate distress,” he added.

The findings were published online in JAMA Psychiatry.

 

Psychotherapy Uptick

Psychotherapy is among the most widely used methods for delivering mental health care in the United States. A recent study conducted by Olfson and colleagues showed that the percentage of US adults receiving psychotherapy increased from 6.5% in 2018 to 8.5% in 2021. However, it was unclear how this overall increase varied across different sociodemographic groups or levels of psychological distress.

Analyzing population-level trends in psychotherapy use can identify sociodemographic groups with declining access to services, providing valuable insights for developing initiatives to improve accessibility, the investigators noted.

To evaluate national trends in psychotherapy use, the researchers analyzed data from the 2018-2021 Medical Expenditure Panel Survey (MEPS). These are yearly surveys representing noninstitutionalized adults across the United States.

The study included 89,619 adults. Of these, 51.5% were women, nearly half were aged 35-64 years, and 62.2% were White individuals. The study used a repeated cross-sectional design with new, nationally representative samples of about 22,000 participants each year.

The investigators tracked the overall increase in psychotherapy use, especially among groups at higher risk for untreated mental health conditions. They also examined how video-based therapy (teletherapy) was being used, paying particular attention to differences in access among various demographic groups and levels of psychological distress, given ongoing concerns about equity in telehealth access.

Psychological distress was measured using the Kessler-6 scale, with scores ≥ 13 defining serious psychological distress, 1-12 defining mild to moderate distress, and 0 defining no distress.

Psychotherapy use increased across all racial and ethnic groups, with rates rising among Black (5.4% to 7.1%), Hispanic (4.1% to 5.8%), White (7.5% to 9.8%), and other, non-Hispanic (4.8% to 6.6%) individuals.

Participants with mild to moderate distress experienced the greatest increases in psychotherapy use (8.6% to 11.2%, respectively).

After adjusting for age, sex, and level of psychological distress, investigators found that psychotherapy use increased to a greater degree among women (7.7% to 10.5%) vs men (5.2% to 6.3%), younger adults aged 18-34 years (8% to 11.9%) vs adults aged 65 years or older (3.6% to 4.6%), and college graduates (7.6% to 11.4%) than those without a high school diploma (5.5% to 7%).

 

A National Priority

Adults with higher incomes — defined as two to four times the federal poverty level — had greater increases in psychotherapy use (5.7% to 8.2%) than those below the poverty level (9.7% to 10%).

Unsurprisingly, privately insured individuals saw more significant increases (6.1% to 8.9%) than publicly insured individuals (8.8% to 8.8%). Also, there was a larger increase in psychotherapy use among employed individuals (5.7% to 8.9%) than among unemployed individuals (10.8% to 10.5%).

In addition, there was a significantly greater increase in psychotherapy use among urban residents (6.5% to 8.7%), whereas it declined among rural residents (6.4% to 5.9%).

Data on teletherapy use from 2021 revealed that 39.9% of adults receiving psychotherapy had one or more teletherapy visits.

Teletherapy use was higher among younger adults, women, college-educated individuals, those with higher incomes, those with private insurance, and those who lived in urban areas.

The authors noted that while teletherapy is intended to remove transportation and time barriers and was widely adopted during the pandemic, the findings show that those who were older, less educated, and with lower incomes were less likely to use it.

Notably, urban residents were more than twice as likely to use teletherapy than rural residents. Prior to the COVID-19 pandemic, teletherapy was viewed as a potential solution for individuals living in rural areas facing a shortage of mental health professionals, but study results showed that “teletherapy does not appear to have addressed this public health challenge,” the investigators wrote.

“The trends we are seeing underscore the need for targeted interventions and health policies that expand psychotherapy access to underserved groups,” said Olfson.

“Ensuring that individuals in psychological distress can access care is a national priority. Addressing technical and financial barriers to teletherapy could help bridge the gap in access and promote equity in mental health care,” he added.

Study limitations included a possible underreporting of psychotherapy use by participants. In addition, MEPS does not include nursing home residents, incarcerated, and unhoused individuals.

Study funding was not disclosed. Olfson reported no relevant disclosures.

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

Outpatient psychotherapy use in the United States rose sharply between 2018 and 2021, an increase that was driven primarily by young, urban professionals with higher family incomes, new data exposed significant disparities in access to this treatment type.

Results of a large population-based repeated cross-sectional study revealed that psychotherapy use increased significantly faster for women vs men, younger individuals vs their older counterparts, college graduates than those without a high school diploma, and privately insured vs publicly insured individuals.

Overall, psychotherapy use increased significantly faster among several socioeconomically advantaged groups, and inequalities were evident in teletherapy access. These trends and patterns highlight a need for clinical interventions and healthcare policies to broaden access to psychotherapy, including teletherapy, the authors noted.

“While psychotherapy access has expanded in the US, there’s concern that recent gains may not be equally distributed, despite or maybe because of the growth of teletherapy,” study author Mark Olfson, MD, MPH, Department of Psychiatry, Mailman School of Public Health, Columbia University, New York City, said in a press release.

“This increase in psychotherapy use, driven by the rise of teletherapy, has largely benefited socioeconomically advantaged adults with mild to moderate distress,” he added.

The findings were published online in JAMA Psychiatry.

 

Psychotherapy Uptick

Psychotherapy is among the most widely used methods for delivering mental health care in the United States. A recent study conducted by Olfson and colleagues showed that the percentage of US adults receiving psychotherapy increased from 6.5% in 2018 to 8.5% in 2021. However, it was unclear how this overall increase varied across different sociodemographic groups or levels of psychological distress.

Analyzing population-level trends in psychotherapy use can identify sociodemographic groups with declining access to services, providing valuable insights for developing initiatives to improve accessibility, the investigators noted.

To evaluate national trends in psychotherapy use, the researchers analyzed data from the 2018-2021 Medical Expenditure Panel Survey (MEPS). These are yearly surveys representing noninstitutionalized adults across the United States.

The study included 89,619 adults. Of these, 51.5% were women, nearly half were aged 35-64 years, and 62.2% were White individuals. The study used a repeated cross-sectional design with new, nationally representative samples of about 22,000 participants each year.

The investigators tracked the overall increase in psychotherapy use, especially among groups at higher risk for untreated mental health conditions. They also examined how video-based therapy (teletherapy) was being used, paying particular attention to differences in access among various demographic groups and levels of psychological distress, given ongoing concerns about equity in telehealth access.

Psychological distress was measured using the Kessler-6 scale, with scores ≥ 13 defining serious psychological distress, 1-12 defining mild to moderate distress, and 0 defining no distress.

Psychotherapy use increased across all racial and ethnic groups, with rates rising among Black (5.4% to 7.1%), Hispanic (4.1% to 5.8%), White (7.5% to 9.8%), and other, non-Hispanic (4.8% to 6.6%) individuals.

Participants with mild to moderate distress experienced the greatest increases in psychotherapy use (8.6% to 11.2%, respectively).

After adjusting for age, sex, and level of psychological distress, investigators found that psychotherapy use increased to a greater degree among women (7.7% to 10.5%) vs men (5.2% to 6.3%), younger adults aged 18-34 years (8% to 11.9%) vs adults aged 65 years or older (3.6% to 4.6%), and college graduates (7.6% to 11.4%) than those without a high school diploma (5.5% to 7%).

 

A National Priority

Adults with higher incomes — defined as two to four times the federal poverty level — had greater increases in psychotherapy use (5.7% to 8.2%) than those below the poverty level (9.7% to 10%).

Unsurprisingly, privately insured individuals saw more significant increases (6.1% to 8.9%) than publicly insured individuals (8.8% to 8.8%). Also, there was a larger increase in psychotherapy use among employed individuals (5.7% to 8.9%) than among unemployed individuals (10.8% to 10.5%).

In addition, there was a significantly greater increase in psychotherapy use among urban residents (6.5% to 8.7%), whereas it declined among rural residents (6.4% to 5.9%).

Data on teletherapy use from 2021 revealed that 39.9% of adults receiving psychotherapy had one or more teletherapy visits.

Teletherapy use was higher among younger adults, women, college-educated individuals, those with higher incomes, those with private insurance, and those who lived in urban areas.

The authors noted that while teletherapy is intended to remove transportation and time barriers and was widely adopted during the pandemic, the findings show that those who were older, less educated, and with lower incomes were less likely to use it.

Notably, urban residents were more than twice as likely to use teletherapy than rural residents. Prior to the COVID-19 pandemic, teletherapy was viewed as a potential solution for individuals living in rural areas facing a shortage of mental health professionals, but study results showed that “teletherapy does not appear to have addressed this public health challenge,” the investigators wrote.

“The trends we are seeing underscore the need for targeted interventions and health policies that expand psychotherapy access to underserved groups,” said Olfson.

“Ensuring that individuals in psychological distress can access care is a national priority. Addressing technical and financial barriers to teletherapy could help bridge the gap in access and promote equity in mental health care,” he added.

Study limitations included a possible underreporting of psychotherapy use by participants. In addition, MEPS does not include nursing home residents, incarcerated, and unhoused individuals.

Study funding was not disclosed. Olfson reported no relevant disclosures.

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

Outpatient psychotherapy use in the United States rose sharply between 2018 and 2021, an increase that was driven primarily by young, urban professionals with higher family incomes, new data exposed significant disparities in access to this treatment type.

Results of a large population-based repeated cross-sectional study revealed that psychotherapy use increased significantly faster for women vs men, younger individuals vs their older counterparts, college graduates than those without a high school diploma, and privately insured vs publicly insured individuals.

Overall, psychotherapy use increased significantly faster among several socioeconomically advantaged groups, and inequalities were evident in teletherapy access. These trends and patterns highlight a need for clinical interventions and healthcare policies to broaden access to psychotherapy, including teletherapy, the authors noted.

“While psychotherapy access has expanded in the US, there’s concern that recent gains may not be equally distributed, despite or maybe because of the growth of teletherapy,” study author Mark Olfson, MD, MPH, Department of Psychiatry, Mailman School of Public Health, Columbia University, New York City, said in a press release.

“This increase in psychotherapy use, driven by the rise of teletherapy, has largely benefited socioeconomically advantaged adults with mild to moderate distress,” he added.

The findings were published online in JAMA Psychiatry.

 

Psychotherapy Uptick

Psychotherapy is among the most widely used methods for delivering mental health care in the United States. A recent study conducted by Olfson and colleagues showed that the percentage of US adults receiving psychotherapy increased from 6.5% in 2018 to 8.5% in 2021. However, it was unclear how this overall increase varied across different sociodemographic groups or levels of psychological distress.

Analyzing population-level trends in psychotherapy use can identify sociodemographic groups with declining access to services, providing valuable insights for developing initiatives to improve accessibility, the investigators noted.

To evaluate national trends in psychotherapy use, the researchers analyzed data from the 2018-2021 Medical Expenditure Panel Survey (MEPS). These are yearly surveys representing noninstitutionalized adults across the United States.

The study included 89,619 adults. Of these, 51.5% were women, nearly half were aged 35-64 years, and 62.2% were White individuals. The study used a repeated cross-sectional design with new, nationally representative samples of about 22,000 participants each year.

The investigators tracked the overall increase in psychotherapy use, especially among groups at higher risk for untreated mental health conditions. They also examined how video-based therapy (teletherapy) was being used, paying particular attention to differences in access among various demographic groups and levels of psychological distress, given ongoing concerns about equity in telehealth access.

Psychological distress was measured using the Kessler-6 scale, with scores ≥ 13 defining serious psychological distress, 1-12 defining mild to moderate distress, and 0 defining no distress.

Psychotherapy use increased across all racial and ethnic groups, with rates rising among Black (5.4% to 7.1%), Hispanic (4.1% to 5.8%), White (7.5% to 9.8%), and other, non-Hispanic (4.8% to 6.6%) individuals.

Participants with mild to moderate distress experienced the greatest increases in psychotherapy use (8.6% to 11.2%, respectively).

After adjusting for age, sex, and level of psychological distress, investigators found that psychotherapy use increased to a greater degree among women (7.7% to 10.5%) vs men (5.2% to 6.3%), younger adults aged 18-34 years (8% to 11.9%) vs adults aged 65 years or older (3.6% to 4.6%), and college graduates (7.6% to 11.4%) than those without a high school diploma (5.5% to 7%).

 

A National Priority

Adults with higher incomes — defined as two to four times the federal poverty level — had greater increases in psychotherapy use (5.7% to 8.2%) than those below the poverty level (9.7% to 10%).

Unsurprisingly, privately insured individuals saw more significant increases (6.1% to 8.9%) than publicly insured individuals (8.8% to 8.8%). Also, there was a larger increase in psychotherapy use among employed individuals (5.7% to 8.9%) than among unemployed individuals (10.8% to 10.5%).

In addition, there was a significantly greater increase in psychotherapy use among urban residents (6.5% to 8.7%), whereas it declined among rural residents (6.4% to 5.9%).

Data on teletherapy use from 2021 revealed that 39.9% of adults receiving psychotherapy had one or more teletherapy visits.

Teletherapy use was higher among younger adults, women, college-educated individuals, those with higher incomes, those with private insurance, and those who lived in urban areas.

The authors noted that while teletherapy is intended to remove transportation and time barriers and was widely adopted during the pandemic, the findings show that those who were older, less educated, and with lower incomes were less likely to use it.

Notably, urban residents were more than twice as likely to use teletherapy than rural residents. Prior to the COVID-19 pandemic, teletherapy was viewed as a potential solution for individuals living in rural areas facing a shortage of mental health professionals, but study results showed that “teletherapy does not appear to have addressed this public health challenge,” the investigators wrote.

“The trends we are seeing underscore the need for targeted interventions and health policies that expand psychotherapy access to underserved groups,” said Olfson.

“Ensuring that individuals in psychological distress can access care is a national priority. Addressing technical and financial barriers to teletherapy could help bridge the gap in access and promote equity in mental health care,” he added.

Study limitations included a possible underreporting of psychotherapy use by participants. In addition, MEPS does not include nursing home residents, incarcerated, and unhoused individuals.

Study funding was not disclosed. Olfson reported no relevant disclosures.

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

If you’ve ever taken a red-eye flight you have probably received a little packet of items the airline hopes will make your night flight more comfortable. If you had shelled out for “extra leg room” or “more comfort” seating, your little kit may have included some one-size-never-fits-all socks, a toothbrush large enough to brush one tooth at a time, and a miniature tube of toothpaste the GEICO gecko would laugh at. I have no personal knowledge what the folks in first class are getting, but I suspect it comes in a calf skin Gucci pouch. But, regardless of where you are sitting, at a minimum your night comfort kit will come with an eye mask and ear plugs. Unfortunately, these freebies are wasted on me because I already use a sleep mask every night and simply turn off my hearing aids to mute the noise. But I appreciate their effort.

Light and sound are well-known sleep disruptors. Temperature gets less attention, but is nonetheless a potent contributor to a poor night’s sleep in my experience. Just by chance while I was recovering from my most recent jet lag, I encountered two papers from investigators who were curious about the association between healthy sleep and ambient light and noise.

 

The first paper looked at the relationship between artificial light at night (ALAN) and the incidence of insomnia. Looking at more than 300 Chinese cities, the investigators measured ALAN using satellite images and correlated the data with insomnia-related posts on social media. The researchers found when ALAN increased insomnia, related posts also increased. Not surprisingly, this relationship was greater in less populated cities during extreme temperatures and when air quality was poor. 

The second paper came from University of Texas at Houston. Using Fitbit data from more than 3000 adolescents, the researchers looked for correlations between blood pressure, sleep health, and “median nighttime anthropogenic noise levels by ZIP code.” Turns out the Federal Highway Administration has a readily available map of these noise levels. 

What the investigators found was that adequate sleep significantly reduces the risk of hypertension in adolescents. Not an unexpected finding to an ex-pediatrician like myself who is obsessed with the importance of sleep deprivation. However, the investigators and I were surprised that they had found no association between neighborhood noise alone or in combination with sleep health. I still suspect there is an association lurking there in the weeds of their data, but obviously it is not robust enough to float to the surface. It may be that in an acute situation noise can contribute to hypertension, but over time individuals adjust to the new sound level and their blood pressure settles down. Sleep is such a critical factor that it is not something our cardiovascular system can adapt to so easily. For various reasons most of us may already be functioning at the margins of sleep deprivation.

How then do we respond to observations by these two research teams? Do we take an approach similar to that the airlines have taken and prescribe, hand out, or sell ear plugs and sleep masks to every patient, or at least those with hypertension? This is what we could call the put-the-onus-on-the-patient approach, which seems to be the default when we lack the political will to take a bolder step.

The other path we could call the socio-environmental approach. The airlines have made a passing attempt at this by turning the cabin lights down on red-eye flights. I recently wrote about the “exposome,” which some investigators define as the total non-genetic exposures an individual endures during a lifetime and which in many situations has a negative effect on the individual’s health. These two papers clearly demonstrate that noise and nighttime artificial light are potent features of an uncountable number of individuals’ exposomes.

Noise and artificial light are both things that as a society we have the power to control if we could only muster up the political will to do so. Unfortunately, it is going to require something far beyond these two relatively obscure studies to move the needle in the direction of a healthier population. It’s is not a stretch to put obesity and the attention deficit phenomenon under this same umbrella where our society needs to look at itself for the answers.

 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected]. 

If you’ve ever taken a red-eye flight you have probably received a little packet of items the airline hopes will make your night flight more comfortable. If you had shelled out for “extra leg room” or “more comfort” seating, your little kit may have included some one-size-never-fits-all socks, a toothbrush large enough to brush one tooth at a time, and a miniature tube of toothpaste the GEICO gecko would laugh at. I have no personal knowledge what the folks in first class are getting, but I suspect it comes in a calf skin Gucci pouch. But, regardless of where you are sitting, at a minimum your night comfort kit will come with an eye mask and ear plugs. Unfortunately, these freebies are wasted on me because I already use a sleep mask every night and simply turn off my hearing aids to mute the noise. But I appreciate their effort.

Light and sound are well-known sleep disruptors. Temperature gets less attention, but is nonetheless a potent contributor to a poor night’s sleep in my experience. Just by chance while I was recovering from my most recent jet lag, I encountered two papers from investigators who were curious about the association between healthy sleep and ambient light and noise.

 

The first paper looked at the relationship between artificial light at night (ALAN) and the incidence of insomnia. Looking at more than 300 Chinese cities, the investigators measured ALAN using satellite images and correlated the data with insomnia-related posts on social media. The researchers found when ALAN increased insomnia, related posts also increased. Not surprisingly, this relationship was greater in less populated cities during extreme temperatures and when air quality was poor. 

The second paper came from University of Texas at Houston. Using Fitbit data from more than 3000 adolescents, the researchers looked for correlations between blood pressure, sleep health, and “median nighttime anthropogenic noise levels by ZIP code.” Turns out the Federal Highway Administration has a readily available map of these noise levels. 

What the investigators found was that adequate sleep significantly reduces the risk of hypertension in adolescents. Not an unexpected finding to an ex-pediatrician like myself who is obsessed with the importance of sleep deprivation. However, the investigators and I were surprised that they had found no association between neighborhood noise alone or in combination with sleep health. I still suspect there is an association lurking there in the weeds of their data, but obviously it is not robust enough to float to the surface. It may be that in an acute situation noise can contribute to hypertension, but over time individuals adjust to the new sound level and their blood pressure settles down. Sleep is such a critical factor that it is not something our cardiovascular system can adapt to so easily. For various reasons most of us may already be functioning at the margins of sleep deprivation.

How then do we respond to observations by these two research teams? Do we take an approach similar to that the airlines have taken and prescribe, hand out, or sell ear plugs and sleep masks to every patient, or at least those with hypertension? This is what we could call the put-the-onus-on-the-patient approach, which seems to be the default when we lack the political will to take a bolder step.

The other path we could call the socio-environmental approach. The airlines have made a passing attempt at this by turning the cabin lights down on red-eye flights. I recently wrote about the “exposome,” which some investigators define as the total non-genetic exposures an individual endures during a lifetime and which in many situations has a negative effect on the individual’s health. These two papers clearly demonstrate that noise and nighttime artificial light are potent features of an uncountable number of individuals’ exposomes.

Noise and artificial light are both things that as a society we have the power to control if we could only muster up the political will to do so. Unfortunately, it is going to require something far beyond these two relatively obscure studies to move the needle in the direction of a healthier population. It’s is not a stretch to put obesity and the attention deficit phenomenon under this same umbrella where our society needs to look at itself for the answers.

 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected]. 

If you’ve ever taken a red-eye flight you have probably received a little packet of items the airline hopes will make your night flight more comfortable. If you had shelled out for “extra leg room” or “more comfort” seating, your little kit may have included some one-size-never-fits-all socks, a toothbrush large enough to brush one tooth at a time, and a miniature tube of toothpaste the GEICO gecko would laugh at. I have no personal knowledge what the folks in first class are getting, but I suspect it comes in a calf skin Gucci pouch. But, regardless of where you are sitting, at a minimum your night comfort kit will come with an eye mask and ear plugs. Unfortunately, these freebies are wasted on me because I already use a sleep mask every night and simply turn off my hearing aids to mute the noise. But I appreciate their effort.

Light and sound are well-known sleep disruptors. Temperature gets less attention, but is nonetheless a potent contributor to a poor night’s sleep in my experience. Just by chance while I was recovering from my most recent jet lag, I encountered two papers from investigators who were curious about the association between healthy sleep and ambient light and noise.

 

The first paper looked at the relationship between artificial light at night (ALAN) and the incidence of insomnia. Looking at more than 300 Chinese cities, the investigators measured ALAN using satellite images and correlated the data with insomnia-related posts on social media. The researchers found when ALAN increased insomnia, related posts also increased. Not surprisingly, this relationship was greater in less populated cities during extreme temperatures and when air quality was poor. 

The second paper came from University of Texas at Houston. Using Fitbit data from more than 3000 adolescents, the researchers looked for correlations between blood pressure, sleep health, and “median nighttime anthropogenic noise levels by ZIP code.” Turns out the Federal Highway Administration has a readily available map of these noise levels. 

What the investigators found was that adequate sleep significantly reduces the risk of hypertension in adolescents. Not an unexpected finding to an ex-pediatrician like myself who is obsessed with the importance of sleep deprivation. However, the investigators and I were surprised that they had found no association between neighborhood noise alone or in combination with sleep health. I still suspect there is an association lurking there in the weeds of their data, but obviously it is not robust enough to float to the surface. It may be that in an acute situation noise can contribute to hypertension, but over time individuals adjust to the new sound level and their blood pressure settles down. Sleep is such a critical factor that it is not something our cardiovascular system can adapt to so easily. For various reasons most of us may already be functioning at the margins of sleep deprivation.

How then do we respond to observations by these two research teams? Do we take an approach similar to that the airlines have taken and prescribe, hand out, or sell ear plugs and sleep masks to every patient, or at least those with hypertension? This is what we could call the put-the-onus-on-the-patient approach, which seems to be the default when we lack the political will to take a bolder step.

The other path we could call the socio-environmental approach. The airlines have made a passing attempt at this by turning the cabin lights down on red-eye flights. I recently wrote about the “exposome,” which some investigators define as the total non-genetic exposures an individual endures during a lifetime and which in many situations has a negative effect on the individual’s health. These two papers clearly demonstrate that noise and nighttime artificial light are potent features of an uncountable number of individuals’ exposomes.

Noise and artificial light are both things that as a society we have the power to control if we could only muster up the political will to do so. Unfortunately, it is going to require something far beyond these two relatively obscure studies to move the needle in the direction of a healthier population. It’s is not a stretch to put obesity and the attention deficit phenomenon under this same umbrella where our society needs to look at itself for the answers.

 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected]. 

Clinical Scenario

Lilly is a 15-year-old girl in her sophomore year of high school. Over the course of a month after a romantic and then a friend-group breakup, her parents have been concerned about her increasing tearfulness every day and retreat from activities to avoid social interactions with others that she once enjoyed so much. She has been missing more and more school, saying that she can’t bear to go, and staying in bed during the days, even on weekends. You start her on an SSRI and recommend psychotherapy in the form of CBT offered through your office. She returns to the appointment in 2 weeks with you and then again in another 2 weeks. Her parents and she tell you, “I thought she would be better by now.” You feel stuck with how to proceed in the visit. You have correctly identified the problem as depression, started the recommended evidence-based treatments, but the parents and Lilly are looking to you for something more or different. There are not many or other local resources. When and how do you all determine what “better” looks and feels like? Where do you go from here?

Metrics Can Guide Next Steps

This clinical scenario is not uncommon. As a psychiatrist consultant in primary care, I often encounter the following comment and question: “Someone isn’t feeling better. I have them taking an SSRI and doing psychotherapy. What is the next thing to do?” In discussions with supervisees and in training residents, I often say that you will know that your consultations have made a real impact on providers’ practices when these questions shift from “what’s the next medication or treatment” to a more robust baseline and follow-up inventory of symptoms via common and available metrics (PHQ9A, PSC-17 or 30, SCARED) shared with you at the start, the middle, and at other times of treatment. Such metrics can more meaningfully guide your collaborative clinical discussions and decisions.

Tracking baseline metrics and follow-up with treatment interventions is a transformative approach to clinical care. But, in primary care, it’s common that the question around mental health care may not receive the same robust screening and tracking of symptoms which have the power to more thoughtfully guide decision-making, even though this is common in other forms of patient care which have more routine use of more objective data. 

Measurement-based treatment to target approaches are well-studied, but not often or always implemented. They involve providing a baseline metric (PHQ9A, Pediatric Symptom Checklist 17 or 30, GAD7, or SCARED), and tracking that metric for response over time using specific scores for decision points. 

 

An Alternative Clinical Scenario

Consider the following alternative scenario for the above patient using a measurement-based treatment to target approach:

Lilly is a 15-year-old girl in her sophomore year of high school with symptoms concerning for depression. A PHQ9A is administered in your appointment, and she scores 20 out of 30, exceeding the threshold score for 11 for depression. You start her on an SSRI and recommend psychotherapy in the form of CBT offered through your office. She returns to the appointment with you in 2 weeks and then again in another 2 weeks. You obtain a PHQ9A at each appointment, and track the change with her and her parents over time. 

You share with her and the family that it is common that there will be fluctuations in measurements, and you know that a score change on the PHQ9A greater than 7 is considered a clinically significant, reliable change. So, a PHQ9 score reduction from 20 to 13 would be meaningful progress. While seeking a score within the normal and non-clinical range, the progress can be tracked in a way that allows a more robust monitoring of treatment response. If the scores do not improve, you can see that and act accordingly. This way of using metrics shifts the conversation from “how are you feeling now and today” to tracking symptoms more broadly and tracking those individual symptoms over time, some of which may improve and some which may be trickier to target. 

Such a way of tracking common mental health symptoms with a focus on having data at baseline and throughout treatment allows a provider to change or adapt interventions, and to not chase something that can feel ephemeral, such as “feeling happy or looking better.” 

For additional information on the measurement-based treatment to target approach, there are resources that share in more depth the research informing this approach, and other and broader real ways to integrate these practices into your own visits:

• Is Treatment Working? Detecting Real Change in the Treatment of Child and Adolescent Depression
• AACAP Clinical Update: Collaborative Mental Health Care for Children and Adolescents in Primary Care 

Pawlowski is a child and adolescent consulting psychiatrist. She is a division chief at the University of Vermont Medical Center where she focuses on primary care mental health integration within primary care pediatrics, internal medicine, and family medicine. 

Clinical Scenario

Lilly is a 15-year-old girl in her sophomore year of high school. Over the course of a month after a romantic and then a friend-group breakup, her parents have been concerned about her increasing tearfulness every day and retreat from activities to avoid social interactions with others that she once enjoyed so much. She has been missing more and more school, saying that she can’t bear to go, and staying in bed during the days, even on weekends. You start her on an SSRI and recommend psychotherapy in the form of CBT offered through your office. She returns to the appointment in 2 weeks with you and then again in another 2 weeks. Her parents and she tell you, “I thought she would be better by now.” You feel stuck with how to proceed in the visit. You have correctly identified the problem as depression, started the recommended evidence-based treatments, but the parents and Lilly are looking to you for something more or different. There are not many or other local resources. When and how do you all determine what “better” looks and feels like? Where do you go from here?

Metrics Can Guide Next Steps

This clinical scenario is not uncommon. As a psychiatrist consultant in primary care, I often encounter the following comment and question: “Someone isn’t feeling better. I have them taking an SSRI and doing psychotherapy. What is the next thing to do?” In discussions with supervisees and in training residents, I often say that you will know that your consultations have made a real impact on providers’ practices when these questions shift from “what’s the next medication or treatment” to a more robust baseline and follow-up inventory of symptoms via common and available metrics (PHQ9A, PSC-17 or 30, SCARED) shared with you at the start, the middle, and at other times of treatment. Such metrics can more meaningfully guide your collaborative clinical discussions and decisions.

Tracking baseline metrics and follow-up with treatment interventions is a transformative approach to clinical care. But, in primary care, it’s common that the question around mental health care may not receive the same robust screening and tracking of symptoms which have the power to more thoughtfully guide decision-making, even though this is common in other forms of patient care which have more routine use of more objective data. 

Measurement-based treatment to target approaches are well-studied, but not often or always implemented. They involve providing a baseline metric (PHQ9A, Pediatric Symptom Checklist 17 or 30, GAD7, or SCARED), and tracking that metric for response over time using specific scores for decision points. 

 

An Alternative Clinical Scenario

Consider the following alternative scenario for the above patient using a measurement-based treatment to target approach:

Lilly is a 15-year-old girl in her sophomore year of high school with symptoms concerning for depression. A PHQ9A is administered in your appointment, and she scores 20 out of 30, exceeding the threshold score for 11 for depression. You start her on an SSRI and recommend psychotherapy in the form of CBT offered through your office. She returns to the appointment with you in 2 weeks and then again in another 2 weeks. You obtain a PHQ9A at each appointment, and track the change with her and her parents over time. 

You share with her and the family that it is common that there will be fluctuations in measurements, and you know that a score change on the PHQ9A greater than 7 is considered a clinically significant, reliable change. So, a PHQ9 score reduction from 20 to 13 would be meaningful progress. While seeking a score within the normal and non-clinical range, the progress can be tracked in a way that allows a more robust monitoring of treatment response. If the scores do not improve, you can see that and act accordingly. This way of using metrics shifts the conversation from “how are you feeling now and today” to tracking symptoms more broadly and tracking those individual symptoms over time, some of which may improve and some which may be trickier to target. 

Such a way of tracking common mental health symptoms with a focus on having data at baseline and throughout treatment allows a provider to change or adapt interventions, and to not chase something that can feel ephemeral, such as “feeling happy or looking better.” 

For additional information on the measurement-based treatment to target approach, there are resources that share in more depth the research informing this approach, and other and broader real ways to integrate these practices into your own visits:

• Is Treatment Working? Detecting Real Change in the Treatment of Child and Adolescent Depression
• AACAP Clinical Update: Collaborative Mental Health Care for Children and Adolescents in Primary Care 

Pawlowski is a child and adolescent consulting psychiatrist. She is a division chief at the University of Vermont Medical Center where she focuses on primary care mental health integration within primary care pediatrics, internal medicine, and family medicine. 

Clinical Scenario

Lilly is a 15-year-old girl in her sophomore year of high school. Over the course of a month after a romantic and then a friend-group breakup, her parents have been concerned about her increasing tearfulness every day and retreat from activities to avoid social interactions with others that she once enjoyed so much. She has been missing more and more school, saying that she can’t bear to go, and staying in bed during the days, even on weekends. You start her on an SSRI and recommend psychotherapy in the form of CBT offered through your office. She returns to the appointment in 2 weeks with you and then again in another 2 weeks. Her parents and she tell you, “I thought she would be better by now.” You feel stuck with how to proceed in the visit. You have correctly identified the problem as depression, started the recommended evidence-based treatments, but the parents and Lilly are looking to you for something more or different. There are not many or other local resources. When and how do you all determine what “better” looks and feels like? Where do you go from here?

Metrics Can Guide Next Steps

This clinical scenario is not uncommon. As a psychiatrist consultant in primary care, I often encounter the following comment and question: “Someone isn’t feeling better. I have them taking an SSRI and doing psychotherapy. What is the next thing to do?” In discussions with supervisees and in training residents, I often say that you will know that your consultations have made a real impact on providers’ practices when these questions shift from “what’s the next medication or treatment” to a more robust baseline and follow-up inventory of symptoms via common and available metrics (PHQ9A, PSC-17 or 30, SCARED) shared with you at the start, the middle, and at other times of treatment. Such metrics can more meaningfully guide your collaborative clinical discussions and decisions.

Tracking baseline metrics and follow-up with treatment interventions is a transformative approach to clinical care. But, in primary care, it’s common that the question around mental health care may not receive the same robust screening and tracking of symptoms which have the power to more thoughtfully guide decision-making, even though this is common in other forms of patient care which have more routine use of more objective data. 

Measurement-based treatment to target approaches are well-studied, but not often or always implemented. They involve providing a baseline metric (PHQ9A, Pediatric Symptom Checklist 17 or 30, GAD7, or SCARED), and tracking that metric for response over time using specific scores for decision points. 

 

An Alternative Clinical Scenario

Consider the following alternative scenario for the above patient using a measurement-based treatment to target approach:

Lilly is a 15-year-old girl in her sophomore year of high school with symptoms concerning for depression. A PHQ9A is administered in your appointment, and she scores 20 out of 30, exceeding the threshold score for 11 for depression. You start her on an SSRI and recommend psychotherapy in the form of CBT offered through your office. She returns to the appointment with you in 2 weeks and then again in another 2 weeks. You obtain a PHQ9A at each appointment, and track the change with her and her parents over time. 

You share with her and the family that it is common that there will be fluctuations in measurements, and you know that a score change on the PHQ9A greater than 7 is considered a clinically significant, reliable change. So, a PHQ9 score reduction from 20 to 13 would be meaningful progress. While seeking a score within the normal and non-clinical range, the progress can be tracked in a way that allows a more robust monitoring of treatment response. If the scores do not improve, you can see that and act accordingly. This way of using metrics shifts the conversation from “how are you feeling now and today” to tracking symptoms more broadly and tracking those individual symptoms over time, some of which may improve and some which may be trickier to target. 

Such a way of tracking common mental health symptoms with a focus on having data at baseline and throughout treatment allows a provider to change or adapt interventions, and to not chase something that can feel ephemeral, such as “feeling happy or looking better.” 

For additional information on the measurement-based treatment to target approach, there are resources that share in more depth the research informing this approach, and other and broader real ways to integrate these practices into your own visits:

• Is Treatment Working? Detecting Real Change in the Treatment of Child and Adolescent Depression
• AACAP Clinical Update: Collaborative Mental Health Care for Children and Adolescents in Primary Care 

Pawlowski is a child and adolescent consulting psychiatrist. She is a division chief at the University of Vermont Medical Center where she focuses on primary care mental health integration within primary care pediatrics, internal medicine, and family medicine. 

TOPLINE:

Internet use is associated with fewer depressive symptoms, higher life satisfaction, and better self-reported health among adults aged 50 years or older across 23 countries than nonuse, a new cohort study suggests.

METHODOLOGY:

• Data were examined for more than 87,000 adults aged 50 years or older across 23 countries and from six aging cohorts.
• Researchers examined the potential association between internet use and mental health outcomes, including depressive symptoms, life satisfaction, and self-reported health.
• Polygenic scores were used for subset analysis to stratify participants from England and the United States according to their genetic risk for depression.
• Participants were followed up for a median of 6 years.

TAKEAWAY:

• Internet use was linked to consistent benefits across countries, including lower depressive symptoms (pooled average marginal effect [AME], –0.09; 95% CI, –0.12 to –0.07), higher life satisfaction (pooled AME, 0.07; 95% CI, 0.05-0.10), and better self-reported health (pooled AME, 0.15; 95% CI, 0.12-0.17).
• Frequent internet users showed better mental health outcomes than nonusers, and daily internet users showed significant improvements in depressive symptoms and self-reported health in England and the United States.
• Each additional wave of internet use was associated with reduced depressive symptoms (pooled AME, –0.06; 95% CI, –0.09 to –0.04) and improved life satisfaction (pooled AME, 0.05; 95% CI, 0.03-0.07).
• Benefits of internet use were observed across all genetic risk categories for depression in England and the United States, suggesting potential utility regardless of genetic predisposition.

IN PRACTICE:

“Our findings are relevant to public health policies and practices in promoting mental health in later life through the internet, especially in countries with limited internet access and mental health services,” the investigators wrote.

SOURCE:

The study was led by Yan Luo, Department of Data Science, City University of Hong Kong, Hong Kong, China. It was published online November 18 in Nature Human Behaviour.

LIMITATIONS:

The possibility of residual confounding and reverse causation prevented the establishment of direct causality between internet use and mental health. Selection bias may have also existed due to differences in baseline characteristics between the analytic samples and entire populations. Internet use was assessed through self-reported items, which could have led to recall and information bias. Additionally, genetic data were available for participants only from England and the United States.

DISCLOSURES:

The study was funded in part by the National Natural Science Foundation of China. The investigators reported no conflicts of interest.

This article was created using several editorial tools, including artificial intelligence, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE:

Internet use is associated with fewer depressive symptoms, higher life satisfaction, and better self-reported health among adults aged 50 years or older across 23 countries than nonuse, a new cohort study suggests.

METHODOLOGY:

• Data were examined for more than 87,000 adults aged 50 years or older across 23 countries and from six aging cohorts.
• Researchers examined the potential association between internet use and mental health outcomes, including depressive symptoms, life satisfaction, and self-reported health.
• Polygenic scores were used for subset analysis to stratify participants from England and the United States according to their genetic risk for depression.
• Participants were followed up for a median of 6 years.

TAKEAWAY:

• Internet use was linked to consistent benefits across countries, including lower depressive symptoms (pooled average marginal effect [AME], –0.09; 95% CI, –0.12 to –0.07), higher life satisfaction (pooled AME, 0.07; 95% CI, 0.05-0.10), and better self-reported health (pooled AME, 0.15; 95% CI, 0.12-0.17).
• Frequent internet users showed better mental health outcomes than nonusers, and daily internet users showed significant improvements in depressive symptoms and self-reported health in England and the United States.
• Each additional wave of internet use was associated with reduced depressive symptoms (pooled AME, –0.06; 95% CI, –0.09 to –0.04) and improved life satisfaction (pooled AME, 0.05; 95% CI, 0.03-0.07).
• Benefits of internet use were observed across all genetic risk categories for depression in England and the United States, suggesting potential utility regardless of genetic predisposition.

IN PRACTICE:

“Our findings are relevant to public health policies and practices in promoting mental health in later life through the internet, especially in countries with limited internet access and mental health services,” the investigators wrote.

SOURCE:

The study was led by Yan Luo, Department of Data Science, City University of Hong Kong, Hong Kong, China. It was published online November 18 in Nature Human Behaviour.

LIMITATIONS:

The possibility of residual confounding and reverse causation prevented the establishment of direct causality between internet use and mental health. Selection bias may have also existed due to differences in baseline characteristics between the analytic samples and entire populations. Internet use was assessed through self-reported items, which could have led to recall and information bias. Additionally, genetic data were available for participants only from England and the United States.

DISCLOSURES:

The study was funded in part by the National Natural Science Foundation of China. The investigators reported no conflicts of interest.

This article was created using several editorial tools, including artificial intelligence, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE:

Internet use is associated with fewer depressive symptoms, higher life satisfaction, and better self-reported health among adults aged 50 years or older across 23 countries than nonuse, a new cohort study suggests.

METHODOLOGY:

• Data were examined for more than 87,000 adults aged 50 years or older across 23 countries and from six aging cohorts.
• Researchers examined the potential association between internet use and mental health outcomes, including depressive symptoms, life satisfaction, and self-reported health.
• Polygenic scores were used for subset analysis to stratify participants from England and the United States according to their genetic risk for depression.
• Participants were followed up for a median of 6 years.

TAKEAWAY:

• Internet use was linked to consistent benefits across countries, including lower depressive symptoms (pooled average marginal effect [AME], –0.09; 95% CI, –0.12 to –0.07), higher life satisfaction (pooled AME, 0.07; 95% CI, 0.05-0.10), and better self-reported health (pooled AME, 0.15; 95% CI, 0.12-0.17).
• Frequent internet users showed better mental health outcomes than nonusers, and daily internet users showed significant improvements in depressive symptoms and self-reported health in England and the United States.
• Each additional wave of internet use was associated with reduced depressive symptoms (pooled AME, –0.06; 95% CI, –0.09 to –0.04) and improved life satisfaction (pooled AME, 0.05; 95% CI, 0.03-0.07).
• Benefits of internet use were observed across all genetic risk categories for depression in England and the United States, suggesting potential utility regardless of genetic predisposition.

IN PRACTICE:

“Our findings are relevant to public health policies and practices in promoting mental health in later life through the internet, especially in countries with limited internet access and mental health services,” the investigators wrote.

SOURCE:

The study was led by Yan Luo, Department of Data Science, City University of Hong Kong, Hong Kong, China. It was published online November 18 in Nature Human Behaviour.

LIMITATIONS:

The possibility of residual confounding and reverse causation prevented the establishment of direct causality between internet use and mental health. Selection bias may have also existed due to differences in baseline characteristics between the analytic samples and entire populations. Internet use was assessed through self-reported items, which could have led to recall and information bias. Additionally, genetic data were available for participants only from England and the United States.

DISCLOSURES:

The study was funded in part by the National Natural Science Foundation of China. The investigators reported no conflicts of interest.

This article was created using several editorial tools, including artificial intelligence, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

’Tis the season for recognizing seasonal affective disorder (SAD). Just don’t expect to find SAD in diagnostic handbooks.

As a memorable term, SAD “stuck in the general public, and to some extent among health professionals,” said Scott Patten, MD, PhD, professor of psychiatry and epidemiology at the University of Calgary in Alberta, Canada. “But it’s important to emphasize that that’s not an officially recognized diagnosis by the major classifications.”

Researchers coined the term SAD 40 years ago to describe a pattern of depression that sets in during the fall or winter and remits in the spring or summer.

Clinicians are diagnosing the disorder, albeit without that exact moniker.

In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the condition is considered a subtype of major depression.

So, for patients who meet criteria for recurrent major depressive disorder, the specifier “with seasonal pattern” might be applied.

The subtype covers cases where depressive episodes have followed a seasonal pattern for at least 2 years. Typically, onset occurs in the fall or winter followed by remission in the spring or summer. The opposite pattern is possible but less common.

When stressors such as seasonal unemployment better explain the pattern, the seasonal specifier should not be used, according to the manual. Bipolar disorder can follow a seasonal pattern as well.

Researchers estimate SAD affects about 5% of adults in the United States. The diagnosis is more common in women than in men, and more prevalent farther from the equator.

 

One Hallmark Symptom?

DSM-5 highlights characteristic features of winter depression, including:

• Loss of energy
• Hypersomnia
• A craving for carbohydrates
• Overeating
• Weight gain

Kelly Rohan, PhD, a researcher at the University of Vermont, Burlington, who has studied SAD since the 1990s, sees one symptom as a possible hallmark for the disorder: fatigue.

“I’ve personally never met someone who met the full diagnostic criteria for the seasonal pattern that did not have fatigue as one of their symptoms,” Rohan said. “In theory, they could exist, but I have spoken to hundreds of people with seasonal depression, and I have never met them if, in fact, they do exist.”

That differs from nonseasonal depression, for which insomnia is a more common problem with sleep, Patten said.

Clinicians look for at least five symptoms of depression that cause substantial impairment and distress for at least 2 weeks, such as pervasive sadness, difficulty concentrating, low self-esteem, or loss of interest in hobbies.

An average episode of winter depression can last 5 months, however, Rohan said. “That’s a long time to be in a major depressive episode.”

 

Seeing Subsyndromal Cases

In people who do not meet criteria for major depression with a seasonal pattern, the change of seasons still can affect energy levels and mood. Some patients have “subsyndromal SAD” and may benefit from treatments that have been developed for SAD such as bright light therapy, said Paul Desan, MD, PhD, director of the Winter Depression Research Clinic at Yale School of Medicine in New Haven, Connecticut.

“Many people come to our clinic because they have seasonal changes that don’t meet the full criteria for depression, but nevertheless, they want help,” Desan said.

The 1984 paper that introduced the term SAD explored artificial bright light as a promising treatment for the condition. The researchers had heard from dozens of patients with “recurrent depressions that occur annually at the same time each year,” and bright light appeared to help alleviate their symptoms.

Subsequent trials have found the approach effective. Even in nonseasonal depression, bright light therapy may increase the likelihood of remission, a recent meta-analysis found. Light therapy also may bolster the effectiveness of antidepressant medication in nonseasonal major depressive disorder, a randomized trial has shown.

Other treatments for SAD include cognitive behavioral therapy (CBT) and bupropion XL, which is approved as a preventive medication. Other drugs for major depressive disorder may be used.

 

Quest for Biomarkers

To better understand SAD and how available treatments work, Rohan is conducting a study that examines potential biomarkers in patients treated with light therapy or CBT. She and her colleagues are examining circadian phase angle difference (how well internal clocks match daily routines) and post-illumination pupil response (how the pupil constricts after a light turns off). They also are measuring participants’ pupil responses and brain activity upon seeing words that are associated with winter or summer (like “blizzard,” “icy,” “sunshine,” and “picnics.”) 

Studies have shown treating patients to remission with CBT reduces the risk for recurrence in subsequent years, relative to other treatment approaches, Rohan said. That may be because CBT gives people tools to avoid slipping into another depressive episode.

 

Avoid Self-Diagnosis

Rohan cautions patients against self-diagnosis and treatment.

“Having a conversation with your doctor is a good starting point,” she said. “Just because you can walk into Costco and walk out with a light box doesn’t mean that you should.” 

Light therapy can have side effects, including headaches, eye strain, and making patients feel wired, and it can be a challenge to determine the right dose, Rohan said.

Desan’s clinic website provides information about available devices for light therapy for patients who are looking to try this approach, but Desan agrees clinicians — especially primary care clinicians — can play a crucial role in helping patients. In more serious cases, a mental health expert may be necessary.

To start light therapy, Desan’s clinic typically recommends patients try 30 minutes of 10,000 lux bright light — roughly the brightness of being outside on a sunny day — before 8 AM for a 4-week trial.

Still, other specific issues might explain why a patient is struggling during winter months, Patten said. For example, people might experience financial stress around the holidays or consume excessive amounts of alcohol during that time.

“It’s important for clinicians to think broadly about it,” Patten said. “It might not always be light therapy or a medication. It might be focusing on some other aspect of what is going on for them in the winter.” 

Rohan’s research is funded by the National Institute of Mental Health, and she receives royalties for a manual on treating SAD with CBT. Patten and Desan had no relevant financial disclosures.

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

’Tis the season for recognizing seasonal affective disorder (SAD). Just don’t expect to find SAD in diagnostic handbooks.

As a memorable term, SAD “stuck in the general public, and to some extent among health professionals,” said Scott Patten, MD, PhD, professor of psychiatry and epidemiology at the University of Calgary in Alberta, Canada. “But it’s important to emphasize that that’s not an officially recognized diagnosis by the major classifications.”

Researchers coined the term SAD 40 years ago to describe a pattern of depression that sets in during the fall or winter and remits in the spring or summer.

Clinicians are diagnosing the disorder, albeit without that exact moniker.

In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the condition is considered a subtype of major depression.

So, for patients who meet criteria for recurrent major depressive disorder, the specifier “with seasonal pattern” might be applied.

The subtype covers cases where depressive episodes have followed a seasonal pattern for at least 2 years. Typically, onset occurs in the fall or winter followed by remission in the spring or summer. The opposite pattern is possible but less common.

When stressors such as seasonal unemployment better explain the pattern, the seasonal specifier should not be used, according to the manual. Bipolar disorder can follow a seasonal pattern as well.

Researchers estimate SAD affects about 5% of adults in the United States. The diagnosis is more common in women than in men, and more prevalent farther from the equator.

 

One Hallmark Symptom?

DSM-5 highlights characteristic features of winter depression, including:

• Loss of energy
• Hypersomnia
• A craving for carbohydrates
• Overeating
• Weight gain

Kelly Rohan, PhD, a researcher at the University of Vermont, Burlington, who has studied SAD since the 1990s, sees one symptom as a possible hallmark for the disorder: fatigue.

“I’ve personally never met someone who met the full diagnostic criteria for the seasonal pattern that did not have fatigue as one of their symptoms,” Rohan said. “In theory, they could exist, but I have spoken to hundreds of people with seasonal depression, and I have never met them if, in fact, they do exist.”

That differs from nonseasonal depression, for which insomnia is a more common problem with sleep, Patten said.

Clinicians look for at least five symptoms of depression that cause substantial impairment and distress for at least 2 weeks, such as pervasive sadness, difficulty concentrating, low self-esteem, or loss of interest in hobbies.

An average episode of winter depression can last 5 months, however, Rohan said. “That’s a long time to be in a major depressive episode.”

 

Seeing Subsyndromal Cases

In people who do not meet criteria for major depression with a seasonal pattern, the change of seasons still can affect energy levels and mood. Some patients have “subsyndromal SAD” and may benefit from treatments that have been developed for SAD such as bright light therapy, said Paul Desan, MD, PhD, director of the Winter Depression Research Clinic at Yale School of Medicine in New Haven, Connecticut.

“Many people come to our clinic because they have seasonal changes that don’t meet the full criteria for depression, but nevertheless, they want help,” Desan said.

The 1984 paper that introduced the term SAD explored artificial bright light as a promising treatment for the condition. The researchers had heard from dozens of patients with “recurrent depressions that occur annually at the same time each year,” and bright light appeared to help alleviate their symptoms.

Subsequent trials have found the approach effective. Even in nonseasonal depression, bright light therapy may increase the likelihood of remission, a recent meta-analysis found. Light therapy also may bolster the effectiveness of antidepressant medication in nonseasonal major depressive disorder, a randomized trial has shown.

Other treatments for SAD include cognitive behavioral therapy (CBT) and bupropion XL, which is approved as a preventive medication. Other drugs for major depressive disorder may be used.

 

Quest for Biomarkers

To better understand SAD and how available treatments work, Rohan is conducting a study that examines potential biomarkers in patients treated with light therapy or CBT. She and her colleagues are examining circadian phase angle difference (how well internal clocks match daily routines) and post-illumination pupil response (how the pupil constricts after a light turns off). They also are measuring participants’ pupil responses and brain activity upon seeing words that are associated with winter or summer (like “blizzard,” “icy,” “sunshine,” and “picnics.”) 

Studies have shown treating patients to remission with CBT reduces the risk for recurrence in subsequent years, relative to other treatment approaches, Rohan said. That may be because CBT gives people tools to avoid slipping into another depressive episode.

 

Avoid Self-Diagnosis

Rohan cautions patients against self-diagnosis and treatment.

“Having a conversation with your doctor is a good starting point,” she said. “Just because you can walk into Costco and walk out with a light box doesn’t mean that you should.” 

Light therapy can have side effects, including headaches, eye strain, and making patients feel wired, and it can be a challenge to determine the right dose, Rohan said.

Desan’s clinic website provides information about available devices for light therapy for patients who are looking to try this approach, but Desan agrees clinicians — especially primary care clinicians — can play a crucial role in helping patients. In more serious cases, a mental health expert may be necessary.

To start light therapy, Desan’s clinic typically recommends patients try 30 minutes of 10,000 lux bright light — roughly the brightness of being outside on a sunny day — before 8 AM for a 4-week trial.

Still, other specific issues might explain why a patient is struggling during winter months, Patten said. For example, people might experience financial stress around the holidays or consume excessive amounts of alcohol during that time.

“It’s important for clinicians to think broadly about it,” Patten said. “It might not always be light therapy or a medication. It might be focusing on some other aspect of what is going on for them in the winter.” 

Rohan’s research is funded by the National Institute of Mental Health, and she receives royalties for a manual on treating SAD with CBT. Patten and Desan had no relevant financial disclosures.

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

’Tis the season for recognizing seasonal affective disorder (SAD). Just don’t expect to find SAD in diagnostic handbooks.

As a memorable term, SAD “stuck in the general public, and to some extent among health professionals,” said Scott Patten, MD, PhD, professor of psychiatry and epidemiology at the University of Calgary in Alberta, Canada. “But it’s important to emphasize that that’s not an officially recognized diagnosis by the major classifications.”

Researchers coined the term SAD 40 years ago to describe a pattern of depression that sets in during the fall or winter and remits in the spring or summer.

Clinicians are diagnosing the disorder, albeit without that exact moniker.

In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the condition is considered a subtype of major depression.

So, for patients who meet criteria for recurrent major depressive disorder, the specifier “with seasonal pattern” might be applied.

The subtype covers cases where depressive episodes have followed a seasonal pattern for at least 2 years. Typically, onset occurs in the fall or winter followed by remission in the spring or summer. The opposite pattern is possible but less common.

When stressors such as seasonal unemployment better explain the pattern, the seasonal specifier should not be used, according to the manual. Bipolar disorder can follow a seasonal pattern as well.

Researchers estimate SAD affects about 5% of adults in the United States. The diagnosis is more common in women than in men, and more prevalent farther from the equator.

 

One Hallmark Symptom?

DSM-5 highlights characteristic features of winter depression, including:

• Loss of energy
• Hypersomnia
• A craving for carbohydrates
• Overeating
• Weight gain

Kelly Rohan, PhD, a researcher at the University of Vermont, Burlington, who has studied SAD since the 1990s, sees one symptom as a possible hallmark for the disorder: fatigue.

“I’ve personally never met someone who met the full diagnostic criteria for the seasonal pattern that did not have fatigue as one of their symptoms,” Rohan said. “In theory, they could exist, but I have spoken to hundreds of people with seasonal depression, and I have never met them if, in fact, they do exist.”

That differs from nonseasonal depression, for which insomnia is a more common problem with sleep, Patten said.

Clinicians look for at least five symptoms of depression that cause substantial impairment and distress for at least 2 weeks, such as pervasive sadness, difficulty concentrating, low self-esteem, or loss of interest in hobbies.

An average episode of winter depression can last 5 months, however, Rohan said. “That’s a long time to be in a major depressive episode.”

 

Seeing Subsyndromal Cases

In people who do not meet criteria for major depression with a seasonal pattern, the change of seasons still can affect energy levels and mood. Some patients have “subsyndromal SAD” and may benefit from treatments that have been developed for SAD such as bright light therapy, said Paul Desan, MD, PhD, director of the Winter Depression Research Clinic at Yale School of Medicine in New Haven, Connecticut.

“Many people come to our clinic because they have seasonal changes that don’t meet the full criteria for depression, but nevertheless, they want help,” Desan said.

The 1984 paper that introduced the term SAD explored artificial bright light as a promising treatment for the condition. The researchers had heard from dozens of patients with “recurrent depressions that occur annually at the same time each year,” and bright light appeared to help alleviate their symptoms.

Subsequent trials have found the approach effective. Even in nonseasonal depression, bright light therapy may increase the likelihood of remission, a recent meta-analysis found. Light therapy also may bolster the effectiveness of antidepressant medication in nonseasonal major depressive disorder, a randomized trial has shown.

Other treatments for SAD include cognitive behavioral therapy (CBT) and bupropion XL, which is approved as a preventive medication. Other drugs for major depressive disorder may be used.

 

Quest for Biomarkers

To better understand SAD and how available treatments work, Rohan is conducting a study that examines potential biomarkers in patients treated with light therapy or CBT. She and her colleagues are examining circadian phase angle difference (how well internal clocks match daily routines) and post-illumination pupil response (how the pupil constricts after a light turns off). They also are measuring participants’ pupil responses and brain activity upon seeing words that are associated with winter or summer (like “blizzard,” “icy,” “sunshine,” and “picnics.”) 

Studies have shown treating patients to remission with CBT reduces the risk for recurrence in subsequent years, relative to other treatment approaches, Rohan said. That may be because CBT gives people tools to avoid slipping into another depressive episode.

 

Avoid Self-Diagnosis

Rohan cautions patients against self-diagnosis and treatment.

“Having a conversation with your doctor is a good starting point,” she said. “Just because you can walk into Costco and walk out with a light box doesn’t mean that you should.” 

Light therapy can have side effects, including headaches, eye strain, and making patients feel wired, and it can be a challenge to determine the right dose, Rohan said.

Desan’s clinic website provides information about available devices for light therapy for patients who are looking to try this approach, but Desan agrees clinicians — especially primary care clinicians — can play a crucial role in helping patients. In more serious cases, a mental health expert may be necessary.

To start light therapy, Desan’s clinic typically recommends patients try 30 minutes of 10,000 lux bright light — roughly the brightness of being outside on a sunny day — before 8 AM for a 4-week trial.

Still, other specific issues might explain why a patient is struggling during winter months, Patten said. For example, people might experience financial stress around the holidays or consume excessive amounts of alcohol during that time.

“It’s important for clinicians to think broadly about it,” Patten said. “It might not always be light therapy or a medication. It might be focusing on some other aspect of what is going on for them in the winter.” 

Rohan’s research is funded by the National Institute of Mental Health, and she receives royalties for a manual on treating SAD with CBT. Patten and Desan had no relevant financial disclosures.

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

Suicide and self-harm continue to be serious concerns in Europe, despite decreasing rates over the past two decades. In 2021 alone, 47,346 people died by suicide in the European Union, close to 1% of all deaths reported that year. Measures have been taken at population, subpopulation, and individual levels to prevent suicide and suicide attempts. But can more be done? Yes, according to experts.

Researchers are investigating factors that contribute to suicide at the individual level, as well as environmental and societal pressures that may increase risk. New predictive tools show promise in identifying individuals at high risk, and ongoing programs offer hope for early and ongoing interventions. Successful preventive strategies are multimodal, emphasizing the need for trained primary care and mental health professionals to work together to identify and support individuals at risk at every age and in all settings.

 

‘Radical Change’ Needed

The medical community’s approach to suicide prevention is all wrong, according to Igor Galynker, MD, PhD, clinical professor of psychiatry and director of the Mount Sinai Suicide Prevention Research Lab in New York City. 

Galynker is collaborating with colleagues in various parts of the world, including Europe, to validate the use of suicide crisis syndrome (SCS) as a diagnosis to help imminent suicide risk evaluation and treatment.

SCS is a negative cognitive-affective state associated with imminent suicidal behavior in those who are already at high risk for suicide. Galynker and his colleagues want to see SCS recognized and accepted as a suicide-specific diagnosis in the Diagnostic and Statistical Manual of Mental Disorders and the World Health Organization’s International Classification of Diseases. 

Currently, he explained to this news organization, clinicians depend on a person at risk for suicide telling them that this is what they are feeling. This is “absurd,” he said, because people in this situation are in acute pain and distress and cannot answer accurately.

“It is the most lethal psychiatric condition, because people die from it ... yet we rely on people at the worst moment of their lives to tell us accurately when and how they are going to kill themselves. We don’t ask people with serious mental illness to diagnose their own mental illness and rely on that diagnosis.”

Data show that most people who attempt or die by suicide deny suicidal thoughts when assessed by healthcare providers using current questionnaires and scales. Thus, there needs to be “a radical change” in how patients at acute risk are assessed and treated to help “prevent suicides and avoid lost opportunities to intervene,” he said.

Galynker explained that SCS is the final and most acute stage of the “ narrative crisis model” of suicide, which reflects the progression of suicidal risk from chronic risk factors to imminent suicidal risk. “The narrative crisis model has four distinct and successive stages, with specific guidance and applicable interventions that enable patients to receive a stage-specific treatment.”

“Suicide crisis syndrome is a very treatable syndrome that rapidly resolves” with appropriate interventions, he said. “Once it is treated, the patient can engage with psychotherapy and other treatments.”

Galynker said he and his colleagues have had encouraging results with their studies so far on the subjective and objective views of clinicians using the risk assessment tools they are developing to assess suicidal ideation. Further studies are ongoing. 

 

Improving Prediction

There is definitely room for improvement in current approaches to suicide prevention, said Raffaella Calati, PhD, assistant professor of clinical psychology at the University of Milano-Bicocca, Italy, who has had research collaborations with Galynker.

Calati advocates for a more integrated approach across disciplines, institutions, and the community to provide an effective support network for those at risk. 

Accurately predicting suicide risk is challenging, she told this news organization. She and colleagues are working to develop more precise predictive tools for identifying individuals at risk, often by leveraging artificial intelligence and data analytics. They have designed and implemented app-based interventions for psychiatric patients at risk for suicide and university students with psychological distress. The interventions are personalized and based on multiple approaches, such as cognitive-behavioral therapy (CBT) and third-wave CBT. 

The results of current studies are preliminary, she acknowledged, “but even if apps are extremely complex, our projects received high interest from participants and the scientific community,” she said. The aim now is to integrate these tools into healthcare systems so that monitoring high-risk patients becomes part of regular care. 

Another area of focus is the identification of specific subtypes of individuals at risk for suicide, particularly by examining factors such as pain, dissociation, and interoception — the ability to sense and interpret internal signals from the body. 

“By understanding how these experiences intersect and contribute to suicide risk, I aim to identify distinct profiles within at-risk populations, which could ultimately enable more tailored and effective prevention efforts,” she said.

Her work also involves meta-research to build large, comprehensive datasets that increase statistical power for exploring suicide risk factors, such as physical health conditions and symptoms associated with borderline personality disorder. By creating these datasets, she aims to “improve understanding of how various factors contribute to suicide risk, ultimately supporting more effective prevention strategies.”

 

Country-Level Efforts

Preventive work is underway in other countries as well. In Nordic countries such as Denmark, Finland, and Sweden, large-scale national registries that track people’s medical histories, prescriptions, and demographic information are being used to develop predictive algorithms that identify those at high risk for suicide. The predictions are based on known risk factors like previous mental health diagnoses, substance abuse, and social determinants of health.

A recent Norwegian study found that a novel assessment tool used at admission to an acute inpatient unit was a powerful predictor of suicide within 3 years post-discharge.

Researchers in the Netherlands have also recently co-designed a digital integrated suicide prevention program, which has led to a significant reduction in suicide mortality. 

SUPREMOCOL (suicide prevention by monitoring and collaborative care) was implemented in Noord-Brabant, a province in the Netherlands that historically had high suicide rates. It combines technology and personal care, allowing healthcare providers to track a person’s mental health, including by phone calls, text messages, and mobile apps that help people express their feelings and report any changes in their mental state. By staying connected, the program aims to identify warning signs early and provide timely interventions.

The results from the 5-year project showed that rates dropped by 21.5%, from 14.4 per 100,000 to 11.8 per 100,000, and remained low, with a rate of 11.3 per 100,000 by 2021.

Finland used to have one of the highest suicide rates in the world. Now it is implementing its suicide prevention program for 2020-2030, with 36 proposed measures to prevent suicide mortality. 

The program includes measures such as increasing public awareness, early intervention, supporting at-risk groups, developing new treatment options, and enhancing research efforts. Earlier successful interventions included limiting access to firearms and poison, and increasing use of antidepressants and other targeted interventions.

“A key is to ensure that the individuals at risk of suicide have access to adequate, timely, and evidence-based care,” said Timo Partonen, MD, research professor at the Finnish Institute for Health and Welfare and associate professor of psychiatry at the University of Helsinki.

“Emergency and frontline professionals, as well as general practitioners and occupational health physicians, have a key role in identifying people at risk of suicide,” he noted. “High-quality competencies will be developed for healthcare professionals, including access to evidence-based suicide prevention models for addressing and assessing suicide risk.” 

 

Global Strategies

Policymakers across Europe are increasingly recognizing the importance of enhanced public health approaches to suicide prevention. 

The recently adopted EU Action Plan on Mental Health emphasizes the need for comprehensive suicide prevention strategies across Europe, including the promotion of mental health literacy and the provision of accessible mental health services.

The plan was informed by initiatives such as the European Alliance Against Depression (EAAD)-Best project, which ran from 2021 until March 2024. The collaborative project brought together researchers, healthcare providers, and community organizations to improve care for patients with depression and to prevent suicidal behavior in Europe. 

The multimodal approach included community engagement and training for healthcare professionals, as well as promoting the international uptake of the iFightDepression tool, an internet-based self-management approach for patients with depression. It has shown promise in reducing suicide rates in participating regions, including Europe, Australia, South America, and Africa.

“What we now know is that multiple interventions produce a synergic effect with a tendency to reduce suicidal behavior,” said EAAD founding member Ricardo Gusmão, MD, PhD, professor of public mental health at the University of Porto, Portugal. Current approaches to suicide prevention globally vary widely, with “many, fragmentary, atomized interventions, and we know that none of them, in isolation, produces spectacular results.” 

Gusmão explained that promising national suicide prevention strategies are based on multicomponent community interventions. On the clinical side, they encompass training primary health and specialized mental health professionals, and have a guaranteed chain of care and functioning pathways for access. They also involve educational programs in schools, universities, prisons, work settings, and geriatric care centers. Additionally, they have well-developed good standards for media communication and health marketing campaigns on well-being and mental health literacy.

Relevant and cohesive themes for successful strategies include the promotion of positive mental health, the identification and available treatments for depression and common mental disorders, and the management of suicidal crisis stigma. 

“We are now focusing on workplace settings and vulnerable groups such as youth, the elderly, unemployed, migrants and, of course, people affected by mental disorders,” he said. “Suicide prevention is like a web that must be weaved by long-lasting efforts and intersectoral collaboration.”

“Even one suicide is one too many,” Brendan Kelly, MD, PhD, professor of psychiatry, Trinity College Dublin, and author of The Modern Psychiatrist’s Guide to Contemporary Practice, told this news organization. “Nobody is born wanting to die by suicide. And every suicide is an individual tragedy, not a statistic. We need to work ever more intensively to reduce rates of suicide. All contributions to research and fresh thinking are welcome.”

Galynker, Calati, Partonen, and Kelly have disclosed no relevant financial relationships.  Gusmão has been involved in organizing Janssen-funded trainings for registrars on suicidal crisis management. 

 

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

Suicide and self-harm continue to be serious concerns in Europe, despite decreasing rates over the past two decades. In 2021 alone, 47,346 people died by suicide in the European Union, close to 1% of all deaths reported that year. Measures have been taken at population, subpopulation, and individual levels to prevent suicide and suicide attempts. But can more be done? Yes, according to experts.

Researchers are investigating factors that contribute to suicide at the individual level, as well as environmental and societal pressures that may increase risk. New predictive tools show promise in identifying individuals at high risk, and ongoing programs offer hope for early and ongoing interventions. Successful preventive strategies are multimodal, emphasizing the need for trained primary care and mental health professionals to work together to identify and support individuals at risk at every age and in all settings.

 

‘Radical Change’ Needed

The medical community’s approach to suicide prevention is all wrong, according to Igor Galynker, MD, PhD, clinical professor of psychiatry and director of the Mount Sinai Suicide Prevention Research Lab in New York City. 

Galynker is collaborating with colleagues in various parts of the world, including Europe, to validate the use of suicide crisis syndrome (SCS) as a diagnosis to help imminent suicide risk evaluation and treatment.

SCS is a negative cognitive-affective state associated with imminent suicidal behavior in those who are already at high risk for suicide. Galynker and his colleagues want to see SCS recognized and accepted as a suicide-specific diagnosis in the Diagnostic and Statistical Manual of Mental Disorders and the World Health Organization’s International Classification of Diseases. 

Currently, he explained to this news organization, clinicians depend on a person at risk for suicide telling them that this is what they are feeling. This is “absurd,” he said, because people in this situation are in acute pain and distress and cannot answer accurately.

“It is the most lethal psychiatric condition, because people die from it ... yet we rely on people at the worst moment of their lives to tell us accurately when and how they are going to kill themselves. We don’t ask people with serious mental illness to diagnose their own mental illness and rely on that diagnosis.”

Data show that most people who attempt or die by suicide deny suicidal thoughts when assessed by healthcare providers using current questionnaires and scales. Thus, there needs to be “a radical change” in how patients at acute risk are assessed and treated to help “prevent suicides and avoid lost opportunities to intervene,” he said.

Galynker explained that SCS is the final and most acute stage of the “ narrative crisis model” of suicide, which reflects the progression of suicidal risk from chronic risk factors to imminent suicidal risk. “The narrative crisis model has four distinct and successive stages, with specific guidance and applicable interventions that enable patients to receive a stage-specific treatment.”

“Suicide crisis syndrome is a very treatable syndrome that rapidly resolves” with appropriate interventions, he said. “Once it is treated, the patient can engage with psychotherapy and other treatments.”

Galynker said he and his colleagues have had encouraging results with their studies so far on the subjective and objective views of clinicians using the risk assessment tools they are developing to assess suicidal ideation. Further studies are ongoing. 

 

Improving Prediction

There is definitely room for improvement in current approaches to suicide prevention, said Raffaella Calati, PhD, assistant professor of clinical psychology at the University of Milano-Bicocca, Italy, who has had research collaborations with Galynker.

Calati advocates for a more integrated approach across disciplines, institutions, and the community to provide an effective support network for those at risk. 

Accurately predicting suicide risk is challenging, she told this news organization. She and colleagues are working to develop more precise predictive tools for identifying individuals at risk, often by leveraging artificial intelligence and data analytics. They have designed and implemented app-based interventions for psychiatric patients at risk for suicide and university students with psychological distress. The interventions are personalized and based on multiple approaches, such as cognitive-behavioral therapy (CBT) and third-wave CBT. 

The results of current studies are preliminary, she acknowledged, “but even if apps are extremely complex, our projects received high interest from participants and the scientific community,” she said. The aim now is to integrate these tools into healthcare systems so that monitoring high-risk patients becomes part of regular care. 

Another area of focus is the identification of specific subtypes of individuals at risk for suicide, particularly by examining factors such as pain, dissociation, and interoception — the ability to sense and interpret internal signals from the body. 

“By understanding how these experiences intersect and contribute to suicide risk, I aim to identify distinct profiles within at-risk populations, which could ultimately enable more tailored and effective prevention efforts,” she said.

Her work also involves meta-research to build large, comprehensive datasets that increase statistical power for exploring suicide risk factors, such as physical health conditions and symptoms associated with borderline personality disorder. By creating these datasets, she aims to “improve understanding of how various factors contribute to suicide risk, ultimately supporting more effective prevention strategies.”

 

Country-Level Efforts

Preventive work is underway in other countries as well. In Nordic countries such as Denmark, Finland, and Sweden, large-scale national registries that track people’s medical histories, prescriptions, and demographic information are being used to develop predictive algorithms that identify those at high risk for suicide. The predictions are based on known risk factors like previous mental health diagnoses, substance abuse, and social determinants of health.

A recent Norwegian study found that a novel assessment tool used at admission to an acute inpatient unit was a powerful predictor of suicide within 3 years post-discharge.

Researchers in the Netherlands have also recently co-designed a digital integrated suicide prevention program, which has led to a significant reduction in suicide mortality. 

SUPREMOCOL (suicide prevention by monitoring and collaborative care) was implemented in Noord-Brabant, a province in the Netherlands that historically had high suicide rates. It combines technology and personal care, allowing healthcare providers to track a person’s mental health, including by phone calls, text messages, and mobile apps that help people express their feelings and report any changes in their mental state. By staying connected, the program aims to identify warning signs early and provide timely interventions.

The results from the 5-year project showed that rates dropped by 21.5%, from 14.4 per 100,000 to 11.8 per 100,000, and remained low, with a rate of 11.3 per 100,000 by 2021.

Finland used to have one of the highest suicide rates in the world. Now it is implementing its suicide prevention program for 2020-2030, with 36 proposed measures to prevent suicide mortality. 

The program includes measures such as increasing public awareness, early intervention, supporting at-risk groups, developing new treatment options, and enhancing research efforts. Earlier successful interventions included limiting access to firearms and poison, and increasing use of antidepressants and other targeted interventions.

“A key is to ensure that the individuals at risk of suicide have access to adequate, timely, and evidence-based care,” said Timo Partonen, MD, research professor at the Finnish Institute for Health and Welfare and associate professor of psychiatry at the University of Helsinki.

“Emergency and frontline professionals, as well as general practitioners and occupational health physicians, have a key role in identifying people at risk of suicide,” he noted. “High-quality competencies will be developed for healthcare professionals, including access to evidence-based suicide prevention models for addressing and assessing suicide risk.” 

 

Global Strategies

Policymakers across Europe are increasingly recognizing the importance of enhanced public health approaches to suicide prevention. 

The recently adopted EU Action Plan on Mental Health emphasizes the need for comprehensive suicide prevention strategies across Europe, including the promotion of mental health literacy and the provision of accessible mental health services.

The plan was informed by initiatives such as the European Alliance Against Depression (EAAD)-Best project, which ran from 2021 until March 2024. The collaborative project brought together researchers, healthcare providers, and community organizations to improve care for patients with depression and to prevent suicidal behavior in Europe. 

The multimodal approach included community engagement and training for healthcare professionals, as well as promoting the international uptake of the iFightDepression tool, an internet-based self-management approach for patients with depression. It has shown promise in reducing suicide rates in participating regions, including Europe, Australia, South America, and Africa.

“What we now know is that multiple interventions produce a synergic effect with a tendency to reduce suicidal behavior,” said EAAD founding member Ricardo Gusmão, MD, PhD, professor of public mental health at the University of Porto, Portugal. Current approaches to suicide prevention globally vary widely, with “many, fragmentary, atomized interventions, and we know that none of them, in isolation, produces spectacular results.” 

Gusmão explained that promising national suicide prevention strategies are based on multicomponent community interventions. On the clinical side, they encompass training primary health and specialized mental health professionals, and have a guaranteed chain of care and functioning pathways for access. They also involve educational programs in schools, universities, prisons, work settings, and geriatric care centers. Additionally, they have well-developed good standards for media communication and health marketing campaigns on well-being and mental health literacy.

Relevant and cohesive themes for successful strategies include the promotion of positive mental health, the identification and available treatments for depression and common mental disorders, and the management of suicidal crisis stigma. 

“We are now focusing on workplace settings and vulnerable groups such as youth, the elderly, unemployed, migrants and, of course, people affected by mental disorders,” he said. “Suicide prevention is like a web that must be weaved by long-lasting efforts and intersectoral collaboration.”

“Even one suicide is one too many,” Brendan Kelly, MD, PhD, professor of psychiatry, Trinity College Dublin, and author of The Modern Psychiatrist’s Guide to Contemporary Practice, told this news organization. “Nobody is born wanting to die by suicide. And every suicide is an individual tragedy, not a statistic. We need to work ever more intensively to reduce rates of suicide. All contributions to research and fresh thinking are welcome.”

Galynker, Calati, Partonen, and Kelly have disclosed no relevant financial relationships.  Gusmão has been involved in organizing Janssen-funded trainings for registrars on suicidal crisis management. 

 

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

Suicide and self-harm continue to be serious concerns in Europe, despite decreasing rates over the past two decades. In 2021 alone, 47,346 people died by suicide in the European Union, close to 1% of all deaths reported that year. Measures have been taken at population, subpopulation, and individual levels to prevent suicide and suicide attempts. But can more be done? Yes, according to experts.

Researchers are investigating factors that contribute to suicide at the individual level, as well as environmental and societal pressures that may increase risk. New predictive tools show promise in identifying individuals at high risk, and ongoing programs offer hope for early and ongoing interventions. Successful preventive strategies are multimodal, emphasizing the need for trained primary care and mental health professionals to work together to identify and support individuals at risk at every age and in all settings.

 

‘Radical Change’ Needed

The medical community’s approach to suicide prevention is all wrong, according to Igor Galynker, MD, PhD, clinical professor of psychiatry and director of the Mount Sinai Suicide Prevention Research Lab in New York City. 

Galynker is collaborating with colleagues in various parts of the world, including Europe, to validate the use of suicide crisis syndrome (SCS) as a diagnosis to help imminent suicide risk evaluation and treatment.

SCS is a negative cognitive-affective state associated with imminent suicidal behavior in those who are already at high risk for suicide. Galynker and his colleagues want to see SCS recognized and accepted as a suicide-specific diagnosis in the Diagnostic and Statistical Manual of Mental Disorders and the World Health Organization’s International Classification of Diseases. 

Currently, he explained to this news organization, clinicians depend on a person at risk for suicide telling them that this is what they are feeling. This is “absurd,” he said, because people in this situation are in acute pain and distress and cannot answer accurately.

“It is the most lethal psychiatric condition, because people die from it ... yet we rely on people at the worst moment of their lives to tell us accurately when and how they are going to kill themselves. We don’t ask people with serious mental illness to diagnose their own mental illness and rely on that diagnosis.”

Data show that most people who attempt or die by suicide deny suicidal thoughts when assessed by healthcare providers using current questionnaires and scales. Thus, there needs to be “a radical change” in how patients at acute risk are assessed and treated to help “prevent suicides and avoid lost opportunities to intervene,” he said.

Galynker explained that SCS is the final and most acute stage of the “ narrative crisis model” of suicide, which reflects the progression of suicidal risk from chronic risk factors to imminent suicidal risk. “The narrative crisis model has four distinct and successive stages, with specific guidance and applicable interventions that enable patients to receive a stage-specific treatment.”

“Suicide crisis syndrome is a very treatable syndrome that rapidly resolves” with appropriate interventions, he said. “Once it is treated, the patient can engage with psychotherapy and other treatments.”

Galynker said he and his colleagues have had encouraging results with their studies so far on the subjective and objective views of clinicians using the risk assessment tools they are developing to assess suicidal ideation. Further studies are ongoing. 

 

Improving Prediction

There is definitely room for improvement in current approaches to suicide prevention, said Raffaella Calati, PhD, assistant professor of clinical psychology at the University of Milano-Bicocca, Italy, who has had research collaborations with Galynker.

Calati advocates for a more integrated approach across disciplines, institutions, and the community to provide an effective support network for those at risk. 

Accurately predicting suicide risk is challenging, she told this news organization. She and colleagues are working to develop more precise predictive tools for identifying individuals at risk, often by leveraging artificial intelligence and data analytics. They have designed and implemented app-based interventions for psychiatric patients at risk for suicide and university students with psychological distress. The interventions are personalized and based on multiple approaches, such as cognitive-behavioral therapy (CBT) and third-wave CBT. 

The results of current studies are preliminary, she acknowledged, “but even if apps are extremely complex, our projects received high interest from participants and the scientific community,” she said. The aim now is to integrate these tools into healthcare systems so that monitoring high-risk patients becomes part of regular care. 

Another area of focus is the identification of specific subtypes of individuals at risk for suicide, particularly by examining factors such as pain, dissociation, and interoception — the ability to sense and interpret internal signals from the body. 

“By understanding how these experiences intersect and contribute to suicide risk, I aim to identify distinct profiles within at-risk populations, which could ultimately enable more tailored and effective prevention efforts,” she said.

Her work also involves meta-research to build large, comprehensive datasets that increase statistical power for exploring suicide risk factors, such as physical health conditions and symptoms associated with borderline personality disorder. By creating these datasets, she aims to “improve understanding of how various factors contribute to suicide risk, ultimately supporting more effective prevention strategies.”

 

Country-Level Efforts

Preventive work is underway in other countries as well. In Nordic countries such as Denmark, Finland, and Sweden, large-scale national registries that track people’s medical histories, prescriptions, and demographic information are being used to develop predictive algorithms that identify those at high risk for suicide. The predictions are based on known risk factors like previous mental health diagnoses, substance abuse, and social determinants of health.

A recent Norwegian study found that a novel assessment tool used at admission to an acute inpatient unit was a powerful predictor of suicide within 3 years post-discharge.

Researchers in the Netherlands have also recently co-designed a digital integrated suicide prevention program, which has led to a significant reduction in suicide mortality. 

SUPREMOCOL (suicide prevention by monitoring and collaborative care) was implemented in Noord-Brabant, a province in the Netherlands that historically had high suicide rates. It combines technology and personal care, allowing healthcare providers to track a person’s mental health, including by phone calls, text messages, and mobile apps that help people express their feelings and report any changes in their mental state. By staying connected, the program aims to identify warning signs early and provide timely interventions.

The results from the 5-year project showed that rates dropped by 21.5%, from 14.4 per 100,000 to 11.8 per 100,000, and remained low, with a rate of 11.3 per 100,000 by 2021.

Finland used to have one of the highest suicide rates in the world. Now it is implementing its suicide prevention program for 2020-2030, with 36 proposed measures to prevent suicide mortality. 

The program includes measures such as increasing public awareness, early intervention, supporting at-risk groups, developing new treatment options, and enhancing research efforts. Earlier successful interventions included limiting access to firearms and poison, and increasing use of antidepressants and other targeted interventions.

“A key is to ensure that the individuals at risk of suicide have access to adequate, timely, and evidence-based care,” said Timo Partonen, MD, research professor at the Finnish Institute for Health and Welfare and associate professor of psychiatry at the University of Helsinki.

“Emergency and frontline professionals, as well as general practitioners and occupational health physicians, have a key role in identifying people at risk of suicide,” he noted. “High-quality competencies will be developed for healthcare professionals, including access to evidence-based suicide prevention models for addressing and assessing suicide risk.” 

 

Global Strategies

Policymakers across Europe are increasingly recognizing the importance of enhanced public health approaches to suicide prevention. 

The recently adopted EU Action Plan on Mental Health emphasizes the need for comprehensive suicide prevention strategies across Europe, including the promotion of mental health literacy and the provision of accessible mental health services.

The plan was informed by initiatives such as the European Alliance Against Depression (EAAD)-Best project, which ran from 2021 until March 2024. The collaborative project brought together researchers, healthcare providers, and community organizations to improve care for patients with depression and to prevent suicidal behavior in Europe. 

The multimodal approach included community engagement and training for healthcare professionals, as well as promoting the international uptake of the iFightDepression tool, an internet-based self-management approach for patients with depression. It has shown promise in reducing suicide rates in participating regions, including Europe, Australia, South America, and Africa.

“What we now know is that multiple interventions produce a synergic effect with a tendency to reduce suicidal behavior,” said EAAD founding member Ricardo Gusmão, MD, PhD, professor of public mental health at the University of Porto, Portugal. Current approaches to suicide prevention globally vary widely, with “many, fragmentary, atomized interventions, and we know that none of them, in isolation, produces spectacular results.” 

Gusmão explained that promising national suicide prevention strategies are based on multicomponent community interventions. On the clinical side, they encompass training primary health and specialized mental health professionals, and have a guaranteed chain of care and functioning pathways for access. They also involve educational programs in schools, universities, prisons, work settings, and geriatric care centers. Additionally, they have well-developed good standards for media communication and health marketing campaigns on well-being and mental health literacy.

Relevant and cohesive themes for successful strategies include the promotion of positive mental health, the identification and available treatments for depression and common mental disorders, and the management of suicidal crisis stigma. 

“We are now focusing on workplace settings and vulnerable groups such as youth, the elderly, unemployed, migrants and, of course, people affected by mental disorders,” he said. “Suicide prevention is like a web that must be weaved by long-lasting efforts and intersectoral collaboration.”

“Even one suicide is one too many,” Brendan Kelly, MD, PhD, professor of psychiatry, Trinity College Dublin, and author of The Modern Psychiatrist’s Guide to Contemporary Practice, told this news organization. “Nobody is born wanting to die by suicide. And every suicide is an individual tragedy, not a statistic. We need to work ever more intensively to reduce rates of suicide. All contributions to research and fresh thinking are welcome.”

Galynker, Calati, Partonen, and Kelly have disclosed no relevant financial relationships.  Gusmão has been involved in organizing Janssen-funded trainings for registrars on suicidal crisis management. 

 

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

A report published in July 2024 by the US Senate Special Committee on Aging is calling for a national coordinated response to what the authors claim may be an emerging hoarding disorder (HD) crisis.

While millions of US adults are estimated to have HD, it is the disorder’s prevalence and severity among older adults that sounded the alarm for the Committee Chair Sen. Bob Casey (D-PA).

HD affects roughly 2% of the overall population but up to 6% of all people older than 70 years, the report stated. Older adults made up about 16% of the US population in 2019. By 2060, that proportion is projected to soar to 25%.

The country’s aging population alone “could fuel a rise in hoarding in the coming decades,” the report authors noted.

These findings underscore the pressing need for a deeper understanding of HD, particularly as reports of its impact continue to rise. The Senate report also raises critical questions about the nature of HD: What is known about the condition? What evidence-based treatments are currently available, and are there national strategies that will prevent it from becoming a systemic crisis?

 

Why the Urgency?

An increase in anecdotal reports of HD in his home state prompted Casey, chair of the Senate Committee on Aging, to launch the investigation into the incidence and consequences of HD. Soon after the committee began its work, it became evident that the problem was not unique to communities in Pennsylvania. It was a nationwide issue.

“Communities throughout the United States are already grappling with HD,” the report noted.

HD is characterized by persistent difficulty discarding possessions, regardless of their monetary value. For individuals with HD, such items frequently hold meaningful reminders of past events and provide a sense of security. Difficulties with emotional regulation, executive functioning, and impulse control all contribute to the excessive buildup of clutter. Problems with attention, organization, and problem-solving are also common.

As individuals with HD age, physical limitations or disabilities may hinder their ability to discard clutter. As the accumulation increases, it can pose serious risks not only to their safety but also to public health.

Dozens of statements submitted to the Senate committee by those with HD, clinicians and social workers, first responders, social service organizations, state and federal agencies, and professional societies paint a concerning picture about the impact of hoarding on emergency and community services.

Data from the National Fire Incident Reporting System show the number of hoarding-related residential structural fires increased 26% between 2014 and 2022. Some 5242 residential fires connected to cluttered environments during that time resulted in 1367 fire service injuries, 1119 civilian injuries, and over $396 million in damages.

“For older adults, those consequences include health and safety risks, social isolation, eviction, and homelessness,” the report authors noted. “For communities, those consequences include public health concerns, increased risk of fire, and dangers to emergency responders.”

 

What Causes HD?

HD was once classified as a symptom of obsessive-compulsive personality disorder, with extreme causes meeting the diagnostic criteria for obsessive-compulsive disorder. That changed in 2010 when a working group recommended that HD be added to the Diagnostic and Statistical Manual of Mental Disorders (DSM), Fifth Edition, as a stand-alone disorder. That recommendation was approved in 2012.

However, a decade later, much about HD’s etiology remains unknown.

Often beginning in early adolescence, HD is a chronic and progressive condition, with genetics and trauma playing a role in its onset and course, Sanjaya Saxena, MD, director of Clinical and Research Affairs at the International OCD Foundation, said in an interview.

Between 50% and 85% of people with HD symptoms have family members with similar behavior. HD is often comorbid with other psychiatric and medical disorders, which can complicate treatment.

Results of a 2022 study showed that, compared with healthy control individuals, people with HD had widespread abnormalities in the prefrontal white matter tract which connects cortical regions involved in executive functioning, including working memory, attention, reward processing, and decision-making.

Some research also suggests that dysregulation of serotonin transmission may contribute to compulsive behaviors and the difficulty in letting go of possessions.

“We do know that there are factors that contribute to worsening of hoarding symptoms, but that’s not the same thing as what really causes it. So unfortunately, it’s still very understudied, and we don’t have great knowledge of what causes it,” Saxena said.

 

What Treatments Are Available?

There are currently no Food and Drug Administration–approved medications to treat HD, although some research has shown antidepressants paroxetine and venlafaxine may have some benefit. Methylphenidate and atomoxetine are also under study for HD.

Nonpharmacological therapies have shown more promising results. Among the first was a specialized cognitive-behavioral therapy (CBT) program developed by Randy Frost, PhD, professor emeritus of psychology at Smith College in Northampton, Massachusetts, and Gail Steketee, PhD, dean emerita and professor emerita of social work at Boston University in Massachusetts.

First published in 2007 and the subject of many clinical trials and studies since, the 26-session program has served as a model for psychosocial treatments for HD. The evidence-based therapy addresses various symptoms, including impulse control. One module encourages participants to develop a set of questions to consider before acquiring new items, gradually helping them build resistance to the urge to accumulate more possessions, said Frost, whose early work on HD was cited by those who supported adding the condition to the DSM in 2012.

“There are several features that I think are important including exercises in resisting acquiring and processing information when making decisions about discarding,” Frost said in an interview.

A number of studies have demonstrated the efficacy of CBT for HD, including a 2015 meta-analysis coauthored by Frost. The research showed symptom severity decreased significantly following CBT, with the largest gains in difficulty discarding and moderate improvements in clutter and acquiring.

Responses were better among women and younger patients, and although symptoms improved, posttreatment scores remained closer to the clinical range, researchers noted. It’s possible that more intervention beyond what is usually included in clinical trials — such as more sessions or adding home decluttering visits — could improve treatment response, they added.

A workshop based on the specialized CBT program has expanded the reach of the treatment. The group therapy project, Buried in Treasures (BiT), was developed by Frost, Steketee, and David Tolin, PhD, founder and director of the Anxiety Disorders Center at the Institute of Living, Hartford, and an adjunct professor of psychiatry at Yale School of Medicine, New Haven, Connecticut. The workshop is designed as a facilitated treatment that can be delivered by clinicians or trained nonclinician facilitators.

A study published in May found that more than half the participants with HD responded to the treatment, and of those, 39% reported significant reductions in HD symptoms. BiT sessions were led by trained facilitators, and the study included in-home decluttering sessions, also led by trained volunteers. Researchers said adding the home intervention could increase engagement with the group therapy.

Another study of a modified version of BiT found a 32% decrease in HD symptoms after 15 weeks of treatment delivered via video teleconference.

“The BiT workshop has been expanding around the world and has the advantage of being relatively inexpensive,” Frost said. Another advantage is that it can be run by nonclinicians, which expands treatment options in areas where mental health professionals trained to treat HD are in short supply.

However, the workshop “is not perfect, and clients usually still have symptoms at the end of the workshop,” Frost noted.

“The point is that the BiT workshop is the first step in changing a lifestyle related to possessions,” he continued. “We do certainly need to train more people in how to treat hoarding, and we need to facilitate research to make our treatments more effective.”

 

What’s New in the Field?

One novel program currently under study combines CBT with a cognitive rehabilitation protocol. Called Cognitive Rehabilitation and Exposure/Sorting Therapy (CREST), the program has been shown to help older adults with HD who don’t respond to traditional CBT for HD.

The program, led by Catherine Ayers, PhD, professor of clinical psychiatry at University of California, San Diego, involves memory training and problem-solving combined with exposure therapy to help participants learn how to tolerate distress associated with discarding their possessions.

Early findings pointed to symptom improvement in older adults following 24 sessions with CREST. The program fared better than geriatric case management in a 2018 study — the first randomized controlled trial of a treatment for HD in older adults — and offered additional benefits compared with exposure therapy in a study published in February 2024.

Virtual reality is also helping people with HD. A program developed at Stanford University in California, allows people with HD to work with a therapist as they practice decluttering in a three-dimensional virtual environment created using photographs and videos of actual hoarded objects and cluttered rooms in patients’ homes.

In a small pilot study, nine people older than 55 years with HD attended 16 weeks of online facilitated therapy where they learned to better understand their attachment to those items. They practiced decluttering by selecting virtual items for recycling, donation, or trash. A virtual garbage truck even hauled away the items they had placed in the trash.

Participants were then asked to discard the actual items at home. Most participants reported a decrease in hoarding symptoms, which was confirmed following a home assessment by a clinician.

“When you pick up an object from a loved one, it still maybe has the scent of the loved one. It has these tactile cues, colors. But in the virtual world, you can take a little bit of a step back,” lead researchers Carolyn Rodriguez, MD, PhD, director of Stanford’s Hoarding Disorders Research Program, said in an interview.

“It’s a little ramp to help people practice these skills. And then what we find is that it actually translated really well. They were able to go home and actually do the real uncluttering,” Rodriguez added.

 

What Else Can Be Done?

While researchers like Rodriguez continue studies of new and existing treatments, the Senate report draws attention to other responses that could aid people with HD. Because of its significant impact on emergency responders, adult protective services, aging services, and housing providers, the report recommends a nationwide response to older adults with HD.

Currently, federal agencies in charge of mental and community health are not doing enough to address HD, the report’s authors noted.

The report demonstrates “the scope and severity of these challenges and offers a path forward for how we can help people, communities, and local governments contend with this condition,” Casey said.

Specifically, the document cites a lack of HD services and tracking by the Substance Abuse and Mental Health Services Administration, the Administration for Community Living, and the Centers for Disease Control and Prevention.

The committee recommended these agencies collaborate to improve HD data collection, which will be critical to managing a potential spike in cases as the population ages. The committee also suggested awareness and training campaigns to better educate clinicians, social service providers, court officials, and first responders about HD.

Further, the report’s authors called for the Department of Housing and Urban Development to provide guidance and technical assistance on HD for landlords and housing assistance programs and urged Congress to collaborate with the Centers for Medicare & Medicaid Services to expand coverage for hoarding treatments.

Finally, the committee encouraged policymakers to engage directly with individuals affected by HD and their families to better understand the impact of the disorder and inform policy development.

“I think the Senate report focuses on education, not just for therapists, but other stakeholders too,” Frost said. “There are lots of other professionals who have a stake in this process, housing specialists, elder service folks, health and human services. Awareness of this problem is something that’s important for them as well.”

Rodriguez characterized the report’s recommendations as “potentially lifesaving” for individuals with HD. She added that it represents the first step in an ongoing effort to address an impending public health crisis related to HD in older adults and its broader impact on communities.

A spokesperson with Casey’s office said it’s unclear whether any federal agencies have acted on the report recommendations since it was released in June. It’s also unknown whether the Senate Committee on Aging will pursue any additional work on HD when new committee leaders are appointed in 2025.

“Although some federal agencies have taken steps to address HD, those steps are frequently limited. Other relevant agencies have not addressed HD at all in recent years,” report authors wrote. “The federal government can, and should, do more to bolster the response to HD.”

Frost agreed.

“I think federal agencies can have a positive effect by promoting, supporting, and tracking local efforts in dealing with this problem,” he said.

With reporting from Eve Bender.

A version of this article appeared on Medscape.com.

A report published in July 2024 by the US Senate Special Committee on Aging is calling for a national coordinated response to what the authors claim may be an emerging hoarding disorder (HD) crisis.

While millions of US adults are estimated to have HD, it is the disorder’s prevalence and severity among older adults that sounded the alarm for the Committee Chair Sen. Bob Casey (D-PA).

HD affects roughly 2% of the overall population but up to 6% of all people older than 70 years, the report stated. Older adults made up about 16% of the US population in 2019. By 2060, that proportion is projected to soar to 25%.

The country’s aging population alone “could fuel a rise in hoarding in the coming decades,” the report authors noted.

These findings underscore the pressing need for a deeper understanding of HD, particularly as reports of its impact continue to rise. The Senate report also raises critical questions about the nature of HD: What is known about the condition? What evidence-based treatments are currently available, and are there national strategies that will prevent it from becoming a systemic crisis?

 

Why the Urgency?

An increase in anecdotal reports of HD in his home state prompted Casey, chair of the Senate Committee on Aging, to launch the investigation into the incidence and consequences of HD. Soon after the committee began its work, it became evident that the problem was not unique to communities in Pennsylvania. It was a nationwide issue.

“Communities throughout the United States are already grappling with HD,” the report noted.

HD is characterized by persistent difficulty discarding possessions, regardless of their monetary value. For individuals with HD, such items frequently hold meaningful reminders of past events and provide a sense of security. Difficulties with emotional regulation, executive functioning, and impulse control all contribute to the excessive buildup of clutter. Problems with attention, organization, and problem-solving are also common.

As individuals with HD age, physical limitations or disabilities may hinder their ability to discard clutter. As the accumulation increases, it can pose serious risks not only to their safety but also to public health.

Dozens of statements submitted to the Senate committee by those with HD, clinicians and social workers, first responders, social service organizations, state and federal agencies, and professional societies paint a concerning picture about the impact of hoarding on emergency and community services.

Data from the National Fire Incident Reporting System show the number of hoarding-related residential structural fires increased 26% between 2014 and 2022. Some 5242 residential fires connected to cluttered environments during that time resulted in 1367 fire service injuries, 1119 civilian injuries, and over $396 million in damages.

“For older adults, those consequences include health and safety risks, social isolation, eviction, and homelessness,” the report authors noted. “For communities, those consequences include public health concerns, increased risk of fire, and dangers to emergency responders.”

 

What Causes HD?

HD was once classified as a symptom of obsessive-compulsive personality disorder, with extreme causes meeting the diagnostic criteria for obsessive-compulsive disorder. That changed in 2010 when a working group recommended that HD be added to the Diagnostic and Statistical Manual of Mental Disorders (DSM), Fifth Edition, as a stand-alone disorder. That recommendation was approved in 2012.

However, a decade later, much about HD’s etiology remains unknown.

Often beginning in early adolescence, HD is a chronic and progressive condition, with genetics and trauma playing a role in its onset and course, Sanjaya Saxena, MD, director of Clinical and Research Affairs at the International OCD Foundation, said in an interview.

Between 50% and 85% of people with HD symptoms have family members with similar behavior. HD is often comorbid with other psychiatric and medical disorders, which can complicate treatment.

Results of a 2022 study showed that, compared with healthy control individuals, people with HD had widespread abnormalities in the prefrontal white matter tract which connects cortical regions involved in executive functioning, including working memory, attention, reward processing, and decision-making.

Some research also suggests that dysregulation of serotonin transmission may contribute to compulsive behaviors and the difficulty in letting go of possessions.

“We do know that there are factors that contribute to worsening of hoarding symptoms, but that’s not the same thing as what really causes it. So unfortunately, it’s still very understudied, and we don’t have great knowledge of what causes it,” Saxena said.

 

What Treatments Are Available?

There are currently no Food and Drug Administration–approved medications to treat HD, although some research has shown antidepressants paroxetine and venlafaxine may have some benefit. Methylphenidate and atomoxetine are also under study for HD.

Nonpharmacological therapies have shown more promising results. Among the first was a specialized cognitive-behavioral therapy (CBT) program developed by Randy Frost, PhD, professor emeritus of psychology at Smith College in Northampton, Massachusetts, and Gail Steketee, PhD, dean emerita and professor emerita of social work at Boston University in Massachusetts.

First published in 2007 and the subject of many clinical trials and studies since, the 26-session program has served as a model for psychosocial treatments for HD. The evidence-based therapy addresses various symptoms, including impulse control. One module encourages participants to develop a set of questions to consider before acquiring new items, gradually helping them build resistance to the urge to accumulate more possessions, said Frost, whose early work on HD was cited by those who supported adding the condition to the DSM in 2012.

“There are several features that I think are important including exercises in resisting acquiring and processing information when making decisions about discarding,” Frost said in an interview.

A number of studies have demonstrated the efficacy of CBT for HD, including a 2015 meta-analysis coauthored by Frost. The research showed symptom severity decreased significantly following CBT, with the largest gains in difficulty discarding and moderate improvements in clutter and acquiring.

Responses were better among women and younger patients, and although symptoms improved, posttreatment scores remained closer to the clinical range, researchers noted. It’s possible that more intervention beyond what is usually included in clinical trials — such as more sessions or adding home decluttering visits — could improve treatment response, they added.

A workshop based on the specialized CBT program has expanded the reach of the treatment. The group therapy project, Buried in Treasures (BiT), was developed by Frost, Steketee, and David Tolin, PhD, founder and director of the Anxiety Disorders Center at the Institute of Living, Hartford, and an adjunct professor of psychiatry at Yale School of Medicine, New Haven, Connecticut. The workshop is designed as a facilitated treatment that can be delivered by clinicians or trained nonclinician facilitators.

A study published in May found that more than half the participants with HD responded to the treatment, and of those, 39% reported significant reductions in HD symptoms. BiT sessions were led by trained facilitators, and the study included in-home decluttering sessions, also led by trained volunteers. Researchers said adding the home intervention could increase engagement with the group therapy.

Another study of a modified version of BiT found a 32% decrease in HD symptoms after 15 weeks of treatment delivered via video teleconference.

“The BiT workshop has been expanding around the world and has the advantage of being relatively inexpensive,” Frost said. Another advantage is that it can be run by nonclinicians, which expands treatment options in areas where mental health professionals trained to treat HD are in short supply.

However, the workshop “is not perfect, and clients usually still have symptoms at the end of the workshop,” Frost noted.

“The point is that the BiT workshop is the first step in changing a lifestyle related to possessions,” he continued. “We do certainly need to train more people in how to treat hoarding, and we need to facilitate research to make our treatments more effective.”

 

What’s New in the Field?

One novel program currently under study combines CBT with a cognitive rehabilitation protocol. Called Cognitive Rehabilitation and Exposure/Sorting Therapy (CREST), the program has been shown to help older adults with HD who don’t respond to traditional CBT for HD.

The program, led by Catherine Ayers, PhD, professor of clinical psychiatry at University of California, San Diego, involves memory training and problem-solving combined with exposure therapy to help participants learn how to tolerate distress associated with discarding their possessions.

Early findings pointed to symptom improvement in older adults following 24 sessions with CREST. The program fared better than geriatric case management in a 2018 study — the first randomized controlled trial of a treatment for HD in older adults — and offered additional benefits compared with exposure therapy in a study published in February 2024.

Virtual reality is also helping people with HD. A program developed at Stanford University in California, allows people with HD to work with a therapist as they practice decluttering in a three-dimensional virtual environment created using photographs and videos of actual hoarded objects and cluttered rooms in patients’ homes.

In a small pilot study, nine people older than 55 years with HD attended 16 weeks of online facilitated therapy where they learned to better understand their attachment to those items. They practiced decluttering by selecting virtual items for recycling, donation, or trash. A virtual garbage truck even hauled away the items they had placed in the trash.

Participants were then asked to discard the actual items at home. Most participants reported a decrease in hoarding symptoms, which was confirmed following a home assessment by a clinician.

“When you pick up an object from a loved one, it still maybe has the scent of the loved one. It has these tactile cues, colors. But in the virtual world, you can take a little bit of a step back,” lead researchers Carolyn Rodriguez, MD, PhD, director of Stanford’s Hoarding Disorders Research Program, said in an interview.

“It’s a little ramp to help people practice these skills. And then what we find is that it actually translated really well. They were able to go home and actually do the real uncluttering,” Rodriguez added.

 

What Else Can Be Done?

While researchers like Rodriguez continue studies of new and existing treatments, the Senate report draws attention to other responses that could aid people with HD. Because of its significant impact on emergency responders, adult protective services, aging services, and housing providers, the report recommends a nationwide response to older adults with HD.

Currently, federal agencies in charge of mental and community health are not doing enough to address HD, the report’s authors noted.

The report demonstrates “the scope and severity of these challenges and offers a path forward for how we can help people, communities, and local governments contend with this condition,” Casey said.

Specifically, the document cites a lack of HD services and tracking by the Substance Abuse and Mental Health Services Administration, the Administration for Community Living, and the Centers for Disease Control and Prevention.

The committee recommended these agencies collaborate to improve HD data collection, which will be critical to managing a potential spike in cases as the population ages. The committee also suggested awareness and training campaigns to better educate clinicians, social service providers, court officials, and first responders about HD.

Further, the report’s authors called for the Department of Housing and Urban Development to provide guidance and technical assistance on HD for landlords and housing assistance programs and urged Congress to collaborate with the Centers for Medicare & Medicaid Services to expand coverage for hoarding treatments.

Finally, the committee encouraged policymakers to engage directly with individuals affected by HD and their families to better understand the impact of the disorder and inform policy development.

“I think the Senate report focuses on education, not just for therapists, but other stakeholders too,” Frost said. “There are lots of other professionals who have a stake in this process, housing specialists, elder service folks, health and human services. Awareness of this problem is something that’s important for them as well.”

Rodriguez characterized the report’s recommendations as “potentially lifesaving” for individuals with HD. She added that it represents the first step in an ongoing effort to address an impending public health crisis related to HD in older adults and its broader impact on communities.

A spokesperson with Casey’s office said it’s unclear whether any federal agencies have acted on the report recommendations since it was released in June. It’s also unknown whether the Senate Committee on Aging will pursue any additional work on HD when new committee leaders are appointed in 2025.

“Although some federal agencies have taken steps to address HD, those steps are frequently limited. Other relevant agencies have not addressed HD at all in recent years,” report authors wrote. “The federal government can, and should, do more to bolster the response to HD.”

Frost agreed.

“I think federal agencies can have a positive effect by promoting, supporting, and tracking local efforts in dealing with this problem,” he said.

With reporting from Eve Bender.

A version of this article appeared on Medscape.com.

A report published in July 2024 by the US Senate Special Committee on Aging is calling for a national coordinated response to what the authors claim may be an emerging hoarding disorder (HD) crisis.

While millions of US adults are estimated to have HD, it is the disorder’s prevalence and severity among older adults that sounded the alarm for the Committee Chair Sen. Bob Casey (D-PA).

HD affects roughly 2% of the overall population but up to 6% of all people older than 70 years, the report stated. Older adults made up about 16% of the US population in 2019. By 2060, that proportion is projected to soar to 25%.

The country’s aging population alone “could fuel a rise in hoarding in the coming decades,” the report authors noted.

These findings underscore the pressing need for a deeper understanding of HD, particularly as reports of its impact continue to rise. The Senate report also raises critical questions about the nature of HD: What is known about the condition? What evidence-based treatments are currently available, and are there national strategies that will prevent it from becoming a systemic crisis?

 

Why the Urgency?

An increase in anecdotal reports of HD in his home state prompted Casey, chair of the Senate Committee on Aging, to launch the investigation into the incidence and consequences of HD. Soon after the committee began its work, it became evident that the problem was not unique to communities in Pennsylvania. It was a nationwide issue.

“Communities throughout the United States are already grappling with HD,” the report noted.

HD is characterized by persistent difficulty discarding possessions, regardless of their monetary value. For individuals with HD, such items frequently hold meaningful reminders of past events and provide a sense of security. Difficulties with emotional regulation, executive functioning, and impulse control all contribute to the excessive buildup of clutter. Problems with attention, organization, and problem-solving are also common.

As individuals with HD age, physical limitations or disabilities may hinder their ability to discard clutter. As the accumulation increases, it can pose serious risks not only to their safety but also to public health.

Dozens of statements submitted to the Senate committee by those with HD, clinicians and social workers, first responders, social service organizations, state and federal agencies, and professional societies paint a concerning picture about the impact of hoarding on emergency and community services.

Data from the National Fire Incident Reporting System show the number of hoarding-related residential structural fires increased 26% between 2014 and 2022. Some 5242 residential fires connected to cluttered environments during that time resulted in 1367 fire service injuries, 1119 civilian injuries, and over $396 million in damages.

“For older adults, those consequences include health and safety risks, social isolation, eviction, and homelessness,” the report authors noted. “For communities, those consequences include public health concerns, increased risk of fire, and dangers to emergency responders.”

 

What Causes HD?

HD was once classified as a symptom of obsessive-compulsive personality disorder, with extreme causes meeting the diagnostic criteria for obsessive-compulsive disorder. That changed in 2010 when a working group recommended that HD be added to the Diagnostic and Statistical Manual of Mental Disorders (DSM), Fifth Edition, as a stand-alone disorder. That recommendation was approved in 2012.

However, a decade later, much about HD’s etiology remains unknown.

Often beginning in early adolescence, HD is a chronic and progressive condition, with genetics and trauma playing a role in its onset and course, Sanjaya Saxena, MD, director of Clinical and Research Affairs at the International OCD Foundation, said in an interview.

Between 50% and 85% of people with HD symptoms have family members with similar behavior. HD is often comorbid with other psychiatric and medical disorders, which can complicate treatment.

Results of a 2022 study showed that, compared with healthy control individuals, people with HD had widespread abnormalities in the prefrontal white matter tract which connects cortical regions involved in executive functioning, including working memory, attention, reward processing, and decision-making.

Some research also suggests that dysregulation of serotonin transmission may contribute to compulsive behaviors and the difficulty in letting go of possessions.

“We do know that there are factors that contribute to worsening of hoarding symptoms, but that’s not the same thing as what really causes it. So unfortunately, it’s still very understudied, and we don’t have great knowledge of what causes it,” Saxena said.

 

What Treatments Are Available?

There are currently no Food and Drug Administration–approved medications to treat HD, although some research has shown antidepressants paroxetine and venlafaxine may have some benefit. Methylphenidate and atomoxetine are also under study for HD.

Nonpharmacological therapies have shown more promising results. Among the first was a specialized cognitive-behavioral therapy (CBT) program developed by Randy Frost, PhD, professor emeritus of psychology at Smith College in Northampton, Massachusetts, and Gail Steketee, PhD, dean emerita and professor emerita of social work at Boston University in Massachusetts.

First published in 2007 and the subject of many clinical trials and studies since, the 26-session program has served as a model for psychosocial treatments for HD. The evidence-based therapy addresses various symptoms, including impulse control. One module encourages participants to develop a set of questions to consider before acquiring new items, gradually helping them build resistance to the urge to accumulate more possessions, said Frost, whose early work on HD was cited by those who supported adding the condition to the DSM in 2012.

“There are several features that I think are important including exercises in resisting acquiring and processing information when making decisions about discarding,” Frost said in an interview.

A number of studies have demonstrated the efficacy of CBT for HD, including a 2015 meta-analysis coauthored by Frost. The research showed symptom severity decreased significantly following CBT, with the largest gains in difficulty discarding and moderate improvements in clutter and acquiring.

Responses were better among women and younger patients, and although symptoms improved, posttreatment scores remained closer to the clinical range, researchers noted. It’s possible that more intervention beyond what is usually included in clinical trials — such as more sessions or adding home decluttering visits — could improve treatment response, they added.

A workshop based on the specialized CBT program has expanded the reach of the treatment. The group therapy project, Buried in Treasures (BiT), was developed by Frost, Steketee, and David Tolin, PhD, founder and director of the Anxiety Disorders Center at the Institute of Living, Hartford, and an adjunct professor of psychiatry at Yale School of Medicine, New Haven, Connecticut. The workshop is designed as a facilitated treatment that can be delivered by clinicians or trained nonclinician facilitators.

A study published in May found that more than half the participants with HD responded to the treatment, and of those, 39% reported significant reductions in HD symptoms. BiT sessions were led by trained facilitators, and the study included in-home decluttering sessions, also led by trained volunteers. Researchers said adding the home intervention could increase engagement with the group therapy.

Another study of a modified version of BiT found a 32% decrease in HD symptoms after 15 weeks of treatment delivered via video teleconference.

“The BiT workshop has been expanding around the world and has the advantage of being relatively inexpensive,” Frost said. Another advantage is that it can be run by nonclinicians, which expands treatment options in areas where mental health professionals trained to treat HD are in short supply.

However, the workshop “is not perfect, and clients usually still have symptoms at the end of the workshop,” Frost noted.

“The point is that the BiT workshop is the first step in changing a lifestyle related to possessions,” he continued. “We do certainly need to train more people in how to treat hoarding, and we need to facilitate research to make our treatments more effective.”

 

What’s New in the Field?

One novel program currently under study combines CBT with a cognitive rehabilitation protocol. Called Cognitive Rehabilitation and Exposure/Sorting Therapy (CREST), the program has been shown to help older adults with HD who don’t respond to traditional CBT for HD.

The program, led by Catherine Ayers, PhD, professor of clinical psychiatry at University of California, San Diego, involves memory training and problem-solving combined with exposure therapy to help participants learn how to tolerate distress associated with discarding their possessions.

Early findings pointed to symptom improvement in older adults following 24 sessions with CREST. The program fared better than geriatric case management in a 2018 study — the first randomized controlled trial of a treatment for HD in older adults — and offered additional benefits compared with exposure therapy in a study published in February 2024.

Virtual reality is also helping people with HD. A program developed at Stanford University in California, allows people with HD to work with a therapist as they practice decluttering in a three-dimensional virtual environment created using photographs and videos of actual hoarded objects and cluttered rooms in patients’ homes.

In a small pilot study, nine people older than 55 years with HD attended 16 weeks of online facilitated therapy where they learned to better understand their attachment to those items. They practiced decluttering by selecting virtual items for recycling, donation, or trash. A virtual garbage truck even hauled away the items they had placed in the trash.

Participants were then asked to discard the actual items at home. Most participants reported a decrease in hoarding symptoms, which was confirmed following a home assessment by a clinician.

“When you pick up an object from a loved one, it still maybe has the scent of the loved one. It has these tactile cues, colors. But in the virtual world, you can take a little bit of a step back,” lead researchers Carolyn Rodriguez, MD, PhD, director of Stanford’s Hoarding Disorders Research Program, said in an interview.

“It’s a little ramp to help people practice these skills. And then what we find is that it actually translated really well. They were able to go home and actually do the real uncluttering,” Rodriguez added.

 

What Else Can Be Done?

While researchers like Rodriguez continue studies of new and existing treatments, the Senate report draws attention to other responses that could aid people with HD. Because of its significant impact on emergency responders, adult protective services, aging services, and housing providers, the report recommends a nationwide response to older adults with HD.

Currently, federal agencies in charge of mental and community health are not doing enough to address HD, the report’s authors noted.

The report demonstrates “the scope and severity of these challenges and offers a path forward for how we can help people, communities, and local governments contend with this condition,” Casey said.

Specifically, the document cites a lack of HD services and tracking by the Substance Abuse and Mental Health Services Administration, the Administration for Community Living, and the Centers for Disease Control and Prevention.

The committee recommended these agencies collaborate to improve HD data collection, which will be critical to managing a potential spike in cases as the population ages. The committee also suggested awareness and training campaigns to better educate clinicians, social service providers, court officials, and first responders about HD.

Further, the report’s authors called for the Department of Housing and Urban Development to provide guidance and technical assistance on HD for landlords and housing assistance programs and urged Congress to collaborate with the Centers for Medicare & Medicaid Services to expand coverage for hoarding treatments.

Finally, the committee encouraged policymakers to engage directly with individuals affected by HD and their families to better understand the impact of the disorder and inform policy development.

“I think the Senate report focuses on education, not just for therapists, but other stakeholders too,” Frost said. “There are lots of other professionals who have a stake in this process, housing specialists, elder service folks, health and human services. Awareness of this problem is something that’s important for them as well.”

Rodriguez characterized the report’s recommendations as “potentially lifesaving” for individuals with HD. She added that it represents the first step in an ongoing effort to address an impending public health crisis related to HD in older adults and its broader impact on communities.

A spokesperson with Casey’s office said it’s unclear whether any federal agencies have acted on the report recommendations since it was released in June. It’s also unknown whether the Senate Committee on Aging will pursue any additional work on HD when new committee leaders are appointed in 2025.

“Although some federal agencies have taken steps to address HD, those steps are frequently limited. Other relevant agencies have not addressed HD at all in recent years,” report authors wrote. “The federal government can, and should, do more to bolster the response to HD.”

Frost agreed.

“I think federal agencies can have a positive effect by promoting, supporting, and tracking local efforts in dealing with this problem,” he said.

With reporting from Eve Bender.

A version of this article appeared on Medscape.com.