PTSD

TOPLINE

First-year medical residents training during COVID-19 were significantly less likely to have posttraumatic stress disorder and workplace trauma, compared with their counterparts who trained before the pandemic, and reported fewer work hours, higher workload satisfaction, and fewer medical errors, new research shows.

METHODOLOGY

• Studies have reported a high prevalence of PTSD symptoms among residents during the pandemic, but it’s unclear if this prevalence differs from prepandemic levels.
• Using the Intern Health Study, a longitudinal cohort study of 1st-year residents, researchers investigated differences in PTSD symptoms among those training before the pandemic (2018-2019) and during its first wave (March to June, 2020).
• The study included 1,957 first-year residents (48.2% female; mean age, 27.6 years) who completed a baseline survey 2 months before their residency start, and then quarterly surveys during their intern year, with the fourth quarterly survey including a screen for PTSD.
• Researchers assessed differences in nonresidency factors and residency-related factors before and during the pandemic and examined exposure to workplace trauma.

TAKEAWAY

• Residents training during the pandemic were significantly less likely than pre-pandemic residents to screen positive for PTSD (7.1% vs. 10.7%; odds ratio, 0.64; 95% confidence interval, 0.46-0.88; P = .01).
• They were also less likely to have workplace trauma exposure (50.9% vs. 56.6%; OR, 0.80; 95% CI, 0.66-0.95; P = .01).
• Residents training during the pandemic compared to prepandemic reported significantly lower weekly duty hours (score mean difference –3.1 hours; 95% CI, –4.1 to −2.0 hours), lower mean reports of medical errors (MD, −0.04; 95% CI, –0.06 to –0.01), and higher workload satisfaction (MD, 0.2; 95% CI, 0.2-0.3).
• However, after accounting for these residency-related factors, training during the pandemic was no longer associated with lower odds of presenting PTSD symptoms.

IN PRACTICE

While the findings show residents training during the first pandemic wave were less likely to have PTSD, future studies should further follow these residents’ PTSD symptoms and investigate whether interventions targeting residency-related factors could reduce their PTSD risk moving forward, the investigators note.

SOURCE

The study was carried out by Michelle K. Ptak, BA, department of psychology, University of Michigan, Ann Arbor, and colleagues. It was published online Aug. 22 in JAMA Network Open.

LIMITATIONS

The study used self-reports and included only the first pandemic wave, 1st-year residents, and prepandemic data for a single academic year. Survey participation decreased during the pandemic, and it’s possible there were unmeasured factors associated with PTSD risk.

DISCLOSURES

The study was supported by the National Institute of Mental Health and the National Institutes of Health. The authors report no relevant financial relationships.

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

TOPLINE

First-year medical residents training during COVID-19 were significantly less likely to have posttraumatic stress disorder and workplace trauma, compared with their counterparts who trained before the pandemic, and reported fewer work hours, higher workload satisfaction, and fewer medical errors, new research shows.

METHODOLOGY

• Studies have reported a high prevalence of PTSD symptoms among residents during the pandemic, but it’s unclear if this prevalence differs from prepandemic levels.
• Using the Intern Health Study, a longitudinal cohort study of 1st-year residents, researchers investigated differences in PTSD symptoms among those training before the pandemic (2018-2019) and during its first wave (March to June, 2020).
• The study included 1,957 first-year residents (48.2% female; mean age, 27.6 years) who completed a baseline survey 2 months before their residency start, and then quarterly surveys during their intern year, with the fourth quarterly survey including a screen for PTSD.
• Researchers assessed differences in nonresidency factors and residency-related factors before and during the pandemic and examined exposure to workplace trauma.

TAKEAWAY

• Residents training during the pandemic were significantly less likely than pre-pandemic residents to screen positive for PTSD (7.1% vs. 10.7%; odds ratio, 0.64; 95% confidence interval, 0.46-0.88; P = .01).
• They were also less likely to have workplace trauma exposure (50.9% vs. 56.6%; OR, 0.80; 95% CI, 0.66-0.95; P = .01).
• Residents training during the pandemic compared to prepandemic reported significantly lower weekly duty hours (score mean difference –3.1 hours; 95% CI, –4.1 to −2.0 hours), lower mean reports of medical errors (MD, −0.04; 95% CI, –0.06 to –0.01), and higher workload satisfaction (MD, 0.2; 95% CI, 0.2-0.3).
• However, after accounting for these residency-related factors, training during the pandemic was no longer associated with lower odds of presenting PTSD symptoms.

IN PRACTICE

While the findings show residents training during the first pandemic wave were less likely to have PTSD, future studies should further follow these residents’ PTSD symptoms and investigate whether interventions targeting residency-related factors could reduce their PTSD risk moving forward, the investigators note.

SOURCE

The study was carried out by Michelle K. Ptak, BA, department of psychology, University of Michigan, Ann Arbor, and colleagues. It was published online Aug. 22 in JAMA Network Open.

LIMITATIONS

The study used self-reports and included only the first pandemic wave, 1st-year residents, and prepandemic data for a single academic year. Survey participation decreased during the pandemic, and it’s possible there were unmeasured factors associated with PTSD risk.

DISCLOSURES

The study was supported by the National Institute of Mental Health and the National Institutes of Health. The authors report no relevant financial relationships.

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

TOPLINE

First-year medical residents training during COVID-19 were significantly less likely to have posttraumatic stress disorder and workplace trauma, compared with their counterparts who trained before the pandemic, and reported fewer work hours, higher workload satisfaction, and fewer medical errors, new research shows.

METHODOLOGY

• Studies have reported a high prevalence of PTSD symptoms among residents during the pandemic, but it’s unclear if this prevalence differs from prepandemic levels.
• Using the Intern Health Study, a longitudinal cohort study of 1st-year residents, researchers investigated differences in PTSD symptoms among those training before the pandemic (2018-2019) and during its first wave (March to June, 2020).
• The study included 1,957 first-year residents (48.2% female; mean age, 27.6 years) who completed a baseline survey 2 months before their residency start, and then quarterly surveys during their intern year, with the fourth quarterly survey including a screen for PTSD.
• Researchers assessed differences in nonresidency factors and residency-related factors before and during the pandemic and examined exposure to workplace trauma.

TAKEAWAY

• Residents training during the pandemic were significantly less likely than pre-pandemic residents to screen positive for PTSD (7.1% vs. 10.7%; odds ratio, 0.64; 95% confidence interval, 0.46-0.88; P = .01).
• They were also less likely to have workplace trauma exposure (50.9% vs. 56.6%; OR, 0.80; 95% CI, 0.66-0.95; P = .01).
• Residents training during the pandemic compared to prepandemic reported significantly lower weekly duty hours (score mean difference –3.1 hours; 95% CI, –4.1 to −2.0 hours), lower mean reports of medical errors (MD, −0.04; 95% CI, –0.06 to –0.01), and higher workload satisfaction (MD, 0.2; 95% CI, 0.2-0.3).
• However, after accounting for these residency-related factors, training during the pandemic was no longer associated with lower odds of presenting PTSD symptoms.

IN PRACTICE

While the findings show residents training during the first pandemic wave were less likely to have PTSD, future studies should further follow these residents’ PTSD symptoms and investigate whether interventions targeting residency-related factors could reduce their PTSD risk moving forward, the investigators note.

SOURCE

The study was carried out by Michelle K. Ptak, BA, department of psychology, University of Michigan, Ann Arbor, and colleagues. It was published online Aug. 22 in JAMA Network Open.

LIMITATIONS

The study used self-reports and included only the first pandemic wave, 1st-year residents, and prepandemic data for a single academic year. Survey participation decreased during the pandemic, and it’s possible there were unmeasured factors associated with PTSD risk.

DISCLOSURES

The study was supported by the National Institute of Mental Health and the National Institutes of Health. The authors report no relevant financial relationships.

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

Suicide is not a trivial matter – it upends families, robs partners of a loved one, prevents children from having a parent, and can destroy a parent’s most cherished being. It is not surprising that societies have repeatedly made it a goal to study and reduce suicide within their populations.

The suicide rate in the United States is trending upward, from about 10 per 100,000 in 2000 to about 15 per 100,000 in more recent reports. The increasing suicide rates have been accompanied by increasing distress among many strata of society. From a public health level, analysts are not just witnessing increasing suicide rates, but a shocking rise in all “deaths of despair,”¹ among which suicide can be considered the ultimate example.

On an individual level, many know someone who has died of suicide or suffered from a serious suicide attempt. From the public health level to the individual level, advocacy has called for various interventions in the field of psychiatry to remedy this tragic problem.

Psychiatrists have been firsthand witnesses to this increasing demand for suicide interventions. When in residency, the norm was to perform a suicide risk assessment at the time of admission to the hospital and again at the time of discharge. As the years passed, the new normal within psychiatric hospitals has shifted to asking about suicidality on a daily basis.

In what seems to us like an escalating arms race, the emerging standard of care at many facilities is now not only for daily suicide risk assessments by each psychiatrist, but also to require nurses to ask about suicidality during every 8-hour shift – in addition to documented inquiries about suicidality by other allied staff on the psychiatric unit. As a result, it is not uncommon for a patient hospitalized at an academic center to receive more than half a dozen suicide risk assessments in a day (first by the medical student, at least once – often more than once – by the resident, again by the attending psychiatrist, then the social worker and three nurses in 24 hours).

One of the concerns about such an approach is the lack of logic inherent to many risk assessment tools and symptom scales. Many of us are familiar with the Patient Health Questionnaire (PHQ-9) to assess depression.² The PHQ-9 asks to consider “over the last 2 weeks, how often have you ...” in relation to nine symptoms associated with depression. It has always defied reason to perform a PHQ-9 every day and expect the answers to change from “nearly every day” to “not at all,” considering only 1 day has passed since the last time the patient has answered the questions. Yet daily, or near daily, PHQ-9 scores are a frequently used tool of tracking symptom improvement in response to treatments, such as electroconvulsive therapy, performed multiple times a week.

One can argue that the patient’s perspective on how symptomatic he or she has been over the past 2 weeks may change rapidly with alleviation of a depressed mood. However, the PHQ-9 is both reported to be, and often regarded as, an objective score. If one wishes to utilize it as such, the defense of its use should not be that it is a subjective report with just as much utility as “Rate your depression on a scale of 0-27.”

Similarly, many suicide scales were intended to assess thoughts of suicide in the past month³ or have been re-tooled to address this particular concern by asking “since the last contact.”⁴ It is baffling to see a chart with many dozens of suicide risk assessments with at times widely differing answers, yet all measuring thoughts of suicide in the past month. Is one to expect the answer to “How many times have you had these thoughts [of suicide ideation]? (1) Less than once a week (2) Once a week ...” to change between 8 a.m. and noon? Furthermore, for the purpose of assessing acute risk of suicidality in the immediate future, to only consider symptoms since the last contact – or past 2 weeks, past month, etc. – is of unclear significance.
 

Provider liability

Another concern is the liability placed on providers. A common problem encountered in the inpatient setting is insurance companies refusing to reimburse a hospital stay for depressed patients denying suicidality.

Any provider in the position of caring for such a patient must ask: What is the likelihood of someone providing a false negative – a false denial of suicidality? Is the likelihood of a suicidal person denying suicidality different if asked 5 or 10 or more times in a day? There are innumerable instances where a patient at a very high risk of self-harm has denied suicidality, been discharged from the hospital, and suffered terrible consequences. Ethically, the psychiatrist aware of this risk is no more at ease discharging these patients, whether it is one suicide risk scale or a dozen that suggests a patient is at low risk.

Alternatively, it may feel untenable from a medicolegal perspective for a psychiatrist to discharge a patient denying suicidality when the chart includes over a dozen previously documented elevated suicide risk assessments in the past 72 hours. By placing the job of suicide risk assessment in the hands of providers of varying levels of training and responsibility, a situation is created in which the seasoned psychiatrist who would otherwise be comfortable discharging a patient feels unable to do so because every other note-writer in the record – from the triage nurse to the medical assistant to the sitter in the emergency department – has recorded the patient as high risk for suicide. When put in such a position, the thought often occurs that systems of care, rather than individual providers, are protected most by ever escalating requirements for suicide risk documentation. To make a clinical decision contrary to the body of suicide risk documentation puts the provider at risk of being scapegoated by the system of care, which can point to its illogical and ineffective, though profusely documented, suicide prevention protocols.
 

Limitations of risk assessments

Considering the ongoing rise in the use of suicide risk assessments, one would expect that the evidence for their efficacy was robust and well established. Yet a thorough review of suicide risk assessments funded by the MacArthur Foundation, which examined decades of research, came to disheartening conclusions: “predictive ability has not improved over the past 50 years”; “no risk factor category or subcategory is substantially stronger than any other”; and “predicting solely according to base rates may be comparable to prediction with current risk factors.”⁵

Those findings were consistent with the conclusions of many other studies, which have summarized the utility of suicide risk assessments as follows: “occurrence of suicide is too low to identify those individuals who are likely to die by suicide”;⁶ “suicide prediction models produce accurate overall classification models, but their accuracy of predicting a future event is near zero”;⁷ “risk stratification is too inaccurate to be clinically useful and might even be harmful”;⁸ “suicide risk prediction [lacks] any items or information that to a useful degree permit the identification of persons who will complete suicide”;⁹ “existing suicide prediction tools have little current clinical value”;¹⁰ “our current preoccupation with risk assessment has ... created a mythology with no evidence to support it.”¹¹ And that’s to cite just a few.

Sadly, we have known about the limitations of suicide risk assessments for many decades. In 1983 a large VA prospective study, which aimed to identify veterans who will die by suicide, examined 4,800 patients with a wide range of instruments and measures.¹² This study concluded that “discriminant analysis was clearly inadequate in correctly classifying the subjects. For an event as rare as suicide, our predictive tools and guides are simply not equal to the task.” The authors described the feelings of many in stating “courts and public opinion expect physicians to be able to pick out the particular persons who will later commit suicide. Although we may reconstruct causal chains and motives, we do not possess the tools to predict suicides.”

Yet, even several decades prior, in 1954, Dr. Albert Rosen performed an elegant statistical analysis and predicted that, considering the low base rate of suicide, suicide risk assessments are “of no practical value, for it would be impossible to treat the prodigious number of false positives.”¹³ It seems that we continue to be unable to accept Dr. Rosen’s premonition despite decades of confirmatory evidence.
 

“Quantity over quality”

Regardless of those sobering reports, the field of psychiatry is seemingly doubling down on efforts to predict and prevent suicide deaths, and the way it is doing so has very questionable validity.

One can reasonably argue that the periodic performance of a suicide risk assessment may have clinical utility in reminding us of modifiable risk factors such as intoxication, social isolation, and access to lethal means. One can also reasonably argue that these risk assessments may provide useful education to patients and their families on epidemiological risk factors such as gender, age, and marital status. But our pursuit of serial suicide risk assessments throughout the day is encouraging providers to focus on a particular risk factor that changes from moment to moment and has particularly low validity, that being self-reported suicidality.

Reported suicidality is one of the few risk factors that can change from shift to shift. But 80% of people who die by suicide had not previously expressed suicidality, and 98.3% of people who have endorsed suicidality do not die by suicide.¹⁴ While the former statistic may improve with increased assessment, the later will likely worsen.

Suicide is not a trivial matter. We admire those that study it and advocate for better interventions. We have compassion for those who have suffered the loss of a loved one to suicide. Our patients have died as a result of the human limitations surrounding suicide prevention. Recognizing the weight of suicide and making an effort to avoid minimizing its immense consequences drive our desire to be honest with ourselves, our patients and their families, and society. That includes the unfortunate truth regarding the current state of the evidence and our ability to enact change.

It is our concern that the rising fascination with repeated suicide risk assessment is misguided in its current form and serves the purpose of appeasing administrators more than reflecting a scientific understanding of the literature. More sadly, we are concerned that this “quantity-over-quality” approach is yet another barrier to practicing what may be one of the few interventions with any hope of meaningfully impacting a patient’s risk of suicide in the clinical setting – spending time connecting with our patients.

Dr. Badre is a clinical and forensic psychiatrist in San Diego. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre can be reached at his website, BadreMD.com. Dr. Compton is a member of the psychiatry faculty at University of California, San Diego. His background includes medical education, mental health advocacy, work with underserved populations, and brain cancer research. Dr. Badre and Dr. Compton have no conflicts of interest.

References

1. Joint Economic Committee. (2019). Long Term Trends in Deaths of Despair. SCP Report 4-19.

2. Kroenke K and Spitzer RL. The PHQ-9: A new depression diagnostic and severity measure. Psychiatr Ann. 2013;32(9):509-15. doi: 10.3928/0048-5713-20020901-06.

3. Columbia-Suicide Severity Rating Scale (C-SSRS) Full Lifetime/Recent.

4. Columbia-Suicide Severity Rating Scale (C-SSRS) Full Since Last Contact.

5. Franklin JC et al. Risk factors for suicidal thoughts and behaviors: A meta-analysis of 50 years of research. Psychol Bull. 2017 Feb;143(2):187-232. doi: 10.1037/bul0000084.

6. Beautrais AL. Further suicidal behavior among medically serious suicide attempters. Suicide Life Threat Behav. 2004 Spring;34(1):1-11. doi: 10.1521/suli.34.1.1.27772.

7. Belsher BE. Prediction models for suicide attempts and deaths: A systematic review and simulation. JAMA Psychiatry. 2019 Jun 1;76(6):642-651. doi: 10.1001/jamapsychiatry.2019.0174.

8. Carter G et al. Royal Australian and New Zealand College of Psychiatrists clinical practice guideline for the management of deliberate self-harm. Aust N Z J Psychiatry. 2016 Oct;50(10):939-1000. doi: 10.1177/0004867416661039.

9. Fosse R et al. Predictors of suicide in the patient population admitted to a locked-door psychiatric acute ward. PLoS One. 2017 Mar 16;12(3):e0173958. doi: 10.1371/journal.pone.0173958.

10. Kessler RC et al. Suicide prediction models: A critical review of recent research with recommendations for the way forward. Mol Psychiatry. 2020 Jan;25(1):168-79. doi: 10.1038/s41380-019-0531-0.

11. Mulder R. Problems with suicide risk assessment. Aust N Z J Psychiatry. 2011 Aug;45(8):605-7. doi: 10.3109/00048674.2011.594786.

12. Pokorny AD. Prediction of suicide in psychiatric patients: Report of a prospective study. Arch Gen Psychiatry. 1983 Mar;40(3):249-57. doi: 10.1001/archpsyc.1983.01790030019002.

13. Rosen A. Detection of suicidal patients: An example of some limitations in the prediction of infrequent events. J Consult Psychol. 1954 Dec;18(6):397-403. doi: 10.1037/h0058579.

14. McHugh CM et al. (2019). Association between suicidal ideation and suicide: Meta-analyses of odds ratios, sensitivity, specificity and positive predictive value. BJPsych Open. 2019 Mar;5(2):e18. doi: 10.1192/bjo.2018.88.

Suicide is not a trivial matter – it upends families, robs partners of a loved one, prevents children from having a parent, and can destroy a parent’s most cherished being. It is not surprising that societies have repeatedly made it a goal to study and reduce suicide within their populations.

The suicide rate in the United States is trending upward, from about 10 per 100,000 in 2000 to about 15 per 100,000 in more recent reports. The increasing suicide rates have been accompanied by increasing distress among many strata of society. From a public health level, analysts are not just witnessing increasing suicide rates, but a shocking rise in all “deaths of despair,”¹ among which suicide can be considered the ultimate example.

On an individual level, many know someone who has died of suicide or suffered from a serious suicide attempt. From the public health level to the individual level, advocacy has called for various interventions in the field of psychiatry to remedy this tragic problem.

Psychiatrists have been firsthand witnesses to this increasing demand for suicide interventions. When in residency, the norm was to perform a suicide risk assessment at the time of admission to the hospital and again at the time of discharge. As the years passed, the new normal within psychiatric hospitals has shifted to asking about suicidality on a daily basis.

In what seems to us like an escalating arms race, the emerging standard of care at many facilities is now not only for daily suicide risk assessments by each psychiatrist, but also to require nurses to ask about suicidality during every 8-hour shift – in addition to documented inquiries about suicidality by other allied staff on the psychiatric unit. As a result, it is not uncommon for a patient hospitalized at an academic center to receive more than half a dozen suicide risk assessments in a day (first by the medical student, at least once – often more than once – by the resident, again by the attending psychiatrist, then the social worker and three nurses in 24 hours).

One of the concerns about such an approach is the lack of logic inherent to many risk assessment tools and symptom scales. Many of us are familiar with the Patient Health Questionnaire (PHQ-9) to assess depression.² The PHQ-9 asks to consider “over the last 2 weeks, how often have you ...” in relation to nine symptoms associated with depression. It has always defied reason to perform a PHQ-9 every day and expect the answers to change from “nearly every day” to “not at all,” considering only 1 day has passed since the last time the patient has answered the questions. Yet daily, or near daily, PHQ-9 scores are a frequently used tool of tracking symptom improvement in response to treatments, such as electroconvulsive therapy, performed multiple times a week.

One can argue that the patient’s perspective on how symptomatic he or she has been over the past 2 weeks may change rapidly with alleviation of a depressed mood. However, the PHQ-9 is both reported to be, and often regarded as, an objective score. If one wishes to utilize it as such, the defense of its use should not be that it is a subjective report with just as much utility as “Rate your depression on a scale of 0-27.”

Similarly, many suicide scales were intended to assess thoughts of suicide in the past month³ or have been re-tooled to address this particular concern by asking “since the last contact.”⁴ It is baffling to see a chart with many dozens of suicide risk assessments with at times widely differing answers, yet all measuring thoughts of suicide in the past month. Is one to expect the answer to “How many times have you had these thoughts [of suicide ideation]? (1) Less than once a week (2) Once a week ...” to change between 8 a.m. and noon? Furthermore, for the purpose of assessing acute risk of suicidality in the immediate future, to only consider symptoms since the last contact – or past 2 weeks, past month, etc. – is of unclear significance.
 

Provider liability

Another concern is the liability placed on providers. A common problem encountered in the inpatient setting is insurance companies refusing to reimburse a hospital stay for depressed patients denying suicidality.

Any provider in the position of caring for such a patient must ask: What is the likelihood of someone providing a false negative – a false denial of suicidality? Is the likelihood of a suicidal person denying suicidality different if asked 5 or 10 or more times in a day? There are innumerable instances where a patient at a very high risk of self-harm has denied suicidality, been discharged from the hospital, and suffered terrible consequences. Ethically, the psychiatrist aware of this risk is no more at ease discharging these patients, whether it is one suicide risk scale or a dozen that suggests a patient is at low risk.

Alternatively, it may feel untenable from a medicolegal perspective for a psychiatrist to discharge a patient denying suicidality when the chart includes over a dozen previously documented elevated suicide risk assessments in the past 72 hours. By placing the job of suicide risk assessment in the hands of providers of varying levels of training and responsibility, a situation is created in which the seasoned psychiatrist who would otherwise be comfortable discharging a patient feels unable to do so because every other note-writer in the record – from the triage nurse to the medical assistant to the sitter in the emergency department – has recorded the patient as high risk for suicide. When put in such a position, the thought often occurs that systems of care, rather than individual providers, are protected most by ever escalating requirements for suicide risk documentation. To make a clinical decision contrary to the body of suicide risk documentation puts the provider at risk of being scapegoated by the system of care, which can point to its illogical and ineffective, though profusely documented, suicide prevention protocols.
 

Limitations of risk assessments

Considering the ongoing rise in the use of suicide risk assessments, one would expect that the evidence for their efficacy was robust and well established. Yet a thorough review of suicide risk assessments funded by the MacArthur Foundation, which examined decades of research, came to disheartening conclusions: “predictive ability has not improved over the past 50 years”; “no risk factor category or subcategory is substantially stronger than any other”; and “predicting solely according to base rates may be comparable to prediction with current risk factors.”⁵

Those findings were consistent with the conclusions of many other studies, which have summarized the utility of suicide risk assessments as follows: “occurrence of suicide is too low to identify those individuals who are likely to die by suicide”;⁶ “suicide prediction models produce accurate overall classification models, but their accuracy of predicting a future event is near zero”;⁷ “risk stratification is too inaccurate to be clinically useful and might even be harmful”;⁸ “suicide risk prediction [lacks] any items or information that to a useful degree permit the identification of persons who will complete suicide”;⁹ “existing suicide prediction tools have little current clinical value”;¹⁰ “our current preoccupation with risk assessment has ... created a mythology with no evidence to support it.”¹¹ And that’s to cite just a few.

Sadly, we have known about the limitations of suicide risk assessments for many decades. In 1983 a large VA prospective study, which aimed to identify veterans who will die by suicide, examined 4,800 patients with a wide range of instruments and measures.¹² This study concluded that “discriminant analysis was clearly inadequate in correctly classifying the subjects. For an event as rare as suicide, our predictive tools and guides are simply not equal to the task.” The authors described the feelings of many in stating “courts and public opinion expect physicians to be able to pick out the particular persons who will later commit suicide. Although we may reconstruct causal chains and motives, we do not possess the tools to predict suicides.”

Yet, even several decades prior, in 1954, Dr. Albert Rosen performed an elegant statistical analysis and predicted that, considering the low base rate of suicide, suicide risk assessments are “of no practical value, for it would be impossible to treat the prodigious number of false positives.”¹³ It seems that we continue to be unable to accept Dr. Rosen’s premonition despite decades of confirmatory evidence.
 

“Quantity over quality”

Regardless of those sobering reports, the field of psychiatry is seemingly doubling down on efforts to predict and prevent suicide deaths, and the way it is doing so has very questionable validity.

One can reasonably argue that the periodic performance of a suicide risk assessment may have clinical utility in reminding us of modifiable risk factors such as intoxication, social isolation, and access to lethal means. One can also reasonably argue that these risk assessments may provide useful education to patients and their families on epidemiological risk factors such as gender, age, and marital status. But our pursuit of serial suicide risk assessments throughout the day is encouraging providers to focus on a particular risk factor that changes from moment to moment and has particularly low validity, that being self-reported suicidality.

Reported suicidality is one of the few risk factors that can change from shift to shift. But 80% of people who die by suicide had not previously expressed suicidality, and 98.3% of people who have endorsed suicidality do not die by suicide.¹⁴ While the former statistic may improve with increased assessment, the later will likely worsen.

Suicide is not a trivial matter. We admire those that study it and advocate for better interventions. We have compassion for those who have suffered the loss of a loved one to suicide. Our patients have died as a result of the human limitations surrounding suicide prevention. Recognizing the weight of suicide and making an effort to avoid minimizing its immense consequences drive our desire to be honest with ourselves, our patients and their families, and society. That includes the unfortunate truth regarding the current state of the evidence and our ability to enact change.

It is our concern that the rising fascination with repeated suicide risk assessment is misguided in its current form and serves the purpose of appeasing administrators more than reflecting a scientific understanding of the literature. More sadly, we are concerned that this “quantity-over-quality” approach is yet another barrier to practicing what may be one of the few interventions with any hope of meaningfully impacting a patient’s risk of suicide in the clinical setting – spending time connecting with our patients.

Dr. Badre is a clinical and forensic psychiatrist in San Diego. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre can be reached at his website, BadreMD.com. Dr. Compton is a member of the psychiatry faculty at University of California, San Diego. His background includes medical education, mental health advocacy, work with underserved populations, and brain cancer research. Dr. Badre and Dr. Compton have no conflicts of interest.

References

1. Joint Economic Committee. (2019). Long Term Trends in Deaths of Despair. SCP Report 4-19.

2. Kroenke K and Spitzer RL. The PHQ-9: A new depression diagnostic and severity measure. Psychiatr Ann. 2013;32(9):509-15. doi: 10.3928/0048-5713-20020901-06.

3. Columbia-Suicide Severity Rating Scale (C-SSRS) Full Lifetime/Recent.

4. Columbia-Suicide Severity Rating Scale (C-SSRS) Full Since Last Contact.

5. Franklin JC et al. Risk factors for suicidal thoughts and behaviors: A meta-analysis of 50 years of research. Psychol Bull. 2017 Feb;143(2):187-232. doi: 10.1037/bul0000084.

6. Beautrais AL. Further suicidal behavior among medically serious suicide attempters. Suicide Life Threat Behav. 2004 Spring;34(1):1-11. doi: 10.1521/suli.34.1.1.27772.

7. Belsher BE. Prediction models for suicide attempts and deaths: A systematic review and simulation. JAMA Psychiatry. 2019 Jun 1;76(6):642-651. doi: 10.1001/jamapsychiatry.2019.0174.

8. Carter G et al. Royal Australian and New Zealand College of Psychiatrists clinical practice guideline for the management of deliberate self-harm. Aust N Z J Psychiatry. 2016 Oct;50(10):939-1000. doi: 10.1177/0004867416661039.

9. Fosse R et al. Predictors of suicide in the patient population admitted to a locked-door psychiatric acute ward. PLoS One. 2017 Mar 16;12(3):e0173958. doi: 10.1371/journal.pone.0173958.

10. Kessler RC et al. Suicide prediction models: A critical review of recent research with recommendations for the way forward. Mol Psychiatry. 2020 Jan;25(1):168-79. doi: 10.1038/s41380-019-0531-0.

11. Mulder R. Problems with suicide risk assessment. Aust N Z J Psychiatry. 2011 Aug;45(8):605-7. doi: 10.3109/00048674.2011.594786.

12. Pokorny AD. Prediction of suicide in psychiatric patients: Report of a prospective study. Arch Gen Psychiatry. 1983 Mar;40(3):249-57. doi: 10.1001/archpsyc.1983.01790030019002.

13. Rosen A. Detection of suicidal patients: An example of some limitations in the prediction of infrequent events. J Consult Psychol. 1954 Dec;18(6):397-403. doi: 10.1037/h0058579.

14. McHugh CM et al. (2019). Association between suicidal ideation and suicide: Meta-analyses of odds ratios, sensitivity, specificity and positive predictive value. BJPsych Open. 2019 Mar;5(2):e18. doi: 10.1192/bjo.2018.88.

Suicide is not a trivial matter – it upends families, robs partners of a loved one, prevents children from having a parent, and can destroy a parent’s most cherished being. It is not surprising that societies have repeatedly made it a goal to study and reduce suicide within their populations.

The suicide rate in the United States is trending upward, from about 10 per 100,000 in 2000 to about 15 per 100,000 in more recent reports. The increasing suicide rates have been accompanied by increasing distress among many strata of society. From a public health level, analysts are not just witnessing increasing suicide rates, but a shocking rise in all “deaths of despair,”¹ among which suicide can be considered the ultimate example.

On an individual level, many know someone who has died of suicide or suffered from a serious suicide attempt. From the public health level to the individual level, advocacy has called for various interventions in the field of psychiatry to remedy this tragic problem.

Psychiatrists have been firsthand witnesses to this increasing demand for suicide interventions. When in residency, the norm was to perform a suicide risk assessment at the time of admission to the hospital and again at the time of discharge. As the years passed, the new normal within psychiatric hospitals has shifted to asking about suicidality on a daily basis.

In what seems to us like an escalating arms race, the emerging standard of care at many facilities is now not only for daily suicide risk assessments by each psychiatrist, but also to require nurses to ask about suicidality during every 8-hour shift – in addition to documented inquiries about suicidality by other allied staff on the psychiatric unit. As a result, it is not uncommon for a patient hospitalized at an academic center to receive more than half a dozen suicide risk assessments in a day (first by the medical student, at least once – often more than once – by the resident, again by the attending psychiatrist, then the social worker and three nurses in 24 hours).

One of the concerns about such an approach is the lack of logic inherent to many risk assessment tools and symptom scales. Many of us are familiar with the Patient Health Questionnaire (PHQ-9) to assess depression.² The PHQ-9 asks to consider “over the last 2 weeks, how often have you ...” in relation to nine symptoms associated with depression. It has always defied reason to perform a PHQ-9 every day and expect the answers to change from “nearly every day” to “not at all,” considering only 1 day has passed since the last time the patient has answered the questions. Yet daily, or near daily, PHQ-9 scores are a frequently used tool of tracking symptom improvement in response to treatments, such as electroconvulsive therapy, performed multiple times a week.

One can argue that the patient’s perspective on how symptomatic he or she has been over the past 2 weeks may change rapidly with alleviation of a depressed mood. However, the PHQ-9 is both reported to be, and often regarded as, an objective score. If one wishes to utilize it as such, the defense of its use should not be that it is a subjective report with just as much utility as “Rate your depression on a scale of 0-27.”

Similarly, many suicide scales were intended to assess thoughts of suicide in the past month³ or have been re-tooled to address this particular concern by asking “since the last contact.”⁴ It is baffling to see a chart with many dozens of suicide risk assessments with at times widely differing answers, yet all measuring thoughts of suicide in the past month. Is one to expect the answer to “How many times have you had these thoughts [of suicide ideation]? (1) Less than once a week (2) Once a week ...” to change between 8 a.m. and noon? Furthermore, for the purpose of assessing acute risk of suicidality in the immediate future, to only consider symptoms since the last contact – or past 2 weeks, past month, etc. – is of unclear significance.
 

Provider liability

Another concern is the liability placed on providers. A common problem encountered in the inpatient setting is insurance companies refusing to reimburse a hospital stay for depressed patients denying suicidality.

Any provider in the position of caring for such a patient must ask: What is the likelihood of someone providing a false negative – a false denial of suicidality? Is the likelihood of a suicidal person denying suicidality different if asked 5 or 10 or more times in a day? There are innumerable instances where a patient at a very high risk of self-harm has denied suicidality, been discharged from the hospital, and suffered terrible consequences. Ethically, the psychiatrist aware of this risk is no more at ease discharging these patients, whether it is one suicide risk scale or a dozen that suggests a patient is at low risk.

Alternatively, it may feel untenable from a medicolegal perspective for a psychiatrist to discharge a patient denying suicidality when the chart includes over a dozen previously documented elevated suicide risk assessments in the past 72 hours. By placing the job of suicide risk assessment in the hands of providers of varying levels of training and responsibility, a situation is created in which the seasoned psychiatrist who would otherwise be comfortable discharging a patient feels unable to do so because every other note-writer in the record – from the triage nurse to the medical assistant to the sitter in the emergency department – has recorded the patient as high risk for suicide. When put in such a position, the thought often occurs that systems of care, rather than individual providers, are protected most by ever escalating requirements for suicide risk documentation. To make a clinical decision contrary to the body of suicide risk documentation puts the provider at risk of being scapegoated by the system of care, which can point to its illogical and ineffective, though profusely documented, suicide prevention protocols.
 

Limitations of risk assessments

Considering the ongoing rise in the use of suicide risk assessments, one would expect that the evidence for their efficacy was robust and well established. Yet a thorough review of suicide risk assessments funded by the MacArthur Foundation, which examined decades of research, came to disheartening conclusions: “predictive ability has not improved over the past 50 years”; “no risk factor category or subcategory is substantially stronger than any other”; and “predicting solely according to base rates may be comparable to prediction with current risk factors.”⁵

Those findings were consistent with the conclusions of many other studies, which have summarized the utility of suicide risk assessments as follows: “occurrence of suicide is too low to identify those individuals who are likely to die by suicide”;⁶ “suicide prediction models produce accurate overall classification models, but their accuracy of predicting a future event is near zero”;⁷ “risk stratification is too inaccurate to be clinically useful and might even be harmful”;⁸ “suicide risk prediction [lacks] any items or information that to a useful degree permit the identification of persons who will complete suicide”;⁹ “existing suicide prediction tools have little current clinical value”;¹⁰ “our current preoccupation with risk assessment has ... created a mythology with no evidence to support it.”¹¹ And that’s to cite just a few.

Sadly, we have known about the limitations of suicide risk assessments for many decades. In 1983 a large VA prospective study, which aimed to identify veterans who will die by suicide, examined 4,800 patients with a wide range of instruments and measures.¹² This study concluded that “discriminant analysis was clearly inadequate in correctly classifying the subjects. For an event as rare as suicide, our predictive tools and guides are simply not equal to the task.” The authors described the feelings of many in stating “courts and public opinion expect physicians to be able to pick out the particular persons who will later commit suicide. Although we may reconstruct causal chains and motives, we do not possess the tools to predict suicides.”

Yet, even several decades prior, in 1954, Dr. Albert Rosen performed an elegant statistical analysis and predicted that, considering the low base rate of suicide, suicide risk assessments are “of no practical value, for it would be impossible to treat the prodigious number of false positives.”¹³ It seems that we continue to be unable to accept Dr. Rosen’s premonition despite decades of confirmatory evidence.
 

“Quantity over quality”

Regardless of those sobering reports, the field of psychiatry is seemingly doubling down on efforts to predict and prevent suicide deaths, and the way it is doing so has very questionable validity.

One can reasonably argue that the periodic performance of a suicide risk assessment may have clinical utility in reminding us of modifiable risk factors such as intoxication, social isolation, and access to lethal means. One can also reasonably argue that these risk assessments may provide useful education to patients and their families on epidemiological risk factors such as gender, age, and marital status. But our pursuit of serial suicide risk assessments throughout the day is encouraging providers to focus on a particular risk factor that changes from moment to moment and has particularly low validity, that being self-reported suicidality.

Reported suicidality is one of the few risk factors that can change from shift to shift. But 80% of people who die by suicide had not previously expressed suicidality, and 98.3% of people who have endorsed suicidality do not die by suicide.¹⁴ While the former statistic may improve with increased assessment, the later will likely worsen.

Suicide is not a trivial matter. We admire those that study it and advocate for better interventions. We have compassion for those who have suffered the loss of a loved one to suicide. Our patients have died as a result of the human limitations surrounding suicide prevention. Recognizing the weight of suicide and making an effort to avoid minimizing its immense consequences drive our desire to be honest with ourselves, our patients and their families, and society. That includes the unfortunate truth regarding the current state of the evidence and our ability to enact change.

It is our concern that the rising fascination with repeated suicide risk assessment is misguided in its current form and serves the purpose of appeasing administrators more than reflecting a scientific understanding of the literature. More sadly, we are concerned that this “quantity-over-quality” approach is yet another barrier to practicing what may be one of the few interventions with any hope of meaningfully impacting a patient’s risk of suicide in the clinical setting – spending time connecting with our patients.

Dr. Badre is a clinical and forensic psychiatrist in San Diego. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre can be reached at his website, BadreMD.com. Dr. Compton is a member of the psychiatry faculty at University of California, San Diego. His background includes medical education, mental health advocacy, work with underserved populations, and brain cancer research. Dr. Badre and Dr. Compton have no conflicts of interest.

References

1. Joint Economic Committee. (2019). Long Term Trends in Deaths of Despair. SCP Report 4-19.

2. Kroenke K and Spitzer RL. The PHQ-9: A new depression diagnostic and severity measure. Psychiatr Ann. 2013;32(9):509-15. doi: 10.3928/0048-5713-20020901-06.

3. Columbia-Suicide Severity Rating Scale (C-SSRS) Full Lifetime/Recent.

4. Columbia-Suicide Severity Rating Scale (C-SSRS) Full Since Last Contact.

5. Franklin JC et al. Risk factors for suicidal thoughts and behaviors: A meta-analysis of 50 years of research. Psychol Bull. 2017 Feb;143(2):187-232. doi: 10.1037/bul0000084.

6. Beautrais AL. Further suicidal behavior among medically serious suicide attempters. Suicide Life Threat Behav. 2004 Spring;34(1):1-11. doi: 10.1521/suli.34.1.1.27772.

7. Belsher BE. Prediction models for suicide attempts and deaths: A systematic review and simulation. JAMA Psychiatry. 2019 Jun 1;76(6):642-651. doi: 10.1001/jamapsychiatry.2019.0174.

8. Carter G et al. Royal Australian and New Zealand College of Psychiatrists clinical practice guideline for the management of deliberate self-harm. Aust N Z J Psychiatry. 2016 Oct;50(10):939-1000. doi: 10.1177/0004867416661039.

9. Fosse R et al. Predictors of suicide in the patient population admitted to a locked-door psychiatric acute ward. PLoS One. 2017 Mar 16;12(3):e0173958. doi: 10.1371/journal.pone.0173958.

10. Kessler RC et al. Suicide prediction models: A critical review of recent research with recommendations for the way forward. Mol Psychiatry. 2020 Jan;25(1):168-79. doi: 10.1038/s41380-019-0531-0.

11. Mulder R. Problems with suicide risk assessment. Aust N Z J Psychiatry. 2011 Aug;45(8):605-7. doi: 10.3109/00048674.2011.594786.

12. Pokorny AD. Prediction of suicide in psychiatric patients: Report of a prospective study. Arch Gen Psychiatry. 1983 Mar;40(3):249-57. doi: 10.1001/archpsyc.1983.01790030019002.

13. Rosen A. Detection of suicidal patients: An example of some limitations in the prediction of infrequent events. J Consult Psychol. 1954 Dec;18(6):397-403. doi: 10.1037/h0058579.

14. McHugh CM et al. (2019). Association between suicidal ideation and suicide: Meta-analyses of odds ratios, sensitivity, specificity and positive predictive value. BJPsych Open. 2019 Mar;5(2):e18. doi: 10.1192/bjo.2018.88.

As psychiatrists know, many of our severely traumatized adult patients were victims of abuse during childhood. We routinely ask every new patient about physical, emotional, or sexual abuse when they were growing up because of the well-established, serious neurobiological and mental repercussions.^1,2

Perhaps one of the worst experiences for a child is to witness bitterly adversarial parents (their vital role models) who argue viciously, despise each other, and hurl insults (and even punches) at each other. Such a chronically and emotionally traumatic upbringing can haunt kids well into adulthood, disrupting their hypothalamic-pituitary-adrenal axis and triggering anxiety, depression, and even psychosis due to epigenetic changes that ultimately lead to abnormal brain development.³

It often feels that the governance of our country, or the national “political family,” is seriously fractured like a hopelessly dysfunctional family. Could that be negatively impacting the mental health of the citizenry? Having 2 antagonistic political parties expressing visceral hatred and undisguised contempt for each other 24/7 (thanks to the enabling era of cable TV, the internet, and social media) has transformed each party’s fanatic followers from fellow citizens to ideological combatants. In this poisonous societal zeitgeist of bidirectional acrimony and mutual detestation, the opposing parties and their “intellectual militias” label each other as “extremists” or “radicals.” They become completely blind to any redeeming social value in the ideas or principles of their political opponents. They spend enormous time and energy on undermining each other instead of attending to the myriad vital issues involved in the governance of a massive and complex country.

Winston Churchill said, “Democracy is the worst form of government, except for all the others that have been tried.”⁴ The current toxic cloud of intense “hyperpartisanship” is emblematic of the dark Machiavellian side of democracy. But those who lament the current distorted version of democracy should contemplate living in a dictatorship or totalitarian regime, where a despot would execute any dissenter or invade and destroy an adjacent country at a whim.

Churchill made that statement in 1947. The internet, social media, and smartphones were science fiction back then. Those technological advances have added fuel to the political process and significantly stoked the flames of hyperpartisanship. It’s now democracy on steroids, where freedom of expression goes to extremes, highlighting the warts and pitfalls of the democratic system. Political rivals can now communicate their ferocious disagreements to millions of their disciples instantaneously, triggering immediate rebuttals and counterattacks by their adversaries. This “virtual guerilla warfare” is mentally and emotionally exhausting to all involved, especially to the subset of neutral bystanders who are unaffiliated with either political party, which, due to the “religification” of politics, have become like secular religions.⁵ Chronic, unremitting, inescapable stress is a sure pathway for anxiety, depression, posttraumatic stress disorder, and even brain atrophy.

Optimists may point out that the United States has weathered and emerged stronger from many serious traumas, including the Civil War (with its lethal divisiveness), World War I, the deadly 1918 influenza pandemic, the Great Depression, Pearl Harbor, World War II, the Cold War, the Vietnam War, the Watergate political scandal, the 9/11 terrorist attacks, the banking collapse and recession, and most recently the COVID-19 pandemic, which brought society to a standstill and induced so much anxiety and uncertainty.

On the other hand, pessimists would insist those sequential crises left indelible scars that cumulatively altered the mindset of political rivals, predisposing them to extreme views of each other. Alienation inevitably leads to fanaticism. It’s perplexing but fascinating how the fierce bidirectional missives of weaponized ideas can be as virulent and destructive as a traditional physical war. Perhaps in this era, the pen is mightier than the sword after all.

Continue to: From a psychiatric perspective...

From a psychiatric perspective, the intransigent groupthink of political partisanship eerily resembles folie en masse, a psychiatric syndrome for which there is no established treatment. It has become a serious threat to our modern democracy. So I decided to ask the “know-it-all” artificial intelligence ChatGPT, whom I previously had “invited” to write a “guest editorial” about myths surrounding psychiatry,⁶ to answer 3 burning questions:

1. Is there toxic hyperpartisanship in the USA today? (Box 1)

Box 1

2. How can severe hyperpartisanship be corrected? (Supplemental Box 1)

Supplemental Box 1

3. What can cause the collapse of a democracy? (Supplemental Box 2).

Supplemental Box 2

Judge for yourself, but I believe the ChatGPT responses were spot-on.

As psychiatrists know, many of our severely traumatized adult patients were victims of abuse during childhood. We routinely ask every new patient about physical, emotional, or sexual abuse when they were growing up because of the well-established, serious neurobiological and mental repercussions.^1,2

Perhaps one of the worst experiences for a child is to witness bitterly adversarial parents (their vital role models) who argue viciously, despise each other, and hurl insults (and even punches) at each other. Such a chronically and emotionally traumatic upbringing can haunt kids well into adulthood, disrupting their hypothalamic-pituitary-adrenal axis and triggering anxiety, depression, and even psychosis due to epigenetic changes that ultimately lead to abnormal brain development.³

It often feels that the governance of our country, or the national “political family,” is seriously fractured like a hopelessly dysfunctional family. Could that be negatively impacting the mental health of the citizenry? Having 2 antagonistic political parties expressing visceral hatred and undisguised contempt for each other 24/7 (thanks to the enabling era of cable TV, the internet, and social media) has transformed each party’s fanatic followers from fellow citizens to ideological combatants. In this poisonous societal zeitgeist of bidirectional acrimony and mutual detestation, the opposing parties and their “intellectual militias” label each other as “extremists” or “radicals.” They become completely blind to any redeeming social value in the ideas or principles of their political opponents. They spend enormous time and energy on undermining each other instead of attending to the myriad vital issues involved in the governance of a massive and complex country.

Winston Churchill said, “Democracy is the worst form of government, except for all the others that have been tried.”⁴ The current toxic cloud of intense “hyperpartisanship” is emblematic of the dark Machiavellian side of democracy. But those who lament the current distorted version of democracy should contemplate living in a dictatorship or totalitarian regime, where a despot would execute any dissenter or invade and destroy an adjacent country at a whim.

Churchill made that statement in 1947. The internet, social media, and smartphones were science fiction back then. Those technological advances have added fuel to the political process and significantly stoked the flames of hyperpartisanship. It’s now democracy on steroids, where freedom of expression goes to extremes, highlighting the warts and pitfalls of the democratic system. Political rivals can now communicate their ferocious disagreements to millions of their disciples instantaneously, triggering immediate rebuttals and counterattacks by their adversaries. This “virtual guerilla warfare” is mentally and emotionally exhausting to all involved, especially to the subset of neutral bystanders who are unaffiliated with either political party, which, due to the “religification” of politics, have become like secular religions.⁵ Chronic, unremitting, inescapable stress is a sure pathway for anxiety, depression, posttraumatic stress disorder, and even brain atrophy.

Optimists may point out that the United States has weathered and emerged stronger from many serious traumas, including the Civil War (with its lethal divisiveness), World War I, the deadly 1918 influenza pandemic, the Great Depression, Pearl Harbor, World War II, the Cold War, the Vietnam War, the Watergate political scandal, the 9/11 terrorist attacks, the banking collapse and recession, and most recently the COVID-19 pandemic, which brought society to a standstill and induced so much anxiety and uncertainty.

On the other hand, pessimists would insist those sequential crises left indelible scars that cumulatively altered the mindset of political rivals, predisposing them to extreme views of each other. Alienation inevitably leads to fanaticism. It’s perplexing but fascinating how the fierce bidirectional missives of weaponized ideas can be as virulent and destructive as a traditional physical war. Perhaps in this era, the pen is mightier than the sword after all.

Continue to: From a psychiatric perspective...

From a psychiatric perspective, the intransigent groupthink of political partisanship eerily resembles folie en masse, a psychiatric syndrome for which there is no established treatment. It has become a serious threat to our modern democracy. So I decided to ask the “know-it-all” artificial intelligence ChatGPT, whom I previously had “invited” to write a “guest editorial” about myths surrounding psychiatry,⁶ to answer 3 burning questions:

1. Is there toxic hyperpartisanship in the USA today? (Box 1)

Box 1

2. How can severe hyperpartisanship be corrected? (Supplemental Box 1)

Supplemental Box 1

3. What can cause the collapse of a democracy? (Supplemental Box 2).

Supplemental Box 2

Judge for yourself, but I believe the ChatGPT responses were spot-on.

As psychiatrists know, many of our severely traumatized adult patients were victims of abuse during childhood. We routinely ask every new patient about physical, emotional, or sexual abuse when they were growing up because of the well-established, serious neurobiological and mental repercussions.^1,2

Perhaps one of the worst experiences for a child is to witness bitterly adversarial parents (their vital role models) who argue viciously, despise each other, and hurl insults (and even punches) at each other. Such a chronically and emotionally traumatic upbringing can haunt kids well into adulthood, disrupting their hypothalamic-pituitary-adrenal axis and triggering anxiety, depression, and even psychosis due to epigenetic changes that ultimately lead to abnormal brain development.³

It often feels that the governance of our country, or the national “political family,” is seriously fractured like a hopelessly dysfunctional family. Could that be negatively impacting the mental health of the citizenry? Having 2 antagonistic political parties expressing visceral hatred and undisguised contempt for each other 24/7 (thanks to the enabling era of cable TV, the internet, and social media) has transformed each party’s fanatic followers from fellow citizens to ideological combatants. In this poisonous societal zeitgeist of bidirectional acrimony and mutual detestation, the opposing parties and their “intellectual militias” label each other as “extremists” or “radicals.” They become completely blind to any redeeming social value in the ideas or principles of their political opponents. They spend enormous time and energy on undermining each other instead of attending to the myriad vital issues involved in the governance of a massive and complex country.

Winston Churchill said, “Democracy is the worst form of government, except for all the others that have been tried.”⁴ The current toxic cloud of intense “hyperpartisanship” is emblematic of the dark Machiavellian side of democracy. But those who lament the current distorted version of democracy should contemplate living in a dictatorship or totalitarian regime, where a despot would execute any dissenter or invade and destroy an adjacent country at a whim.

Churchill made that statement in 1947. The internet, social media, and smartphones were science fiction back then. Those technological advances have added fuel to the political process and significantly stoked the flames of hyperpartisanship. It’s now democracy on steroids, where freedom of expression goes to extremes, highlighting the warts and pitfalls of the democratic system. Political rivals can now communicate their ferocious disagreements to millions of their disciples instantaneously, triggering immediate rebuttals and counterattacks by their adversaries. This “virtual guerilla warfare” is mentally and emotionally exhausting to all involved, especially to the subset of neutral bystanders who are unaffiliated with either political party, which, due to the “religification” of politics, have become like secular religions.⁵ Chronic, unremitting, inescapable stress is a sure pathway for anxiety, depression, posttraumatic stress disorder, and even brain atrophy.

Optimists may point out that the United States has weathered and emerged stronger from many serious traumas, including the Civil War (with its lethal divisiveness), World War I, the deadly 1918 influenza pandemic, the Great Depression, Pearl Harbor, World War II, the Cold War, the Vietnam War, the Watergate political scandal, the 9/11 terrorist attacks, the banking collapse and recession, and most recently the COVID-19 pandemic, which brought society to a standstill and induced so much anxiety and uncertainty.

On the other hand, pessimists would insist those sequential crises left indelible scars that cumulatively altered the mindset of political rivals, predisposing them to extreme views of each other. Alienation inevitably leads to fanaticism. It’s perplexing but fascinating how the fierce bidirectional missives of weaponized ideas can be as virulent and destructive as a traditional physical war. Perhaps in this era, the pen is mightier than the sword after all.

Continue to: From a psychiatric perspective...

From a psychiatric perspective, the intransigent groupthink of political partisanship eerily resembles folie en masse, a psychiatric syndrome for which there is no established treatment. It has become a serious threat to our modern democracy. So I decided to ask the “know-it-all” artificial intelligence ChatGPT, whom I previously had “invited” to write a “guest editorial” about myths surrounding psychiatry,⁶ to answer 3 burning questions:

1. Is there toxic hyperpartisanship in the USA today? (Box 1)

Box 1

2. How can severe hyperpartisanship be corrected? (Supplemental Box 1)

Supplemental Box 1

3. What can cause the collapse of a democracy? (Supplemental Box 2).

Supplemental Box 2

Judge for yourself, but I believe the ChatGPT responses were spot-on.

Written exposure therapy (WET) for posttraumatic stress disorder was just as effective as prolonged exposure therapy (PE), results of a new randomized clinical trial show.

Investigators also found that participants randomly assigned to receive WET were significantly less likely to drop out of treatment than those receiving PE.

Written exposure therapy involves writing about thoughts and feelings during a specific traumatic event during five supervised, 30-minute sessions and discussing the writing process with the therapist supervising the sessions.

In the latter sessions, the participant talks about how the event affected them.

“Clinicians should consider using WET in their practices as some clients would prefer a shorter treatment approach, and it may be the only option for some clients – for instance, those who have limited time for therapy and may not be able to do a longer treatment,” study investigator Denise Sloan, PhD, said in an interview.

She also noted that WET is covered by insurance and that “most providers I know indicate that they list it as CBT [cognitive-behavioral therapy] code to insurance companies.”

Sloan is senior clinician investigator of the National Center for PTSD at VA Boston Healthcare System and professor of psychiatry at Boston University.

The findings were published online in JAMA Psychiatry.
 

High attrition rates

The disadvantage to the three major types of therapy used most often to treat PTSD in veterans – eye movement desensitization and reprocessing, cognitive processing therapy (CPT), and PE – are the dropout rates, that range from 18% to as high as 50%.

Prior studies have shown that WET is briefer and just as effective as CPT, but investigators noted that it had never been tested against PE in a randomized clinical trial.

To find out how the two types of therapy compare, Dr. Sloan and associates randomized 178 veterans with PTSD from three VA centers – Boston; Charleston, S.C.; and Madison, Wisc. – to receive either WET or PE.

PE consisted of 8-15 90-minute therapy sessions during which participants imagine the most distressing aspect of their traumatic memory, and between sessions, they confront the people, places, or situations they have been avoiding because of the trauma.

The investigators used the Structured Clinical Interview for DSM-5 at baseline to screen participants at high risk for suicide, comorbid substance use disorder, and unstable bipolar disorder, who were excluded from the study.

At baseline, 10, 20, and 30 weeks after the first treatment session, the investigators measured the severity of each patient’s PTSD symptoms with the Clinician-Administered PTSD Scale for DSM-5, which has a range of 0 (no PTSD symptoms) to 80 (most severe PTSD symptoms).

Of the 178 veterans, 134 were men, and their mean age was 45 years. The majority (63%) was White, while 21% were Black.

The researchers found that study participants were not significantly more likely to meet PTSD diagnostic criteria in the WET or PE conditions at any assessment.
 

WET briefer, better retention

Investigators noted the largest difference in PTSD scores in favor of WET at the 10-month assessment: The mean score for those receiving WET was 27.7, and the mean score for those receiving PE was 30.1 (odds ratio, 0.72; 95% CI, 0.35-1.46).

Among those who finished treatment, the mean number of treatment sessions was 12.5 for PE and 6 for WET.

Participants assigned to receive PE were significantly more likely to drop out of the study prematurely; 32 (35.6%) dropped out, compared with 11 (12.5%) participants assigned to WET.

Notably, of the 32 participants who dropped out of PE, 30 did so by session 7, so the increased dropout in PE was not related to the greater number of sessions, the investigators noted.

They added that findings could have been limited by stressors related to the global COVID-19 pandemic, which was taking place during the treatment, and the fact that all of the participants were veterans, which could limit the generalizability of the findings.

In an editorial, Charles Taylor, PhD, and Murray Stein, MD, MPH, both from the department of psychiatry at the University of California, San Diego, wrote that “WET achieved comparable reductions in PTSD symptoms through fewer sessions, shorter duration sessions, less therapist involvement, and no explicit prescription of homework.

“These findings should galvanize the psychotherapy field to design parsimonious treatments from the start, systematically testing the effects of different dose parameters,” they concluded.

The study was supported by the VA. Dr. Sloan reported receiving royalty payments for the published Written Exposure Therapy manual from the American Psychological Association outside the submitted work.

A version of this article appeared on Medscape.com.

Written exposure therapy (WET) for posttraumatic stress disorder was just as effective as prolonged exposure therapy (PE), results of a new randomized clinical trial show.

Investigators also found that participants randomly assigned to receive WET were significantly less likely to drop out of treatment than those receiving PE.

Written exposure therapy involves writing about thoughts and feelings during a specific traumatic event during five supervised, 30-minute sessions and discussing the writing process with the therapist supervising the sessions.

In the latter sessions, the participant talks about how the event affected them.

“Clinicians should consider using WET in their practices as some clients would prefer a shorter treatment approach, and it may be the only option for some clients – for instance, those who have limited time for therapy and may not be able to do a longer treatment,” study investigator Denise Sloan, PhD, said in an interview.

She also noted that WET is covered by insurance and that “most providers I know indicate that they list it as CBT [cognitive-behavioral therapy] code to insurance companies.”

Sloan is senior clinician investigator of the National Center for PTSD at VA Boston Healthcare System and professor of psychiatry at Boston University.

The findings were published online in JAMA Psychiatry.
 

High attrition rates

The disadvantage to the three major types of therapy used most often to treat PTSD in veterans – eye movement desensitization and reprocessing, cognitive processing therapy (CPT), and PE – are the dropout rates, that range from 18% to as high as 50%.

Prior studies have shown that WET is briefer and just as effective as CPT, but investigators noted that it had never been tested against PE in a randomized clinical trial.

To find out how the two types of therapy compare, Dr. Sloan and associates randomized 178 veterans with PTSD from three VA centers – Boston; Charleston, S.C.; and Madison, Wisc. – to receive either WET or PE.

PE consisted of 8-15 90-minute therapy sessions during which participants imagine the most distressing aspect of their traumatic memory, and between sessions, they confront the people, places, or situations they have been avoiding because of the trauma.

The investigators used the Structured Clinical Interview for DSM-5 at baseline to screen participants at high risk for suicide, comorbid substance use disorder, and unstable bipolar disorder, who were excluded from the study.

At baseline, 10, 20, and 30 weeks after the first treatment session, the investigators measured the severity of each patient’s PTSD symptoms with the Clinician-Administered PTSD Scale for DSM-5, which has a range of 0 (no PTSD symptoms) to 80 (most severe PTSD symptoms).

Of the 178 veterans, 134 were men, and their mean age was 45 years. The majority (63%) was White, while 21% were Black.

The researchers found that study participants were not significantly more likely to meet PTSD diagnostic criteria in the WET or PE conditions at any assessment.
 

WET briefer, better retention

Investigators noted the largest difference in PTSD scores in favor of WET at the 10-month assessment: The mean score for those receiving WET was 27.7, and the mean score for those receiving PE was 30.1 (odds ratio, 0.72; 95% CI, 0.35-1.46).

Among those who finished treatment, the mean number of treatment sessions was 12.5 for PE and 6 for WET.

Participants assigned to receive PE were significantly more likely to drop out of the study prematurely; 32 (35.6%) dropped out, compared with 11 (12.5%) participants assigned to WET.

Notably, of the 32 participants who dropped out of PE, 30 did so by session 7, so the increased dropout in PE was not related to the greater number of sessions, the investigators noted.

They added that findings could have been limited by stressors related to the global COVID-19 pandemic, which was taking place during the treatment, and the fact that all of the participants were veterans, which could limit the generalizability of the findings.

In an editorial, Charles Taylor, PhD, and Murray Stein, MD, MPH, both from the department of psychiatry at the University of California, San Diego, wrote that “WET achieved comparable reductions in PTSD symptoms through fewer sessions, shorter duration sessions, less therapist involvement, and no explicit prescription of homework.

“These findings should galvanize the psychotherapy field to design parsimonious treatments from the start, systematically testing the effects of different dose parameters,” they concluded.

The study was supported by the VA. Dr. Sloan reported receiving royalty payments for the published Written Exposure Therapy manual from the American Psychological Association outside the submitted work.

A version of this article appeared on Medscape.com.

Written exposure therapy (WET) for posttraumatic stress disorder was just as effective as prolonged exposure therapy (PE), results of a new randomized clinical trial show.

Investigators also found that participants randomly assigned to receive WET were significantly less likely to drop out of treatment than those receiving PE.

Written exposure therapy involves writing about thoughts and feelings during a specific traumatic event during five supervised, 30-minute sessions and discussing the writing process with the therapist supervising the sessions.

In the latter sessions, the participant talks about how the event affected them.

“Clinicians should consider using WET in their practices as some clients would prefer a shorter treatment approach, and it may be the only option for some clients – for instance, those who have limited time for therapy and may not be able to do a longer treatment,” study investigator Denise Sloan, PhD, said in an interview.

She also noted that WET is covered by insurance and that “most providers I know indicate that they list it as CBT [cognitive-behavioral therapy] code to insurance companies.”

Sloan is senior clinician investigator of the National Center for PTSD at VA Boston Healthcare System and professor of psychiatry at Boston University.

The findings were published online in JAMA Psychiatry.
 

High attrition rates

The disadvantage to the three major types of therapy used most often to treat PTSD in veterans – eye movement desensitization and reprocessing, cognitive processing therapy (CPT), and PE – are the dropout rates, that range from 18% to as high as 50%.

Prior studies have shown that WET is briefer and just as effective as CPT, but investigators noted that it had never been tested against PE in a randomized clinical trial.

To find out how the two types of therapy compare, Dr. Sloan and associates randomized 178 veterans with PTSD from three VA centers – Boston; Charleston, S.C.; and Madison, Wisc. – to receive either WET or PE.

PE consisted of 8-15 90-minute therapy sessions during which participants imagine the most distressing aspect of their traumatic memory, and between sessions, they confront the people, places, or situations they have been avoiding because of the trauma.

The investigators used the Structured Clinical Interview for DSM-5 at baseline to screen participants at high risk for suicide, comorbid substance use disorder, and unstable bipolar disorder, who were excluded from the study.

At baseline, 10, 20, and 30 weeks after the first treatment session, the investigators measured the severity of each patient’s PTSD symptoms with the Clinician-Administered PTSD Scale for DSM-5, which has a range of 0 (no PTSD symptoms) to 80 (most severe PTSD symptoms).

Of the 178 veterans, 134 were men, and their mean age was 45 years. The majority (63%) was White, while 21% were Black.

The researchers found that study participants were not significantly more likely to meet PTSD diagnostic criteria in the WET or PE conditions at any assessment.
 

WET briefer, better retention

Investigators noted the largest difference in PTSD scores in favor of WET at the 10-month assessment: The mean score for those receiving WET was 27.7, and the mean score for those receiving PE was 30.1 (odds ratio, 0.72; 95% CI, 0.35-1.46).

Among those who finished treatment, the mean number of treatment sessions was 12.5 for PE and 6 for WET.

Participants assigned to receive PE were significantly more likely to drop out of the study prematurely; 32 (35.6%) dropped out, compared with 11 (12.5%) participants assigned to WET.

Notably, of the 32 participants who dropped out of PE, 30 did so by session 7, so the increased dropout in PE was not related to the greater number of sessions, the investigators noted.

They added that findings could have been limited by stressors related to the global COVID-19 pandemic, which was taking place during the treatment, and the fact that all of the participants were veterans, which could limit the generalizability of the findings.

In an editorial, Charles Taylor, PhD, and Murray Stein, MD, MPH, both from the department of psychiatry at the University of California, San Diego, wrote that “WET achieved comparable reductions in PTSD symptoms through fewer sessions, shorter duration sessions, less therapist involvement, and no explicit prescription of homework.

“These findings should galvanize the psychotherapy field to design parsimonious treatments from the start, systematically testing the effects of different dose parameters,” they concluded.

The study was supported by the VA. Dr. Sloan reported receiving royalty payments for the published Written Exposure Therapy manual from the American Psychological Association outside the submitted work.

A version of this article appeared on Medscape.com.

The risks of common postpartum mental health (PMH) problems may soon be more predictable, thanks to a new comprehensive index for identifying mothers’ 1-year risk at time of delivery.

Developed by Canadian researchers, the easily implementable PMH CAREPLAN index “creates a framework for clinically actionable risk stratification that could assist patients and providers in determining an individual’s level of risk for common postpartum mental health disorders and direct them to appropriate intervention,” wrote a group led by Simone N. Vigod, MD, MSc, head of the department of psychiatry at Women’s College Hospital, Toronto, in the British Journal of Psychiatry.

courtesy Women's College Hospital

After giving birth, women are especially vulnerable to major depression, anxiety, PTSD, and obsessive-compulsive disorder, which have a general postpartum prevalence of 7%-20%.

Common PMH disorders are to be distinguished from the more rare but severe PMH disorders such as postpartum psychosis and bipolar disorder, the researchers stressed.

“We know there are interventions that can prevent these disorders, but these seem to work best in people who are at high risk for developing the illnesses, “ Dr. Vigod said. “So, we wanted to be able to determine the level of risk that a person might actually experience them.”

In an ideal world, she continued, physicians might be able to say to a patient: “You have a 50% chance of developing postpartum depression and anxiety, so it may be worth investing your time and resources in a course of preventive psychotherapy.” Or: “You have a 90% chance of developing these disorders, so it might be worth going back on your medications even though you are breastfeeding.” Or: “You have only a 1% chance of developing them, so probably it’s not worthwhile to go back on your medication prophylactically.”

A need for a new assessment tool, akin to the Framingham Risk Score for 10-year cardiovascular events and the FRAX scoring system for 10-year fracture risk, was evident since previous indices based largely on patient self-reporting have had moderate predictive capacity, and have not been adopted in clinical practice, Dr. Vigod and associates noted.
 

Split-cohort design

Using population-based health administrative data and hospital birth records from Ontario during 2012-2015, Dr. Vigod’s group created and internally validated a predictive model for common PMH disorders in a cohort of 152,362 mothers. They then converted it to a risk index after validation in an additional cohort of 75,772 mothers. The women had delivered live infants during 2012-2014.

A common PMH disorder occurred in 13,608 mothers, while 214,526 were unaffected.

Independently associated PMH variables were many: prenatal care provider, mental health diagnosis history and medications during pregnancy, psychiatric hospital admissions or ED visits, conception type and complications, and apprehension of newborn by child services. Other factors were region of maternal origin, extremes of gestational age at birth, primary maternal language, lactation intention, maternal age, and number of prenatal visits.

Based on a broad span of scores from 0 to 39, 1-year common PMH disorder risk ranged from 1.5% to 40.5%, with an overall 1-year prevalence of 6%, consistent with previous studies. That included 11,262 (5%) mothers with an anxiety or related disorder, 3,392 (1.5%) with a depressive episode, and 1,046 (0.5%) with both. The best trade-off of sensitivity/specificity for risk appeared to be at a screening threshold score of 17 or above.
 

Risk drivers

PMH-affected mothers were slightly younger than unaffected women (mean age, 29.9 years vs. 30.6 years), more likely to be primiparous (45.2% vs. 42%), and less likely to be recent immigrants (16.7% vs. 27.2%).

They were also more likely to have previously experienced postpartum depression (4.4% vs. 1.4%), any depression (15.3% vs. 4.4%), and any anxiety disorder (13.8% vs. 4.3%).

As to lifestyle, smoking was more common in women with PMH (15.0% vs. 10.2%), as were the use of nonprescribed substances (3% vs. 1.4%) and intimate partner violence in pregnancy (2.7% vs. 1.5%).

In addition, the affected group experienced more pregnancy complications than their unaffected peers (16% vs. 13.9%), preterm birth (8.2% vs. 6.8%), and Apgar scores below 7 at 1 or 5 minutes (10.5% vs. 7.6%).

Low income did not appear to have an impact since just over 20% in either group fell into the lowest neighborhood income quintile.

courtesy Northwestern Medicine

Commenting on the index but not involved in developing it, LaTasha D. Nelson, MD, an associate professor or medicine and a maternal-fetal medicine specialist at Northwestern Medicine in Chicago, doubted the Canadian model would work as well in the more fragmented U.S. health care system, compared with Canada’s universal model with its large provincial health databases.

She also found the large number of variables and broad score range potentially problematic, especially if the risk threshold is set at less than half the maximum score at 17, at which some low-risk mothers might get screening and perhaps intervention. “Are we going to use up the resources we have for those who might not need help, or are we going to treat someone who really needs it?” she asked.

Another concern is the postpartum timing of assessment. At Dr. Nelson’s center, mothers are checked for mental health at two points during pregnancy and those with higher scores are triaged for further care.

Dr. Nelson was also puzzled by the score-lowering impact of prenatal care given by a nurse practitioner and “other” provider : –5 and –2, respectively, versus +3 for a midwife and +1 for a family doctor. “This may capture more relaxed, easy-going multiparous mothers who felt comfortable turning to an NP,” she said.

It may indeed reflect that the risk level of a person who sees those providers is overall lower, Dr. Vigod agreed. “This is one reason why we would want to see replication of these results in other jurisdictions and by other ways of diagnosis before putting it out into clinical practice.”

As to the score-lowering effect of not speaking English as the primary tongue, Dr. Nelson wondered, “is that because we’re taking better care of mothers who speak the main language and missing those who speak other languages? Are they not getting the same level of interrogation?”

It may be that individuals in these groups were less likely to access mental health care, Dr. Vigod agreed, or it might reflect the so-called healthy immigrant effect or culturally different levels of postpartum support. “It might mean that there are more people who benefit from community-level protective factors in these groups. We know that social support is an important protective factor.”

Despite her reservations about the index, Dr. Nelson said that increasing attention to the pre- and postnatal mental health of mothers is an important part of maternal care. “This is an issue that needs to be recognized.”

The next step, Dr. Vigod said, is to determine whether the index holds up in other populations. “Then, we would want to test it out to see if recommending interventions based on a certain level of risk improves outcomes. At what percentage risk would starting an antidepressant medication result in a reduced risk for postpartum depression or anxiety – 90%, 80%, 70%, or less?”

The study received funding from the Canadian Institutes of Health Research. Data were analyzed by ICES, an independent nonprofit research organization that holds population-based data. Dr. Vigod reported royalties from UpToDate for materials related to depression and pregnancy. Dr. Nelson disclosed no relevant competing interests.

The risks of common postpartum mental health (PMH) problems may soon be more predictable, thanks to a new comprehensive index for identifying mothers’ 1-year risk at time of delivery.

Developed by Canadian researchers, the easily implementable PMH CAREPLAN index “creates a framework for clinically actionable risk stratification that could assist patients and providers in determining an individual’s level of risk for common postpartum mental health disorders and direct them to appropriate intervention,” wrote a group led by Simone N. Vigod, MD, MSc, head of the department of psychiatry at Women’s College Hospital, Toronto, in the British Journal of Psychiatry.

courtesy Women's College Hospital

After giving birth, women are especially vulnerable to major depression, anxiety, PTSD, and obsessive-compulsive disorder, which have a general postpartum prevalence of 7%-20%.

Common PMH disorders are to be distinguished from the more rare but severe PMH disorders such as postpartum psychosis and bipolar disorder, the researchers stressed.

“We know there are interventions that can prevent these disorders, but these seem to work best in people who are at high risk for developing the illnesses, “ Dr. Vigod said. “So, we wanted to be able to determine the level of risk that a person might actually experience them.”

In an ideal world, she continued, physicians might be able to say to a patient: “You have a 50% chance of developing postpartum depression and anxiety, so it may be worth investing your time and resources in a course of preventive psychotherapy.” Or: “You have a 90% chance of developing these disorders, so it might be worth going back on your medications even though you are breastfeeding.” Or: “You have only a 1% chance of developing them, so probably it’s not worthwhile to go back on your medication prophylactically.”

A need for a new assessment tool, akin to the Framingham Risk Score for 10-year cardiovascular events and the FRAX scoring system for 10-year fracture risk, was evident since previous indices based largely on patient self-reporting have had moderate predictive capacity, and have not been adopted in clinical practice, Dr. Vigod and associates noted.
 

Split-cohort design

Using population-based health administrative data and hospital birth records from Ontario during 2012-2015, Dr. Vigod’s group created and internally validated a predictive model for common PMH disorders in a cohort of 152,362 mothers. They then converted it to a risk index after validation in an additional cohort of 75,772 mothers. The women had delivered live infants during 2012-2014.

A common PMH disorder occurred in 13,608 mothers, while 214,526 were unaffected.

Independently associated PMH variables were many: prenatal care provider, mental health diagnosis history and medications during pregnancy, psychiatric hospital admissions or ED visits, conception type and complications, and apprehension of newborn by child services. Other factors were region of maternal origin, extremes of gestational age at birth, primary maternal language, lactation intention, maternal age, and number of prenatal visits.

Based on a broad span of scores from 0 to 39, 1-year common PMH disorder risk ranged from 1.5% to 40.5%, with an overall 1-year prevalence of 6%, consistent with previous studies. That included 11,262 (5%) mothers with an anxiety or related disorder, 3,392 (1.5%) with a depressive episode, and 1,046 (0.5%) with both. The best trade-off of sensitivity/specificity for risk appeared to be at a screening threshold score of 17 or above.
 

Risk drivers

PMH-affected mothers were slightly younger than unaffected women (mean age, 29.9 years vs. 30.6 years), more likely to be primiparous (45.2% vs. 42%), and less likely to be recent immigrants (16.7% vs. 27.2%).

They were also more likely to have previously experienced postpartum depression (4.4% vs. 1.4%), any depression (15.3% vs. 4.4%), and any anxiety disorder (13.8% vs. 4.3%).

As to lifestyle, smoking was more common in women with PMH (15.0% vs. 10.2%), as were the use of nonprescribed substances (3% vs. 1.4%) and intimate partner violence in pregnancy (2.7% vs. 1.5%).

In addition, the affected group experienced more pregnancy complications than their unaffected peers (16% vs. 13.9%), preterm birth (8.2% vs. 6.8%), and Apgar scores below 7 at 1 or 5 minutes (10.5% vs. 7.6%).

Low income did not appear to have an impact since just over 20% in either group fell into the lowest neighborhood income quintile.

courtesy Northwestern Medicine

Commenting on the index but not involved in developing it, LaTasha D. Nelson, MD, an associate professor or medicine and a maternal-fetal medicine specialist at Northwestern Medicine in Chicago, doubted the Canadian model would work as well in the more fragmented U.S. health care system, compared with Canada’s universal model with its large provincial health databases.

She also found the large number of variables and broad score range potentially problematic, especially if the risk threshold is set at less than half the maximum score at 17, at which some low-risk mothers might get screening and perhaps intervention. “Are we going to use up the resources we have for those who might not need help, or are we going to treat someone who really needs it?” she asked.

Another concern is the postpartum timing of assessment. At Dr. Nelson’s center, mothers are checked for mental health at two points during pregnancy and those with higher scores are triaged for further care.

Dr. Nelson was also puzzled by the score-lowering impact of prenatal care given by a nurse practitioner and “other” provider : –5 and –2, respectively, versus +3 for a midwife and +1 for a family doctor. “This may capture more relaxed, easy-going multiparous mothers who felt comfortable turning to an NP,” she said.

It may indeed reflect that the risk level of a person who sees those providers is overall lower, Dr. Vigod agreed. “This is one reason why we would want to see replication of these results in other jurisdictions and by other ways of diagnosis before putting it out into clinical practice.”

As to the score-lowering effect of not speaking English as the primary tongue, Dr. Nelson wondered, “is that because we’re taking better care of mothers who speak the main language and missing those who speak other languages? Are they not getting the same level of interrogation?”

It may be that individuals in these groups were less likely to access mental health care, Dr. Vigod agreed, or it might reflect the so-called healthy immigrant effect or culturally different levels of postpartum support. “It might mean that there are more people who benefit from community-level protective factors in these groups. We know that social support is an important protective factor.”

Despite her reservations about the index, Dr. Nelson said that increasing attention to the pre- and postnatal mental health of mothers is an important part of maternal care. “This is an issue that needs to be recognized.”

The next step, Dr. Vigod said, is to determine whether the index holds up in other populations. “Then, we would want to test it out to see if recommending interventions based on a certain level of risk improves outcomes. At what percentage risk would starting an antidepressant medication result in a reduced risk for postpartum depression or anxiety – 90%, 80%, 70%, or less?”

The study received funding from the Canadian Institutes of Health Research. Data were analyzed by ICES, an independent nonprofit research organization that holds population-based data. Dr. Vigod reported royalties from UpToDate for materials related to depression and pregnancy. Dr. Nelson disclosed no relevant competing interests.

The risks of common postpartum mental health (PMH) problems may soon be more predictable, thanks to a new comprehensive index for identifying mothers’ 1-year risk at time of delivery.

Developed by Canadian researchers, the easily implementable PMH CAREPLAN index “creates a framework for clinically actionable risk stratification that could assist patients and providers in determining an individual’s level of risk for common postpartum mental health disorders and direct them to appropriate intervention,” wrote a group led by Simone N. Vigod, MD, MSc, head of the department of psychiatry at Women’s College Hospital, Toronto, in the British Journal of Psychiatry.

courtesy Women's College Hospital

After giving birth, women are especially vulnerable to major depression, anxiety, PTSD, and obsessive-compulsive disorder, which have a general postpartum prevalence of 7%-20%.

Common PMH disorders are to be distinguished from the more rare but severe PMH disorders such as postpartum psychosis and bipolar disorder, the researchers stressed.

“We know there are interventions that can prevent these disorders, but these seem to work best in people who are at high risk for developing the illnesses, “ Dr. Vigod said. “So, we wanted to be able to determine the level of risk that a person might actually experience them.”

In an ideal world, she continued, physicians might be able to say to a patient: “You have a 50% chance of developing postpartum depression and anxiety, so it may be worth investing your time and resources in a course of preventive psychotherapy.” Or: “You have a 90% chance of developing these disorders, so it might be worth going back on your medications even though you are breastfeeding.” Or: “You have only a 1% chance of developing them, so probably it’s not worthwhile to go back on your medication prophylactically.”

A need for a new assessment tool, akin to the Framingham Risk Score for 10-year cardiovascular events and the FRAX scoring system for 10-year fracture risk, was evident since previous indices based largely on patient self-reporting have had moderate predictive capacity, and have not been adopted in clinical practice, Dr. Vigod and associates noted.
 

Split-cohort design

Using population-based health administrative data and hospital birth records from Ontario during 2012-2015, Dr. Vigod’s group created and internally validated a predictive model for common PMH disorders in a cohort of 152,362 mothers. They then converted it to a risk index after validation in an additional cohort of 75,772 mothers. The women had delivered live infants during 2012-2014.

A common PMH disorder occurred in 13,608 mothers, while 214,526 were unaffected.

Independently associated PMH variables were many: prenatal care provider, mental health diagnosis history and medications during pregnancy, psychiatric hospital admissions or ED visits, conception type and complications, and apprehension of newborn by child services. Other factors were region of maternal origin, extremes of gestational age at birth, primary maternal language, lactation intention, maternal age, and number of prenatal visits.

Based on a broad span of scores from 0 to 39, 1-year common PMH disorder risk ranged from 1.5% to 40.5%, with an overall 1-year prevalence of 6%, consistent with previous studies. That included 11,262 (5%) mothers with an anxiety or related disorder, 3,392 (1.5%) with a depressive episode, and 1,046 (0.5%) with both. The best trade-off of sensitivity/specificity for risk appeared to be at a screening threshold score of 17 or above.
 

Risk drivers

PMH-affected mothers were slightly younger than unaffected women (mean age, 29.9 years vs. 30.6 years), more likely to be primiparous (45.2% vs. 42%), and less likely to be recent immigrants (16.7% vs. 27.2%).

They were also more likely to have previously experienced postpartum depression (4.4% vs. 1.4%), any depression (15.3% vs. 4.4%), and any anxiety disorder (13.8% vs. 4.3%).

As to lifestyle, smoking was more common in women with PMH (15.0% vs. 10.2%), as were the use of nonprescribed substances (3% vs. 1.4%) and intimate partner violence in pregnancy (2.7% vs. 1.5%).

In addition, the affected group experienced more pregnancy complications than their unaffected peers (16% vs. 13.9%), preterm birth (8.2% vs. 6.8%), and Apgar scores below 7 at 1 or 5 minutes (10.5% vs. 7.6%).

Low income did not appear to have an impact since just over 20% in either group fell into the lowest neighborhood income quintile.

courtesy Northwestern Medicine

Commenting on the index but not involved in developing it, LaTasha D. Nelson, MD, an associate professor or medicine and a maternal-fetal medicine specialist at Northwestern Medicine in Chicago, doubted the Canadian model would work as well in the more fragmented U.S. health care system, compared with Canada’s universal model with its large provincial health databases.

She also found the large number of variables and broad score range potentially problematic, especially if the risk threshold is set at less than half the maximum score at 17, at which some low-risk mothers might get screening and perhaps intervention. “Are we going to use up the resources we have for those who might not need help, or are we going to treat someone who really needs it?” she asked.

Another concern is the postpartum timing of assessment. At Dr. Nelson’s center, mothers are checked for mental health at two points during pregnancy and those with higher scores are triaged for further care.

Dr. Nelson was also puzzled by the score-lowering impact of prenatal care given by a nurse practitioner and “other” provider : –5 and –2, respectively, versus +3 for a midwife and +1 for a family doctor. “This may capture more relaxed, easy-going multiparous mothers who felt comfortable turning to an NP,” she said.

It may indeed reflect that the risk level of a person who sees those providers is overall lower, Dr. Vigod agreed. “This is one reason why we would want to see replication of these results in other jurisdictions and by other ways of diagnosis before putting it out into clinical practice.”

As to the score-lowering effect of not speaking English as the primary tongue, Dr. Nelson wondered, “is that because we’re taking better care of mothers who speak the main language and missing those who speak other languages? Are they not getting the same level of interrogation?”

It may be that individuals in these groups were less likely to access mental health care, Dr. Vigod agreed, or it might reflect the so-called healthy immigrant effect or culturally different levels of postpartum support. “It might mean that there are more people who benefit from community-level protective factors in these groups. We know that social support is an important protective factor.”

Despite her reservations about the index, Dr. Nelson said that increasing attention to the pre- and postnatal mental health of mothers is an important part of maternal care. “This is an issue that needs to be recognized.”

The next step, Dr. Vigod said, is to determine whether the index holds up in other populations. “Then, we would want to test it out to see if recommending interventions based on a certain level of risk improves outcomes. At what percentage risk would starting an antidepressant medication result in a reduced risk for postpartum depression or anxiety – 90%, 80%, 70%, or less?”

The study received funding from the Canadian Institutes of Health Research. Data were analyzed by ICES, an independent nonprofit research organization that holds population-based data. Dr. Vigod reported royalties from UpToDate for materials related to depression and pregnancy. Dr. Nelson disclosed no relevant competing interests.

As children learn to walk and talk, their brains are remarkably open to new information. They gather knowledge from parents, their environment, and trial and error. Teenagers do too, as they adopt the emotional and intellectual skills needed to become adults. 

In adulthood, however, our minds become relatively locked, closed to new information. This saves energy and lets us navigate the world more efficiently. But that also makes it harder to adapt, learn a new language or skill, or recover from psychological or physical trauma. For those who’ve dealt with abuse, abandonment, or physical violence, that lockdown can lead to a lifetime of suffering, substance abuse, and other maladaptive behaviors.

But recent research offers promise that psychedelic drugs may “reopen” the brain to help it recover from trauma. The study, published in Nature, reflects a renaissance of using and researching psychedelics to treat a range of mental health conditions. 

Scientists at Johns Hopkins University in Baltimore were investigating the drugs’ effects on “critical periods” for social learning, times when the brain is more open to new information that diminish as we age. Success in mice suggests that psychedelics can start a fresh period of learning.

If the finding bears out in future studies, the therapeutic horizon for psychedelics could expand to other opportunities to retrain the brain, including recovery from a stroke, traumatic brain injury, and even hearing loss and paralysis. 

The stakes are big, and the future is promising, said lead researcher Gul Dolen, MD, PhD, an associate professor of neuroscience at Johns Hopkins University. Psychedelics “could be the key that unlocks the brain and helps people after one dose, rather than subjecting them to a lifetime of drugs.” 
 

The psychedelic advantage

Dr. Dolen, who launched her career in addiction studies, has long been fascinated by critical periods and their influence on adult behavior. 

“There have been three Nobel Prizes awarded for work on critical periods,” she said. One study in mice, for instance, identified 15 periods of social learning that define their behaviors for a lifetime. 

Prior research has found that MDMA (commonly known as ecstasy) can help soldiers reconsider traumatic events on the battlefield, learn from them, and move on. That phenomenon had all the earmarks of a critical period for social learning. Perhaps, Dr. Dolen said, psychedelics could open a critical period in a soldier’s life – or a drug-addicted person’s or rape survivor’s – and give them tools to process their trauma.

In the placebo-controlled experiment, she and her team gave mice psychedelic drugs and a behavioral test to gauge the rodents’ ability to learn from their environment. 

“All of the psychedelics opened the critical period of social learning for varying lengths of time,” said Dr. Dolen. 

Ketamine achieved that reopening for 2 days, while the other drugs – ibogaine, LSD, MDMA, and psilocybin – opened critical periods of between 2 and 4 weeks, long after the drugs’ acute effects had worn off.

In humans, Dr. Dolen stressed, opening a critical period would be a sensitive process. 

“You wouldn’t achieve these results if you dropped ecstasy and attended a rave,” she said. “The key seems to be to establish an intention for the therapy: Discuss what you hope to get from the experience, be guided through it, and process it with the therapist after the fact.” 

“You need to be careful with a patient once they’re off the psychedelic,” she said, “because they’re in a state of openness and vulnerability similar to a child.” 
 

The push for psychedelic therapy

Another psychedelics researcher, Matthew Lowe, PhD, sees promise in the Johns Hopkins study. The drugs “place the brain in a more malleable and flexible state,” said Dr. Lowe, the executive director and chief science officer for Unlimited Sciences, a psychedelics research nonprofit.

He expects that psychedelics may help people break out of negative behavior patterns. 

“These findings show significant promise for treating a wide range of neuropsychiatric diseases, including depression, PTSD, and addiction,” he said. 

Dr. Dolen said using psychedelics in critical-period therapy “opens up all sorts of possibilities for the rest of the brain.” Future research may also lead to treatments for deafness, physical disabilities, and drug and alcohol addiction. She is currently raising funds for a clinical trial to see if psychedelics can improve motor impairment after a stroke. 

“Growing legislative openness” to the use of psychedelics could open the door for millions to benefit from mental health treatment “through clinical trials and legal therapeutic pathways as they open up,” said Benjamin Lightburn, CEO and cofounder of Filament Health, a company based in British Columbia that provides naturally derived psilocybin for clinical trials. 

Several states have made moves toward decriminalization or permitting the drugs’ use under medical supervision. In a scientific paper, Washington University researchers, using an analytic model based on marijuana legalization, projected that most states will legalize psychedelics in the next 10-15 years. And on July 1, Australia became the first country to allow psilocybin and MDMA to be prescribed by doctors to treat psychiatric conditions. The U.S. could potentially approve MDMA for therapy later in 2023.

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

As children learn to walk and talk, their brains are remarkably open to new information. They gather knowledge from parents, their environment, and trial and error. Teenagers do too, as they adopt the emotional and intellectual skills needed to become adults. 

In adulthood, however, our minds become relatively locked, closed to new information. This saves energy and lets us navigate the world more efficiently. But that also makes it harder to adapt, learn a new language or skill, or recover from psychological or physical trauma. For those who’ve dealt with abuse, abandonment, or physical violence, that lockdown can lead to a lifetime of suffering, substance abuse, and other maladaptive behaviors.

But recent research offers promise that psychedelic drugs may “reopen” the brain to help it recover from trauma. The study, published in Nature, reflects a renaissance of using and researching psychedelics to treat a range of mental health conditions. 

Scientists at Johns Hopkins University in Baltimore were investigating the drugs’ effects on “critical periods” for social learning, times when the brain is more open to new information that diminish as we age. Success in mice suggests that psychedelics can start a fresh period of learning.

If the finding bears out in future studies, the therapeutic horizon for psychedelics could expand to other opportunities to retrain the brain, including recovery from a stroke, traumatic brain injury, and even hearing loss and paralysis. 

The stakes are big, and the future is promising, said lead researcher Gul Dolen, MD, PhD, an associate professor of neuroscience at Johns Hopkins University. Psychedelics “could be the key that unlocks the brain and helps people after one dose, rather than subjecting them to a lifetime of drugs.” 
 

The psychedelic advantage

Dr. Dolen, who launched her career in addiction studies, has long been fascinated by critical periods and their influence on adult behavior. 

“There have been three Nobel Prizes awarded for work on critical periods,” she said. One study in mice, for instance, identified 15 periods of social learning that define their behaviors for a lifetime. 

Prior research has found that MDMA (commonly known as ecstasy) can help soldiers reconsider traumatic events on the battlefield, learn from them, and move on. That phenomenon had all the earmarks of a critical period for social learning. Perhaps, Dr. Dolen said, psychedelics could open a critical period in a soldier’s life – or a drug-addicted person’s or rape survivor’s – and give them tools to process their trauma.

In the placebo-controlled experiment, she and her team gave mice psychedelic drugs and a behavioral test to gauge the rodents’ ability to learn from their environment. 

“All of the psychedelics opened the critical period of social learning for varying lengths of time,” said Dr. Dolen. 

Ketamine achieved that reopening for 2 days, while the other drugs – ibogaine, LSD, MDMA, and psilocybin – opened critical periods of between 2 and 4 weeks, long after the drugs’ acute effects had worn off.

In humans, Dr. Dolen stressed, opening a critical period would be a sensitive process. 

“You wouldn’t achieve these results if you dropped ecstasy and attended a rave,” she said. “The key seems to be to establish an intention for the therapy: Discuss what you hope to get from the experience, be guided through it, and process it with the therapist after the fact.” 

“You need to be careful with a patient once they’re off the psychedelic,” she said, “because they’re in a state of openness and vulnerability similar to a child.” 
 

The push for psychedelic therapy

Another psychedelics researcher, Matthew Lowe, PhD, sees promise in the Johns Hopkins study. The drugs “place the brain in a more malleable and flexible state,” said Dr. Lowe, the executive director and chief science officer for Unlimited Sciences, a psychedelics research nonprofit.

He expects that psychedelics may help people break out of negative behavior patterns. 

“These findings show significant promise for treating a wide range of neuropsychiatric diseases, including depression, PTSD, and addiction,” he said. 

Dr. Dolen said using psychedelics in critical-period therapy “opens up all sorts of possibilities for the rest of the brain.” Future research may also lead to treatments for deafness, physical disabilities, and drug and alcohol addiction. She is currently raising funds for a clinical trial to see if psychedelics can improve motor impairment after a stroke. 

“Growing legislative openness” to the use of psychedelics could open the door for millions to benefit from mental health treatment “through clinical trials and legal therapeutic pathways as they open up,” said Benjamin Lightburn, CEO and cofounder of Filament Health, a company based in British Columbia that provides naturally derived psilocybin for clinical trials. 

Several states have made moves toward decriminalization or permitting the drugs’ use under medical supervision. In a scientific paper, Washington University researchers, using an analytic model based on marijuana legalization, projected that most states will legalize psychedelics in the next 10-15 years. And on July 1, Australia became the first country to allow psilocybin and MDMA to be prescribed by doctors to treat psychiatric conditions. The U.S. could potentially approve MDMA for therapy later in 2023.

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

As children learn to walk and talk, their brains are remarkably open to new information. They gather knowledge from parents, their environment, and trial and error. Teenagers do too, as they adopt the emotional and intellectual skills needed to become adults. 

In adulthood, however, our minds become relatively locked, closed to new information. This saves energy and lets us navigate the world more efficiently. But that also makes it harder to adapt, learn a new language or skill, or recover from psychological or physical trauma. For those who’ve dealt with abuse, abandonment, or physical violence, that lockdown can lead to a lifetime of suffering, substance abuse, and other maladaptive behaviors.

But recent research offers promise that psychedelic drugs may “reopen” the brain to help it recover from trauma. The study, published in Nature, reflects a renaissance of using and researching psychedelics to treat a range of mental health conditions. 

Scientists at Johns Hopkins University in Baltimore were investigating the drugs’ effects on “critical periods” for social learning, times when the brain is more open to new information that diminish as we age. Success in mice suggests that psychedelics can start a fresh period of learning.

If the finding bears out in future studies, the therapeutic horizon for psychedelics could expand to other opportunities to retrain the brain, including recovery from a stroke, traumatic brain injury, and even hearing loss and paralysis. 

The stakes are big, and the future is promising, said lead researcher Gul Dolen, MD, PhD, an associate professor of neuroscience at Johns Hopkins University. Psychedelics “could be the key that unlocks the brain and helps people after one dose, rather than subjecting them to a lifetime of drugs.” 
 

The psychedelic advantage

Dr. Dolen, who launched her career in addiction studies, has long been fascinated by critical periods and their influence on adult behavior. 

“There have been three Nobel Prizes awarded for work on critical periods,” she said. One study in mice, for instance, identified 15 periods of social learning that define their behaviors for a lifetime. 

Prior research has found that MDMA (commonly known as ecstasy) can help soldiers reconsider traumatic events on the battlefield, learn from them, and move on. That phenomenon had all the earmarks of a critical period for social learning. Perhaps, Dr. Dolen said, psychedelics could open a critical period in a soldier’s life – or a drug-addicted person’s or rape survivor’s – and give them tools to process their trauma.

In the placebo-controlled experiment, she and her team gave mice psychedelic drugs and a behavioral test to gauge the rodents’ ability to learn from their environment. 

“All of the psychedelics opened the critical period of social learning for varying lengths of time,” said Dr. Dolen. 

Ketamine achieved that reopening for 2 days, while the other drugs – ibogaine, LSD, MDMA, and psilocybin – opened critical periods of between 2 and 4 weeks, long after the drugs’ acute effects had worn off.

In humans, Dr. Dolen stressed, opening a critical period would be a sensitive process. 

“You wouldn’t achieve these results if you dropped ecstasy and attended a rave,” she said. “The key seems to be to establish an intention for the therapy: Discuss what you hope to get from the experience, be guided through it, and process it with the therapist after the fact.” 

“You need to be careful with a patient once they’re off the psychedelic,” she said, “because they’re in a state of openness and vulnerability similar to a child.” 
 

The push for psychedelic therapy

Another psychedelics researcher, Matthew Lowe, PhD, sees promise in the Johns Hopkins study. The drugs “place the brain in a more malleable and flexible state,” said Dr. Lowe, the executive director and chief science officer for Unlimited Sciences, a psychedelics research nonprofit.

He expects that psychedelics may help people break out of negative behavior patterns. 

“These findings show significant promise for treating a wide range of neuropsychiatric diseases, including depression, PTSD, and addiction,” he said. 

Dr. Dolen said using psychedelics in critical-period therapy “opens up all sorts of possibilities for the rest of the brain.” Future research may also lead to treatments for deafness, physical disabilities, and drug and alcohol addiction. She is currently raising funds for a clinical trial to see if psychedelics can improve motor impairment after a stroke. 

“Growing legislative openness” to the use of psychedelics could open the door for millions to benefit from mental health treatment “through clinical trials and legal therapeutic pathways as they open up,” said Benjamin Lightburn, CEO and cofounder of Filament Health, a company based in British Columbia that provides naturally derived psilocybin for clinical trials. 

Several states have made moves toward decriminalization or permitting the drugs’ use under medical supervision. In a scientific paper, Washington University researchers, using an analytic model based on marijuana legalization, projected that most states will legalize psychedelics in the next 10-15 years. And on July 1, Australia became the first country to allow psilocybin and MDMA to be prescribed by doctors to treat psychiatric conditions. The U.S. could potentially approve MDMA for therapy later in 2023.

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

COVID-19’s increased demand on the mental health care delivery system led to expanded utilization of technology-based solutions, including digital tools to deliver care.¹ Technology-based solutions include both synchronous telehealth (eg, real-time interactive audio/video visits) and asynchronous tools such as smartphone applications (apps). Both real-time telehealth and apps continue to gain popularity. More than 10,000 mental health–related apps are available, and that number continues to rise.² Numerous web- or mobile-based apps are available to aid in the treatment of various psychiatric conditions, including generalized anxiety disorder (GAD), major depressive disorder, insomnia, and posttraumatic stress disorder (PTSD).

Clinicians may find it challenging to choose the best psychiatry-related apps to recommend to patients. This dilemma calls for an approach to help clinicians select apps that are safe and effective.² The American Psychiatric Association provides information to help mental health professionals navigate these issues and identify which aspects to consider when selecting an app for clinical use.³ The M-Health Index and Navigation Database also provides a set of objective evaluative criteria and offers guidance on choosing apps.⁴

In this article, we review 8 randomized controlled trials (RCTs) of mental health–related apps. We took several steps to ensure the RCTs we included were impactful and meaningful. First, we conducted a general search using mainstream search engines to assess which psychiatric apps were most popular for use in clinical practice. Using this list, we conducted a scholarly search engine query of RCTs using the name of the apps as a search parameter along with the following keywords: “mobile,” “web,” “applications,” and “psychiatry.” This search yielded approximately 50 results, which were narrowed down based on content and interest to a list of 8 articles (Table^5-12). These articles were then graded using the limitations of each study as the primary substrate for evaluation.

1. Linardon J, Shatte A, Rosato J, et al. Efficacy of a transdiagnostic cognitive-behavioral intervention for eating disorder psychopathology delivered through a smartphone app: a randomized controlled trial. Psychol Med. 2022;52(9):1679-1690. doi:10.1017/S0033291720003426

Many patients with eating disorders are unable to receive effective treatment due to problems with accessing health care. Smartphone apps may help bridge the treatment gap for patients in this position. Linardon et al⁵ developed an app that uses the principles of cognitive-behavioral therapy (CBT) for treating eating disorders and conducted this study to evaluate its effectiveness.

Study design

• This RCT assigned individuals who reported episodes of binge eating to a group that used a mobile app (n = 197) or to a waiting list (n = 195). At baseline, 42% of participants exhibited diagnostic-level symptoms of bulimia nervosa and 31% had symptoms of binge-eating disorder.
• Assessments took place at baseline, Week 4, and Week 8.
• The primary outcome was global levels of eating disorder psychopathology.
• Secondary outcomes were other eating disorder symptoms, impairment, and distress.

Outcomes

• Compared to the control group, participants who used the mobile app reported greater reductions in global eating disorder psychopathology (d = -0.80).
• Significant effects were also observed for secondary outcomes except compensatory behavior frequency.
• Overall, participants reported they were satisfied with the app.

Continue to: Conclusions/limitations

• Findings show this app could potentially be a cost-effective and easily accessible option for patients who cannot receive standard treatment for eating disorders.
• Limitations: The overall posttest attrition rate was 35%.

2. Christoforou M, Sáez Fonseca JA, Tsakanikos E. Two novel cognitive behavioral therapy–based mobile apps for agoraphobia: randomized controlled trial. J Med Internet Res. 2017;19(11):e398. doi:10.2196/jmir.7747

CBT is generally the most accepted first-line treatment for agoraphobia. However, numerous barriers to obtaining CBT can prevent successful treatment. Limited research has evaluated the efficacy of apps for treating agoraphobia. Christoforou et al⁶ conducted an RCT to determine the effectiveness of a self-guided smartphone app for improving agoraphobic symptoms, compared to a mobile app used to treat anxiety.

Study design

• Participants (N = 170) who self-identified as having agoraphobia were randomly assigned to use a smartphone app designed to target agoraphobia (Agoraphobia Free) or a smartphone app designed to help with symptoms of anxiety (Stress Free) for 12 weeks. Both apps were based on established cognitive behavioral principles.
• Assessment occurred at baseline, midpoint, and end point.
• The primary outcome was symptom severity as measured by the Panic and Agoraphobia Scale (PAS).

Outcomes

• Both groups experienced statistically significant improvements in symptom severity over time. The differences in PAS score were -5.97 (95% CI, -8.49 to -3.44, P < .001) for Agoraphobia Free and -6.35 (95% CI, -8.82 to -3.87, P < .001) for Stress Free.
• There were no significant between-group differences in symptom severity.

Continue to: Conclusions/limitations

• This study is the first RCT to show that patients with agoraphobia could benefit from mobile-based interventions.
• Limitations: There was no waitlist control group. Limited information was collected about participant characteristics; there were no data on comorbid disorders, other psychological or physiological treatments, or other demographic characteristics such as ethnicity or computer literacy.

3. Everitt N, Broadbent J, Richardson B, et al. Exploring the features of an app-based just-in-time intervention for depression. J Affect Disord. 2021;291:279-287. doi:10.1016/j.jad.2021.05.021

The apps MoodTracker, ImproveYourMood, and ImproveYourMood+ deliver content “just in time” (in response to acute negative symptoms) to help patients with depression. In an RCT, Everitt et al⁷ evaluated delivering acute care for depressive mood states via a smartphone app. They sought to delineate whether symptom improvement was due to microintervention content, mood augmentation, or just-in-time prompts to use content.

Study design

• Participants (N = 235) from the general population who said they wanted to improve their mood were randomly assigned to a waitlist control group (n = 55) or 1 of 3 intervention groups: MoodTracker (monitoring-only; n = 58), ImproveYourMood (monitoring and content; n = 62), or ImproveYourMood+ (monitoring, content, and prompts; n = 60).
• The microintervention content provided by these apps consisted of 4 audio files of brief (2- to 3-minute) mindfulness and relaxation exercises. Participants used the assigned app for 3 weeks.
• Depressive symptoms, anxiety symptoms, and negative automatic thoughts were assessed at baseline, immediately following the intervention, and 1 month after the intervention using the 9-item Patient Health Questionnaire (PHQ-9), 7-item GAD scale (GAD-7), and 8-item Automatic Thoughts Questionnaire, respectively.

Outcomes

• Compared to the waitlist control group, participants in the ImproveYourMood group showed greater declines in depressive symptoms and anxiety symptoms (at follow-up only), and negative automatic thoughts (at both postintervention and follow-up).
• Those in the ImproveYourMood+ group only showed significantly greater improvements for automatic negative thoughts (at postintervention).
• MoodTracker participants did not differ from waitlist controls for any variables at any timepoints.

Continue to: Conclusions/limitations

• This study suggests that using microinterventions in acute settings can effectively reduce depressive symptoms both as they occur, and 1 to 2 months later.
• Limitations: The study featured a naturalistic design, where participants self-selected whether they wanted to use the program. Participants did not complete eligibility assessments or receive compensation, and the study had high dropout rates, ranging from 20% for the waitlist control group to 67% for the ImproveYourMood+ group.

4. McLean C, Davis CA, Miller M, et al. The effects of an exposure-based mobile app on symptoms of posttraumatic stress disorder in veterans: pilot randomized controlled trial. JMIR Mhealth Uhealth. 2022;10(11):e38951. doi:10.2196/38951

Veterans with PTSD face barriers when receiving trauma-focused treatments such as exposure therapy or CBT. Smartphone apps may help veterans self-treat and self-manage their PTSD symptoms. McLean et al⁸ studied the efficacy of Renew, a smartphone app that uses exposure therapy and social support to treat PTSD.

Study design

• In this pilot RCT, 93 veterans with clinically significant PTSD symptoms were randomly assigned to use the Renew app with and without support from a research staff member (active use group) or to a waitlist (delayed use group) for 6 weeks.
• The PTSD Checklist for DSM-5 (PCL-5) was used to measure PTSD symptoms at preintervention, postintervention, and 6-week follow-up.
• Most participants (69%) were women, and the mean age was 49.

Outcomes

• Compared to the delayed use group, participants in the active use group experienced a larger decrease in PCL-5 score (-6.14 vs -1.84). However, this difference was not statistically significant (P = .29), and the effect size was small (d = -0.39).
• There was no difference in engagement with the app between participants who received support from a research staff member and those who did not receive such support.

Continue to: Conclusions/limitations

• Renew may show promise as a tool to reduce PTSD symptoms in veterans.
• Educating family and friends on how to best support a patient using a mobile mental health app may help improve the efficacy of Renew and increase app engagement.
• Limitations: Because the study was conducted in veterans, the results may not be generalizable to other populations. Because most data collection occurred during the first wave of the COVID-19 pandemic in the United States, COVID-19–related stress may have impacted PTSD symptoms, app engagement, or outcomes.

5. Graham AK, Greene CJ, Kwasny MJ, et al. Coached mobile app platform for the treatment of depression and anxiety among primary care patients: a randomized clinical trial. JAMA Psychiatry. 2020;77(9):906-914. doi:10.1001/jamapsychiatry.2020.1011

Many cases of depression and anxiety are initially treated in primary care settings. However, these settings may have limited resources and inadequate training, and mobile interventions might be helpful to augment patient care. Graham et al⁹ studied the mobile platform IntelliCare to determine its efficacy as a tool to be used in primary care settings to treat depression and anxiety.

Study design

• This RCT randomly assigned adult primary care patients (N = 146) who screened positive for depression on the PHQ-9 (score ≥10) or anxiety on the GAD-7 (score ≥8) to the coach-supported IntelliCare platform, which consisted of 5 clinically focused apps, or to a waitlist control group. Interventions were delivered over 8 weeks.
• Overall, 122 (83.6%) patients were diagnosed with depression and 131 (89.7%) were diagnosed with anxiety.
• The primary outcomes were changes in depression (as measured by change in PHQ-9 score) and anxiety (change in GAD-7 score) during the intervention period.

Outcomes

• Participants who used the IntelliCare platform had a greater reduction in depression and anxiety symptoms compared to waitlist controls, and changes were sustained over 2-month follow-up.
• The least square means (LSM) difference in depression scores at Week 4 was 2.91 (SE = 0.83; d = 0.43) and at Week 8 was 4.37 (SE = 0.83; d = 0.64). The LSM difference in anxiety scores at Week 4 was 2.51 (SE = 0.78; d = 0.41) and at Week 8 was 3.33 (SE = 0.76; d = 0.55).
• A median number of 93 and 98 sessions among participants with depression and anxiety were recorded, respectively, indicating high use of the IntelliCare platform.

Continue to: Conclusions/limitations

• The IntelliCare platform was shown to be effective in reducing depression and anxiety among primary care patients. Simple apps can be bundled together and used by patients in conjunction to treat their individual needs.
• Limitations: The study had a limited follow-up period and did not record participants’ use of other apps. Slightly more than one-half (56%) of participants were taking an antidepressant.

6. Wilhelm S, Weingarden H, Greenberg JL, et al. Efficacy of app-based cognitive behavioral therapy for body dysmorphic disorder with coach support: initial randomized controlled clinical trial. Psychother Psychosom. 2022;91(4):277-285. doi:10.1159/000524628

Body dysmorphic disorder (BDD) is a severe yet undertreated disorder. Apps can improve access to treatment for patients experiencing BDD. Wilhelm et al¹⁰ studied the usability and efficacy of a coach-supported app called Perspectives that was specifically designed for treating BDD. Perspectives provide CBT in 7 modules: psychoeducation, cognitive restructuring, exposure, response prevention, mindfulness, attention retraining, and relapse prevention.

Study design

• Adults (N = 80) with primary BDD were assigned to use the Perspectives app for 12 weeks or to a waitlist control group. Participants were predominately female (84%) and White (71%), with a mean age of 27.
• Coaches promoted engagement and answered questions via in-app messaging and phone calls.
• Blinded independent evaluators used the Yale-Brown Obsessive Compulsive Scale Modified for BDD (BDD-YBOCS) to measure BDD severity at baseline, midtreatment (Week 6), and end of treatment (Week 12).
• Secondary outcomes included BDD-related insight, depression, quality of life, and functioning. Various scales were used to measure these outcomes.

Outcomes

• In intent-to-treat analyses, patients who received CBT via the Perspectives app had significantly lower BDD severity at the end of treatment compared to the waitlist control group, with a mean (SD) BDD-YBOCS score of 16.8 (7.5) vs 26.7 (6.2), with P < .001 and d = 1.44.
• Slightly more than one-half (52%) of those who used Perspectives achieved full or partial remission, compared to 8% in the waitlist control group.

Continue to: Conclusions/limitations

• CBT delivered via the Perspectives app and a coach proved to be effective treatment for adults with BDD.
• Adoption of the application was relatively high; 86% of Perspectives users were very or mostly satisfied.
• Limitations: Because the participants in this study were predominantly female and White, the findings might not be generalizable to other populations.

7. Kuhn E, Miller KE, Puran D, et al. A pilot randomized controlled trial of the Insomnia Coach mobile app to assess its feasibility, acceptability, and potential efficacy. Behav Ther. 2022;53(3):440-457. doi:10.1016/j.beth.2021.11.003

Insomnia remains a substantial problem among military veterans. First-line treatments for the disorder are sleep hygiene modification and CBT. Access to CBT is limited, especially for veterans. Kuhn et al¹¹ studied the effectiveness of using Insomnia Coach, a CBT for insomnia–based app, to improve insomnia symptoms.

Study design

• Fifty US veterans who were mostly male (58%) with a mean age of 44.5 and moderate insomnia symptoms were randomized to use Insomnia Coach (n = 25) or to a waitlist control group (n = 25) for 6 weeks.
• All participants completed self-report measures and sleep diaries at baseline, posttreatment, and follow-up (12 weeks). Those who used the app (n = 15) completed a qualitative interview at posttreatment.

Outcomes

• At posttreatment, 28% of participants who used Insomnia Coach achieved clinically significant improvement, vs 4% of waitlist control participants. There was also a significant treatment effect on daytime sleep-related impairment (P = .044, d = -0.6).
• Additional treatment effects emerged at follow-up for insomnia severity, sleep onset latency, global sleep quality, and depression symptoms.
• Based on self-reports and qualitative interview responses, participants’ perceptions of Insomnia Coach were favorable. Three-fourths of participants used the app through 6 weeks and engaged with active elements.

Continue to: Conclusions/limitations

• Insomnia Coach may provide an accessible and convenient public health intervention for patients who aren’t receiving adequate care or CBT.
• Limitations: Because this study evaluated only veterans, the findings might not be generalizable to other populations.

8. Dahne J, Lejuez CW, Diaz VA, et al. Pilot randomized trial of a self-help behavioral activation mobile app for utilization in primary care. Behav Ther. 2019;50(4):817-827. doi:10.1016/j.beth.2018.12.003

Previous mobile technologies have shown the ability to treat depression in primary care settings. Moodivate is a self-help mobile app based on the Brief Behavioral Activation Treatment for Depression, which is an evidence-based treatment. This app is designed to help the user reengage in positive, nondepressed activities by identifying, scheduling, and completing activities. Dahne et al¹² investigated the feasibility and efficacy of Moodivate for depressive symptoms in primary care patients.

Study design

• Participants (N = 52) were recruited from primary care practices and randomized 2:2:1 to receive Moodivate, a CBT-based mobile app called MoodKit, or treatment as usual (no app). All participants had an initial PHQ-8 score >10.
• Participants completed assessments of depressive symptoms (PHQ-8) weekly for 8 weeks.
• App analytics data were captured to examine if the use of Moodivate was feasible. (Analytics were not available for MoodKit).

Outcomes

• Participants who used Moodivate had a mean (SD) of 46.76 (30.10) sessions throughout the trial, spent 3.50 (2.76) minutes using the app per session, and spent 120.76 (101.02) minutes using the app in total.
• Nearly 70% of Moodivate participants continued to use the app 1 month after trial enrollment and 50% at the end of the 8-week follow-up period.
• Compared to the treatment as usual group, participants who used Moodivate and those who used MoodKit experienced significant decreases in depressive symptoms over time.

Conclusions/limitations

• The results show that for primary care patients with depression, the use of Moodivate is feasible and may reduce depressive symptoms.
• Limitations: For the first 3 months of enrollment, patients who met diagnostic criteria for a current major depressive episode were excluded. This study did not assess duration of medication use (ie, whether a study participant was stabilized on medication or recently started taking a new medication) and therefore could not ascertain whether treatment gains were a result of the use of the app or of possible new medication use.

COVID-19’s increased demand on the mental health care delivery system led to expanded utilization of technology-based solutions, including digital tools to deliver care.¹ Technology-based solutions include both synchronous telehealth (eg, real-time interactive audio/video visits) and asynchronous tools such as smartphone applications (apps). Both real-time telehealth and apps continue to gain popularity. More than 10,000 mental health–related apps are available, and that number continues to rise.² Numerous web- or mobile-based apps are available to aid in the treatment of various psychiatric conditions, including generalized anxiety disorder (GAD), major depressive disorder, insomnia, and posttraumatic stress disorder (PTSD).

Clinicians may find it challenging to choose the best psychiatry-related apps to recommend to patients. This dilemma calls for an approach to help clinicians select apps that are safe and effective.² The American Psychiatric Association provides information to help mental health professionals navigate these issues and identify which aspects to consider when selecting an app for clinical use.³ The M-Health Index and Navigation Database also provides a set of objective evaluative criteria and offers guidance on choosing apps.⁴

In this article, we review 8 randomized controlled trials (RCTs) of mental health–related apps. We took several steps to ensure the RCTs we included were impactful and meaningful. First, we conducted a general search using mainstream search engines to assess which psychiatric apps were most popular for use in clinical practice. Using this list, we conducted a scholarly search engine query of RCTs using the name of the apps as a search parameter along with the following keywords: “mobile,” “web,” “applications,” and “psychiatry.” This search yielded approximately 50 results, which were narrowed down based on content and interest to a list of 8 articles (Table^5-12). These articles were then graded using the limitations of each study as the primary substrate for evaluation.

1. Linardon J, Shatte A, Rosato J, et al. Efficacy of a transdiagnostic cognitive-behavioral intervention for eating disorder psychopathology delivered through a smartphone app: a randomized controlled trial. Psychol Med. 2022;52(9):1679-1690. doi:10.1017/S0033291720003426

Many patients with eating disorders are unable to receive effective treatment due to problems with accessing health care. Smartphone apps may help bridge the treatment gap for patients in this position. Linardon et al⁵ developed an app that uses the principles of cognitive-behavioral therapy (CBT) for treating eating disorders and conducted this study to evaluate its effectiveness.

Study design

• This RCT assigned individuals who reported episodes of binge eating to a group that used a mobile app (n = 197) or to a waiting list (n = 195). At baseline, 42% of participants exhibited diagnostic-level symptoms of bulimia nervosa and 31% had symptoms of binge-eating disorder.
• Assessments took place at baseline, Week 4, and Week 8.
• The primary outcome was global levels of eating disorder psychopathology.
• Secondary outcomes were other eating disorder symptoms, impairment, and distress.

Outcomes

• Compared to the control group, participants who used the mobile app reported greater reductions in global eating disorder psychopathology (d = -0.80).
• Significant effects were also observed for secondary outcomes except compensatory behavior frequency.
• Overall, participants reported they were satisfied with the app.

Continue to: Conclusions/limitations

• Findings show this app could potentially be a cost-effective and easily accessible option for patients who cannot receive standard treatment for eating disorders.
• Limitations: The overall posttest attrition rate was 35%.

2. Christoforou M, Sáez Fonseca JA, Tsakanikos E. Two novel cognitive behavioral therapy–based mobile apps for agoraphobia: randomized controlled trial. J Med Internet Res. 2017;19(11):e398. doi:10.2196/jmir.7747

CBT is generally the most accepted first-line treatment for agoraphobia. However, numerous barriers to obtaining CBT can prevent successful treatment. Limited research has evaluated the efficacy of apps for treating agoraphobia. Christoforou et al⁶ conducted an RCT to determine the effectiveness of a self-guided smartphone app for improving agoraphobic symptoms, compared to a mobile app used to treat anxiety.

Study design

• Participants (N = 170) who self-identified as having agoraphobia were randomly assigned to use a smartphone app designed to target agoraphobia (Agoraphobia Free) or a smartphone app designed to help with symptoms of anxiety (Stress Free) for 12 weeks. Both apps were based on established cognitive behavioral principles.
• Assessment occurred at baseline, midpoint, and end point.
• The primary outcome was symptom severity as measured by the Panic and Agoraphobia Scale (PAS).

Outcomes

• Both groups experienced statistically significant improvements in symptom severity over time. The differences in PAS score were -5.97 (95% CI, -8.49 to -3.44, P < .001) for Agoraphobia Free and -6.35 (95% CI, -8.82 to -3.87, P < .001) for Stress Free.
• There were no significant between-group differences in symptom severity.

Continue to: Conclusions/limitations

• This study is the first RCT to show that patients with agoraphobia could benefit from mobile-based interventions.
• Limitations: There was no waitlist control group. Limited information was collected about participant characteristics; there were no data on comorbid disorders, other psychological or physiological treatments, or other demographic characteristics such as ethnicity or computer literacy.

3. Everitt N, Broadbent J, Richardson B, et al. Exploring the features of an app-based just-in-time intervention for depression. J Affect Disord. 2021;291:279-287. doi:10.1016/j.jad.2021.05.021

The apps MoodTracker, ImproveYourMood, and ImproveYourMood+ deliver content “just in time” (in response to acute negative symptoms) to help patients with depression. In an RCT, Everitt et al⁷ evaluated delivering acute care for depressive mood states via a smartphone app. They sought to delineate whether symptom improvement was due to microintervention content, mood augmentation, or just-in-time prompts to use content.

Study design

• Participants (N = 235) from the general population who said they wanted to improve their mood were randomly assigned to a waitlist control group (n = 55) or 1 of 3 intervention groups: MoodTracker (monitoring-only; n = 58), ImproveYourMood (monitoring and content; n = 62), or ImproveYourMood+ (monitoring, content, and prompts; n = 60).
• The microintervention content provided by these apps consisted of 4 audio files of brief (2- to 3-minute) mindfulness and relaxation exercises. Participants used the assigned app for 3 weeks.
• Depressive symptoms, anxiety symptoms, and negative automatic thoughts were assessed at baseline, immediately following the intervention, and 1 month after the intervention using the 9-item Patient Health Questionnaire (PHQ-9), 7-item GAD scale (GAD-7), and 8-item Automatic Thoughts Questionnaire, respectively.

Outcomes

• Compared to the waitlist control group, participants in the ImproveYourMood group showed greater declines in depressive symptoms and anxiety symptoms (at follow-up only), and negative automatic thoughts (at both postintervention and follow-up).
• Those in the ImproveYourMood+ group only showed significantly greater improvements for automatic negative thoughts (at postintervention).
• MoodTracker participants did not differ from waitlist controls for any variables at any timepoints.

Continue to: Conclusions/limitations

• This study suggests that using microinterventions in acute settings can effectively reduce depressive symptoms both as they occur, and 1 to 2 months later.
• Limitations: The study featured a naturalistic design, where participants self-selected whether they wanted to use the program. Participants did not complete eligibility assessments or receive compensation, and the study had high dropout rates, ranging from 20% for the waitlist control group to 67% for the ImproveYourMood+ group.

4. McLean C, Davis CA, Miller M, et al. The effects of an exposure-based mobile app on symptoms of posttraumatic stress disorder in veterans: pilot randomized controlled trial. JMIR Mhealth Uhealth. 2022;10(11):e38951. doi:10.2196/38951

Veterans with PTSD face barriers when receiving trauma-focused treatments such as exposure therapy or CBT. Smartphone apps may help veterans self-treat and self-manage their PTSD symptoms. McLean et al⁸ studied the efficacy of Renew, a smartphone app that uses exposure therapy and social support to treat PTSD.

Study design

• In this pilot RCT, 93 veterans with clinically significant PTSD symptoms were randomly assigned to use the Renew app with and without support from a research staff member (active use group) or to a waitlist (delayed use group) for 6 weeks.
• The PTSD Checklist for DSM-5 (PCL-5) was used to measure PTSD symptoms at preintervention, postintervention, and 6-week follow-up.
• Most participants (69%) were women, and the mean age was 49.

Outcomes

• Compared to the delayed use group, participants in the active use group experienced a larger decrease in PCL-5 score (-6.14 vs -1.84). However, this difference was not statistically significant (P = .29), and the effect size was small (d = -0.39).
• There was no difference in engagement with the app between participants who received support from a research staff member and those who did not receive such support.

Continue to: Conclusions/limitations

• Renew may show promise as a tool to reduce PTSD symptoms in veterans.
• Educating family and friends on how to best support a patient using a mobile mental health app may help improve the efficacy of Renew and increase app engagement.
• Limitations: Because the study was conducted in veterans, the results may not be generalizable to other populations. Because most data collection occurred during the first wave of the COVID-19 pandemic in the United States, COVID-19–related stress may have impacted PTSD symptoms, app engagement, or outcomes.

5. Graham AK, Greene CJ, Kwasny MJ, et al. Coached mobile app platform for the treatment of depression and anxiety among primary care patients: a randomized clinical trial. JAMA Psychiatry. 2020;77(9):906-914. doi:10.1001/jamapsychiatry.2020.1011

Many cases of depression and anxiety are initially treated in primary care settings. However, these settings may have limited resources and inadequate training, and mobile interventions might be helpful to augment patient care. Graham et al⁹ studied the mobile platform IntelliCare to determine its efficacy as a tool to be used in primary care settings to treat depression and anxiety.

Study design

• This RCT randomly assigned adult primary care patients (N = 146) who screened positive for depression on the PHQ-9 (score ≥10) or anxiety on the GAD-7 (score ≥8) to the coach-supported IntelliCare platform, which consisted of 5 clinically focused apps, or to a waitlist control group. Interventions were delivered over 8 weeks.
• Overall, 122 (83.6%) patients were diagnosed with depression and 131 (89.7%) were diagnosed with anxiety.
• The primary outcomes were changes in depression (as measured by change in PHQ-9 score) and anxiety (change in GAD-7 score) during the intervention period.

Outcomes

• Participants who used the IntelliCare platform had a greater reduction in depression and anxiety symptoms compared to waitlist controls, and changes were sustained over 2-month follow-up.
• The least square means (LSM) difference in depression scores at Week 4 was 2.91 (SE = 0.83; d = 0.43) and at Week 8 was 4.37 (SE = 0.83; d = 0.64). The LSM difference in anxiety scores at Week 4 was 2.51 (SE = 0.78; d = 0.41) and at Week 8 was 3.33 (SE = 0.76; d = 0.55).
• A median number of 93 and 98 sessions among participants with depression and anxiety were recorded, respectively, indicating high use of the IntelliCare platform.

Continue to: Conclusions/limitations

• The IntelliCare platform was shown to be effective in reducing depression and anxiety among primary care patients. Simple apps can be bundled together and used by patients in conjunction to treat their individual needs.
• Limitations: The study had a limited follow-up period and did not record participants’ use of other apps. Slightly more than one-half (56%) of participants were taking an antidepressant.

6. Wilhelm S, Weingarden H, Greenberg JL, et al. Efficacy of app-based cognitive behavioral therapy for body dysmorphic disorder with coach support: initial randomized controlled clinical trial. Psychother Psychosom. 2022;91(4):277-285. doi:10.1159/000524628

Body dysmorphic disorder (BDD) is a severe yet undertreated disorder. Apps can improve access to treatment for patients experiencing BDD. Wilhelm et al¹⁰ studied the usability and efficacy of a coach-supported app called Perspectives that was specifically designed for treating BDD. Perspectives provide CBT in 7 modules: psychoeducation, cognitive restructuring, exposure, response prevention, mindfulness, attention retraining, and relapse prevention.

Study design

• Adults (N = 80) with primary BDD were assigned to use the Perspectives app for 12 weeks or to a waitlist control group. Participants were predominately female (84%) and White (71%), with a mean age of 27.
• Coaches promoted engagement and answered questions via in-app messaging and phone calls.
• Blinded independent evaluators used the Yale-Brown Obsessive Compulsive Scale Modified for BDD (BDD-YBOCS) to measure BDD severity at baseline, midtreatment (Week 6), and end of treatment (Week 12).
• Secondary outcomes included BDD-related insight, depression, quality of life, and functioning. Various scales were used to measure these outcomes.

Outcomes

• In intent-to-treat analyses, patients who received CBT via the Perspectives app had significantly lower BDD severity at the end of treatment compared to the waitlist control group, with a mean (SD) BDD-YBOCS score of 16.8 (7.5) vs 26.7 (6.2), with P < .001 and d = 1.44.
• Slightly more than one-half (52%) of those who used Perspectives achieved full or partial remission, compared to 8% in the waitlist control group.

Continue to: Conclusions/limitations

• CBT delivered via the Perspectives app and a coach proved to be effective treatment for adults with BDD.
• Adoption of the application was relatively high; 86% of Perspectives users were very or mostly satisfied.
• Limitations: Because the participants in this study were predominantly female and White, the findings might not be generalizable to other populations.

7. Kuhn E, Miller KE, Puran D, et al. A pilot randomized controlled trial of the Insomnia Coach mobile app to assess its feasibility, acceptability, and potential efficacy. Behav Ther. 2022;53(3):440-457. doi:10.1016/j.beth.2021.11.003

Insomnia remains a substantial problem among military veterans. First-line treatments for the disorder are sleep hygiene modification and CBT. Access to CBT is limited, especially for veterans. Kuhn et al¹¹ studied the effectiveness of using Insomnia Coach, a CBT for insomnia–based app, to improve insomnia symptoms.

Study design

• Fifty US veterans who were mostly male (58%) with a mean age of 44.5 and moderate insomnia symptoms were randomized to use Insomnia Coach (n = 25) or to a waitlist control group (n = 25) for 6 weeks.
• All participants completed self-report measures and sleep diaries at baseline, posttreatment, and follow-up (12 weeks). Those who used the app (n = 15) completed a qualitative interview at posttreatment.

Outcomes

• At posttreatment, 28% of participants who used Insomnia Coach achieved clinically significant improvement, vs 4% of waitlist control participants. There was also a significant treatment effect on daytime sleep-related impairment (P = .044, d = -0.6).
• Additional treatment effects emerged at follow-up for insomnia severity, sleep onset latency, global sleep quality, and depression symptoms.
• Based on self-reports and qualitative interview responses, participants’ perceptions of Insomnia Coach were favorable. Three-fourths of participants used the app through 6 weeks and engaged with active elements.

Continue to: Conclusions/limitations

• Insomnia Coach may provide an accessible and convenient public health intervention for patients who aren’t receiving adequate care or CBT.
• Limitations: Because this study evaluated only veterans, the findings might not be generalizable to other populations.

8. Dahne J, Lejuez CW, Diaz VA, et al. Pilot randomized trial of a self-help behavioral activation mobile app for utilization in primary care. Behav Ther. 2019;50(4):817-827. doi:10.1016/j.beth.2018.12.003

Previous mobile technologies have shown the ability to treat depression in primary care settings. Moodivate is a self-help mobile app based on the Brief Behavioral Activation Treatment for Depression, which is an evidence-based treatment. This app is designed to help the user reengage in positive, nondepressed activities by identifying, scheduling, and completing activities. Dahne et al¹² investigated the feasibility and efficacy of Moodivate for depressive symptoms in primary care patients.

Study design

• Participants (N = 52) were recruited from primary care practices and randomized 2:2:1 to receive Moodivate, a CBT-based mobile app called MoodKit, or treatment as usual (no app). All participants had an initial PHQ-8 score >10.
• Participants completed assessments of depressive symptoms (PHQ-8) weekly for 8 weeks.
• App analytics data were captured to examine if the use of Moodivate was feasible. (Analytics were not available for MoodKit).

Outcomes

• Participants who used Moodivate had a mean (SD) of 46.76 (30.10) sessions throughout the trial, spent 3.50 (2.76) minutes using the app per session, and spent 120.76 (101.02) minutes using the app in total.
• Nearly 70% of Moodivate participants continued to use the app 1 month after trial enrollment and 50% at the end of the 8-week follow-up period.
• Compared to the treatment as usual group, participants who used Moodivate and those who used MoodKit experienced significant decreases in depressive symptoms over time.

Conclusions/limitations

• The results show that for primary care patients with depression, the use of Moodivate is feasible and may reduce depressive symptoms.
• Limitations: For the first 3 months of enrollment, patients who met diagnostic criteria for a current major depressive episode were excluded. This study did not assess duration of medication use (ie, whether a study participant was stabilized on medication or recently started taking a new medication) and therefore could not ascertain whether treatment gains were a result of the use of the app or of possible new medication use.

COVID-19’s increased demand on the mental health care delivery system led to expanded utilization of technology-based solutions, including digital tools to deliver care.¹ Technology-based solutions include both synchronous telehealth (eg, real-time interactive audio/video visits) and asynchronous tools such as smartphone applications (apps). Both real-time telehealth and apps continue to gain popularity. More than 10,000 mental health–related apps are available, and that number continues to rise.² Numerous web- or mobile-based apps are available to aid in the treatment of various psychiatric conditions, including generalized anxiety disorder (GAD), major depressive disorder, insomnia, and posttraumatic stress disorder (PTSD).

Clinicians may find it challenging to choose the best psychiatry-related apps to recommend to patients. This dilemma calls for an approach to help clinicians select apps that are safe and effective.² The American Psychiatric Association provides information to help mental health professionals navigate these issues and identify which aspects to consider when selecting an app for clinical use.³ The M-Health Index and Navigation Database also provides a set of objective evaluative criteria and offers guidance on choosing apps.⁴

In this article, we review 8 randomized controlled trials (RCTs) of mental health–related apps. We took several steps to ensure the RCTs we included were impactful and meaningful. First, we conducted a general search using mainstream search engines to assess which psychiatric apps were most popular for use in clinical practice. Using this list, we conducted a scholarly search engine query of RCTs using the name of the apps as a search parameter along with the following keywords: “mobile,” “web,” “applications,” and “psychiatry.” This search yielded approximately 50 results, which were narrowed down based on content and interest to a list of 8 articles (Table^5-12). These articles were then graded using the limitations of each study as the primary substrate for evaluation.

1. Linardon J, Shatte A, Rosato J, et al. Efficacy of a transdiagnostic cognitive-behavioral intervention for eating disorder psychopathology delivered through a smartphone app: a randomized controlled trial. Psychol Med. 2022;52(9):1679-1690. doi:10.1017/S0033291720003426

Many patients with eating disorders are unable to receive effective treatment due to problems with accessing health care. Smartphone apps may help bridge the treatment gap for patients in this position. Linardon et al⁵ developed an app that uses the principles of cognitive-behavioral therapy (CBT) for treating eating disorders and conducted this study to evaluate its effectiveness.

Study design

• This RCT assigned individuals who reported episodes of binge eating to a group that used a mobile app (n = 197) or to a waiting list (n = 195). At baseline, 42% of participants exhibited diagnostic-level symptoms of bulimia nervosa and 31% had symptoms of binge-eating disorder.
• Assessments took place at baseline, Week 4, and Week 8.
• The primary outcome was global levels of eating disorder psychopathology.
• Secondary outcomes were other eating disorder symptoms, impairment, and distress.

Outcomes

• Compared to the control group, participants who used the mobile app reported greater reductions in global eating disorder psychopathology (d = -0.80).
• Significant effects were also observed for secondary outcomes except compensatory behavior frequency.
• Overall, participants reported they were satisfied with the app.

Continue to: Conclusions/limitations

• Findings show this app could potentially be a cost-effective and easily accessible option for patients who cannot receive standard treatment for eating disorders.
• Limitations: The overall posttest attrition rate was 35%.

2. Christoforou M, Sáez Fonseca JA, Tsakanikos E. Two novel cognitive behavioral therapy–based mobile apps for agoraphobia: randomized controlled trial. J Med Internet Res. 2017;19(11):e398. doi:10.2196/jmir.7747

CBT is generally the most accepted first-line treatment for agoraphobia. However, numerous barriers to obtaining CBT can prevent successful treatment. Limited research has evaluated the efficacy of apps for treating agoraphobia. Christoforou et al⁶ conducted an RCT to determine the effectiveness of a self-guided smartphone app for improving agoraphobic symptoms, compared to a mobile app used to treat anxiety.

Study design

• Participants (N = 170) who self-identified as having agoraphobia were randomly assigned to use a smartphone app designed to target agoraphobia (Agoraphobia Free) or a smartphone app designed to help with symptoms of anxiety (Stress Free) for 12 weeks. Both apps were based on established cognitive behavioral principles.
• Assessment occurred at baseline, midpoint, and end point.
• The primary outcome was symptom severity as measured by the Panic and Agoraphobia Scale (PAS).

Outcomes

• Both groups experienced statistically significant improvements in symptom severity over time. The differences in PAS score were -5.97 (95% CI, -8.49 to -3.44, P < .001) for Agoraphobia Free and -6.35 (95% CI, -8.82 to -3.87, P < .001) for Stress Free.
• There were no significant between-group differences in symptom severity.

Continue to: Conclusions/limitations

• This study is the first RCT to show that patients with agoraphobia could benefit from mobile-based interventions.
• Limitations: There was no waitlist control group. Limited information was collected about participant characteristics; there were no data on comorbid disorders, other psychological or physiological treatments, or other demographic characteristics such as ethnicity or computer literacy.

3. Everitt N, Broadbent J, Richardson B, et al. Exploring the features of an app-based just-in-time intervention for depression. J Affect Disord. 2021;291:279-287. doi:10.1016/j.jad.2021.05.021

The apps MoodTracker, ImproveYourMood, and ImproveYourMood+ deliver content “just in time” (in response to acute negative symptoms) to help patients with depression. In an RCT, Everitt et al⁷ evaluated delivering acute care for depressive mood states via a smartphone app. They sought to delineate whether symptom improvement was due to microintervention content, mood augmentation, or just-in-time prompts to use content.

Study design

• Participants (N = 235) from the general population who said they wanted to improve their mood were randomly assigned to a waitlist control group (n = 55) or 1 of 3 intervention groups: MoodTracker (monitoring-only; n = 58), ImproveYourMood (monitoring and content; n = 62), or ImproveYourMood+ (monitoring, content, and prompts; n = 60).
• The microintervention content provided by these apps consisted of 4 audio files of brief (2- to 3-minute) mindfulness and relaxation exercises. Participants used the assigned app for 3 weeks.
• Depressive symptoms, anxiety symptoms, and negative automatic thoughts were assessed at baseline, immediately following the intervention, and 1 month after the intervention using the 9-item Patient Health Questionnaire (PHQ-9), 7-item GAD scale (GAD-7), and 8-item Automatic Thoughts Questionnaire, respectively.

Outcomes

• Compared to the waitlist control group, participants in the ImproveYourMood group showed greater declines in depressive symptoms and anxiety symptoms (at follow-up only), and negative automatic thoughts (at both postintervention and follow-up).
• Those in the ImproveYourMood+ group only showed significantly greater improvements for automatic negative thoughts (at postintervention).
• MoodTracker participants did not differ from waitlist controls for any variables at any timepoints.

Continue to: Conclusions/limitations

• This study suggests that using microinterventions in acute settings can effectively reduce depressive symptoms both as they occur, and 1 to 2 months later.
• Limitations: The study featured a naturalistic design, where participants self-selected whether they wanted to use the program. Participants did not complete eligibility assessments or receive compensation, and the study had high dropout rates, ranging from 20% for the waitlist control group to 67% for the ImproveYourMood+ group.

4. McLean C, Davis CA, Miller M, et al. The effects of an exposure-based mobile app on symptoms of posttraumatic stress disorder in veterans: pilot randomized controlled trial. JMIR Mhealth Uhealth. 2022;10(11):e38951. doi:10.2196/38951

Veterans with PTSD face barriers when receiving trauma-focused treatments such as exposure therapy or CBT. Smartphone apps may help veterans self-treat and self-manage their PTSD symptoms. McLean et al⁸ studied the efficacy of Renew, a smartphone app that uses exposure therapy and social support to treat PTSD.

Study design

• In this pilot RCT, 93 veterans with clinically significant PTSD symptoms were randomly assigned to use the Renew app with and without support from a research staff member (active use group) or to a waitlist (delayed use group) for 6 weeks.
• The PTSD Checklist for DSM-5 (PCL-5) was used to measure PTSD symptoms at preintervention, postintervention, and 6-week follow-up.
• Most participants (69%) were women, and the mean age was 49.

Outcomes

• Compared to the delayed use group, participants in the active use group experienced a larger decrease in PCL-5 score (-6.14 vs -1.84). However, this difference was not statistically significant (P = .29), and the effect size was small (d = -0.39).
• There was no difference in engagement with the app between participants who received support from a research staff member and those who did not receive such support.

Continue to: Conclusions/limitations

• Renew may show promise as a tool to reduce PTSD symptoms in veterans.
• Educating family and friends on how to best support a patient using a mobile mental health app may help improve the efficacy of Renew and increase app engagement.
• Limitations: Because the study was conducted in veterans, the results may not be generalizable to other populations. Because most data collection occurred during the first wave of the COVID-19 pandemic in the United States, COVID-19–related stress may have impacted PTSD symptoms, app engagement, or outcomes.

5. Graham AK, Greene CJ, Kwasny MJ, et al. Coached mobile app platform for the treatment of depression and anxiety among primary care patients: a randomized clinical trial. JAMA Psychiatry. 2020;77(9):906-914. doi:10.1001/jamapsychiatry.2020.1011

Many cases of depression and anxiety are initially treated in primary care settings. However, these settings may have limited resources and inadequate training, and mobile interventions might be helpful to augment patient care. Graham et al⁹ studied the mobile platform IntelliCare to determine its efficacy as a tool to be used in primary care settings to treat depression and anxiety.

Study design

• This RCT randomly assigned adult primary care patients (N = 146) who screened positive for depression on the PHQ-9 (score ≥10) or anxiety on the GAD-7 (score ≥8) to the coach-supported IntelliCare platform, which consisted of 5 clinically focused apps, or to a waitlist control group. Interventions were delivered over 8 weeks.
• Overall, 122 (83.6%) patients were diagnosed with depression and 131 (89.7%) were diagnosed with anxiety.
• The primary outcomes were changes in depression (as measured by change in PHQ-9 score) and anxiety (change in GAD-7 score) during the intervention period.

Outcomes

• Participants who used the IntelliCare platform had a greater reduction in depression and anxiety symptoms compared to waitlist controls, and changes were sustained over 2-month follow-up.
• The least square means (LSM) difference in depression scores at Week 4 was 2.91 (SE = 0.83; d = 0.43) and at Week 8 was 4.37 (SE = 0.83; d = 0.64). The LSM difference in anxiety scores at Week 4 was 2.51 (SE = 0.78; d = 0.41) and at Week 8 was 3.33 (SE = 0.76; d = 0.55).
• A median number of 93 and 98 sessions among participants with depression and anxiety were recorded, respectively, indicating high use of the IntelliCare platform.

Continue to: Conclusions/limitations

• The IntelliCare platform was shown to be effective in reducing depression and anxiety among primary care patients. Simple apps can be bundled together and used by patients in conjunction to treat their individual needs.
• Limitations: The study had a limited follow-up period and did not record participants’ use of other apps. Slightly more than one-half (56%) of participants were taking an antidepressant.

6. Wilhelm S, Weingarden H, Greenberg JL, et al. Efficacy of app-based cognitive behavioral therapy for body dysmorphic disorder with coach support: initial randomized controlled clinical trial. Psychother Psychosom. 2022;91(4):277-285. doi:10.1159/000524628

Body dysmorphic disorder (BDD) is a severe yet undertreated disorder. Apps can improve access to treatment for patients experiencing BDD. Wilhelm et al¹⁰ studied the usability and efficacy of a coach-supported app called Perspectives that was specifically designed for treating BDD. Perspectives provide CBT in 7 modules: psychoeducation, cognitive restructuring, exposure, response prevention, mindfulness, attention retraining, and relapse prevention.

Study design

• Adults (N = 80) with primary BDD were assigned to use the Perspectives app for 12 weeks or to a waitlist control group. Participants were predominately female (84%) and White (71%), with a mean age of 27.
• Coaches promoted engagement and answered questions via in-app messaging and phone calls.
• Blinded independent evaluators used the Yale-Brown Obsessive Compulsive Scale Modified for BDD (BDD-YBOCS) to measure BDD severity at baseline, midtreatment (Week 6), and end of treatment (Week 12).
• Secondary outcomes included BDD-related insight, depression, quality of life, and functioning. Various scales were used to measure these outcomes.

Outcomes

• In intent-to-treat analyses, patients who received CBT via the Perspectives app had significantly lower BDD severity at the end of treatment compared to the waitlist control group, with a mean (SD) BDD-YBOCS score of 16.8 (7.5) vs 26.7 (6.2), with P < .001 and d = 1.44.
• Slightly more than one-half (52%) of those who used Perspectives achieved full or partial remission, compared to 8% in the waitlist control group.

Continue to: Conclusions/limitations

• CBT delivered via the Perspectives app and a coach proved to be effective treatment for adults with BDD.
• Adoption of the application was relatively high; 86% of Perspectives users were very or mostly satisfied.
• Limitations: Because the participants in this study were predominantly female and White, the findings might not be generalizable to other populations.

7. Kuhn E, Miller KE, Puran D, et al. A pilot randomized controlled trial of the Insomnia Coach mobile app to assess its feasibility, acceptability, and potential efficacy. Behav Ther. 2022;53(3):440-457. doi:10.1016/j.beth.2021.11.003

Insomnia remains a substantial problem among military veterans. First-line treatments for the disorder are sleep hygiene modification and CBT. Access to CBT is limited, especially for veterans. Kuhn et al¹¹ studied the effectiveness of using Insomnia Coach, a CBT for insomnia–based app, to improve insomnia symptoms.

Study design

• Fifty US veterans who were mostly male (58%) with a mean age of 44.5 and moderate insomnia symptoms were randomized to use Insomnia Coach (n = 25) or to a waitlist control group (n = 25) for 6 weeks.
• All participants completed self-report measures and sleep diaries at baseline, posttreatment, and follow-up (12 weeks). Those who used the app (n = 15) completed a qualitative interview at posttreatment.

Outcomes

• At posttreatment, 28% of participants who used Insomnia Coach achieved clinically significant improvement, vs 4% of waitlist control participants. There was also a significant treatment effect on daytime sleep-related impairment (P = .044, d = -0.6).
• Additional treatment effects emerged at follow-up for insomnia severity, sleep onset latency, global sleep quality, and depression symptoms.
• Based on self-reports and qualitative interview responses, participants’ perceptions of Insomnia Coach were favorable. Three-fourths of participants used the app through 6 weeks and engaged with active elements.

Continue to: Conclusions/limitations

• Insomnia Coach may provide an accessible and convenient public health intervention for patients who aren’t receiving adequate care or CBT.
• Limitations: Because this study evaluated only veterans, the findings might not be generalizable to other populations.

8. Dahne J, Lejuez CW, Diaz VA, et al. Pilot randomized trial of a self-help behavioral activation mobile app for utilization in primary care. Behav Ther. 2019;50(4):817-827. doi:10.1016/j.beth.2018.12.003

Previous mobile technologies have shown the ability to treat depression in primary care settings. Moodivate is a self-help mobile app based on the Brief Behavioral Activation Treatment for Depression, which is an evidence-based treatment. This app is designed to help the user reengage in positive, nondepressed activities by identifying, scheduling, and completing activities. Dahne et al¹² investigated the feasibility and efficacy of Moodivate for depressive symptoms in primary care patients.

Study design

• Participants (N = 52) were recruited from primary care practices and randomized 2:2:1 to receive Moodivate, a CBT-based mobile app called MoodKit, or treatment as usual (no app). All participants had an initial PHQ-8 score >10.
• Participants completed assessments of depressive symptoms (PHQ-8) weekly for 8 weeks.
• App analytics data were captured to examine if the use of Moodivate was feasible. (Analytics were not available for MoodKit).

Outcomes

• Participants who used Moodivate had a mean (SD) of 46.76 (30.10) sessions throughout the trial, spent 3.50 (2.76) minutes using the app per session, and spent 120.76 (101.02) minutes using the app in total.
• Nearly 70% of Moodivate participants continued to use the app 1 month after trial enrollment and 50% at the end of the 8-week follow-up period.
• Compared to the treatment as usual group, participants who used Moodivate and those who used MoodKit experienced significant decreases in depressive symptoms over time.

Conclusions/limitations

• The results show that for primary care patients with depression, the use of Moodivate is feasible and may reduce depressive symptoms.
• Limitations: For the first 3 months of enrollment, patients who met diagnostic criteria for a current major depressive episode were excluded. This study did not assess duration of medication use (ie, whether a study participant was stabilized on medication or recently started taking a new medication) and therefore could not ascertain whether treatment gains were a result of the use of the app or of possible new medication use.

My first wish is to see this plague to Mankind, war, banished from the Earth; & the Sons and daughters of this World employed in more pleasing & innocent amusements than in preparing implements, & exercising them for the destruction of the human race.

General George Washington¹

When I was a child, every Fourth of July holiday my father would take me to the military fireworks display at Fort Sam Houston in Texas. We would take our place in the long cascade of cars parked at the huge parade ground in front of Brooke Army Medical Center. It was the most spectacular display of the year not to be found anywhere else in the city. Army fire engines and medics were always on site in case anything went wrong, which rarely occurred thanks to the pyrotechnic experts who ran the display.

Later, when I began my psychiatric residency at the US Department of Veterans Affairs (VA) New Mexico Healthcare System, I quickly learned a darker truth about fireworks. What seemed to me and many other civilians in General Washington’s words, a “pleasing and innocent amusement,” instead was a distressing and terrifying revisiting of trauma for many service members and veterans, likely including my father, who was a World War II combat veteran.

Fireworks are so closely linked to the birth of our young nation that we often forget they were invented in China a millennia ago. Fireworks were first associated with the fledgling nation in the middle of the War of Independence. On July 4, 1776, representatives of the 13 colonies signed the Declaration of Independence. In one of several ironies of history, what was used at the initial commemorations was not fireworks but the very “implements of destruction,” to use Washington’s phrase—guns and cannons. The demonstrations of firepower were meant to be morale boosters. After the war, the dangers of the detonations were recognized, and firearms were replaced with the fireworks we still launch today.²

The country celebrates the holiday with cookouts, parades, brass band concerts, and of course fireworks. Added to the organized shows are the millions of citizens who demonstrate private patriotism by shooting off fireworks in their neighborhoods. In 2021, Americans spent $1.5 billion on fireworks, and 33% said they planned to attend a public display.³

However, people are increasingly recognizing the negative side of fireworks for wild and companion animals and the environment. Most of us who have dogs and I am sure cats, horses, and other animals dread the impending darkness of the Fourth as it signals the coming loud noise and the cringing, pacing animals who want to run yet have nowhere to go to be safe from the sound.⁴

Sitting in the clinic with veterans, I realized it was not only pets and wildlife that feared the ultimate American holiday but also the very individuals who fought to preserve the freedom those fireworks celebrate. The VA’s National Center for Posttraumatic Stress Disorder (PTSD) estimates that about 7% of veterans will meet the diagnostic criteria for PTSD in their lifetimes. The prevalence of PTSD differs, depending on the methodology used, era and type of services, and demographics. Some studies have found higher rates of PTSD in women, young veterans, and those who served in Vietnam. Among the veterans who receive health care at the VA, like those I saw in the clinic, 23 in 1000 may have PTSD.⁵

We, after all, are remarkably similar in physiology to other mammals, and not surprisingly, veterans with PTSD exhibit many of the same reactions to fireworks. The sights, sounds, and odor of fireworks, as well as the vocal responses of the crowd at large displays evoke memories that trigger fear and anxiety. Many veterans experience flashbacks in which they relive combat and training accidents and have nightmares of those events, interrupting sleep. The instinct of many veterans is to avoid the holiday altogether: Many patients I knew sought refuge in remote mountain campsites often to find that even there they were not safe from revelers.

Avoidance being a cardinal symptom and coping mechanism of PTSD, therapists advise other methods of managing the Fourth of July, such as distractions that are calming and people who are reassuring. Therapists often rehearse self-talk scripts and teach breathing exercises targeted to break the behavioral conditioning that links present innocuous sensory overstimulation with a past life-threatening danger. The heat of summer worsens the stress, cooling down literally and figuratively can help.⁶

Many VA medical centers send announcements to the media or have their experts do interviews to educate the public about the potentially traumatizing effects of fireworks. They also encourage veterans who are apprehensive about the holiday to seek additional mental health help, including the Veterans Crisis Line. With my patients, we started early and developed a preventive plan to manage the anticipatory apprehension and arrange a means of enduring the ordeal. I do not have data to prove it, but anecdotally I know from my years on-call that visits to VA emergency departments and admissions to our inpatient psychiatry unit always increased around Independence Day in part because some veterans used drugs and/or alcohol to dampen their stress response.

VA experts also have advice for the families and friends of veterans who want to reduce the impact of fireworks and other holiday activities on them. Many veterans will feel at once intensely present to the disturbing aspects like fireworks and crowds and at the same time, distant and separated from the more positive parts of celebrations like being with loved ones in the outdoors. We can simply ask the veterans in our lives and neighborhoods how the festivities affect them and how we can help them get through the long hot night.⁷ Yet it would not be America without some controversy, and opinions are divided even among veterans about whether yard signs that say, “Combat Veteran Lives Here Please Be Courteous With Fireworks” enhance or impede the effort to increase awareness of the connection between fireworks, veterans, and PTSD.⁸

This editorial began with my own story of enjoying fireworks to emphasize that my aim is not to ruin the fun but to ask us to think before we shoot and consider the veterans near us for whom our recreation may cause unnecessary distress. Fourth of July would not have been possible without the soldiers who fought and died in the American Revolution and all the conflicts since. We owe it to all who have worn the uniform for the United States of America to remember the extraordinary toll it has taken on their ability to live ordinary lives. Like General Washington, we should vow to end the wars that wounded them so future generations will be able to join in celebrating Independence Day.

My first wish is to see this plague to Mankind, war, banished from the Earth; & the Sons and daughters of this World employed in more pleasing & innocent amusements than in preparing implements, & exercising them for the destruction of the human race.

General George Washington¹

When I was a child, every Fourth of July holiday my father would take me to the military fireworks display at Fort Sam Houston in Texas. We would take our place in the long cascade of cars parked at the huge parade ground in front of Brooke Army Medical Center. It was the most spectacular display of the year not to be found anywhere else in the city. Army fire engines and medics were always on site in case anything went wrong, which rarely occurred thanks to the pyrotechnic experts who ran the display.

Later, when I began my psychiatric residency at the US Department of Veterans Affairs (VA) New Mexico Healthcare System, I quickly learned a darker truth about fireworks. What seemed to me and many other civilians in General Washington’s words, a “pleasing and innocent amusement,” instead was a distressing and terrifying revisiting of trauma for many service members and veterans, likely including my father, who was a World War II combat veteran.

Fireworks are so closely linked to the birth of our young nation that we often forget they were invented in China a millennia ago. Fireworks were first associated with the fledgling nation in the middle of the War of Independence. On July 4, 1776, representatives of the 13 colonies signed the Declaration of Independence. In one of several ironies of history, what was used at the initial commemorations was not fireworks but the very “implements of destruction,” to use Washington’s phrase—guns and cannons. The demonstrations of firepower were meant to be morale boosters. After the war, the dangers of the detonations were recognized, and firearms were replaced with the fireworks we still launch today.²

The country celebrates the holiday with cookouts, parades, brass band concerts, and of course fireworks. Added to the organized shows are the millions of citizens who demonstrate private patriotism by shooting off fireworks in their neighborhoods. In 2021, Americans spent $1.5 billion on fireworks, and 33% said they planned to attend a public display.³

However, people are increasingly recognizing the negative side of fireworks for wild and companion animals and the environment. Most of us who have dogs and I am sure cats, horses, and other animals dread the impending darkness of the Fourth as it signals the coming loud noise and the cringing, pacing animals who want to run yet have nowhere to go to be safe from the sound.⁴

Sitting in the clinic with veterans, I realized it was not only pets and wildlife that feared the ultimate American holiday but also the very individuals who fought to preserve the freedom those fireworks celebrate. The VA’s National Center for Posttraumatic Stress Disorder (PTSD) estimates that about 7% of veterans will meet the diagnostic criteria for PTSD in their lifetimes. The prevalence of PTSD differs, depending on the methodology used, era and type of services, and demographics. Some studies have found higher rates of PTSD in women, young veterans, and those who served in Vietnam. Among the veterans who receive health care at the VA, like those I saw in the clinic, 23 in 1000 may have PTSD.⁵

We, after all, are remarkably similar in physiology to other mammals, and not surprisingly, veterans with PTSD exhibit many of the same reactions to fireworks. The sights, sounds, and odor of fireworks, as well as the vocal responses of the crowd at large displays evoke memories that trigger fear and anxiety. Many veterans experience flashbacks in which they relive combat and training accidents and have nightmares of those events, interrupting sleep. The instinct of many veterans is to avoid the holiday altogether: Many patients I knew sought refuge in remote mountain campsites often to find that even there they were not safe from revelers.

Avoidance being a cardinal symptom and coping mechanism of PTSD, therapists advise other methods of managing the Fourth of July, such as distractions that are calming and people who are reassuring. Therapists often rehearse self-talk scripts and teach breathing exercises targeted to break the behavioral conditioning that links present innocuous sensory overstimulation with a past life-threatening danger. The heat of summer worsens the stress, cooling down literally and figuratively can help.⁶

Many VA medical centers send announcements to the media or have their experts do interviews to educate the public about the potentially traumatizing effects of fireworks. They also encourage veterans who are apprehensive about the holiday to seek additional mental health help, including the Veterans Crisis Line. With my patients, we started early and developed a preventive plan to manage the anticipatory apprehension and arrange a means of enduring the ordeal. I do not have data to prove it, but anecdotally I know from my years on-call that visits to VA emergency departments and admissions to our inpatient psychiatry unit always increased around Independence Day in part because some veterans used drugs and/or alcohol to dampen their stress response.

VA experts also have advice for the families and friends of veterans who want to reduce the impact of fireworks and other holiday activities on them. Many veterans will feel at once intensely present to the disturbing aspects like fireworks and crowds and at the same time, distant and separated from the more positive parts of celebrations like being with loved ones in the outdoors. We can simply ask the veterans in our lives and neighborhoods how the festivities affect them and how we can help them get through the long hot night.⁷ Yet it would not be America without some controversy, and opinions are divided even among veterans about whether yard signs that say, “Combat Veteran Lives Here Please Be Courteous With Fireworks” enhance or impede the effort to increase awareness of the connection between fireworks, veterans, and PTSD.⁸

This editorial began with my own story of enjoying fireworks to emphasize that my aim is not to ruin the fun but to ask us to think before we shoot and consider the veterans near us for whom our recreation may cause unnecessary distress. Fourth of July would not have been possible without the soldiers who fought and died in the American Revolution and all the conflicts since. We owe it to all who have worn the uniform for the United States of America to remember the extraordinary toll it has taken on their ability to live ordinary lives. Like General Washington, we should vow to end the wars that wounded them so future generations will be able to join in celebrating Independence Day.

My first wish is to see this plague to Mankind, war, banished from the Earth; & the Sons and daughters of this World employed in more pleasing & innocent amusements than in preparing implements, & exercising them for the destruction of the human race.

General George Washington¹

When I was a child, every Fourth of July holiday my father would take me to the military fireworks display at Fort Sam Houston in Texas. We would take our place in the long cascade of cars parked at the huge parade ground in front of Brooke Army Medical Center. It was the most spectacular display of the year not to be found anywhere else in the city. Army fire engines and medics were always on site in case anything went wrong, which rarely occurred thanks to the pyrotechnic experts who ran the display.

Later, when I began my psychiatric residency at the US Department of Veterans Affairs (VA) New Mexico Healthcare System, I quickly learned a darker truth about fireworks. What seemed to me and many other civilians in General Washington’s words, a “pleasing and innocent amusement,” instead was a distressing and terrifying revisiting of trauma for many service members and veterans, likely including my father, who was a World War II combat veteran.

Fireworks are so closely linked to the birth of our young nation that we often forget they were invented in China a millennia ago. Fireworks were first associated with the fledgling nation in the middle of the War of Independence. On July 4, 1776, representatives of the 13 colonies signed the Declaration of Independence. In one of several ironies of history, what was used at the initial commemorations was not fireworks but the very “implements of destruction,” to use Washington’s phrase—guns and cannons. The demonstrations of firepower were meant to be morale boosters. After the war, the dangers of the detonations were recognized, and firearms were replaced with the fireworks we still launch today.²

The country celebrates the holiday with cookouts, parades, brass band concerts, and of course fireworks. Added to the organized shows are the millions of citizens who demonstrate private patriotism by shooting off fireworks in their neighborhoods. In 2021, Americans spent $1.5 billion on fireworks, and 33% said they planned to attend a public display.³

However, people are increasingly recognizing the negative side of fireworks for wild and companion animals and the environment. Most of us who have dogs and I am sure cats, horses, and other animals dread the impending darkness of the Fourth as it signals the coming loud noise and the cringing, pacing animals who want to run yet have nowhere to go to be safe from the sound.⁴

Sitting in the clinic with veterans, I realized it was not only pets and wildlife that feared the ultimate American holiday but also the very individuals who fought to preserve the freedom those fireworks celebrate. The VA’s National Center for Posttraumatic Stress Disorder (PTSD) estimates that about 7% of veterans will meet the diagnostic criteria for PTSD in their lifetimes. The prevalence of PTSD differs, depending on the methodology used, era and type of services, and demographics. Some studies have found higher rates of PTSD in women, young veterans, and those who served in Vietnam. Among the veterans who receive health care at the VA, like those I saw in the clinic, 23 in 1000 may have PTSD.⁵

We, after all, are remarkably similar in physiology to other mammals, and not surprisingly, veterans with PTSD exhibit many of the same reactions to fireworks. The sights, sounds, and odor of fireworks, as well as the vocal responses of the crowd at large displays evoke memories that trigger fear and anxiety. Many veterans experience flashbacks in which they relive combat and training accidents and have nightmares of those events, interrupting sleep. The instinct of many veterans is to avoid the holiday altogether: Many patients I knew sought refuge in remote mountain campsites often to find that even there they were not safe from revelers.

Avoidance being a cardinal symptom and coping mechanism of PTSD, therapists advise other methods of managing the Fourth of July, such as distractions that are calming and people who are reassuring. Therapists often rehearse self-talk scripts and teach breathing exercises targeted to break the behavioral conditioning that links present innocuous sensory overstimulation with a past life-threatening danger. The heat of summer worsens the stress, cooling down literally and figuratively can help.⁶

Many VA medical centers send announcements to the media or have their experts do interviews to educate the public about the potentially traumatizing effects of fireworks. They also encourage veterans who are apprehensive about the holiday to seek additional mental health help, including the Veterans Crisis Line. With my patients, we started early and developed a preventive plan to manage the anticipatory apprehension and arrange a means of enduring the ordeal. I do not have data to prove it, but anecdotally I know from my years on-call that visits to VA emergency departments and admissions to our inpatient psychiatry unit always increased around Independence Day in part because some veterans used drugs and/or alcohol to dampen their stress response.

VA experts also have advice for the families and friends of veterans who want to reduce the impact of fireworks and other holiday activities on them. Many veterans will feel at once intensely present to the disturbing aspects like fireworks and crowds and at the same time, distant and separated from the more positive parts of celebrations like being with loved ones in the outdoors. We can simply ask the veterans in our lives and neighborhoods how the festivities affect them and how we can help them get through the long hot night.⁷ Yet it would not be America without some controversy, and opinions are divided even among veterans about whether yard signs that say, “Combat Veteran Lives Here Please Be Courteous With Fireworks” enhance or impede the effort to increase awareness of the connection between fireworks, veterans, and PTSD.⁸

This editorial began with my own story of enjoying fireworks to emphasize that my aim is not to ruin the fun but to ask us to think before we shoot and consider the veterans near us for whom our recreation may cause unnecessary distress. Fourth of July would not have been possible without the soldiers who fought and died in the American Revolution and all the conflicts since. We owe it to all who have worn the uniform for the United States of America to remember the extraordinary toll it has taken on their ability to live ordinary lives. Like General Washington, we should vow to end the wars that wounded them so future generations will be able to join in celebrating Independence Day.

The Department of Health & Human Services has issued an advisory to help medical professionals better recognize the mental health symptoms that may come with long COVID.

The nine mental health symptoms highlighted in the advisory are fatigue; cognitive impairment, including brain fog; anxiety; depression; obsessive-compulsive disorder; sleep disorders; PTSD; psychotic disorder; and start of a substance use disorder.

The advisory noted that social factors can contribute to the mental health problems for racial and ethnic minorities; people with limited access to health care; people who already have behavioral health conditions and physical disabilities; and people who are lesbian, gay, bisexual, transgender, queer, or intersex.

“Long COVID has a range of burdensome physical symptoms and can take a toll on a person’s mental health. It can be very challenging for a person, whether they are impacted themselves, or they are a caregiver for someone who is affected,” Health and Human Services Secretary Xavier Becerra said in a statement. “This advisory helps to raise awareness, especially among primary care practitioners and clinicians who are often the ones treating patients with long COVID.”

The department says about 10% of people infected with COVID have at least one long COVID symptom. Physical symptoms include dizziness, stomach upset, heart palpitations, issues with sexual desire or capacity, loss of smell or taste, thirst, chronic coughing, chest pain, and abnormal movements. 

“We know that people living with long COVID need help today, and providers need help understanding what long COVID is and how to treat it,” Admiral Rachel Levine, MD, assistant secretary for health, said in the statement. “This advisory helps bridge that gap for the behavioral health impacts of long COVID.”

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

The Department of Health & Human Services has issued an advisory to help medical professionals better recognize the mental health symptoms that may come with long COVID.

The nine mental health symptoms highlighted in the advisory are fatigue; cognitive impairment, including brain fog; anxiety; depression; obsessive-compulsive disorder; sleep disorders; PTSD; psychotic disorder; and start of a substance use disorder.

The advisory noted that social factors can contribute to the mental health problems for racial and ethnic minorities; people with limited access to health care; people who already have behavioral health conditions and physical disabilities; and people who are lesbian, gay, bisexual, transgender, queer, or intersex.

“Long COVID has a range of burdensome physical symptoms and can take a toll on a person’s mental health. It can be very challenging for a person, whether they are impacted themselves, or they are a caregiver for someone who is affected,” Health and Human Services Secretary Xavier Becerra said in a statement. “This advisory helps to raise awareness, especially among primary care practitioners and clinicians who are often the ones treating patients with long COVID.”

The department says about 10% of people infected with COVID have at least one long COVID symptom. Physical symptoms include dizziness, stomach upset, heart palpitations, issues with sexual desire or capacity, loss of smell or taste, thirst, chronic coughing, chest pain, and abnormal movements. 

“We know that people living with long COVID need help today, and providers need help understanding what long COVID is and how to treat it,” Admiral Rachel Levine, MD, assistant secretary for health, said in the statement. “This advisory helps bridge that gap for the behavioral health impacts of long COVID.”

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

The Department of Health & Human Services has issued an advisory to help medical professionals better recognize the mental health symptoms that may come with long COVID.

The nine mental health symptoms highlighted in the advisory are fatigue; cognitive impairment, including brain fog; anxiety; depression; obsessive-compulsive disorder; sleep disorders; PTSD; psychotic disorder; and start of a substance use disorder.

The advisory noted that social factors can contribute to the mental health problems for racial and ethnic minorities; people with limited access to health care; people who already have behavioral health conditions and physical disabilities; and people who are lesbian, gay, bisexual, transgender, queer, or intersex.

“Long COVID has a range of burdensome physical symptoms and can take a toll on a person’s mental health. It can be very challenging for a person, whether they are impacted themselves, or they are a caregiver for someone who is affected,” Health and Human Services Secretary Xavier Becerra said in a statement. “This advisory helps to raise awareness, especially among primary care practitioners and clinicians who are often the ones treating patients with long COVID.”

The department says about 10% of people infected with COVID have at least one long COVID symptom. Physical symptoms include dizziness, stomach upset, heart palpitations, issues with sexual desire or capacity, loss of smell or taste, thirst, chronic coughing, chest pain, and abnormal movements. 

“We know that people living with long COVID need help today, and providers need help understanding what long COVID is and how to treat it,” Admiral Rachel Levine, MD, assistant secretary for health, said in the statement. “This advisory helps bridge that gap for the behavioral health impacts of long COVID.”

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

The Sexual Health Initiative to Foster Transformation (SHIFT)¹ is a landmark study about sexual assault at college, which has generated 20 scientific articles and several chapters in books, but unfortunately, has not made its way into the psychiatric literature.

“Sexual Citizens: Sex, Power and Assault on Campus,” by Jennifer Hirsch and Shamus Khan, (available in audio book and paperback) was written as a follow up to the SHIFT study, so the rest of us can absorb the findings.² This mixed-methods study included a survey of over 1,600 students aged 18-29 from Columbia University and Barnard College regarding their relationships and sexual histories, including assault. Data were collected using daily diaries, focus groups, and hundreds of hours of field work observation by young researchers. One- to 3-hour in-depth interviews exploring sexual experiences on campus were conducted with 151 students. These interviews are the focus of the book. It is a well-written, provocative story brimming with insights for those of us who lack the time to scour social science literature.

Dr. Higgins

“Sexual Citizens” and the SHIFT study confirmed much of what we know. Sexual assault is common and has enduring effects. The study found that 36% of women and 15% of men had experienced unwanted, nonconsensual sexual contact by senior year. Twenty percent of women and 6% of men were rape survivors. Freshman, LGBTQ, and minority students were found at highest risk of assault. SHIFT reaffirmed that abstinence-only education is not a protective factor against college sexual assault, but neither was knowledge of affirmative consent (the practice of “ongoing and explicit” checking-in with partners) which few students ever employed. Encouragingly, students taught refusal skills were less likely to experience sexual assault.

Many of the book’s valuable lessons fall under the umbrella of failures of language and communication. For example, after drinking, they went to his room. She was expecting a social interaction, but with no other place to sit, they sat on his bed where she was coaxed or pressured into a sexual encounter. Afterward, she leaves, and it is never discussed again. One partner desires emotional intimacy, and the other, bragging rights in the fraternity or at the girls’ weekly brunch. Numerous personal stories like these, though at times heart wrenching, provide perspective on the barriers to addressing assault.

Subjects relayed experiences of assault by strangers or friends, and some provided details of their own actions as perpetrators. Stumbling around words and emotions, an avoidance of explicit language stemmed from shame, a fear of personal responsibility, the desire to maintain social cohesion, and concern for potential consequences for the perpetrator. Many subjects were resistant to calling nonconsensual sexual activity rape or even assault. Some who had perpetrated were unaware their behavior may have been experienced as assault, with recognition of this fact dawning during interviews.

This apparent limitation in self-reflective capacity may be in part due to the conceptualization of what assault is. Focus groups identified a discernible difference in how men and women understood assaults, with men believing rapes looked like a woman fighting back and screaming for help ... which is rarely what happens.

Notably absent among the interviewed are any flagrant perpetrators. The methodology section theorizes that individuals who intentionally harmed their peers were unlikely to choose to participate in this study. In addition, the characterization of assailants as “sociopathic predators” is based in a history of racialized imagery that leads us astray from the truth about campus sexual assault. Most assaults do not involve force, and SHIFT data showed 75% of victims knew their assailants. Ultimately, a major aim of the research was to study assault alongside healthy sex to “understand those pivotal moments when encounters change from being sex, to being assault.” Doing this requires understanding the where, how, and why students have sex, a more complicated undertaking than we may think.

In discussing their sexual lives, subjects frequently noted they did not have space to talk about their assaults. Though 81% of students discussed their experiences with someone, friend groups were often overburdened with stories, which minimized the victim’s experience. Furthermore, most had not sought help from the student counseling centers. Students navigating this complex field were frequently doing so in isolation. SHIFT found subjects to be eager to participate; they would often express thankfulness, and a sense of freedom in sharing with researchers. Commonly, students expressly did not want retribution for perpetrators, but simply a place to be heard without challenge. The current legal system precludes that possibility, leaving individuals without the option to confront perpetrators, and perpetrators often not knowing the extent of the damage they caused.

Where can psychiatrists have an impact right now? “Sexual Citizens” identifies four key areas for intervention to work toward a world with less sexual assault. These are:

• Improving diversity, inequality, and power distortions.
• Education about sex and sexual assault.
• Substance use.
• Mental health.

Substance use and mental health are especially relevant for psychiatrists (That substance use contributes to sexual assault is known by approximately ... everybody!). “Sexual Citizens” notes that mental illness is likely “both a cause and a consequence of sexual assault.” Unwanted sexual contact prior to college (20% of students) increased the odds of experiencing assault during college. Harm reduction strategies should be introduced before college, according to the SHIFT research, particularly in skills-based training on how to say “No” to unwanted sex. Psychiatrists are likely used to asking brief history questions related to sexual assault and rape. “Sexual Citizens” highlights the inadequacy of this blunt language and guides the reader toward a refined knowledge of the language needed to address sexual assault.

Dr. Whisler is a child and adolescent psychiatry fellow at the Stanford (Calif.) University. Dr. Higgins is affiliate associate professor of psychiatry and family medicine at the Medical University of South Carolina, Charleston.

References

1. Hirsch JS et al. Social dimensions of sexual consent among cisgender heterosexual college students: Insights from ethnographic research. J Adolesc Health. 2019 Jan;64(1):26-35. doi: 10.1016/j.jadohealth.2018.06.011.

2. Hirsch JS and Khan S. Sexual citizens: Sex, power, and assault on campus. New York: W.W. Norton & Company, 2020.

The Sexual Health Initiative to Foster Transformation (SHIFT)¹ is a landmark study about sexual assault at college, which has generated 20 scientific articles and several chapters in books, but unfortunately, has not made its way into the psychiatric literature.

“Sexual Citizens: Sex, Power and Assault on Campus,” by Jennifer Hirsch and Shamus Khan, (available in audio book and paperback) was written as a follow up to the SHIFT study, so the rest of us can absorb the findings.² This mixed-methods study included a survey of over 1,600 students aged 18-29 from Columbia University and Barnard College regarding their relationships and sexual histories, including assault. Data were collected using daily diaries, focus groups, and hundreds of hours of field work observation by young researchers. One- to 3-hour in-depth interviews exploring sexual experiences on campus were conducted with 151 students. These interviews are the focus of the book. It is a well-written, provocative story brimming with insights for those of us who lack the time to scour social science literature.

Dr. Higgins

“Sexual Citizens” and the SHIFT study confirmed much of what we know. Sexual assault is common and has enduring effects. The study found that 36% of women and 15% of men had experienced unwanted, nonconsensual sexual contact by senior year. Twenty percent of women and 6% of men were rape survivors. Freshman, LGBTQ, and minority students were found at highest risk of assault. SHIFT reaffirmed that abstinence-only education is not a protective factor against college sexual assault, but neither was knowledge of affirmative consent (the practice of “ongoing and explicit” checking-in with partners) which few students ever employed. Encouragingly, students taught refusal skills were less likely to experience sexual assault.

Many of the book’s valuable lessons fall under the umbrella of failures of language and communication. For example, after drinking, they went to his room. She was expecting a social interaction, but with no other place to sit, they sat on his bed where she was coaxed or pressured into a sexual encounter. Afterward, she leaves, and it is never discussed again. One partner desires emotional intimacy, and the other, bragging rights in the fraternity or at the girls’ weekly brunch. Numerous personal stories like these, though at times heart wrenching, provide perspective on the barriers to addressing assault.

Subjects relayed experiences of assault by strangers or friends, and some provided details of their own actions as perpetrators. Stumbling around words and emotions, an avoidance of explicit language stemmed from shame, a fear of personal responsibility, the desire to maintain social cohesion, and concern for potential consequences for the perpetrator. Many subjects were resistant to calling nonconsensual sexual activity rape or even assault. Some who had perpetrated were unaware their behavior may have been experienced as assault, with recognition of this fact dawning during interviews.

This apparent limitation in self-reflective capacity may be in part due to the conceptualization of what assault is. Focus groups identified a discernible difference in how men and women understood assaults, with men believing rapes looked like a woman fighting back and screaming for help ... which is rarely what happens.

Notably absent among the interviewed are any flagrant perpetrators. The methodology section theorizes that individuals who intentionally harmed their peers were unlikely to choose to participate in this study. In addition, the characterization of assailants as “sociopathic predators” is based in a history of racialized imagery that leads us astray from the truth about campus sexual assault. Most assaults do not involve force, and SHIFT data showed 75% of victims knew their assailants. Ultimately, a major aim of the research was to study assault alongside healthy sex to “understand those pivotal moments when encounters change from being sex, to being assault.” Doing this requires understanding the where, how, and why students have sex, a more complicated undertaking than we may think.

In discussing their sexual lives, subjects frequently noted they did not have space to talk about their assaults. Though 81% of students discussed their experiences with someone, friend groups were often overburdened with stories, which minimized the victim’s experience. Furthermore, most had not sought help from the student counseling centers. Students navigating this complex field were frequently doing so in isolation. SHIFT found subjects to be eager to participate; they would often express thankfulness, and a sense of freedom in sharing with researchers. Commonly, students expressly did not want retribution for perpetrators, but simply a place to be heard without challenge. The current legal system precludes that possibility, leaving individuals without the option to confront perpetrators, and perpetrators often not knowing the extent of the damage they caused.

Where can psychiatrists have an impact right now? “Sexual Citizens” identifies four key areas for intervention to work toward a world with less sexual assault. These are:

• Improving diversity, inequality, and power distortions.
• Education about sex and sexual assault.
• Substance use.
• Mental health.

Substance use and mental health are especially relevant for psychiatrists (That substance use contributes to sexual assault is known by approximately ... everybody!). “Sexual Citizens” notes that mental illness is likely “both a cause and a consequence of sexual assault.” Unwanted sexual contact prior to college (20% of students) increased the odds of experiencing assault during college. Harm reduction strategies should be introduced before college, according to the SHIFT research, particularly in skills-based training on how to say “No” to unwanted sex. Psychiatrists are likely used to asking brief history questions related to sexual assault and rape. “Sexual Citizens” highlights the inadequacy of this blunt language and guides the reader toward a refined knowledge of the language needed to address sexual assault.

Dr. Whisler is a child and adolescent psychiatry fellow at the Stanford (Calif.) University. Dr. Higgins is affiliate associate professor of psychiatry and family medicine at the Medical University of South Carolina, Charleston.

References

1. Hirsch JS et al. Social dimensions of sexual consent among cisgender heterosexual college students: Insights from ethnographic research. J Adolesc Health. 2019 Jan;64(1):26-35. doi: 10.1016/j.jadohealth.2018.06.011.

2. Hirsch JS and Khan S. Sexual citizens: Sex, power, and assault on campus. New York: W.W. Norton & Company, 2020.

The Sexual Health Initiative to Foster Transformation (SHIFT)¹ is a landmark study about sexual assault at college, which has generated 20 scientific articles and several chapters in books, but unfortunately, has not made its way into the psychiatric literature.

“Sexual Citizens: Sex, Power and Assault on Campus,” by Jennifer Hirsch and Shamus Khan, (available in audio book and paperback) was written as a follow up to the SHIFT study, so the rest of us can absorb the findings.² This mixed-methods study included a survey of over 1,600 students aged 18-29 from Columbia University and Barnard College regarding their relationships and sexual histories, including assault. Data were collected using daily diaries, focus groups, and hundreds of hours of field work observation by young researchers. One- to 3-hour in-depth interviews exploring sexual experiences on campus were conducted with 151 students. These interviews are the focus of the book. It is a well-written, provocative story brimming with insights for those of us who lack the time to scour social science literature.

Dr. Higgins

“Sexual Citizens” and the SHIFT study confirmed much of what we know. Sexual assault is common and has enduring effects. The study found that 36% of women and 15% of men had experienced unwanted, nonconsensual sexual contact by senior year. Twenty percent of women and 6% of men were rape survivors. Freshman, LGBTQ, and minority students were found at highest risk of assault. SHIFT reaffirmed that abstinence-only education is not a protective factor against college sexual assault, but neither was knowledge of affirmative consent (the practice of “ongoing and explicit” checking-in with partners) which few students ever employed. Encouragingly, students taught refusal skills were less likely to experience sexual assault.

Many of the book’s valuable lessons fall under the umbrella of failures of language and communication. For example, after drinking, they went to his room. She was expecting a social interaction, but with no other place to sit, they sat on his bed where she was coaxed or pressured into a sexual encounter. Afterward, she leaves, and it is never discussed again. One partner desires emotional intimacy, and the other, bragging rights in the fraternity or at the girls’ weekly brunch. Numerous personal stories like these, though at times heart wrenching, provide perspective on the barriers to addressing assault.

Subjects relayed experiences of assault by strangers or friends, and some provided details of their own actions as perpetrators. Stumbling around words and emotions, an avoidance of explicit language stemmed from shame, a fear of personal responsibility, the desire to maintain social cohesion, and concern for potential consequences for the perpetrator. Many subjects were resistant to calling nonconsensual sexual activity rape or even assault. Some who had perpetrated were unaware their behavior may have been experienced as assault, with recognition of this fact dawning during interviews.

This apparent limitation in self-reflective capacity may be in part due to the conceptualization of what assault is. Focus groups identified a discernible difference in how men and women understood assaults, with men believing rapes looked like a woman fighting back and screaming for help ... which is rarely what happens.

Notably absent among the interviewed are any flagrant perpetrators. The methodology section theorizes that individuals who intentionally harmed their peers were unlikely to choose to participate in this study. In addition, the characterization of assailants as “sociopathic predators” is based in a history of racialized imagery that leads us astray from the truth about campus sexual assault. Most assaults do not involve force, and SHIFT data showed 75% of victims knew their assailants. Ultimately, a major aim of the research was to study assault alongside healthy sex to “understand those pivotal moments when encounters change from being sex, to being assault.” Doing this requires understanding the where, how, and why students have sex, a more complicated undertaking than we may think.

In discussing their sexual lives, subjects frequently noted they did not have space to talk about their assaults. Though 81% of students discussed their experiences with someone, friend groups were often overburdened with stories, which minimized the victim’s experience. Furthermore, most had not sought help from the student counseling centers. Students navigating this complex field were frequently doing so in isolation. SHIFT found subjects to be eager to participate; they would often express thankfulness, and a sense of freedom in sharing with researchers. Commonly, students expressly did not want retribution for perpetrators, but simply a place to be heard without challenge. The current legal system precludes that possibility, leaving individuals without the option to confront perpetrators, and perpetrators often not knowing the extent of the damage they caused.

Where can psychiatrists have an impact right now? “Sexual Citizens” identifies four key areas for intervention to work toward a world with less sexual assault. These are:

• Improving diversity, inequality, and power distortions.
• Education about sex and sexual assault.
• Substance use.
• Mental health.

Substance use and mental health are especially relevant for psychiatrists (That substance use contributes to sexual assault is known by approximately ... everybody!). “Sexual Citizens” notes that mental illness is likely “both a cause and a consequence of sexual assault.” Unwanted sexual contact prior to college (20% of students) increased the odds of experiencing assault during college. Harm reduction strategies should be introduced before college, according to the SHIFT research, particularly in skills-based training on how to say “No” to unwanted sex. Psychiatrists are likely used to asking brief history questions related to sexual assault and rape. “Sexual Citizens” highlights the inadequacy of this blunt language and guides the reader toward a refined knowledge of the language needed to address sexual assault.

Dr. Whisler is a child and adolescent psychiatry fellow at the Stanford (Calif.) University. Dr. Higgins is affiliate associate professor of psychiatry and family medicine at the Medical University of South Carolina, Charleston.

References

1. Hirsch JS et al. Social dimensions of sexual consent among cisgender heterosexual college students: Insights from ethnographic research. J Adolesc Health. 2019 Jan;64(1):26-35. doi: 10.1016/j.jadohealth.2018.06.011.

2. Hirsch JS and Khan S. Sexual citizens: Sex, power, and assault on campus. New York: W.W. Norton & Company, 2020.