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Family estrangement: Would mutual respect make a difference?
Families are the bedrock of the lives of many, but some people opt to separate permanently from family members. A recent episode of the NPR program “1A” explored why families sever ties.
For journalist Harriet Brown, author of “Shadow Daughter: A Memoir of Estrangement,” (Da Capo Press, 2018), the decision to end her relationship with her mother came after she blamed Ms. Brown in “a blistering email” for the relapsed anorexia of Ms. Brown’s daughter.
“I was done with her,” Ms. Brown said on the program. “I told her I was done. That was it. And I never talked to her again. I think for both of us it felt final in some way.”
She said a lot of shame and stigma comes from having a bad relationship with a parent. “I really wanted to make it clear that ... sometimes walking away is really the best thing to do.”
Kristina M. Scharp, PhD, who has studied the estrangement phenomenon, said no national data exist on family estrangement. “About 12% of mothers and research would suggest even more fathers would report being estranged from one of their children,” said Dr. Scharp, who is with the University of Washington, Seattle. “It’s fairly common.”
Estrangement might be more common today because times have changed, said Joshua Coleman, PhD, author of “When Parents Hurt: Compassionate Strategies When you and Your Grown Child Don’t get Along” (HarperCollins, 2008). “Today’s adult children don’t view their relationships with their parents the way their folks did with their parents … the principles of obligation, duty, and respect that baby boomers and generations before them had for their elders aren’t necessarily there anymore,” Dr. Coleman said in a previous interview with the Chicago Tribune.
For her part, Ms. Brown said, the relationship with her mother – who is now deceased – might have been healed with respect. she said. “Honestly, it was that basic with my mother.”
Phelps gets mental health advocacy award
In the pool, Michael Phelps was golden, with 28 Olympics medals, 23 of them gold, hanging around his neck by the end of his swimming career. But the release from the water to real life after the 2016 Summer Olympics left no outlet for troubles that had dogged him for years. Drunk driving convictions and a ban from competition during his competitive years had failed to stop his downward spiral of depression. His thoughts turned to suicide.
But his story has a bright ending. With his realization that he had hit rock bottom, and with the help of his wife and therapists, he accepted his depression and learned to live with the reality that his life is, for the most part, pretty good.
His openness about his struggles with depression has been influential. The latest recognition came in early January, when he received the Morton E. Ruderman Award in Inclusion from the Ruderman Family Foundation. As reported in the Boston Globe, Mr. Phelps was recognized for his advocacy for people with disabilities and “his own journey with mental health.”
“I do like who I am and I’m comfortable with who I am. I couldn’t say that a few years ago. So I’m in a very good place and just living life one day at a time,” Mr. Phelps remarked in an interview with CNN last year.
Mr. Phelps is now a paid spokesperson for TalkSpace, an online therapy company.
“I’d like to make a difference. I’d like to be able to save a life if I can. You know, for me that’s more important than winning a gold medal. The stuff that I’m doing now is very exciting. It’s hard, it’s challenging but it’s fun for me. That’s what drives me to get out of bed every morning,” he said.
Offenders with mental illness get a break
A law included as part of budget legislation that was signed by then-Gov. Jerry Brown of California in June 2018 has offered people with mental health troubles who have been charged with a crime the opportunity for treatment instead of jail time.
As reported in the Los Angeles Times, the law provides judges with the discretion to order offenders into treatment rather than sentencing them. Success in treatment can lead to charges being dropped.
The law has been praised by some mental health advocates but panned by law enforcement officials and prosecutors with a harder view of criminal justice. The opposition stems largely from a December 2018 ruling by the 4th District Court of Appeal that the law could be applied to retroactively address the case of a man imprisoned for 29 years in 2017 for multiple felony charges that included domestic violence and assault.
The law does not extend to those charged with murder, manslaughter, rape, and child sexual abuse. To date, citing mental illness in seeking diversion of sentencing has not proven successful in most cases.
Schools get mental health allocation
The Orleans Parish School Board, which serves all of New Orleans, will allocate $1.3 million to the Center for Resilience, a local mental health day treatment program, beginning this year. The new program will expand mental health help to children in grades 9-12, according to a report in the Times-Picayune.
The funding will enable the center to expand an existing program that helps students with behavioral issues. Such help is not available in the traditional school system. By offsetting part of the price tag for the mental health care, the initiative “[helps to make] this critical service more available for our students most in need,” said Dominique Ellis, a spokesperson for the school board. “Mental health day treatment programs like the Center for Resilience typically cost between the ranges of $80,000-$100,000 per student to operate effectively.”
The development brings New Orleans level with money spent on similar programs in other school boards nationwide. It’s a service that is sorely needed. According to statistics supplied by the Center for Resilience, 60% of New Orleans children suffer from PTSD and are 4.5 times more likely to suffer from hyperactivity, aggression, and social withdrawal than similarly aged children elsewhere in the United States.
Bill addressing opioid crisis a “no-brainer”
Legislation put forward in the current session of the Texas Legislature would require pharmacists to identify all prescription opioids with a red cap and a hard-to-miss warning of the addictive risk of the medications. In addition, pharmacists would have to explain the risk in person to those receiving the medications and get signed acknowledgment of the conversation before dispensing the drugs.
As described in an article in the Austin American-Stateman, nearly 3,000 people in Texas died from drug overdoses in 2017. The deaths tied to opioid overdoses are not certain, but other data from 2015 suggest that one-third is a reasonable estimate.
“Losing a loved one to an opioid overdose is a tragedy that far too many Texas families experience,” said Rep. Shawn Thierry last month, when she introduced the three bills. “These distinctive red caps will serve as a clear notice to Texans that opioids are unlike milder forms of prescription pain relievers and have life-altering risks that must be considered before taking them.”
Warning labels on everything from food to tobacco products, and including them on prescription opioids is a “no-brainer,” Ms. Thierry said. “The more we can educate our residents the less likely they will be to misuse these medications.”
A report issued in November 2018 chronicled the drug crisis in Texas and offered recommendations. Many of the 100 recommendations involved the absence of treatment resources in the state.
Families are the bedrock of the lives of many, but some people opt to separate permanently from family members. A recent episode of the NPR program “1A” explored why families sever ties.
For journalist Harriet Brown, author of “Shadow Daughter: A Memoir of Estrangement,” (Da Capo Press, 2018), the decision to end her relationship with her mother came after she blamed Ms. Brown in “a blistering email” for the relapsed anorexia of Ms. Brown’s daughter.
“I was done with her,” Ms. Brown said on the program. “I told her I was done. That was it. And I never talked to her again. I think for both of us it felt final in some way.”
She said a lot of shame and stigma comes from having a bad relationship with a parent. “I really wanted to make it clear that ... sometimes walking away is really the best thing to do.”
Kristina M. Scharp, PhD, who has studied the estrangement phenomenon, said no national data exist on family estrangement. “About 12% of mothers and research would suggest even more fathers would report being estranged from one of their children,” said Dr. Scharp, who is with the University of Washington, Seattle. “It’s fairly common.”
Estrangement might be more common today because times have changed, said Joshua Coleman, PhD, author of “When Parents Hurt: Compassionate Strategies When you and Your Grown Child Don’t get Along” (HarperCollins, 2008). “Today’s adult children don’t view their relationships with their parents the way their folks did with their parents … the principles of obligation, duty, and respect that baby boomers and generations before them had for their elders aren’t necessarily there anymore,” Dr. Coleman said in a previous interview with the Chicago Tribune.
For her part, Ms. Brown said, the relationship with her mother – who is now deceased – might have been healed with respect. she said. “Honestly, it was that basic with my mother.”
Phelps gets mental health advocacy award
In the pool, Michael Phelps was golden, with 28 Olympics medals, 23 of them gold, hanging around his neck by the end of his swimming career. But the release from the water to real life after the 2016 Summer Olympics left no outlet for troubles that had dogged him for years. Drunk driving convictions and a ban from competition during his competitive years had failed to stop his downward spiral of depression. His thoughts turned to suicide.
But his story has a bright ending. With his realization that he had hit rock bottom, and with the help of his wife and therapists, he accepted his depression and learned to live with the reality that his life is, for the most part, pretty good.
His openness about his struggles with depression has been influential. The latest recognition came in early January, when he received the Morton E. Ruderman Award in Inclusion from the Ruderman Family Foundation. As reported in the Boston Globe, Mr. Phelps was recognized for his advocacy for people with disabilities and “his own journey with mental health.”
“I do like who I am and I’m comfortable with who I am. I couldn’t say that a few years ago. So I’m in a very good place and just living life one day at a time,” Mr. Phelps remarked in an interview with CNN last year.
Mr. Phelps is now a paid spokesperson for TalkSpace, an online therapy company.
“I’d like to make a difference. I’d like to be able to save a life if I can. You know, for me that’s more important than winning a gold medal. The stuff that I’m doing now is very exciting. It’s hard, it’s challenging but it’s fun for me. That’s what drives me to get out of bed every morning,” he said.
Offenders with mental illness get a break
A law included as part of budget legislation that was signed by then-Gov. Jerry Brown of California in June 2018 has offered people with mental health troubles who have been charged with a crime the opportunity for treatment instead of jail time.
As reported in the Los Angeles Times, the law provides judges with the discretion to order offenders into treatment rather than sentencing them. Success in treatment can lead to charges being dropped.
The law has been praised by some mental health advocates but panned by law enforcement officials and prosecutors with a harder view of criminal justice. The opposition stems largely from a December 2018 ruling by the 4th District Court of Appeal that the law could be applied to retroactively address the case of a man imprisoned for 29 years in 2017 for multiple felony charges that included domestic violence and assault.
The law does not extend to those charged with murder, manslaughter, rape, and child sexual abuse. To date, citing mental illness in seeking diversion of sentencing has not proven successful in most cases.
Schools get mental health allocation
The Orleans Parish School Board, which serves all of New Orleans, will allocate $1.3 million to the Center for Resilience, a local mental health day treatment program, beginning this year. The new program will expand mental health help to children in grades 9-12, according to a report in the Times-Picayune.
The funding will enable the center to expand an existing program that helps students with behavioral issues. Such help is not available in the traditional school system. By offsetting part of the price tag for the mental health care, the initiative “[helps to make] this critical service more available for our students most in need,” said Dominique Ellis, a spokesperson for the school board. “Mental health day treatment programs like the Center for Resilience typically cost between the ranges of $80,000-$100,000 per student to operate effectively.”
The development brings New Orleans level with money spent on similar programs in other school boards nationwide. It’s a service that is sorely needed. According to statistics supplied by the Center for Resilience, 60% of New Orleans children suffer from PTSD and are 4.5 times more likely to suffer from hyperactivity, aggression, and social withdrawal than similarly aged children elsewhere in the United States.
Bill addressing opioid crisis a “no-brainer”
Legislation put forward in the current session of the Texas Legislature would require pharmacists to identify all prescription opioids with a red cap and a hard-to-miss warning of the addictive risk of the medications. In addition, pharmacists would have to explain the risk in person to those receiving the medications and get signed acknowledgment of the conversation before dispensing the drugs.
As described in an article in the Austin American-Stateman, nearly 3,000 people in Texas died from drug overdoses in 2017. The deaths tied to opioid overdoses are not certain, but other data from 2015 suggest that one-third is a reasonable estimate.
“Losing a loved one to an opioid overdose is a tragedy that far too many Texas families experience,” said Rep. Shawn Thierry last month, when she introduced the three bills. “These distinctive red caps will serve as a clear notice to Texans that opioids are unlike milder forms of prescription pain relievers and have life-altering risks that must be considered before taking them.”
Warning labels on everything from food to tobacco products, and including them on prescription opioids is a “no-brainer,” Ms. Thierry said. “The more we can educate our residents the less likely they will be to misuse these medications.”
A report issued in November 2018 chronicled the drug crisis in Texas and offered recommendations. Many of the 100 recommendations involved the absence of treatment resources in the state.
Families are the bedrock of the lives of many, but some people opt to separate permanently from family members. A recent episode of the NPR program “1A” explored why families sever ties.
For journalist Harriet Brown, author of “Shadow Daughter: A Memoir of Estrangement,” (Da Capo Press, 2018), the decision to end her relationship with her mother came after she blamed Ms. Brown in “a blistering email” for the relapsed anorexia of Ms. Brown’s daughter.
“I was done with her,” Ms. Brown said on the program. “I told her I was done. That was it. And I never talked to her again. I think for both of us it felt final in some way.”
She said a lot of shame and stigma comes from having a bad relationship with a parent. “I really wanted to make it clear that ... sometimes walking away is really the best thing to do.”
Kristina M. Scharp, PhD, who has studied the estrangement phenomenon, said no national data exist on family estrangement. “About 12% of mothers and research would suggest even more fathers would report being estranged from one of their children,” said Dr. Scharp, who is with the University of Washington, Seattle. “It’s fairly common.”
Estrangement might be more common today because times have changed, said Joshua Coleman, PhD, author of “When Parents Hurt: Compassionate Strategies When you and Your Grown Child Don’t get Along” (HarperCollins, 2008). “Today’s adult children don’t view their relationships with their parents the way their folks did with their parents … the principles of obligation, duty, and respect that baby boomers and generations before them had for their elders aren’t necessarily there anymore,” Dr. Coleman said in a previous interview with the Chicago Tribune.
For her part, Ms. Brown said, the relationship with her mother – who is now deceased – might have been healed with respect. she said. “Honestly, it was that basic with my mother.”
Phelps gets mental health advocacy award
In the pool, Michael Phelps was golden, with 28 Olympics medals, 23 of them gold, hanging around his neck by the end of his swimming career. But the release from the water to real life after the 2016 Summer Olympics left no outlet for troubles that had dogged him for years. Drunk driving convictions and a ban from competition during his competitive years had failed to stop his downward spiral of depression. His thoughts turned to suicide.
But his story has a bright ending. With his realization that he had hit rock bottom, and with the help of his wife and therapists, he accepted his depression and learned to live with the reality that his life is, for the most part, pretty good.
His openness about his struggles with depression has been influential. The latest recognition came in early January, when he received the Morton E. Ruderman Award in Inclusion from the Ruderman Family Foundation. As reported in the Boston Globe, Mr. Phelps was recognized for his advocacy for people with disabilities and “his own journey with mental health.”
“I do like who I am and I’m comfortable with who I am. I couldn’t say that a few years ago. So I’m in a very good place and just living life one day at a time,” Mr. Phelps remarked in an interview with CNN last year.
Mr. Phelps is now a paid spokesperson for TalkSpace, an online therapy company.
“I’d like to make a difference. I’d like to be able to save a life if I can. You know, for me that’s more important than winning a gold medal. The stuff that I’m doing now is very exciting. It’s hard, it’s challenging but it’s fun for me. That’s what drives me to get out of bed every morning,” he said.
Offenders with mental illness get a break
A law included as part of budget legislation that was signed by then-Gov. Jerry Brown of California in June 2018 has offered people with mental health troubles who have been charged with a crime the opportunity for treatment instead of jail time.
As reported in the Los Angeles Times, the law provides judges with the discretion to order offenders into treatment rather than sentencing them. Success in treatment can lead to charges being dropped.
The law has been praised by some mental health advocates but panned by law enforcement officials and prosecutors with a harder view of criminal justice. The opposition stems largely from a December 2018 ruling by the 4th District Court of Appeal that the law could be applied to retroactively address the case of a man imprisoned for 29 years in 2017 for multiple felony charges that included domestic violence and assault.
The law does not extend to those charged with murder, manslaughter, rape, and child sexual abuse. To date, citing mental illness in seeking diversion of sentencing has not proven successful in most cases.
Schools get mental health allocation
The Orleans Parish School Board, which serves all of New Orleans, will allocate $1.3 million to the Center for Resilience, a local mental health day treatment program, beginning this year. The new program will expand mental health help to children in grades 9-12, according to a report in the Times-Picayune.
The funding will enable the center to expand an existing program that helps students with behavioral issues. Such help is not available in the traditional school system. By offsetting part of the price tag for the mental health care, the initiative “[helps to make] this critical service more available for our students most in need,” said Dominique Ellis, a spokesperson for the school board. “Mental health day treatment programs like the Center for Resilience typically cost between the ranges of $80,000-$100,000 per student to operate effectively.”
The development brings New Orleans level with money spent on similar programs in other school boards nationwide. It’s a service that is sorely needed. According to statistics supplied by the Center for Resilience, 60% of New Orleans children suffer from PTSD and are 4.5 times more likely to suffer from hyperactivity, aggression, and social withdrawal than similarly aged children elsewhere in the United States.
Bill addressing opioid crisis a “no-brainer”
Legislation put forward in the current session of the Texas Legislature would require pharmacists to identify all prescription opioids with a red cap and a hard-to-miss warning of the addictive risk of the medications. In addition, pharmacists would have to explain the risk in person to those receiving the medications and get signed acknowledgment of the conversation before dispensing the drugs.
As described in an article in the Austin American-Stateman, nearly 3,000 people in Texas died from drug overdoses in 2017. The deaths tied to opioid overdoses are not certain, but other data from 2015 suggest that one-third is a reasonable estimate.
“Losing a loved one to an opioid overdose is a tragedy that far too many Texas families experience,” said Rep. Shawn Thierry last month, when she introduced the three bills. “These distinctive red caps will serve as a clear notice to Texans that opioids are unlike milder forms of prescription pain relievers and have life-altering risks that must be considered before taking them.”
Warning labels on everything from food to tobacco products, and including them on prescription opioids is a “no-brainer,” Ms. Thierry said. “The more we can educate our residents the less likely they will be to misuse these medications.”
A report issued in November 2018 chronicled the drug crisis in Texas and offered recommendations. Many of the 100 recommendations involved the absence of treatment resources in the state.
Rural suicidality and resilience
Overall U.S. life expectancy decreased from 78.7 years to 78.6 years from 2016 to 2017. Researchers from the Centers for Disease Control and Prevention noted that, along with drug overdose deaths, suicide also drove the decrease in average lifespan over that time period. Addressing suicide in rural communities presents unique challenges.
Dr. Bonham is vice chair of community behavioral health in the department of psychiatry and behavioral sciences at the University of New Mexico, Albuquerque. Dr. Kriechman is a child, adolescent and family psychiatrist at the university, where he serves as principal investigator on ASPYR – Alliance-building for Suicide Prevention & Youth Resilience.
You can hear more on resilience and suicide from the MDedge Psychcast in these past episodes:
- Find the MDedge Psychcast where ever you listen:
Overall U.S. life expectancy decreased from 78.7 years to 78.6 years from 2016 to 2017. Researchers from the Centers for Disease Control and Prevention noted that, along with drug overdose deaths, suicide also drove the decrease in average lifespan over that time period. Addressing suicide in rural communities presents unique challenges.
Dr. Bonham is vice chair of community behavioral health in the department of psychiatry and behavioral sciences at the University of New Mexico, Albuquerque. Dr. Kriechman is a child, adolescent and family psychiatrist at the university, where he serves as principal investigator on ASPYR – Alliance-building for Suicide Prevention & Youth Resilience.
You can hear more on resilience and suicide from the MDedge Psychcast in these past episodes:
- Find the MDedge Psychcast where ever you listen:
Overall U.S. life expectancy decreased from 78.7 years to 78.6 years from 2016 to 2017. Researchers from the Centers for Disease Control and Prevention noted that, along with drug overdose deaths, suicide also drove the decrease in average lifespan over that time period. Addressing suicide in rural communities presents unique challenges.
Dr. Bonham is vice chair of community behavioral health in the department of psychiatry and behavioral sciences at the University of New Mexico, Albuquerque. Dr. Kriechman is a child, adolescent and family psychiatrist at the university, where he serves as principal investigator on ASPYR – Alliance-building for Suicide Prevention & Youth Resilience.
You can hear more on resilience and suicide from the MDedge Psychcast in these past episodes:
- Find the MDedge Psychcast where ever you listen:
Opioid crisis offers poignant lessons for public health
Populations and circumstances matter
As a medical student in New York City in the mid-1980s, I did several of my clinical clerkships at Memorial Sloan Kettering Cancer Center. One night during my general surgery rotation, there was a young woman with anal cancer who complained of pain.
My resident did not want to give her more medication and I asked why. After all, this was a cancer center with progressive ideas about pain management, this patient was suffering, and she was ill enough to be hospitalized.
The resident responded to my inquiry: “She doesn’t have a terminal condition and she has an addictive personality.” It seemed to me a draconian (and perhaps sexist) response in a hospital where patient-controlled analgesia was becoming routine and, as an aspiring psychiatrist, I didn’t quite trust the surgical resident’s evaluation of the patient’s personality or his ability to predict if she might become addicted to opiates.
This encounter happened about 6 years after Jane Porter and Hershel Jink, MD, had published a letter titled, “Addiction Rare in Patients Treated with Narcotics” in the New England Journal of Medicine (1980 Jan 10;302:123) with the following finding: “... of 11,800 patients given narcotic painkillers while in hospital, only four developed an addiction to those drugs.” This fragment of a sentence, published as a one-paragraph letter and not as a full, peer-reviewed study, was in the process of changing how all of American medicine responded to pain.
In his book, “Dreamland: The True Tale of America’s Opiate Epidemic” (Bloomsbury Press, 2015), journalist Sam Quinones was quick to point out that these findings were made at a time when doctors, like my surgical resident, were hesitant to use opiates for fear of addiction. Their use was limited to cancer patients, postoperative patients, and those suffering from an acute injury. This finding that prescribed opiates did not cause addiction was true in these hospitalized patients, at a time when pills were doled out with caution for short-term use, and their use for chronic pain had not yet been tested.
Nearly 40 years later, we know that the answer to that national experiment did not work out so well: A proportion of patients given long-term, sometimes high-dose, opiates for chronic pain do sometimes become addicted. Some chronic pain patients received narcotics at “pill mills,” and some went on to use heroin obtained illegally. Furthermore, the widespread use of these medicines made them more readily available to those looking for something besides pain relief.
I would like to suggest that the opioid epidemic is not solely the fault of the medical community: We had drug addiction long before we had the Porter and Jink paragraph and not all addiction starts with a prescription pad. Still, the lesson for public health is a poignant one: Populations and circumstances matter. Be careful with generalizations.
Still, we see these generalizations all the time. I am sometimes surprised at how many people have “the answer.” Whether it’s more widespread availability of Narcan, medication-assisted treatment (MAT), safe injection sites, 12-step programs, or “Just Say No,” every method has its proponents. I always wonder when I see public health officials propose safe injection sites as something that would surely save thousands of lives, citing data out of cities such as Vancouver, as well as in Europe, and Australia, if results in those places would transfer to my city – Baltimore – where drug addiction, violence, and poverty are rampant. Perhaps they would, and I would love to see Baltimore try anything that might work. But I hope cities that do set up such sites will follow the numbers and halt any program that does not offer robust results.
I wonder, as well, why, with the clear success of MAT strategies in reducing mortality, we don’t experiment with ways of making these methods more accessible. Might Suboxone work if doctors could prescribe it as easily as they can prescribe oxycodone, with no 8-hour course or DEA waiver? Might methadone both work and be more acceptable to patients if given in a way that didn’t require daily travel to a clinic for administration? With such a deadly pervasive epidemic, I wonder also about our focus on treating addiction, when it seems we should have a parallel focus on understanding and addressing the factors that cause addiction. Medical prescribing is but one avenue to addiction, yet we have no understanding as to why some people become addicted when others do not. Shouldn’t we be able to prevent addiction? From Richard Nixon’s “war on drugs” to Donald Trump’s physical border wall, there are many answers, but few solutions.
There are other public health issues that suffer from the same generalizations. In psychiatry, advocacy groups tout involuntary outpatient treatment as a successful way of getting treatment to vulnerable individuals who will not willingly negotiate their own care. While a pilot study at Bellevue showed no benefit to mandated care, a follow-up study showed that mandated treatment was effective at reducing hospital days. While outpatient commitment studies look at rates of hospitalization, incarceration, and quality-of-life measures, mandated treatment is often cited as a means to prevent all forms of violence, including mass shootings, while there is no evidence to support these ideas. Still, 47 states and the District of Columbia now have outpatient commitment laws.
Does involuntary care benefit those with substance use disorders? In Massachusetts, Section 35 allows for civil commitment for drug treatment, and many of the treatment facilities are run by the Department of Corrections. It would be good to know if these measures worked. So far, it looks like opioid deaths in Massachusetts have stabilized, while the overdose death rate continues to rise in other states. Whether this is a result of Section 35 or other measures is unknown.
I’m not against innovation, and desperate situations call for creative responses. We need to be careful that our responses are measured and these experiments are contained while ascertaining what really does work and what does not cause unintended harms. Will a concrete wall stem the flow of illegal heroin? I imagine a new world of drones making drug drops.
Sometimes our innovative best guesses don’t work, and sometimes they do. Despite easy access to antidepressant medications, a national suicide hotline, increased numbers of mental health professionals, and anti-stigma/awareness campaigns, suicide rates continue to rise. Efforts to end smoking, however, have been quite successful, as have measures to get Americans to buckle their seat belts, and these measures have decreased mortality rates. The recommendation for healthy women to take hormone therapy is a good example: It was an innovative recommendation to help cardiac and orthopedic outcomes, yet studies that were run alongside these recommendations were quick to show an unintended increased risk of breast and uterine cancer.
I don’t know what happened to the young woman on my surgical rotation. If the decision were mine, I would have given her more pain medication, even now, but I don’t know if that would have been the right thing to do., and to look carefully at our outcomes in a variety of populations and circumstances.
Dr. Miller is the coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice in Baltimore.
Populations and circumstances matter
Populations and circumstances matter
As a medical student in New York City in the mid-1980s, I did several of my clinical clerkships at Memorial Sloan Kettering Cancer Center. One night during my general surgery rotation, there was a young woman with anal cancer who complained of pain.
My resident did not want to give her more medication and I asked why. After all, this was a cancer center with progressive ideas about pain management, this patient was suffering, and she was ill enough to be hospitalized.
The resident responded to my inquiry: “She doesn’t have a terminal condition and she has an addictive personality.” It seemed to me a draconian (and perhaps sexist) response in a hospital where patient-controlled analgesia was becoming routine and, as an aspiring psychiatrist, I didn’t quite trust the surgical resident’s evaluation of the patient’s personality or his ability to predict if she might become addicted to opiates.
This encounter happened about 6 years after Jane Porter and Hershel Jink, MD, had published a letter titled, “Addiction Rare in Patients Treated with Narcotics” in the New England Journal of Medicine (1980 Jan 10;302:123) with the following finding: “... of 11,800 patients given narcotic painkillers while in hospital, only four developed an addiction to those drugs.” This fragment of a sentence, published as a one-paragraph letter and not as a full, peer-reviewed study, was in the process of changing how all of American medicine responded to pain.
In his book, “Dreamland: The True Tale of America’s Opiate Epidemic” (Bloomsbury Press, 2015), journalist Sam Quinones was quick to point out that these findings were made at a time when doctors, like my surgical resident, were hesitant to use opiates for fear of addiction. Their use was limited to cancer patients, postoperative patients, and those suffering from an acute injury. This finding that prescribed opiates did not cause addiction was true in these hospitalized patients, at a time when pills were doled out with caution for short-term use, and their use for chronic pain had not yet been tested.
Nearly 40 years later, we know that the answer to that national experiment did not work out so well: A proportion of patients given long-term, sometimes high-dose, opiates for chronic pain do sometimes become addicted. Some chronic pain patients received narcotics at “pill mills,” and some went on to use heroin obtained illegally. Furthermore, the widespread use of these medicines made them more readily available to those looking for something besides pain relief.
I would like to suggest that the opioid epidemic is not solely the fault of the medical community: We had drug addiction long before we had the Porter and Jink paragraph and not all addiction starts with a prescription pad. Still, the lesson for public health is a poignant one: Populations and circumstances matter. Be careful with generalizations.
Still, we see these generalizations all the time. I am sometimes surprised at how many people have “the answer.” Whether it’s more widespread availability of Narcan, medication-assisted treatment (MAT), safe injection sites, 12-step programs, or “Just Say No,” every method has its proponents. I always wonder when I see public health officials propose safe injection sites as something that would surely save thousands of lives, citing data out of cities such as Vancouver, as well as in Europe, and Australia, if results in those places would transfer to my city – Baltimore – where drug addiction, violence, and poverty are rampant. Perhaps they would, and I would love to see Baltimore try anything that might work. But I hope cities that do set up such sites will follow the numbers and halt any program that does not offer robust results.
I wonder, as well, why, with the clear success of MAT strategies in reducing mortality, we don’t experiment with ways of making these methods more accessible. Might Suboxone work if doctors could prescribe it as easily as they can prescribe oxycodone, with no 8-hour course or DEA waiver? Might methadone both work and be more acceptable to patients if given in a way that didn’t require daily travel to a clinic for administration? With such a deadly pervasive epidemic, I wonder also about our focus on treating addiction, when it seems we should have a parallel focus on understanding and addressing the factors that cause addiction. Medical prescribing is but one avenue to addiction, yet we have no understanding as to why some people become addicted when others do not. Shouldn’t we be able to prevent addiction? From Richard Nixon’s “war on drugs” to Donald Trump’s physical border wall, there are many answers, but few solutions.
There are other public health issues that suffer from the same generalizations. In psychiatry, advocacy groups tout involuntary outpatient treatment as a successful way of getting treatment to vulnerable individuals who will not willingly negotiate their own care. While a pilot study at Bellevue showed no benefit to mandated care, a follow-up study showed that mandated treatment was effective at reducing hospital days. While outpatient commitment studies look at rates of hospitalization, incarceration, and quality-of-life measures, mandated treatment is often cited as a means to prevent all forms of violence, including mass shootings, while there is no evidence to support these ideas. Still, 47 states and the District of Columbia now have outpatient commitment laws.
Does involuntary care benefit those with substance use disorders? In Massachusetts, Section 35 allows for civil commitment for drug treatment, and many of the treatment facilities are run by the Department of Corrections. It would be good to know if these measures worked. So far, it looks like opioid deaths in Massachusetts have stabilized, while the overdose death rate continues to rise in other states. Whether this is a result of Section 35 or other measures is unknown.
I’m not against innovation, and desperate situations call for creative responses. We need to be careful that our responses are measured and these experiments are contained while ascertaining what really does work and what does not cause unintended harms. Will a concrete wall stem the flow of illegal heroin? I imagine a new world of drones making drug drops.
Sometimes our innovative best guesses don’t work, and sometimes they do. Despite easy access to antidepressant medications, a national suicide hotline, increased numbers of mental health professionals, and anti-stigma/awareness campaigns, suicide rates continue to rise. Efforts to end smoking, however, have been quite successful, as have measures to get Americans to buckle their seat belts, and these measures have decreased mortality rates. The recommendation for healthy women to take hormone therapy is a good example: It was an innovative recommendation to help cardiac and orthopedic outcomes, yet studies that were run alongside these recommendations were quick to show an unintended increased risk of breast and uterine cancer.
I don’t know what happened to the young woman on my surgical rotation. If the decision were mine, I would have given her more pain medication, even now, but I don’t know if that would have been the right thing to do., and to look carefully at our outcomes in a variety of populations and circumstances.
Dr. Miller is the coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice in Baltimore.
As a medical student in New York City in the mid-1980s, I did several of my clinical clerkships at Memorial Sloan Kettering Cancer Center. One night during my general surgery rotation, there was a young woman with anal cancer who complained of pain.
My resident did not want to give her more medication and I asked why. After all, this was a cancer center with progressive ideas about pain management, this patient was suffering, and she was ill enough to be hospitalized.
The resident responded to my inquiry: “She doesn’t have a terminal condition and she has an addictive personality.” It seemed to me a draconian (and perhaps sexist) response in a hospital where patient-controlled analgesia was becoming routine and, as an aspiring psychiatrist, I didn’t quite trust the surgical resident’s evaluation of the patient’s personality or his ability to predict if she might become addicted to opiates.
This encounter happened about 6 years after Jane Porter and Hershel Jink, MD, had published a letter titled, “Addiction Rare in Patients Treated with Narcotics” in the New England Journal of Medicine (1980 Jan 10;302:123) with the following finding: “... of 11,800 patients given narcotic painkillers while in hospital, only four developed an addiction to those drugs.” This fragment of a sentence, published as a one-paragraph letter and not as a full, peer-reviewed study, was in the process of changing how all of American medicine responded to pain.
In his book, “Dreamland: The True Tale of America’s Opiate Epidemic” (Bloomsbury Press, 2015), journalist Sam Quinones was quick to point out that these findings were made at a time when doctors, like my surgical resident, were hesitant to use opiates for fear of addiction. Their use was limited to cancer patients, postoperative patients, and those suffering from an acute injury. This finding that prescribed opiates did not cause addiction was true in these hospitalized patients, at a time when pills were doled out with caution for short-term use, and their use for chronic pain had not yet been tested.
Nearly 40 years later, we know that the answer to that national experiment did not work out so well: A proportion of patients given long-term, sometimes high-dose, opiates for chronic pain do sometimes become addicted. Some chronic pain patients received narcotics at “pill mills,” and some went on to use heroin obtained illegally. Furthermore, the widespread use of these medicines made them more readily available to those looking for something besides pain relief.
I would like to suggest that the opioid epidemic is not solely the fault of the medical community: We had drug addiction long before we had the Porter and Jink paragraph and not all addiction starts with a prescription pad. Still, the lesson for public health is a poignant one: Populations and circumstances matter. Be careful with generalizations.
Still, we see these generalizations all the time. I am sometimes surprised at how many people have “the answer.” Whether it’s more widespread availability of Narcan, medication-assisted treatment (MAT), safe injection sites, 12-step programs, or “Just Say No,” every method has its proponents. I always wonder when I see public health officials propose safe injection sites as something that would surely save thousands of lives, citing data out of cities such as Vancouver, as well as in Europe, and Australia, if results in those places would transfer to my city – Baltimore – where drug addiction, violence, and poverty are rampant. Perhaps they would, and I would love to see Baltimore try anything that might work. But I hope cities that do set up such sites will follow the numbers and halt any program that does not offer robust results.
I wonder, as well, why, with the clear success of MAT strategies in reducing mortality, we don’t experiment with ways of making these methods more accessible. Might Suboxone work if doctors could prescribe it as easily as they can prescribe oxycodone, with no 8-hour course or DEA waiver? Might methadone both work and be more acceptable to patients if given in a way that didn’t require daily travel to a clinic for administration? With such a deadly pervasive epidemic, I wonder also about our focus on treating addiction, when it seems we should have a parallel focus on understanding and addressing the factors that cause addiction. Medical prescribing is but one avenue to addiction, yet we have no understanding as to why some people become addicted when others do not. Shouldn’t we be able to prevent addiction? From Richard Nixon’s “war on drugs” to Donald Trump’s physical border wall, there are many answers, but few solutions.
There are other public health issues that suffer from the same generalizations. In psychiatry, advocacy groups tout involuntary outpatient treatment as a successful way of getting treatment to vulnerable individuals who will not willingly negotiate their own care. While a pilot study at Bellevue showed no benefit to mandated care, a follow-up study showed that mandated treatment was effective at reducing hospital days. While outpatient commitment studies look at rates of hospitalization, incarceration, and quality-of-life measures, mandated treatment is often cited as a means to prevent all forms of violence, including mass shootings, while there is no evidence to support these ideas. Still, 47 states and the District of Columbia now have outpatient commitment laws.
Does involuntary care benefit those with substance use disorders? In Massachusetts, Section 35 allows for civil commitment for drug treatment, and many of the treatment facilities are run by the Department of Corrections. It would be good to know if these measures worked. So far, it looks like opioid deaths in Massachusetts have stabilized, while the overdose death rate continues to rise in other states. Whether this is a result of Section 35 or other measures is unknown.
I’m not against innovation, and desperate situations call for creative responses. We need to be careful that our responses are measured and these experiments are contained while ascertaining what really does work and what does not cause unintended harms. Will a concrete wall stem the flow of illegal heroin? I imagine a new world of drones making drug drops.
Sometimes our innovative best guesses don’t work, and sometimes they do. Despite easy access to antidepressant medications, a national suicide hotline, increased numbers of mental health professionals, and anti-stigma/awareness campaigns, suicide rates continue to rise. Efforts to end smoking, however, have been quite successful, as have measures to get Americans to buckle their seat belts, and these measures have decreased mortality rates. The recommendation for healthy women to take hormone therapy is a good example: It was an innovative recommendation to help cardiac and orthopedic outcomes, yet studies that were run alongside these recommendations were quick to show an unintended increased risk of breast and uterine cancer.
I don’t know what happened to the young woman on my surgical rotation. If the decision were mine, I would have given her more pain medication, even now, but I don’t know if that would have been the right thing to do., and to look carefully at our outcomes in a variety of populations and circumstances.
Dr. Miller is the coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice in Baltimore.
A prescription for ‘deprescribing’: A case report
In 2016, Swapnil Gupta, MD, and John Daniel Cahill, MD, PhD, challenged the field of psychiatry to reexamine our prescribing patterns. They warned against our use of polypharmacy when not attached to improvement in functioning for our patients.1 They were concerned about the lack of evidence for those treatment regimens and for our diagnostic criteria. In their inspiring article, they described how psychiatrists might proceed in the process of “deprescribing” – which they define as a process of pharmacologic regimen optimization through reducing or ending medications for which “benefits no longer outweigh risks.”1
In my practice, I routinely confront medication regimens that I have never encountered in the literature. The evidence for two psychotropics is limited but certainly available, in particular adjunct treatment of antidepressants2 and mood stabilizers.3 The evidence supporting the use of more than two psychotropics, however, is quite sparse. Yet, patients often enter my office on more than five psychotropics. I am also confronted with poorly defined diagnostic labels – which present more as means to justify polypharmacy than a thorough review of the patient’s current state.
Dr. Gupta and Dr. Cahill recommend a series of steps aimed at attempting the deprescription of psychotropics. Those steps include timeliness, knowledge of the patient’s current regimen, discussion about the risk of prescriptions, discussion about deprescribing, choosing the right medications to stop, a plan for describing, and monitoring. In the case presented below, I used some of those steps in an effort to provide the best care for the patient. Key details of the case have been changed, including the name, to protect the patient’s confidentiality.
Overview of the case
Rosalie Bertin is a 54-year-old female who has been treated for depression by a variety of primary care physicians for the better part of the last 30 years. She had tried an array of antidepressants, including sertraline, citalopram, duloxetine, and mirtazapine, over that time. Each seemed to provide some benefit when reviewing the notes, but there is no mention of why she was continued on those medications despite the absence of continuing symptoms. Occasionally, Rosalie would present to her clinician tearful and endorsing sadness, though the record did not comment on reports of energy, concentration, sleep, appetite, and interest.
In 2014, Rosalie’s husband passed away from lung cancer. His death was fairly quick, and initially, Rosalie did not mention any significant emotional complaints. However, when visiting her primary care physician 4 months later, she was noted to experience auditory hallucinations. “Sometimes I hear my husband when I am alone in my home,” she said. Rosalie was referred to a psychiatrist with a diagnosis of “psychosis not otherwise specified.”
When discussing her condition with the psychiatrist, Rosalie mentioned experiencing low mood, and having diminished interest in engaging in activities. “I miss Marc when I go places; I used to do everything with him.” She reported hearing him often but only when at her home. He would say things like, “I miss you,” or ask her about her day. She was diagnosed with “major depressive disorder with psychotic features.” Risperidone was added to the escitalopram, buspirone, and gabapentin that had been started by her primary care physician.
After several months of psychotropic management, the dose of risperidone was titrated to 8 mg per day. Her mood symptoms were unchanged, but she now was complaining of poor concentration and memory. The psychiatrist performed a Mini-Mental State Examination (MMSE). It was noted that taking the MMSE engendered significant anxiety for the patient. Rosalie received a score suggesting mild cognitive impairment. She was started on donepezil for the memory complaint, quetiapine for the continued voices, and recommended for disability.
Once on short-term disability, the patient relocated to live closer to her mother in San Diego and subsequently contacted me about continuing psychiatric care.
Initial visit
Rosalie is a petite white woman, raised in the Midwest, who married her high school sweetheart, and subsequently became an administrative assistant. Rosalie and Marc were unable to have children. Marc was an engineer, and a longtime smoker. She describes their lives as simple – “few friends, few vacations, few problems, few regrets.” She states she misses her husband and often cries when thinking about him.
When asked about psychiatric diagnoses, she answered: “I have psychosis. … My doctor said maybe schizophrenia, but he is not sure yet.” She described schizophrenia as hearing voices. Rosalie also mentioned having memory problems: “They cannot tell if it is Alzheimer’s disease until I die and they look at my brain, but the medication should delay the progression.”
She reported no significant effect from her prior antidepressant trials: “I am not sure if or how they helped.” Rosalie could not explain the role of the medication. “I take medications as prescribed by my doctor,” she said.
When discussing her antipsychotics, she mentioned: “Those are strong medications; it is hard for me to stay awake with them.” She declared having had no changes in the voices while on the risperidone but said they went away since also being on the quetiapine: “I wonder if the combination of the two really fixed my brain imbalance.”
Assessment
I admit that I have a critical bias against the overuse of psychotropics, and this might have painted how I interpreted Rosalie’s story. Nonetheless, I was honest with her and told her of my concerns. I informed her that her diagnosis was not consistent with my understanding of mood and thought disorders. Her initial reports of depression neither met the DSM criteria for depression nor felt consistent with my conceptualization of the illness. She had retained appropriate functioning and seemed to be responding with the sadness expected when facing difficult challenges like grief.
Her subsequent reports of auditory hallucinations were not associated with delusions or forms of disorganization that I would expect in someone with a thought disorder. Furthermore, the context of the onset gave me the impression that this was part of her process of grief. Her poor result in the dementia screen was most surprising and inconsistent with my evaluation. I told her that I suspected that she was not suffering from Alzheimer’s but from being overmedicated and from anxiety at the time of the testing.
She was excited and hesitant about my report. She was surprised by the length of our visit and interested in hearing more from me. Strangely, I wished she had challenged my different approach. I think that I was hoping she would question my conceptualization, the way I hoped she would have done with her prior clinicians. Nonetheless, she agreed to make a plan with me.
Treatment plan
We decided to review each of her medications and discuss their benefits and risks over a couple of visits. She was most eager to discontinue the donepezil, which had caused diarrhea. She was concerned when I informed her of the potential side effects of antipsychotics. “My doctor asked me if I had any side effects at each visit; I answered that I felt nothing wrong; I had not realized that side effects could appear later.”
She was adamant about staying on buspirone, as she felt it helped her the most with her anxiety at social events. She voiced concern about discontinuing the antipsychotics despite being unsettled by my review of their risks. She asked that we taper them slowly.
In regard to receiving psychosocial support throughout this period of deprescribing, Rosalie declined weekly psychotherapy. She reported having a good social network in San Diego that she wanted to rely on.
Outcome
I often worry about consequences of stopping a medication, especially when I was not present at the time of its initiation. I agonize that the patient might relapse from my need to carry out my agenda on deprescribing. I try to remind myself that the evidence supports my decision making. The risks of psychotropics often are slow to show up, making the benefit of deprescribing less tangible. However, this case was straightforward.
Rosalie quickly improved. Tapering the antipsychotics was astonishing to her: “I can think clearly again.” Within 6 months, she was on buspirone only – though willing to discuss its discontinuation. She had a lead for a job and was hoping to return to work soon. Rosalie continued to miss her husband but had not heard him in some time. She has not had symptoms of psychosis or depression. Her cognition and mood were intact on my clinical assessment.
Discussion
Sadly and shockingly, cases like that of Rosalie are common. In my practice, I routinely see patients on multiple psychotropics – often on more than one antipsychotic. Their diagnoses are vague and dubious, and include diagnoses such as “unspecified psychosis” and “cognitive impairments.” Clinicians occasionally worry about relapse and promote a narrative that treatment must be not only long term but lifelong.4 There is some evidence for this perspective in a research context, but the clinical world also is filled with patients like Rosalie.
Her reports of auditory hallucinations were better explained by her grief than by a psychotic process.5 Her memory complaints were better explained by anxiety at the time of her testing while suffering from the side effects from her numerous psychotropics.6 Her depressive complaints were better explained by appropriate sadness in response to stressors. Several months later with fewer diagnoses and far fewer psychotropics, she is functioning better.
Take-home points
- Polypharmacy can lead to psychiatric symptoms and functional impairment.
- Patients often are unaware of the complete risks of psychotropics.
- Psychiatric symptoms are not always associated with a psychiatric disorder.
- Deprescribing can be performed safely and effectively.
- Deprescribing can be performed with the patient’s informed consent and agreement.
References
1. Psychiatr Serv. 2016 Aug 1;67(8):904-7.
2. Focus. 2016 Apr 13; doi: 10.1176/appi.focus.20150041.
3. Bipolar Disord. 2016 Dec;18(8):684-91.
4. Am J Psychiatry. 2017 Sep 1;174(9):840-9.
5. World Psychiatry. 2009 Jun;8(2):67-74.
6. Hosp Community Psychiatry. 1983 Sep;34(9):830-5.
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. 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. Among his writings is chapter 7 in the new book “Critical Psychiatry: Controversies and Clinical Implications” (Springer, 2019).
*This column was updated 1/11/2019.
In 2016, Swapnil Gupta, MD, and John Daniel Cahill, MD, PhD, challenged the field of psychiatry to reexamine our prescribing patterns. They warned against our use of polypharmacy when not attached to improvement in functioning for our patients.1 They were concerned about the lack of evidence for those treatment regimens and for our diagnostic criteria. In their inspiring article, they described how psychiatrists might proceed in the process of “deprescribing” – which they define as a process of pharmacologic regimen optimization through reducing or ending medications for which “benefits no longer outweigh risks.”1
In my practice, I routinely confront medication regimens that I have never encountered in the literature. The evidence for two psychotropics is limited but certainly available, in particular adjunct treatment of antidepressants2 and mood stabilizers.3 The evidence supporting the use of more than two psychotropics, however, is quite sparse. Yet, patients often enter my office on more than five psychotropics. I am also confronted with poorly defined diagnostic labels – which present more as means to justify polypharmacy than a thorough review of the patient’s current state.
Dr. Gupta and Dr. Cahill recommend a series of steps aimed at attempting the deprescription of psychotropics. Those steps include timeliness, knowledge of the patient’s current regimen, discussion about the risk of prescriptions, discussion about deprescribing, choosing the right medications to stop, a plan for describing, and monitoring. In the case presented below, I used some of those steps in an effort to provide the best care for the patient. Key details of the case have been changed, including the name, to protect the patient’s confidentiality.
Overview of the case
Rosalie Bertin is a 54-year-old female who has been treated for depression by a variety of primary care physicians for the better part of the last 30 years. She had tried an array of antidepressants, including sertraline, citalopram, duloxetine, and mirtazapine, over that time. Each seemed to provide some benefit when reviewing the notes, but there is no mention of why she was continued on those medications despite the absence of continuing symptoms. Occasionally, Rosalie would present to her clinician tearful and endorsing sadness, though the record did not comment on reports of energy, concentration, sleep, appetite, and interest.
In 2014, Rosalie’s husband passed away from lung cancer. His death was fairly quick, and initially, Rosalie did not mention any significant emotional complaints. However, when visiting her primary care physician 4 months later, she was noted to experience auditory hallucinations. “Sometimes I hear my husband when I am alone in my home,” she said. Rosalie was referred to a psychiatrist with a diagnosis of “psychosis not otherwise specified.”
When discussing her condition with the psychiatrist, Rosalie mentioned experiencing low mood, and having diminished interest in engaging in activities. “I miss Marc when I go places; I used to do everything with him.” She reported hearing him often but only when at her home. He would say things like, “I miss you,” or ask her about her day. She was diagnosed with “major depressive disorder with psychotic features.” Risperidone was added to the escitalopram, buspirone, and gabapentin that had been started by her primary care physician.
After several months of psychotropic management, the dose of risperidone was titrated to 8 mg per day. Her mood symptoms were unchanged, but she now was complaining of poor concentration and memory. The psychiatrist performed a Mini-Mental State Examination (MMSE). It was noted that taking the MMSE engendered significant anxiety for the patient. Rosalie received a score suggesting mild cognitive impairment. She was started on donepezil for the memory complaint, quetiapine for the continued voices, and recommended for disability.
Once on short-term disability, the patient relocated to live closer to her mother in San Diego and subsequently contacted me about continuing psychiatric care.
Initial visit
Rosalie is a petite white woman, raised in the Midwest, who married her high school sweetheart, and subsequently became an administrative assistant. Rosalie and Marc were unable to have children. Marc was an engineer, and a longtime smoker. She describes their lives as simple – “few friends, few vacations, few problems, few regrets.” She states she misses her husband and often cries when thinking about him.
When asked about psychiatric diagnoses, she answered: “I have psychosis. … My doctor said maybe schizophrenia, but he is not sure yet.” She described schizophrenia as hearing voices. Rosalie also mentioned having memory problems: “They cannot tell if it is Alzheimer’s disease until I die and they look at my brain, but the medication should delay the progression.”
She reported no significant effect from her prior antidepressant trials: “I am not sure if or how they helped.” Rosalie could not explain the role of the medication. “I take medications as prescribed by my doctor,” she said.
When discussing her antipsychotics, she mentioned: “Those are strong medications; it is hard for me to stay awake with them.” She declared having had no changes in the voices while on the risperidone but said they went away since also being on the quetiapine: “I wonder if the combination of the two really fixed my brain imbalance.”
Assessment
I admit that I have a critical bias against the overuse of psychotropics, and this might have painted how I interpreted Rosalie’s story. Nonetheless, I was honest with her and told her of my concerns. I informed her that her diagnosis was not consistent with my understanding of mood and thought disorders. Her initial reports of depression neither met the DSM criteria for depression nor felt consistent with my conceptualization of the illness. She had retained appropriate functioning and seemed to be responding with the sadness expected when facing difficult challenges like grief.
Her subsequent reports of auditory hallucinations were not associated with delusions or forms of disorganization that I would expect in someone with a thought disorder. Furthermore, the context of the onset gave me the impression that this was part of her process of grief. Her poor result in the dementia screen was most surprising and inconsistent with my evaluation. I told her that I suspected that she was not suffering from Alzheimer’s but from being overmedicated and from anxiety at the time of the testing.
She was excited and hesitant about my report. She was surprised by the length of our visit and interested in hearing more from me. Strangely, I wished she had challenged my different approach. I think that I was hoping she would question my conceptualization, the way I hoped she would have done with her prior clinicians. Nonetheless, she agreed to make a plan with me.
Treatment plan
We decided to review each of her medications and discuss their benefits and risks over a couple of visits. She was most eager to discontinue the donepezil, which had caused diarrhea. She was concerned when I informed her of the potential side effects of antipsychotics. “My doctor asked me if I had any side effects at each visit; I answered that I felt nothing wrong; I had not realized that side effects could appear later.”
She was adamant about staying on buspirone, as she felt it helped her the most with her anxiety at social events. She voiced concern about discontinuing the antipsychotics despite being unsettled by my review of their risks. She asked that we taper them slowly.
In regard to receiving psychosocial support throughout this period of deprescribing, Rosalie declined weekly psychotherapy. She reported having a good social network in San Diego that she wanted to rely on.
Outcome
I often worry about consequences of stopping a medication, especially when I was not present at the time of its initiation. I agonize that the patient might relapse from my need to carry out my agenda on deprescribing. I try to remind myself that the evidence supports my decision making. The risks of psychotropics often are slow to show up, making the benefit of deprescribing less tangible. However, this case was straightforward.
Rosalie quickly improved. Tapering the antipsychotics was astonishing to her: “I can think clearly again.” Within 6 months, she was on buspirone only – though willing to discuss its discontinuation. She had a lead for a job and was hoping to return to work soon. Rosalie continued to miss her husband but had not heard him in some time. She has not had symptoms of psychosis or depression. Her cognition and mood were intact on my clinical assessment.
Discussion
Sadly and shockingly, cases like that of Rosalie are common. In my practice, I routinely see patients on multiple psychotropics – often on more than one antipsychotic. Their diagnoses are vague and dubious, and include diagnoses such as “unspecified psychosis” and “cognitive impairments.” Clinicians occasionally worry about relapse and promote a narrative that treatment must be not only long term but lifelong.4 There is some evidence for this perspective in a research context, but the clinical world also is filled with patients like Rosalie.
Her reports of auditory hallucinations were better explained by her grief than by a psychotic process.5 Her memory complaints were better explained by anxiety at the time of her testing while suffering from the side effects from her numerous psychotropics.6 Her depressive complaints were better explained by appropriate sadness in response to stressors. Several months later with fewer diagnoses and far fewer psychotropics, she is functioning better.
Take-home points
- Polypharmacy can lead to psychiatric symptoms and functional impairment.
- Patients often are unaware of the complete risks of psychotropics.
- Psychiatric symptoms are not always associated with a psychiatric disorder.
- Deprescribing can be performed safely and effectively.
- Deprescribing can be performed with the patient’s informed consent and agreement.
References
1. Psychiatr Serv. 2016 Aug 1;67(8):904-7.
2. Focus. 2016 Apr 13; doi: 10.1176/appi.focus.20150041.
3. Bipolar Disord. 2016 Dec;18(8):684-91.
4. Am J Psychiatry. 2017 Sep 1;174(9):840-9.
5. World Psychiatry. 2009 Jun;8(2):67-74.
6. Hosp Community Psychiatry. 1983 Sep;34(9):830-5.
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. 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. Among his writings is chapter 7 in the new book “Critical Psychiatry: Controversies and Clinical Implications” (Springer, 2019).
*This column was updated 1/11/2019.
In 2016, Swapnil Gupta, MD, and John Daniel Cahill, MD, PhD, challenged the field of psychiatry to reexamine our prescribing patterns. They warned against our use of polypharmacy when not attached to improvement in functioning for our patients.1 They were concerned about the lack of evidence for those treatment regimens and for our diagnostic criteria. In their inspiring article, they described how psychiatrists might proceed in the process of “deprescribing” – which they define as a process of pharmacologic regimen optimization through reducing or ending medications for which “benefits no longer outweigh risks.”1
In my practice, I routinely confront medication regimens that I have never encountered in the literature. The evidence for two psychotropics is limited but certainly available, in particular adjunct treatment of antidepressants2 and mood stabilizers.3 The evidence supporting the use of more than two psychotropics, however, is quite sparse. Yet, patients often enter my office on more than five psychotropics. I am also confronted with poorly defined diagnostic labels – which present more as means to justify polypharmacy than a thorough review of the patient’s current state.
Dr. Gupta and Dr. Cahill recommend a series of steps aimed at attempting the deprescription of psychotropics. Those steps include timeliness, knowledge of the patient’s current regimen, discussion about the risk of prescriptions, discussion about deprescribing, choosing the right medications to stop, a plan for describing, and monitoring. In the case presented below, I used some of those steps in an effort to provide the best care for the patient. Key details of the case have been changed, including the name, to protect the patient’s confidentiality.
Overview of the case
Rosalie Bertin is a 54-year-old female who has been treated for depression by a variety of primary care physicians for the better part of the last 30 years. She had tried an array of antidepressants, including sertraline, citalopram, duloxetine, and mirtazapine, over that time. Each seemed to provide some benefit when reviewing the notes, but there is no mention of why she was continued on those medications despite the absence of continuing symptoms. Occasionally, Rosalie would present to her clinician tearful and endorsing sadness, though the record did not comment on reports of energy, concentration, sleep, appetite, and interest.
In 2014, Rosalie’s husband passed away from lung cancer. His death was fairly quick, and initially, Rosalie did not mention any significant emotional complaints. However, when visiting her primary care physician 4 months later, she was noted to experience auditory hallucinations. “Sometimes I hear my husband when I am alone in my home,” she said. Rosalie was referred to a psychiatrist with a diagnosis of “psychosis not otherwise specified.”
When discussing her condition with the psychiatrist, Rosalie mentioned experiencing low mood, and having diminished interest in engaging in activities. “I miss Marc when I go places; I used to do everything with him.” She reported hearing him often but only when at her home. He would say things like, “I miss you,” or ask her about her day. She was diagnosed with “major depressive disorder with psychotic features.” Risperidone was added to the escitalopram, buspirone, and gabapentin that had been started by her primary care physician.
After several months of psychotropic management, the dose of risperidone was titrated to 8 mg per day. Her mood symptoms were unchanged, but she now was complaining of poor concentration and memory. The psychiatrist performed a Mini-Mental State Examination (MMSE). It was noted that taking the MMSE engendered significant anxiety for the patient. Rosalie received a score suggesting mild cognitive impairment. She was started on donepezil for the memory complaint, quetiapine for the continued voices, and recommended for disability.
Once on short-term disability, the patient relocated to live closer to her mother in San Diego and subsequently contacted me about continuing psychiatric care.
Initial visit
Rosalie is a petite white woman, raised in the Midwest, who married her high school sweetheart, and subsequently became an administrative assistant. Rosalie and Marc were unable to have children. Marc was an engineer, and a longtime smoker. She describes their lives as simple – “few friends, few vacations, few problems, few regrets.” She states she misses her husband and often cries when thinking about him.
When asked about psychiatric diagnoses, she answered: “I have psychosis. … My doctor said maybe schizophrenia, but he is not sure yet.” She described schizophrenia as hearing voices. Rosalie also mentioned having memory problems: “They cannot tell if it is Alzheimer’s disease until I die and they look at my brain, but the medication should delay the progression.”
She reported no significant effect from her prior antidepressant trials: “I am not sure if or how they helped.” Rosalie could not explain the role of the medication. “I take medications as prescribed by my doctor,” she said.
When discussing her antipsychotics, she mentioned: “Those are strong medications; it is hard for me to stay awake with them.” She declared having had no changes in the voices while on the risperidone but said they went away since also being on the quetiapine: “I wonder if the combination of the two really fixed my brain imbalance.”
Assessment
I admit that I have a critical bias against the overuse of psychotropics, and this might have painted how I interpreted Rosalie’s story. Nonetheless, I was honest with her and told her of my concerns. I informed her that her diagnosis was not consistent with my understanding of mood and thought disorders. Her initial reports of depression neither met the DSM criteria for depression nor felt consistent with my conceptualization of the illness. She had retained appropriate functioning and seemed to be responding with the sadness expected when facing difficult challenges like grief.
Her subsequent reports of auditory hallucinations were not associated with delusions or forms of disorganization that I would expect in someone with a thought disorder. Furthermore, the context of the onset gave me the impression that this was part of her process of grief. Her poor result in the dementia screen was most surprising and inconsistent with my evaluation. I told her that I suspected that she was not suffering from Alzheimer’s but from being overmedicated and from anxiety at the time of the testing.
She was excited and hesitant about my report. She was surprised by the length of our visit and interested in hearing more from me. Strangely, I wished she had challenged my different approach. I think that I was hoping she would question my conceptualization, the way I hoped she would have done with her prior clinicians. Nonetheless, she agreed to make a plan with me.
Treatment plan
We decided to review each of her medications and discuss their benefits and risks over a couple of visits. She was most eager to discontinue the donepezil, which had caused diarrhea. She was concerned when I informed her of the potential side effects of antipsychotics. “My doctor asked me if I had any side effects at each visit; I answered that I felt nothing wrong; I had not realized that side effects could appear later.”
She was adamant about staying on buspirone, as she felt it helped her the most with her anxiety at social events. She voiced concern about discontinuing the antipsychotics despite being unsettled by my review of their risks. She asked that we taper them slowly.
In regard to receiving psychosocial support throughout this period of deprescribing, Rosalie declined weekly psychotherapy. She reported having a good social network in San Diego that she wanted to rely on.
Outcome
I often worry about consequences of stopping a medication, especially when I was not present at the time of its initiation. I agonize that the patient might relapse from my need to carry out my agenda on deprescribing. I try to remind myself that the evidence supports my decision making. The risks of psychotropics often are slow to show up, making the benefit of deprescribing less tangible. However, this case was straightforward.
Rosalie quickly improved. Tapering the antipsychotics was astonishing to her: “I can think clearly again.” Within 6 months, she was on buspirone only – though willing to discuss its discontinuation. She had a lead for a job and was hoping to return to work soon. Rosalie continued to miss her husband but had not heard him in some time. She has not had symptoms of psychosis or depression. Her cognition and mood were intact on my clinical assessment.
Discussion
Sadly and shockingly, cases like that of Rosalie are common. In my practice, I routinely see patients on multiple psychotropics – often on more than one antipsychotic. Their diagnoses are vague and dubious, and include diagnoses such as “unspecified psychosis” and “cognitive impairments.” Clinicians occasionally worry about relapse and promote a narrative that treatment must be not only long term but lifelong.4 There is some evidence for this perspective in a research context, but the clinical world also is filled with patients like Rosalie.
Her reports of auditory hallucinations were better explained by her grief than by a psychotic process.5 Her memory complaints were better explained by anxiety at the time of her testing while suffering from the side effects from her numerous psychotropics.6 Her depressive complaints were better explained by appropriate sadness in response to stressors. Several months later with fewer diagnoses and far fewer psychotropics, she is functioning better.
Take-home points
- Polypharmacy can lead to psychiatric symptoms and functional impairment.
- Patients often are unaware of the complete risks of psychotropics.
- Psychiatric symptoms are not always associated with a psychiatric disorder.
- Deprescribing can be performed safely and effectively.
- Deprescribing can be performed with the patient’s informed consent and agreement.
References
1. Psychiatr Serv. 2016 Aug 1;67(8):904-7.
2. Focus. 2016 Apr 13; doi: 10.1176/appi.focus.20150041.
3. Bipolar Disord. 2016 Dec;18(8):684-91.
4. Am J Psychiatry. 2017 Sep 1;174(9):840-9.
5. World Psychiatry. 2009 Jun;8(2):67-74.
6. Hosp Community Psychiatry. 1983 Sep;34(9):830-5.
Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. 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. Among his writings is chapter 7 in the new book “Critical Psychiatry: Controversies and Clinical Implications” (Springer, 2019).
*This column was updated 1/11/2019.
Mental health patients flocking to emergency departments
Emergency department visits in the United States climbed by 15% overall from 2006 to 2014. Over the same time period, ED visits by people with mental health issues soared by 44%, according to a report from the Agency for Health Care Research & Quality.
“The extent to which ERs are now flooded with patients with mental illness is unprecedented,” David R. Rubinow, MD, chairman of the department of psychiatry at the University of North Carolina, Chapel Hill, said in an interview with CNN.
This overflow is “having a really destructive effect on health care delivery in general,” Dr. Rubinow said. “There are ERs now that are repeatedly on diversion – which means they can’t see any more patients – because there are so many patients with mental illness or behavioral problems [who] are populating the ER.”
Physicians such as Mark D. Pearlmutter, MD, are convinced that EDs have become the medical refuge for many people with mental illness. “We are the safety net,” said Dr. Pearlmutter, an emergency physician affiliated with Steward Health Care in Brighton, Mass. Dr. Pearlmutter said some patients he has seen in the ED often have dual diagnoses, such as “substance abuse and depression, for example.”
As a result of this situation, patients with psychiatric needs might not receive the care that they really need, and care might be delayed for patients with other life-threatening conditions. “The ER is not a great place if you’re a mental health patient; the cardiac patients get put in front of you, and you could end up being there for a really long time, said David Morris, PhD, a psychologist at the O’Donnell Brain Institute in Dallas.
, Dr. Pearlmutter suggested. After all, increasingly, primary care physicians are providing mental health care.
Twists on New Year’s resolutions
Some people bring in each new year by shifting their perspectives – without making resolutions.
Tim Ferriss, an entrepreneur known for blogs and podcasts on work and life, engages in what he calls “past year reviews,” where accomplishments are tallied frequently throughout the year in terms of their positive or negative effect, with the latter being ruled out for the coming year. Over a few years, he hopes, the list of negatives will shrink and the positive items will increase, according to a post on the NBC News website.
Instead of making resolutions, Oprah Winfrey keeps a journal that is updated nightly with five things that spark gratitude. “I live in the present moment. I try to find the good that’s going on in any given situation,” Ms. Winfrey said in a 2017 interview. The practice has taught her to be careful in her personal wishes.
Melinda Gates starts the new year with a single word to provide guidance. Past examples include “gentle,” “spacious,” and, last year, “grace.” Her selections, she said, have helped her sharpen her focus on the really important aspects of her life.
“[Grace] even helped me find a beam of peace through the sadness of a friend’s funeral. When I was upset or distressed, I whispered to myself: ‘Grace.’ That’s the power of a well-chosen word of the year. It makes the year better – and it helps me be better, too, she wrote in a recent LinkedIn post.
20-somethings facing challenges
A recent article in the Guardian lamented a life that is not progressing as expected.
“I am 25 and a half, single, unable to pay my rent, and the closest thing I own to a car is a broken skateboard,” wrote Juliana Piskorz. “I’m in the throes of a quarter-life crisis.”
Ms. Piskorz, who said she suffers from anxiety attacks, said her experience of this crisis manifests itself by making her want to run away, start all over, or distract herself from reality.
She is not alone. According to LinkedIn, about three-quarters of people aged 25-33 share this kind of insecurity and doubt. Low self-esteem is an important culprit, according to James Arkell, MD, a psychiatrist affiliated with the Nightingale Hospital London. “Very often, 20-somethings I see here are beautiful, talented, and have the world on a plate, but they don’t like themselves and that’s got to be about society making them feel as if they have to keep up with these unrelenting standards.”
There are other reasons for millennial despair, Ms. Piskorz speculated.
“Our childhood visions for our lives ... are no longer realistic,” she wrote. “Due to unaffordable housing, less job security, and lower incomes, the traditional ‘markers’ of adulthood, such as owning a home, getting married, and having children, are being pushed back. This has left a vacuum between our teenage years and late 20s with many of us feeling we’re navigating a no man’s land with zero clue when we’ll reach the other side.”
Seeking optimism, Ms. Piskorz noted that, as a community, millennials share many positive characteristics that should serve them well.
“We are not afraid to talk about how we feel, although we should probably talk more,” she wrote. “We stand up for the causes that we think matter; we are not afraid to try new things, and we are not willing to live a life half lived.”
Apps monitor teen angst, depression
The smartphone, often seen as a tool that fuels angst, might be a resource that could identify teenagers in trouble.
According to an article in the Washington Post, research is underway on smartphone apps that can decipher the digital footprints left by users during their Internet ramblings.
“As teens scroll through Instagram or Snapchat, tap out texts, or watch YouTube videos, they also leave digital footprints that might offer clues to their psychological well-being,” wrote article author Lindsey Tanner, of the Associated Press. “Changes in typing speed, voice tone, word choice, and how often kids stay home could signal trouble.”
“We are tracking the equivalent of a heartbeat for the human brain,” said Alex Leow, MD, PhD, an app developer, and associate professor of psychiatry and bioengineering at the University of Illinois at Chicago.
The technology is not ready for deployment because of technical glitches and, more importantly, ethical issues concerning the recording and scrutiny of a user’s personal data being roadblocks. Still, with the permission of the user, mood-detecting apps might one day be a smartphone feature. “[Users] could withdraw permission at any time, said Nick B. Allen, PhD, a psychologist at the University of Oregon, Portland, who has helped create an app that is being tested on young people who have attempted suicide.
He said the biggest hurdle is figuring out “what’s the signal and what’s the noise – what is in this enormous amount of data that people accumulate on their phone that is indicative of a mental health crisis.”
Virtues of “intellectual humility”
Intellectual humility is neither a character flaw nor a sign of being a pushover.
Instead, wrote science reporter Brian Resnick in an article posted on Vox.com, “it’s a method of thinking. It’s about entertaining the possibility that you may be wrong and being open to learning from the experience of others. Intellectual humility is about being actively curious about your blind spots.”
In an effort to promote intellectual humility in psychology, two researchers, Tal Yarkoni, PhD, and Christopher F. Chabris, PhD, launched the Loss-of-Confidence project. The project is a safe space where researchers who doubt a previous finding in psychology can recalibrate. “I do think it’s a cultural issue that people are not willing to admit mistakes,” said Julia M. Rohrer, a PhD candidate and personality psychologist at the Max Planck Institute for Human Development in Berlin who joined the team in 2017. “Our broader goal is to gently nudge the whole scientific system and psychology toward a different culture where it’s okay, normalized, and expected for researchers to admit past mistakes and not get penalized for it.”
Put another way, the aim is to foster a culture where intellectually humble, honest, and curious people can thrive. For that to occur, “we all, even the smartest among us, need to better appreciate our cognitive blind spots,” Mr. Resnick wrote. “Our minds are more imperfect and imprecise than we’d often like to admit.”
In a recent paper, Ms. Rohrer and her associates said the Loss-of-Confidence project grew out of an online discussion in the wake of a post by Dana R. Carney, PhD, and associates on power poses. In that post, Dr. Carney explains why she changed her position on the value of power poses, concluding that the data gathered by her lab at the time leading to the power poses theory (Psychol Sci. 2010 Oct 21 [10]:1363-8) were real but flimsy. “My views have been updated to reflect the evidence,” she wrote. “As such, I do not believe that ‘power pose’ effects are real.”
In the Vox.com article, Mr. Resnick wrote that intellectual humility is needed for two reasons. “One is that our culture promotes and rewards overconfidence and arrogance. At the same time, when we are wrong – out of ignorance or error – and realize it, our culture doesn’t make it easy to admit it. Humbling moments too easily can turn into moments of humiliation.”
Emergency department visits in the United States climbed by 15% overall from 2006 to 2014. Over the same time period, ED visits by people with mental health issues soared by 44%, according to a report from the Agency for Health Care Research & Quality.
“The extent to which ERs are now flooded with patients with mental illness is unprecedented,” David R. Rubinow, MD, chairman of the department of psychiatry at the University of North Carolina, Chapel Hill, said in an interview with CNN.
This overflow is “having a really destructive effect on health care delivery in general,” Dr. Rubinow said. “There are ERs now that are repeatedly on diversion – which means they can’t see any more patients – because there are so many patients with mental illness or behavioral problems [who] are populating the ER.”
Physicians such as Mark D. Pearlmutter, MD, are convinced that EDs have become the medical refuge for many people with mental illness. “We are the safety net,” said Dr. Pearlmutter, an emergency physician affiliated with Steward Health Care in Brighton, Mass. Dr. Pearlmutter said some patients he has seen in the ED often have dual diagnoses, such as “substance abuse and depression, for example.”
As a result of this situation, patients with psychiatric needs might not receive the care that they really need, and care might be delayed for patients with other life-threatening conditions. “The ER is not a great place if you’re a mental health patient; the cardiac patients get put in front of you, and you could end up being there for a really long time, said David Morris, PhD, a psychologist at the O’Donnell Brain Institute in Dallas.
, Dr. Pearlmutter suggested. After all, increasingly, primary care physicians are providing mental health care.
Twists on New Year’s resolutions
Some people bring in each new year by shifting their perspectives – without making resolutions.
Tim Ferriss, an entrepreneur known for blogs and podcasts on work and life, engages in what he calls “past year reviews,” where accomplishments are tallied frequently throughout the year in terms of their positive or negative effect, with the latter being ruled out for the coming year. Over a few years, he hopes, the list of negatives will shrink and the positive items will increase, according to a post on the NBC News website.
Instead of making resolutions, Oprah Winfrey keeps a journal that is updated nightly with five things that spark gratitude. “I live in the present moment. I try to find the good that’s going on in any given situation,” Ms. Winfrey said in a 2017 interview. The practice has taught her to be careful in her personal wishes.
Melinda Gates starts the new year with a single word to provide guidance. Past examples include “gentle,” “spacious,” and, last year, “grace.” Her selections, she said, have helped her sharpen her focus on the really important aspects of her life.
“[Grace] even helped me find a beam of peace through the sadness of a friend’s funeral. When I was upset or distressed, I whispered to myself: ‘Grace.’ That’s the power of a well-chosen word of the year. It makes the year better – and it helps me be better, too, she wrote in a recent LinkedIn post.
20-somethings facing challenges
A recent article in the Guardian lamented a life that is not progressing as expected.
“I am 25 and a half, single, unable to pay my rent, and the closest thing I own to a car is a broken skateboard,” wrote Juliana Piskorz. “I’m in the throes of a quarter-life crisis.”
Ms. Piskorz, who said she suffers from anxiety attacks, said her experience of this crisis manifests itself by making her want to run away, start all over, or distract herself from reality.
She is not alone. According to LinkedIn, about three-quarters of people aged 25-33 share this kind of insecurity and doubt. Low self-esteem is an important culprit, according to James Arkell, MD, a psychiatrist affiliated with the Nightingale Hospital London. “Very often, 20-somethings I see here are beautiful, talented, and have the world on a plate, but they don’t like themselves and that’s got to be about society making them feel as if they have to keep up with these unrelenting standards.”
There are other reasons for millennial despair, Ms. Piskorz speculated.
“Our childhood visions for our lives ... are no longer realistic,” she wrote. “Due to unaffordable housing, less job security, and lower incomes, the traditional ‘markers’ of adulthood, such as owning a home, getting married, and having children, are being pushed back. This has left a vacuum between our teenage years and late 20s with many of us feeling we’re navigating a no man’s land with zero clue when we’ll reach the other side.”
Seeking optimism, Ms. Piskorz noted that, as a community, millennials share many positive characteristics that should serve them well.
“We are not afraid to talk about how we feel, although we should probably talk more,” she wrote. “We stand up for the causes that we think matter; we are not afraid to try new things, and we are not willing to live a life half lived.”
Apps monitor teen angst, depression
The smartphone, often seen as a tool that fuels angst, might be a resource that could identify teenagers in trouble.
According to an article in the Washington Post, research is underway on smartphone apps that can decipher the digital footprints left by users during their Internet ramblings.
“As teens scroll through Instagram or Snapchat, tap out texts, or watch YouTube videos, they also leave digital footprints that might offer clues to their psychological well-being,” wrote article author Lindsey Tanner, of the Associated Press. “Changes in typing speed, voice tone, word choice, and how often kids stay home could signal trouble.”
“We are tracking the equivalent of a heartbeat for the human brain,” said Alex Leow, MD, PhD, an app developer, and associate professor of psychiatry and bioengineering at the University of Illinois at Chicago.
The technology is not ready for deployment because of technical glitches and, more importantly, ethical issues concerning the recording and scrutiny of a user’s personal data being roadblocks. Still, with the permission of the user, mood-detecting apps might one day be a smartphone feature. “[Users] could withdraw permission at any time, said Nick B. Allen, PhD, a psychologist at the University of Oregon, Portland, who has helped create an app that is being tested on young people who have attempted suicide.
He said the biggest hurdle is figuring out “what’s the signal and what’s the noise – what is in this enormous amount of data that people accumulate on their phone that is indicative of a mental health crisis.”
Virtues of “intellectual humility”
Intellectual humility is neither a character flaw nor a sign of being a pushover.
Instead, wrote science reporter Brian Resnick in an article posted on Vox.com, “it’s a method of thinking. It’s about entertaining the possibility that you may be wrong and being open to learning from the experience of others. Intellectual humility is about being actively curious about your blind spots.”
In an effort to promote intellectual humility in psychology, two researchers, Tal Yarkoni, PhD, and Christopher F. Chabris, PhD, launched the Loss-of-Confidence project. The project is a safe space where researchers who doubt a previous finding in psychology can recalibrate. “I do think it’s a cultural issue that people are not willing to admit mistakes,” said Julia M. Rohrer, a PhD candidate and personality psychologist at the Max Planck Institute for Human Development in Berlin who joined the team in 2017. “Our broader goal is to gently nudge the whole scientific system and psychology toward a different culture where it’s okay, normalized, and expected for researchers to admit past mistakes and not get penalized for it.”
Put another way, the aim is to foster a culture where intellectually humble, honest, and curious people can thrive. For that to occur, “we all, even the smartest among us, need to better appreciate our cognitive blind spots,” Mr. Resnick wrote. “Our minds are more imperfect and imprecise than we’d often like to admit.”
In a recent paper, Ms. Rohrer and her associates said the Loss-of-Confidence project grew out of an online discussion in the wake of a post by Dana R. Carney, PhD, and associates on power poses. In that post, Dr. Carney explains why she changed her position on the value of power poses, concluding that the data gathered by her lab at the time leading to the power poses theory (Psychol Sci. 2010 Oct 21 [10]:1363-8) were real but flimsy. “My views have been updated to reflect the evidence,” she wrote. “As such, I do not believe that ‘power pose’ effects are real.”
In the Vox.com article, Mr. Resnick wrote that intellectual humility is needed for two reasons. “One is that our culture promotes and rewards overconfidence and arrogance. At the same time, when we are wrong – out of ignorance or error – and realize it, our culture doesn’t make it easy to admit it. Humbling moments too easily can turn into moments of humiliation.”
Emergency department visits in the United States climbed by 15% overall from 2006 to 2014. Over the same time period, ED visits by people with mental health issues soared by 44%, according to a report from the Agency for Health Care Research & Quality.
“The extent to which ERs are now flooded with patients with mental illness is unprecedented,” David R. Rubinow, MD, chairman of the department of psychiatry at the University of North Carolina, Chapel Hill, said in an interview with CNN.
This overflow is “having a really destructive effect on health care delivery in general,” Dr. Rubinow said. “There are ERs now that are repeatedly on diversion – which means they can’t see any more patients – because there are so many patients with mental illness or behavioral problems [who] are populating the ER.”
Physicians such as Mark D. Pearlmutter, MD, are convinced that EDs have become the medical refuge for many people with mental illness. “We are the safety net,” said Dr. Pearlmutter, an emergency physician affiliated with Steward Health Care in Brighton, Mass. Dr. Pearlmutter said some patients he has seen in the ED often have dual diagnoses, such as “substance abuse and depression, for example.”
As a result of this situation, patients with psychiatric needs might not receive the care that they really need, and care might be delayed for patients with other life-threatening conditions. “The ER is not a great place if you’re a mental health patient; the cardiac patients get put in front of you, and you could end up being there for a really long time, said David Morris, PhD, a psychologist at the O’Donnell Brain Institute in Dallas.
, Dr. Pearlmutter suggested. After all, increasingly, primary care physicians are providing mental health care.
Twists on New Year’s resolutions
Some people bring in each new year by shifting their perspectives – without making resolutions.
Tim Ferriss, an entrepreneur known for blogs and podcasts on work and life, engages in what he calls “past year reviews,” where accomplishments are tallied frequently throughout the year in terms of their positive or negative effect, with the latter being ruled out for the coming year. Over a few years, he hopes, the list of negatives will shrink and the positive items will increase, according to a post on the NBC News website.
Instead of making resolutions, Oprah Winfrey keeps a journal that is updated nightly with five things that spark gratitude. “I live in the present moment. I try to find the good that’s going on in any given situation,” Ms. Winfrey said in a 2017 interview. The practice has taught her to be careful in her personal wishes.
Melinda Gates starts the new year with a single word to provide guidance. Past examples include “gentle,” “spacious,” and, last year, “grace.” Her selections, she said, have helped her sharpen her focus on the really important aspects of her life.
“[Grace] even helped me find a beam of peace through the sadness of a friend’s funeral. When I was upset or distressed, I whispered to myself: ‘Grace.’ That’s the power of a well-chosen word of the year. It makes the year better – and it helps me be better, too, she wrote in a recent LinkedIn post.
20-somethings facing challenges
A recent article in the Guardian lamented a life that is not progressing as expected.
“I am 25 and a half, single, unable to pay my rent, and the closest thing I own to a car is a broken skateboard,” wrote Juliana Piskorz. “I’m in the throes of a quarter-life crisis.”
Ms. Piskorz, who said she suffers from anxiety attacks, said her experience of this crisis manifests itself by making her want to run away, start all over, or distract herself from reality.
She is not alone. According to LinkedIn, about three-quarters of people aged 25-33 share this kind of insecurity and doubt. Low self-esteem is an important culprit, according to James Arkell, MD, a psychiatrist affiliated with the Nightingale Hospital London. “Very often, 20-somethings I see here are beautiful, talented, and have the world on a plate, but they don’t like themselves and that’s got to be about society making them feel as if they have to keep up with these unrelenting standards.”
There are other reasons for millennial despair, Ms. Piskorz speculated.
“Our childhood visions for our lives ... are no longer realistic,” she wrote. “Due to unaffordable housing, less job security, and lower incomes, the traditional ‘markers’ of adulthood, such as owning a home, getting married, and having children, are being pushed back. This has left a vacuum between our teenage years and late 20s with many of us feeling we’re navigating a no man’s land with zero clue when we’ll reach the other side.”
Seeking optimism, Ms. Piskorz noted that, as a community, millennials share many positive characteristics that should serve them well.
“We are not afraid to talk about how we feel, although we should probably talk more,” she wrote. “We stand up for the causes that we think matter; we are not afraid to try new things, and we are not willing to live a life half lived.”
Apps monitor teen angst, depression
The smartphone, often seen as a tool that fuels angst, might be a resource that could identify teenagers in trouble.
According to an article in the Washington Post, research is underway on smartphone apps that can decipher the digital footprints left by users during their Internet ramblings.
“As teens scroll through Instagram or Snapchat, tap out texts, or watch YouTube videos, they also leave digital footprints that might offer clues to their psychological well-being,” wrote article author Lindsey Tanner, of the Associated Press. “Changes in typing speed, voice tone, word choice, and how often kids stay home could signal trouble.”
“We are tracking the equivalent of a heartbeat for the human brain,” said Alex Leow, MD, PhD, an app developer, and associate professor of psychiatry and bioengineering at the University of Illinois at Chicago.
The technology is not ready for deployment because of technical glitches and, more importantly, ethical issues concerning the recording and scrutiny of a user’s personal data being roadblocks. Still, with the permission of the user, mood-detecting apps might one day be a smartphone feature. “[Users] could withdraw permission at any time, said Nick B. Allen, PhD, a psychologist at the University of Oregon, Portland, who has helped create an app that is being tested on young people who have attempted suicide.
He said the biggest hurdle is figuring out “what’s the signal and what’s the noise – what is in this enormous amount of data that people accumulate on their phone that is indicative of a mental health crisis.”
Virtues of “intellectual humility”
Intellectual humility is neither a character flaw nor a sign of being a pushover.
Instead, wrote science reporter Brian Resnick in an article posted on Vox.com, “it’s a method of thinking. It’s about entertaining the possibility that you may be wrong and being open to learning from the experience of others. Intellectual humility is about being actively curious about your blind spots.”
In an effort to promote intellectual humility in psychology, two researchers, Tal Yarkoni, PhD, and Christopher F. Chabris, PhD, launched the Loss-of-Confidence project. The project is a safe space where researchers who doubt a previous finding in psychology can recalibrate. “I do think it’s a cultural issue that people are not willing to admit mistakes,” said Julia M. Rohrer, a PhD candidate and personality psychologist at the Max Planck Institute for Human Development in Berlin who joined the team in 2017. “Our broader goal is to gently nudge the whole scientific system and psychology toward a different culture where it’s okay, normalized, and expected for researchers to admit past mistakes and not get penalized for it.”
Put another way, the aim is to foster a culture where intellectually humble, honest, and curious people can thrive. For that to occur, “we all, even the smartest among us, need to better appreciate our cognitive blind spots,” Mr. Resnick wrote. “Our minds are more imperfect and imprecise than we’d often like to admit.”
In a recent paper, Ms. Rohrer and her associates said the Loss-of-Confidence project grew out of an online discussion in the wake of a post by Dana R. Carney, PhD, and associates on power poses. In that post, Dr. Carney explains why she changed her position on the value of power poses, concluding that the data gathered by her lab at the time leading to the power poses theory (Psychol Sci. 2010 Oct 21 [10]:1363-8) were real but flimsy. “My views have been updated to reflect the evidence,” she wrote. “As such, I do not believe that ‘power pose’ effects are real.”
In the Vox.com article, Mr. Resnick wrote that intellectual humility is needed for two reasons. “One is that our culture promotes and rewards overconfidence and arrogance. At the same time, when we are wrong – out of ignorance or error – and realize it, our culture doesn’t make it easy to admit it. Humbling moments too easily can turn into moments of humiliation.”
Naltrexone/ketamine combo may reduce depressive symptoms in MDD/AUD patients
Combined naltrexone and ketamine reduced depressive symptoms in a small group of patients with major depressive disorder (MDD) and alcohol use disorder (AUD), according to Gihyun Yoon, MD, of the department of psychiatry at Yale University, New Haven, Conn., and associates.
A total of five patients with major depressive disorder and comorbid alcohol use disorder were included in the 8-week, open-label pilot study. The patients were followed for an additional 4 weeks. The primary outcome was the clinical response, defined as a 50% or higher improvement from baseline in the Montgomery-Åsberg Depression Rating Scale.
After the first ketamine dose, three of the five study participants met the primary outcome, and all five met the outcome after receiving all four doses. Depressive symptoms improved 57%-92% overall. In addition, four of the five patients reported improvement in alcohol craving and consumption; no adverse events were reported.
“Larger randomized clinical trials are needed to better understand whether opiate receptor stimulation contributes to the antidepressant effects of ketamine. If so, then preclinical research will be needed to help us to understand this role for opiates and its implications for future rapid-acting antidepressant treatments,” concluded Dr. Yoon and associates.
Two study authors reported conflicts of interest with numerous companies. All study authors are listed inventors on a patent application by Yale University.
SOURCE: Yoon G et al. JAMA Psychiatry. 2019 Jan 9. doi: 10.1001/jamapsychiatry.2018.3990.
Combined naltrexone and ketamine reduced depressive symptoms in a small group of patients with major depressive disorder (MDD) and alcohol use disorder (AUD), according to Gihyun Yoon, MD, of the department of psychiatry at Yale University, New Haven, Conn., and associates.
A total of five patients with major depressive disorder and comorbid alcohol use disorder were included in the 8-week, open-label pilot study. The patients were followed for an additional 4 weeks. The primary outcome was the clinical response, defined as a 50% or higher improvement from baseline in the Montgomery-Åsberg Depression Rating Scale.
After the first ketamine dose, three of the five study participants met the primary outcome, and all five met the outcome after receiving all four doses. Depressive symptoms improved 57%-92% overall. In addition, four of the five patients reported improvement in alcohol craving and consumption; no adverse events were reported.
“Larger randomized clinical trials are needed to better understand whether opiate receptor stimulation contributes to the antidepressant effects of ketamine. If so, then preclinical research will be needed to help us to understand this role for opiates and its implications for future rapid-acting antidepressant treatments,” concluded Dr. Yoon and associates.
Two study authors reported conflicts of interest with numerous companies. All study authors are listed inventors on a patent application by Yale University.
SOURCE: Yoon G et al. JAMA Psychiatry. 2019 Jan 9. doi: 10.1001/jamapsychiatry.2018.3990.
Combined naltrexone and ketamine reduced depressive symptoms in a small group of patients with major depressive disorder (MDD) and alcohol use disorder (AUD), according to Gihyun Yoon, MD, of the department of psychiatry at Yale University, New Haven, Conn., and associates.
A total of five patients with major depressive disorder and comorbid alcohol use disorder were included in the 8-week, open-label pilot study. The patients were followed for an additional 4 weeks. The primary outcome was the clinical response, defined as a 50% or higher improvement from baseline in the Montgomery-Åsberg Depression Rating Scale.
After the first ketamine dose, three of the five study participants met the primary outcome, and all five met the outcome after receiving all four doses. Depressive symptoms improved 57%-92% overall. In addition, four of the five patients reported improvement in alcohol craving and consumption; no adverse events were reported.
“Larger randomized clinical trials are needed to better understand whether opiate receptor stimulation contributes to the antidepressant effects of ketamine. If so, then preclinical research will be needed to help us to understand this role for opiates and its implications for future rapid-acting antidepressant treatments,” concluded Dr. Yoon and associates.
Two study authors reported conflicts of interest with numerous companies. All study authors are listed inventors on a patent application by Yale University.
SOURCE: Yoon G et al. JAMA Psychiatry. 2019 Jan 9. doi: 10.1001/jamapsychiatry.2018.3990.
FROM JAMA PSYCHIATRY
Gender, racial, socioeconomic differences found in obesity-depression link
Association holds for white women across income levels, black men with incomes of $100,000 or higher.
Among white women, obesity is positively associated with depressive symptoms across all income levels. However, among black women, no such associations are found – regardless of income. Meanwhile, among men, the link between obesity and depression appears strong for black men with high household incomes, a cross-sectional analysis of 12,220 adults suggests.
“This work underscores the importance of disentangling the association of race and [socioeconomic status] to gain a better understanding of how each operates to impact health outcomes,” wrote Caryn N. Bell, PhD, and her associates. The report is in Preventive Medicine.
The study comprised 3,755 black subjects, 55.5% of whom were women, and 8,465 white subjects, 51.8% of whom were women. They completed a detailed questionnaire as part of the 2007-2014 National Health and Nutrition Examination Survey and had a physical exam. Depressive symptoms were measured by the Patient Health Questionnaire-9 (PHQ-9), and obesity was defined as a body mass index of 30 kg/m2 or higher. About 1% of both black and white subjects had severe depressive symptoms, meaning a PHQ-9 score ranging from 20 to 27 points.
A greater percentage of black participants were obese (47.3% vs. 34.4%), and black participants were less likely to live in a household earning $100,000 per year or more (10.9% vs. 28.3%). Black participants were a bit younger (mean age 44.8 years vs. 49.2 years), and less likely to be currently married, college graduates, insured, and physically active. A higher percentage reported fair to poor health (23.9% vs. 14.6%). The differences were statistically significant.
For white women, the association between obesity and depression held across all income levels. For black women, this association was not found at any income level. For black men, the link between obesity and depression was limited to those with a household income of $100,000 or more (odds ratio, 4.65; 95% confidence interval, 1.48-14.59). And for white men, the association was limited to those with a household income of $35,000-$74,999 (OR, 1.44; 95% CI, 1.02-2.03).
The effect of race on obesity and depression has been well studied – it’s known, for instance, that the association between obesity and depression is strongest among white women – but the role of income as a modifier has not been well addressed, wrote Dr. Bell, an assistant professor in the department of African American studies at the University of Maryland, College Park, and her associates.
Dr. Bell and her associates wrote.
As for explanations, the authors suggested that strong, antiobesity stigma “may be present among white women at all income levels,” and may drive depression regardless of how much they make.
The prevalence of depressive symptoms at specific income levels among men suggests that something other than stigma is at work. Depression among obese, middle-income white men might be tied to “an unmeasured factor like subjective social status.” Meanwhile, obese black men with high household incomes “have less income and wealth than their white counterparts” because “of various forms of structural racism. ... This may be manifested with higher rates of depression through obesity-related factors like unhealthy coping behaviors and stress,” the investigators said.
Dr. Bell and her associates cited a few limitations. One is that the study looked only at those factors among black and white people. “Results could differ with other ethnic groups,” they wrote. In addition, income was self-reported, and three-way interactions – which are tough to interpret – were used. Nevertheless, they said, the study results have key public health implications.
The study had no financial disclosures, and the investigators reported having no conflicts of interest.
SOURCE: Bell CN et al. Prev Med. 2018 Dec 3. doi: 10.1016/j.ypmed.2018.11.024.
Association holds for white women across income levels, black men with incomes of $100,000 or higher.
Association holds for white women across income levels, black men with incomes of $100,000 or higher.
Among white women, obesity is positively associated with depressive symptoms across all income levels. However, among black women, no such associations are found – regardless of income. Meanwhile, among men, the link between obesity and depression appears strong for black men with high household incomes, a cross-sectional analysis of 12,220 adults suggests.
“This work underscores the importance of disentangling the association of race and [socioeconomic status] to gain a better understanding of how each operates to impact health outcomes,” wrote Caryn N. Bell, PhD, and her associates. The report is in Preventive Medicine.
The study comprised 3,755 black subjects, 55.5% of whom were women, and 8,465 white subjects, 51.8% of whom were women. They completed a detailed questionnaire as part of the 2007-2014 National Health and Nutrition Examination Survey and had a physical exam. Depressive symptoms were measured by the Patient Health Questionnaire-9 (PHQ-9), and obesity was defined as a body mass index of 30 kg/m2 or higher. About 1% of both black and white subjects had severe depressive symptoms, meaning a PHQ-9 score ranging from 20 to 27 points.
A greater percentage of black participants were obese (47.3% vs. 34.4%), and black participants were less likely to live in a household earning $100,000 per year or more (10.9% vs. 28.3%). Black participants were a bit younger (mean age 44.8 years vs. 49.2 years), and less likely to be currently married, college graduates, insured, and physically active. A higher percentage reported fair to poor health (23.9% vs. 14.6%). The differences were statistically significant.
For white women, the association between obesity and depression held across all income levels. For black women, this association was not found at any income level. For black men, the link between obesity and depression was limited to those with a household income of $100,000 or more (odds ratio, 4.65; 95% confidence interval, 1.48-14.59). And for white men, the association was limited to those with a household income of $35,000-$74,999 (OR, 1.44; 95% CI, 1.02-2.03).
The effect of race on obesity and depression has been well studied – it’s known, for instance, that the association between obesity and depression is strongest among white women – but the role of income as a modifier has not been well addressed, wrote Dr. Bell, an assistant professor in the department of African American studies at the University of Maryland, College Park, and her associates.
Dr. Bell and her associates wrote.
As for explanations, the authors suggested that strong, antiobesity stigma “may be present among white women at all income levels,” and may drive depression regardless of how much they make.
The prevalence of depressive symptoms at specific income levels among men suggests that something other than stigma is at work. Depression among obese, middle-income white men might be tied to “an unmeasured factor like subjective social status.” Meanwhile, obese black men with high household incomes “have less income and wealth than their white counterparts” because “of various forms of structural racism. ... This may be manifested with higher rates of depression through obesity-related factors like unhealthy coping behaviors and stress,” the investigators said.
Dr. Bell and her associates cited a few limitations. One is that the study looked only at those factors among black and white people. “Results could differ with other ethnic groups,” they wrote. In addition, income was self-reported, and three-way interactions – which are tough to interpret – were used. Nevertheless, they said, the study results have key public health implications.
The study had no financial disclosures, and the investigators reported having no conflicts of interest.
SOURCE: Bell CN et al. Prev Med. 2018 Dec 3. doi: 10.1016/j.ypmed.2018.11.024.
Among white women, obesity is positively associated with depressive symptoms across all income levels. However, among black women, no such associations are found – regardless of income. Meanwhile, among men, the link between obesity and depression appears strong for black men with high household incomes, a cross-sectional analysis of 12,220 adults suggests.
“This work underscores the importance of disentangling the association of race and [socioeconomic status] to gain a better understanding of how each operates to impact health outcomes,” wrote Caryn N. Bell, PhD, and her associates. The report is in Preventive Medicine.
The study comprised 3,755 black subjects, 55.5% of whom were women, and 8,465 white subjects, 51.8% of whom were women. They completed a detailed questionnaire as part of the 2007-2014 National Health and Nutrition Examination Survey and had a physical exam. Depressive symptoms were measured by the Patient Health Questionnaire-9 (PHQ-9), and obesity was defined as a body mass index of 30 kg/m2 or higher. About 1% of both black and white subjects had severe depressive symptoms, meaning a PHQ-9 score ranging from 20 to 27 points.
A greater percentage of black participants were obese (47.3% vs. 34.4%), and black participants were less likely to live in a household earning $100,000 per year or more (10.9% vs. 28.3%). Black participants were a bit younger (mean age 44.8 years vs. 49.2 years), and less likely to be currently married, college graduates, insured, and physically active. A higher percentage reported fair to poor health (23.9% vs. 14.6%). The differences were statistically significant.
For white women, the association between obesity and depression held across all income levels. For black women, this association was not found at any income level. For black men, the link between obesity and depression was limited to those with a household income of $100,000 or more (odds ratio, 4.65; 95% confidence interval, 1.48-14.59). And for white men, the association was limited to those with a household income of $35,000-$74,999 (OR, 1.44; 95% CI, 1.02-2.03).
The effect of race on obesity and depression has been well studied – it’s known, for instance, that the association between obesity and depression is strongest among white women – but the role of income as a modifier has not been well addressed, wrote Dr. Bell, an assistant professor in the department of African American studies at the University of Maryland, College Park, and her associates.
Dr. Bell and her associates wrote.
As for explanations, the authors suggested that strong, antiobesity stigma “may be present among white women at all income levels,” and may drive depression regardless of how much they make.
The prevalence of depressive symptoms at specific income levels among men suggests that something other than stigma is at work. Depression among obese, middle-income white men might be tied to “an unmeasured factor like subjective social status.” Meanwhile, obese black men with high household incomes “have less income and wealth than their white counterparts” because “of various forms of structural racism. ... This may be manifested with higher rates of depression through obesity-related factors like unhealthy coping behaviors and stress,” the investigators said.
Dr. Bell and her associates cited a few limitations. One is that the study looked only at those factors among black and white people. “Results could differ with other ethnic groups,” they wrote. In addition, income was self-reported, and three-way interactions – which are tough to interpret – were used. Nevertheless, they said, the study results have key public health implications.
The study had no financial disclosures, and the investigators reported having no conflicts of interest.
SOURCE: Bell CN et al. Prev Med. 2018 Dec 3. doi: 10.1016/j.ypmed.2018.11.024.
FROM PREVENTIVE MEDICINE
White matter volume reduced in first-episode depression
Decrements ‘seem to vanish’ after 2-year follow-up
White matter volume was significantly reduced initially in patients with first-episode depression, but not after a 2-year follow-up, according to Mar Carceller-Sindreu, MD, of the department of psychiatry at Hospital de la Santa Creu i Sant Pau in Barcelona, and her associates.
A total of 33 patients with first-episode depression and 33 healthy controls were included in the study. Among them, 27 first-episode depression patients and 17 controls completed the 2-year follow-up. They underwent structural MRIs at baseline and at follow-up, the Hamilton Depressive Rating Scale was administered throughout the study period, and whole-brain, voxel-based morphometry was used to measure white matter and gray matter, Dr. Carceller-Sindreu and her associates wrote. The report is in the Journal of Affective Disorders.
At baseline, the white matter volume in the prefrontal cortex of patients with first-episode depression was significantly lower than in healthy controls; no difference was seen in gray matter volume. At the 2-year follow-up, no difference was seen in either white matter or gray matter volume. In other words, the baseline differences “seem to vanish, as if they were normalized,” Dr. Carceller-Sindreu said. The normalization of white matter might have been caused by treatment normalization or attributable to lack of study power, she and her associates noted.
In addition, patients who had recurring depression over the study period had higher white matter volume in the left posterior corona radiata and right posterior thalamic radiation at follow-up, compared with patients whose depression did not recur. This finding “could represent compensatory effects to cope with the disease,” the investigators wrote.
“, so as to unveil many of the open questions,” they concluded.
The study was supported by the Spanish FIS grant, the European Regional Development Fund, and the CERCA Programme. Two study authors reported conflicts of interest with numerous pharmaceutical companies.
SOURCE: Carceller-Sindreu M et al. J Affect Disord. 2018 Nov 13. doi: 10.1016/j.jad.2018.11.085.
Decrements ‘seem to vanish’ after 2-year follow-up
Decrements ‘seem to vanish’ after 2-year follow-up
White matter volume was significantly reduced initially in patients with first-episode depression, but not after a 2-year follow-up, according to Mar Carceller-Sindreu, MD, of the department of psychiatry at Hospital de la Santa Creu i Sant Pau in Barcelona, and her associates.
A total of 33 patients with first-episode depression and 33 healthy controls were included in the study. Among them, 27 first-episode depression patients and 17 controls completed the 2-year follow-up. They underwent structural MRIs at baseline and at follow-up, the Hamilton Depressive Rating Scale was administered throughout the study period, and whole-brain, voxel-based morphometry was used to measure white matter and gray matter, Dr. Carceller-Sindreu and her associates wrote. The report is in the Journal of Affective Disorders.
At baseline, the white matter volume in the prefrontal cortex of patients with first-episode depression was significantly lower than in healthy controls; no difference was seen in gray matter volume. At the 2-year follow-up, no difference was seen in either white matter or gray matter volume. In other words, the baseline differences “seem to vanish, as if they were normalized,” Dr. Carceller-Sindreu said. The normalization of white matter might have been caused by treatment normalization or attributable to lack of study power, she and her associates noted.
In addition, patients who had recurring depression over the study period had higher white matter volume in the left posterior corona radiata and right posterior thalamic radiation at follow-up, compared with patients whose depression did not recur. This finding “could represent compensatory effects to cope with the disease,” the investigators wrote.
“, so as to unveil many of the open questions,” they concluded.
The study was supported by the Spanish FIS grant, the European Regional Development Fund, and the CERCA Programme. Two study authors reported conflicts of interest with numerous pharmaceutical companies.
SOURCE: Carceller-Sindreu M et al. J Affect Disord. 2018 Nov 13. doi: 10.1016/j.jad.2018.11.085.
White matter volume was significantly reduced initially in patients with first-episode depression, but not after a 2-year follow-up, according to Mar Carceller-Sindreu, MD, of the department of psychiatry at Hospital de la Santa Creu i Sant Pau in Barcelona, and her associates.
A total of 33 patients with first-episode depression and 33 healthy controls were included in the study. Among them, 27 first-episode depression patients and 17 controls completed the 2-year follow-up. They underwent structural MRIs at baseline and at follow-up, the Hamilton Depressive Rating Scale was administered throughout the study period, and whole-brain, voxel-based morphometry was used to measure white matter and gray matter, Dr. Carceller-Sindreu and her associates wrote. The report is in the Journal of Affective Disorders.
At baseline, the white matter volume in the prefrontal cortex of patients with first-episode depression was significantly lower than in healthy controls; no difference was seen in gray matter volume. At the 2-year follow-up, no difference was seen in either white matter or gray matter volume. In other words, the baseline differences “seem to vanish, as if they were normalized,” Dr. Carceller-Sindreu said. The normalization of white matter might have been caused by treatment normalization or attributable to lack of study power, she and her associates noted.
In addition, patients who had recurring depression over the study period had higher white matter volume in the left posterior corona radiata and right posterior thalamic radiation at follow-up, compared with patients whose depression did not recur. This finding “could represent compensatory effects to cope with the disease,” the investigators wrote.
“, so as to unveil many of the open questions,” they concluded.
The study was supported by the Spanish FIS grant, the European Regional Development Fund, and the CERCA Programme. Two study authors reported conflicts of interest with numerous pharmaceutical companies.
SOURCE: Carceller-Sindreu M et al. J Affect Disord. 2018 Nov 13. doi: 10.1016/j.jad.2018.11.085.
FROM THE JOURNAL OF AFFECTIVE DISORDERS
Antidepressants tied to greater hip fracture incidence in older adults
Older patients in a Swedish registry who took antidepressants had a greater incidence of hip fracture the year before beginning antidepressant therapy and the year after starting therapy, compared with individuals in a matched control group.
The use of antidepressants is associated with adverse events such as a higher risk of falls, wrote Jon Brännström, MD, and his colleagues in JAMA Psychiatry. Some evidence also suggests that antidepressants “might affect bone metabolism, thereby increasing the risk of hip fracture.”
To examine the relationship between antidepressants and hip fracture, Dr. Brännström and his colleagues performed a nationwide cohort study of 204,072 individuals in the Prescribed Drug Register of Sweden’s National Board of Health and Welfare. All of the individuals were aged at least 65 years (mean age, 80.1 years; 63.1% women) and filled a prescription for an antidepressant between July 2006 and December 2011. Selective serotonin reuptake inhibitors made up 62.6% of the antidepressants used.
Patients who filled an antidepressant prescription during that time period were matched with a control group of individuals by birth year and gender and were studied the year before and after beginning antidepressant therapy.
In the year after initiating antidepressant therapy, there was a 3.5% incidence rate for hip fractures, compared with 1.3% in the control group.
After adjusting the results using a conditional logistic regression model, the highest rate of hip fracture among antidepressant users occurred between 16 days and 30 days prior to filling the prescription (odds ratio, 5.76; 95% confidence interval, 4.73-7.01); this association persisted in further subgroup analyses based on age, reported Dr. Brännström, who is affiliated with the department of community medicine and rehabilitation and geriatric medicine at Umeå University (Sweden), and his colleagues.
They noted that, although the study included all Swedish individuals who filled prescriptions for antidepressants during the study period, there is an absence of primary care comorbidity data and indications for antidepressant use. In addition, the definition of high- and low-medication doses does not always match what is considered high and low therapeutically and the information that can be gleaned from merging data from several different registries was limited.
“These findings raise questions about associations between antidepressant use and hip fracture seen in previous observational studies,” Dr. Brännström and his colleagues wrote. “Further analysis of this association in treatment studies and examination of the incidence of hip fracture before and after the discontinuation of treatment is required and may shed further light on the possible residual risk associated with treatment.”
This study was funded by the Swedish Research Council. The authors reported no relevant conflicts of interest.
SOURCE: Brännström J et al. JAMA Psychiatry. 2019 Jan 2. doi: 10.1001/jamapsychiatry.2018.3679.
In many cases where an adverse event is linked to a medication, such as in the case of gastrointestinal bleeds and blood thinners, the adverse event is not linked to the medication. However, this is not the case with antidepressants and hip fracture, Andrea Iaboni, MD, DPhil, and Donovan T. Maust, MD, wrote in a related editorial (JAMA Psychiatry. 2019 Jan 2. doi: 10.1001/jamapsychiatry.2018.3632).
“Patients are routinely prescribed antidepressants following a fracture,” the authors wrote, noting that depression can occur for patients who do not have a history of depression and can last as long as 1 year after hip fracture. The reasons for depression after hip fracture are possibly caused by the consequences of the event or a comorbid condition, such as cerebrovascular disease burden, cognitive impairment, frailty, and impaired functional status. In addition, new antidepressant prescriptions are 10 times the normal rate for older adults in the months after a hip fracture.
Many older users of antidepressants have a hip fracture event in their past, which could be caused by an untreated case of depression and an elevated risk of elevated fall or fracture, as suggested by Brännström et al., while other reasons could include off-label indications such as insomnia, poor motivation during rehabilitation therapy, pain, or hyperactive delirium.
“If individuals with untreated depression are at risk of falls and fractures, it follows that there would be an elevated rate of fractures before antidepressant use,” the authors wrote. “However, as discussed earlier, it is also important to recognize that, during the postfracture period, rightly or wrongly, antidepressants are prescribed at a high rate.”
Clinicians who treat these patients should not stop all antidepressant prescribing to this population. Instead, “a pragmatic preventive approach is warranted, starting with selecting the antidepressant, a cautious initial dose and dose-escalation schedule, a review of potentially interacting therapies ... and referral to fall prevention programs for patients with other risk factors for falls,” they wrote.
“For most older adults, the toll of untreated depression will likely outweigh the potential risks associated with antidepressant use.”
Dr. Iabroni is with the Toronto Rehabilitation Institute and the University of Toronto. He reported receiving fees from serving as a scientific adviser for Winterlight Labs. Dr. Maust is with the department of psychiatry at the University of Michigan, Ann Arbor. He reported no relevant conflicts of interest.
In many cases where an adverse event is linked to a medication, such as in the case of gastrointestinal bleeds and blood thinners, the adverse event is not linked to the medication. However, this is not the case with antidepressants and hip fracture, Andrea Iaboni, MD, DPhil, and Donovan T. Maust, MD, wrote in a related editorial (JAMA Psychiatry. 2019 Jan 2. doi: 10.1001/jamapsychiatry.2018.3632).
“Patients are routinely prescribed antidepressants following a fracture,” the authors wrote, noting that depression can occur for patients who do not have a history of depression and can last as long as 1 year after hip fracture. The reasons for depression after hip fracture are possibly caused by the consequences of the event or a comorbid condition, such as cerebrovascular disease burden, cognitive impairment, frailty, and impaired functional status. In addition, new antidepressant prescriptions are 10 times the normal rate for older adults in the months after a hip fracture.
Many older users of antidepressants have a hip fracture event in their past, which could be caused by an untreated case of depression and an elevated risk of elevated fall or fracture, as suggested by Brännström et al., while other reasons could include off-label indications such as insomnia, poor motivation during rehabilitation therapy, pain, or hyperactive delirium.
“If individuals with untreated depression are at risk of falls and fractures, it follows that there would be an elevated rate of fractures before antidepressant use,” the authors wrote. “However, as discussed earlier, it is also important to recognize that, during the postfracture period, rightly or wrongly, antidepressants are prescribed at a high rate.”
Clinicians who treat these patients should not stop all antidepressant prescribing to this population. Instead, “a pragmatic preventive approach is warranted, starting with selecting the antidepressant, a cautious initial dose and dose-escalation schedule, a review of potentially interacting therapies ... and referral to fall prevention programs for patients with other risk factors for falls,” they wrote.
“For most older adults, the toll of untreated depression will likely outweigh the potential risks associated with antidepressant use.”
Dr. Iabroni is with the Toronto Rehabilitation Institute and the University of Toronto. He reported receiving fees from serving as a scientific adviser for Winterlight Labs. Dr. Maust is with the department of psychiatry at the University of Michigan, Ann Arbor. He reported no relevant conflicts of interest.
In many cases where an adverse event is linked to a medication, such as in the case of gastrointestinal bleeds and blood thinners, the adverse event is not linked to the medication. However, this is not the case with antidepressants and hip fracture, Andrea Iaboni, MD, DPhil, and Donovan T. Maust, MD, wrote in a related editorial (JAMA Psychiatry. 2019 Jan 2. doi: 10.1001/jamapsychiatry.2018.3632).
“Patients are routinely prescribed antidepressants following a fracture,” the authors wrote, noting that depression can occur for patients who do not have a history of depression and can last as long as 1 year after hip fracture. The reasons for depression after hip fracture are possibly caused by the consequences of the event or a comorbid condition, such as cerebrovascular disease burden, cognitive impairment, frailty, and impaired functional status. In addition, new antidepressant prescriptions are 10 times the normal rate for older adults in the months after a hip fracture.
Many older users of antidepressants have a hip fracture event in their past, which could be caused by an untreated case of depression and an elevated risk of elevated fall or fracture, as suggested by Brännström et al., while other reasons could include off-label indications such as insomnia, poor motivation during rehabilitation therapy, pain, or hyperactive delirium.
“If individuals with untreated depression are at risk of falls and fractures, it follows that there would be an elevated rate of fractures before antidepressant use,” the authors wrote. “However, as discussed earlier, it is also important to recognize that, during the postfracture period, rightly or wrongly, antidepressants are prescribed at a high rate.”
Clinicians who treat these patients should not stop all antidepressant prescribing to this population. Instead, “a pragmatic preventive approach is warranted, starting with selecting the antidepressant, a cautious initial dose and dose-escalation schedule, a review of potentially interacting therapies ... and referral to fall prevention programs for patients with other risk factors for falls,” they wrote.
“For most older adults, the toll of untreated depression will likely outweigh the potential risks associated with antidepressant use.”
Dr. Iabroni is with the Toronto Rehabilitation Institute and the University of Toronto. He reported receiving fees from serving as a scientific adviser for Winterlight Labs. Dr. Maust is with the department of psychiatry at the University of Michigan, Ann Arbor. He reported no relevant conflicts of interest.
Older patients in a Swedish registry who took antidepressants had a greater incidence of hip fracture the year before beginning antidepressant therapy and the year after starting therapy, compared with individuals in a matched control group.
The use of antidepressants is associated with adverse events such as a higher risk of falls, wrote Jon Brännström, MD, and his colleagues in JAMA Psychiatry. Some evidence also suggests that antidepressants “might affect bone metabolism, thereby increasing the risk of hip fracture.”
To examine the relationship between antidepressants and hip fracture, Dr. Brännström and his colleagues performed a nationwide cohort study of 204,072 individuals in the Prescribed Drug Register of Sweden’s National Board of Health and Welfare. All of the individuals were aged at least 65 years (mean age, 80.1 years; 63.1% women) and filled a prescription for an antidepressant between July 2006 and December 2011. Selective serotonin reuptake inhibitors made up 62.6% of the antidepressants used.
Patients who filled an antidepressant prescription during that time period were matched with a control group of individuals by birth year and gender and were studied the year before and after beginning antidepressant therapy.
In the year after initiating antidepressant therapy, there was a 3.5% incidence rate for hip fractures, compared with 1.3% in the control group.
After adjusting the results using a conditional logistic regression model, the highest rate of hip fracture among antidepressant users occurred between 16 days and 30 days prior to filling the prescription (odds ratio, 5.76; 95% confidence interval, 4.73-7.01); this association persisted in further subgroup analyses based on age, reported Dr. Brännström, who is affiliated with the department of community medicine and rehabilitation and geriatric medicine at Umeå University (Sweden), and his colleagues.
They noted that, although the study included all Swedish individuals who filled prescriptions for antidepressants during the study period, there is an absence of primary care comorbidity data and indications for antidepressant use. In addition, the definition of high- and low-medication doses does not always match what is considered high and low therapeutically and the information that can be gleaned from merging data from several different registries was limited.
“These findings raise questions about associations between antidepressant use and hip fracture seen in previous observational studies,” Dr. Brännström and his colleagues wrote. “Further analysis of this association in treatment studies and examination of the incidence of hip fracture before and after the discontinuation of treatment is required and may shed further light on the possible residual risk associated with treatment.”
This study was funded by the Swedish Research Council. The authors reported no relevant conflicts of interest.
SOURCE: Brännström J et al. JAMA Psychiatry. 2019 Jan 2. doi: 10.1001/jamapsychiatry.2018.3679.
Older patients in a Swedish registry who took antidepressants had a greater incidence of hip fracture the year before beginning antidepressant therapy and the year after starting therapy, compared with individuals in a matched control group.
The use of antidepressants is associated with adverse events such as a higher risk of falls, wrote Jon Brännström, MD, and his colleagues in JAMA Psychiatry. Some evidence also suggests that antidepressants “might affect bone metabolism, thereby increasing the risk of hip fracture.”
To examine the relationship between antidepressants and hip fracture, Dr. Brännström and his colleagues performed a nationwide cohort study of 204,072 individuals in the Prescribed Drug Register of Sweden’s National Board of Health and Welfare. All of the individuals were aged at least 65 years (mean age, 80.1 years; 63.1% women) and filled a prescription for an antidepressant between July 2006 and December 2011. Selective serotonin reuptake inhibitors made up 62.6% of the antidepressants used.
Patients who filled an antidepressant prescription during that time period were matched with a control group of individuals by birth year and gender and were studied the year before and after beginning antidepressant therapy.
In the year after initiating antidepressant therapy, there was a 3.5% incidence rate for hip fractures, compared with 1.3% in the control group.
After adjusting the results using a conditional logistic regression model, the highest rate of hip fracture among antidepressant users occurred between 16 days and 30 days prior to filling the prescription (odds ratio, 5.76; 95% confidence interval, 4.73-7.01); this association persisted in further subgroup analyses based on age, reported Dr. Brännström, who is affiliated with the department of community medicine and rehabilitation and geriatric medicine at Umeå University (Sweden), and his colleagues.
They noted that, although the study included all Swedish individuals who filled prescriptions for antidepressants during the study period, there is an absence of primary care comorbidity data and indications for antidepressant use. In addition, the definition of high- and low-medication doses does not always match what is considered high and low therapeutically and the information that can be gleaned from merging data from several different registries was limited.
“These findings raise questions about associations between antidepressant use and hip fracture seen in previous observational studies,” Dr. Brännström and his colleagues wrote. “Further analysis of this association in treatment studies and examination of the incidence of hip fracture before and after the discontinuation of treatment is required and may shed further light on the possible residual risk associated with treatment.”
This study was funded by the Swedish Research Council. The authors reported no relevant conflicts of interest.
SOURCE: Brännström J et al. JAMA Psychiatry. 2019 Jan 2. doi: 10.1001/jamapsychiatry.2018.3679.
FROM JAMA PSYCHIATRY
Key clinical point: An association was found between greater hip fracture incidence for older individuals taking antidepressants in the year before beginning therapy and the year after starting therapy.
Major finding: Individuals who took antidepressants had a greater incidence of hip fractures in the year before (2.8% vs. 1.1%) and the year after (3.5% vs. 1.3%) beginning antidepressants, compared with individuals in a matched control group.
Study details: A nationwide cohort study of 408,144 individuals in the Prescribed Drugs Register of Sweden’s National Board of Health and Welfare who were aged 65 years or older.
Disclosures: This study was funded by the Swedish Research Council. The authors reported no relevant conflicts of interest.
Source: Brännström J et al. JAMA Psychiatry. 2019 Jan 2. doi: 10.1001/jamapsychiatry.2018.3679.
Mothers may play role in depression link between fathers and daughters
Researchers say they’ve gained new insight into possible links between paternal depression after birth and depression in the fathers’ offspring at age 18 years. In girls, the depression risk seems to rise if their mothers also were depressed shortly after birth and if the girls show conduct problems at age 42 months, reported Leticia Gutiérrez-Galve, PhD, and her associates.
“Overall, Dr. Gutiérrez-Galve of the Center for Psychiatry at Imperial College, London, and her associates wrote in JAMA Psychiatry.
Previous research has linked postnatal depression in less-educated mothers and fathers to a higher risk of depression in children at the age of 18 years.
For the new study, Dr. Gutiérrez-Galve and her associates analyzed data about father-child pairs from the Avon Longitudinal Study of Parents and Children. The project, also known as Children of the ’90s, has tracked thousands of British children born in 1991 and 1992 and their parents. In a subset of 3,165 father-child pairs, the researchers found that the adolescent offspring were more likely to be depressed at age 18 years if their fathers were depressed at 8 weeks after birth (odds ratio, 1.52; 95% confidence interval, 0.78-2.98).
Another analysis tracked 3,176 father-child pairs. In girls, they found two factors mediated the risk of depression among those whose fathers were depressed postnatally: maternal depression at 8 months after birth and conduct problems of the child at age 42 months. “The mediating effect of maternal depression at 8 months explains one-fifth of the total association of paternal depression in the postnatal period with offspring depression, and conduct problems at age 3.5 years explains almost one-tenth of this association,” Dr. Gutiérrez-Galve and her associates wrote. Those factors did not boost the risk of depression in boys. In addition, they found that two other factors – couple conflict and paternal involvement – did not play mediation roles.
The findings on the possible effects of paternal depression on offspring depression at age 18 years contrast with the potential influence of maternal depression. The link between maternal depression and depression in children “may be better explained by other factors, including the association of depression with mother-infant interaction, genetic loading, and transmission of negative cognitions,” said Dr. Gutiérrez-Galve and her associates.
They cited several limitations. One is that paternal depression was assessed not by a diagnostic interview but by self-report. As a strength of the study, Dr. Gutiérrez-Galve cited the large sample size. Also, the first measure of paternal depression was taken 18 years earlier than the offspring depression measure, making reverse causality implausible, they wrote.
The study was funded by the U.K. Medical Research Council/Wellcome Trust and the University Hospitals Bristol (England) National Health Service Foundation Trust. The University of Bristol provided core support for the Avon Longitudinal Study of Parents and Children. One of the study authors disclosed funding from the National Institute of Health Research U.K. and the LEGO Foundation. No other disclosures were reported.
SOURCE: Gutiérrez-Galve L et al. JAMA Psychiatry. 2018 Dec 26. doi: 10.1001/jamapsychiatry.2018.3667.
Researchers say they’ve gained new insight into possible links between paternal depression after birth and depression in the fathers’ offspring at age 18 years. In girls, the depression risk seems to rise if their mothers also were depressed shortly after birth and if the girls show conduct problems at age 42 months, reported Leticia Gutiérrez-Galve, PhD, and her associates.
“Overall, Dr. Gutiérrez-Galve of the Center for Psychiatry at Imperial College, London, and her associates wrote in JAMA Psychiatry.
Previous research has linked postnatal depression in less-educated mothers and fathers to a higher risk of depression in children at the age of 18 years.
For the new study, Dr. Gutiérrez-Galve and her associates analyzed data about father-child pairs from the Avon Longitudinal Study of Parents and Children. The project, also known as Children of the ’90s, has tracked thousands of British children born in 1991 and 1992 and their parents. In a subset of 3,165 father-child pairs, the researchers found that the adolescent offspring were more likely to be depressed at age 18 years if their fathers were depressed at 8 weeks after birth (odds ratio, 1.52; 95% confidence interval, 0.78-2.98).
Another analysis tracked 3,176 father-child pairs. In girls, they found two factors mediated the risk of depression among those whose fathers were depressed postnatally: maternal depression at 8 months after birth and conduct problems of the child at age 42 months. “The mediating effect of maternal depression at 8 months explains one-fifth of the total association of paternal depression in the postnatal period with offspring depression, and conduct problems at age 3.5 years explains almost one-tenth of this association,” Dr. Gutiérrez-Galve and her associates wrote. Those factors did not boost the risk of depression in boys. In addition, they found that two other factors – couple conflict and paternal involvement – did not play mediation roles.
The findings on the possible effects of paternal depression on offspring depression at age 18 years contrast with the potential influence of maternal depression. The link between maternal depression and depression in children “may be better explained by other factors, including the association of depression with mother-infant interaction, genetic loading, and transmission of negative cognitions,” said Dr. Gutiérrez-Galve and her associates.
They cited several limitations. One is that paternal depression was assessed not by a diagnostic interview but by self-report. As a strength of the study, Dr. Gutiérrez-Galve cited the large sample size. Also, the first measure of paternal depression was taken 18 years earlier than the offspring depression measure, making reverse causality implausible, they wrote.
The study was funded by the U.K. Medical Research Council/Wellcome Trust and the University Hospitals Bristol (England) National Health Service Foundation Trust. The University of Bristol provided core support for the Avon Longitudinal Study of Parents and Children. One of the study authors disclosed funding from the National Institute of Health Research U.K. and the LEGO Foundation. No other disclosures were reported.
SOURCE: Gutiérrez-Galve L et al. JAMA Psychiatry. 2018 Dec 26. doi: 10.1001/jamapsychiatry.2018.3667.
Researchers say they’ve gained new insight into possible links between paternal depression after birth and depression in the fathers’ offspring at age 18 years. In girls, the depression risk seems to rise if their mothers also were depressed shortly after birth and if the girls show conduct problems at age 42 months, reported Leticia Gutiérrez-Galve, PhD, and her associates.
“Overall, Dr. Gutiérrez-Galve of the Center for Psychiatry at Imperial College, London, and her associates wrote in JAMA Psychiatry.
Previous research has linked postnatal depression in less-educated mothers and fathers to a higher risk of depression in children at the age of 18 years.
For the new study, Dr. Gutiérrez-Galve and her associates analyzed data about father-child pairs from the Avon Longitudinal Study of Parents and Children. The project, also known as Children of the ’90s, has tracked thousands of British children born in 1991 and 1992 and their parents. In a subset of 3,165 father-child pairs, the researchers found that the adolescent offspring were more likely to be depressed at age 18 years if their fathers were depressed at 8 weeks after birth (odds ratio, 1.52; 95% confidence interval, 0.78-2.98).
Another analysis tracked 3,176 father-child pairs. In girls, they found two factors mediated the risk of depression among those whose fathers were depressed postnatally: maternal depression at 8 months after birth and conduct problems of the child at age 42 months. “The mediating effect of maternal depression at 8 months explains one-fifth of the total association of paternal depression in the postnatal period with offspring depression, and conduct problems at age 3.5 years explains almost one-tenth of this association,” Dr. Gutiérrez-Galve and her associates wrote. Those factors did not boost the risk of depression in boys. In addition, they found that two other factors – couple conflict and paternal involvement – did not play mediation roles.
The findings on the possible effects of paternal depression on offspring depression at age 18 years contrast with the potential influence of maternal depression. The link between maternal depression and depression in children “may be better explained by other factors, including the association of depression with mother-infant interaction, genetic loading, and transmission of negative cognitions,” said Dr. Gutiérrez-Galve and her associates.
They cited several limitations. One is that paternal depression was assessed not by a diagnostic interview but by self-report. As a strength of the study, Dr. Gutiérrez-Galve cited the large sample size. Also, the first measure of paternal depression was taken 18 years earlier than the offspring depression measure, making reverse causality implausible, they wrote.
The study was funded by the U.K. Medical Research Council/Wellcome Trust and the University Hospitals Bristol (England) National Health Service Foundation Trust. The University of Bristol provided core support for the Avon Longitudinal Study of Parents and Children. One of the study authors disclosed funding from the National Institute of Health Research U.K. and the LEGO Foundation. No other disclosures were reported.
SOURCE: Gutiérrez-Galve L et al. JAMA Psychiatry. 2018 Dec 26. doi: 10.1001/jamapsychiatry.2018.3667.
FROM JAMA PSYCHIATRY
Key clinical point: Offspring at age 18 years are more likely to be depressed if their fathers were depressed postnatally, and girls seem to face even more risk linked to conduct problems and maternal depression.
Major finding: Maternal depression at 8 months after birth and offspring’s conduct problems at age 42 months mediated the risk of depression at age 18 years in women whose fathers were depressed postnatally.
Study details: Analysis of data from the Avon Longitudinal Study of Parents and Children, a prospective study of 3,176 children born in 1991 and 1992 and their parents.
Disclosures: The study was funded by the U.K. Medical Research Council/Wellcome Trust and the University Hospitals Bristol (England) National Health Service Foundation Trust. The University of Bristol provides core support for the Avon Longitudinal Study of Parents and Children. One of the study authors disclosed funding from the National Institute of Health Research U.K. and the LEGO Foundation. No other disclosures were reported.
Source: Gutiérrez-Galve L et al. JAMA Psychiatry. 2018 Dec 26. doi: 10.1001/jamapsychiatry.2018.3667.