Mental Health

Women with endometriosis have a much higher risk of being diagnosed with several psychiatric disorders during the postpartum period according to an oral abstract presented at the American Society for Reproductive Medicine’s 2024 Scientific Congress and Expo in Denver, Colorado.

Researchers compared rates of postpartum depression, anxiety, mood disturbance (temporary low or anxious mood requiring no treatment), and obsessive-compulsive disorder (OCD) diagnoses among over 200 million adult women from 67 healthcare organizations who had a child between 2005 and 2023.

Within a year after giving birth, women with prepregnancy endometriosis were 25% more likely to be diagnosed with postpartum depression, 85% more likely to be diagnosed with postpartum mood disturbance, 44% more likely to be diagnosed with anxiety, and 1.26 times more likely to be diagnosed with OCD.

About 75% of women studied had no preexisting depression. This population had a 17% higher risk of receiving a postpartum depression diagnosis, a 95% higher risk of receiving an OCD diagnosis, a 72% higher risk of receiving a postpartum mood disturbance diagnosis, and a 38% risk of receiving an anxiety diagnosis.

Among women without preexisting depression, the risk increased by 64% for OCD, 42% for postpartum mood disturbance, and 25% for anxiety, while the risk for postpartum depression was negligible, indicating that women already experiencing depression likely have a higher baseline risk for worsening symptoms postpartum, said the study’s lead author Tina Yi-Jin Hsieh, MD, MPH, biomedical researcher at Harvard Medical School in Boston, Massachusetts.

“We think that because preexisting depression is the more dominant risk factor, it doesn’t really matter if you have another additional risk factor like endometriosis to really change the risk of postpartum depression,” said Hsieh.

Endometriosis is a debilitating condition in which tissue similar to uterine lining grows on the outside of the uterus, causing chronic pain and infertility. It affects between 6% and 10% of women worldwide and takes an average of between 4 and 11 years to be diagnosed. It has been linked to depression and anxiety disorders, yet the study authors say there’s little research examining its impact on women in the year after giving birth.

“Endometriosis is a complex condition that can affect both physical and mental health over much of a person’s life,” said Anna Modest, PhD, assistant professor of Obstetrics, Gynecology, and Reproductive Biology at Harvard Medical School and a study author. “Perinatal and maternal mental health can have a huge impact on children and their family — we need to better understand who is at risk for challenges in the postpartum period.”

“Most chronic medical illnesses, particularly those causing pain, have been shown to increase the risk of mood disorders,” said Ripal Shah, MD, MPH, clinical associate professor of Psychiatry and Behavioral Sciences at Stanford Medicine in California. Shah specializes in reproductive psychiatry and was not associated with the study.

“What’s interesting about endometriosis though is that genome-wide association studies have shown that there may be a genetic predisposition for some women to develop both endometriosis and a mood disorder,” said Shah.

A 2023 study suggested that endometriosis, anxiety, and depression may be connected through a shared genetic basis.

But the experience patients with endometriosis go through also lends itself to the development of mood disorders, said Daniel Ginn, DO, assistant clinical professor of Obstetrics and Gynecology at the David Geffen School of Medicine at the University of California, Los Angeles. Ginn specializes in the treatment of endometriosis and was not a part of the study.

Beyond postpartum depression, Ginn wasn’t surprised by the association of endometriosis with anxiety or OCD because what he hears from patients “on a daily basis is the telling of a history that has been hallmarked by not being listened to, not being believed, and not having symptoms managed well.”

As a result, he said many patients focus heavily on learning about their condition, coming into office visits with binders full of test results and information in an effort to understand and manage it themselves. This “does lead to a certain sense of a need to grasp for control because no one else is helping them [treat their condition effectively].”

He added: “I find it hard to believe that anxiety and OCD were preexisting of the conditions rather than the consequence of a long-term suboptimally managed disease.”

The authors reported no disclosures or sources of funding.

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

Women with endometriosis have a much higher risk of being diagnosed with several psychiatric disorders during the postpartum period according to an oral abstract presented at the American Society for Reproductive Medicine’s 2024 Scientific Congress and Expo in Denver, Colorado.

Researchers compared rates of postpartum depression, anxiety, mood disturbance (temporary low or anxious mood requiring no treatment), and obsessive-compulsive disorder (OCD) diagnoses among over 200 million adult women from 67 healthcare organizations who had a child between 2005 and 2023.

Within a year after giving birth, women with prepregnancy endometriosis were 25% more likely to be diagnosed with postpartum depression, 85% more likely to be diagnosed with postpartum mood disturbance, 44% more likely to be diagnosed with anxiety, and 1.26 times more likely to be diagnosed with OCD.

About 75% of women studied had no preexisting depression. This population had a 17% higher risk of receiving a postpartum depression diagnosis, a 95% higher risk of receiving an OCD diagnosis, a 72% higher risk of receiving a postpartum mood disturbance diagnosis, and a 38% risk of receiving an anxiety diagnosis.

Among women without preexisting depression, the risk increased by 64% for OCD, 42% for postpartum mood disturbance, and 25% for anxiety, while the risk for postpartum depression was negligible, indicating that women already experiencing depression likely have a higher baseline risk for worsening symptoms postpartum, said the study’s lead author Tina Yi-Jin Hsieh, MD, MPH, biomedical researcher at Harvard Medical School in Boston, Massachusetts.

“We think that because preexisting depression is the more dominant risk factor, it doesn’t really matter if you have another additional risk factor like endometriosis to really change the risk of postpartum depression,” said Hsieh.

Endometriosis is a debilitating condition in which tissue similar to uterine lining grows on the outside of the uterus, causing chronic pain and infertility. It affects between 6% and 10% of women worldwide and takes an average of between 4 and 11 years to be diagnosed. It has been linked to depression and anxiety disorders, yet the study authors say there’s little research examining its impact on women in the year after giving birth.

“Endometriosis is a complex condition that can affect both physical and mental health over much of a person’s life,” said Anna Modest, PhD, assistant professor of Obstetrics, Gynecology, and Reproductive Biology at Harvard Medical School and a study author. “Perinatal and maternal mental health can have a huge impact on children and their family — we need to better understand who is at risk for challenges in the postpartum period.”

“Most chronic medical illnesses, particularly those causing pain, have been shown to increase the risk of mood disorders,” said Ripal Shah, MD, MPH, clinical associate professor of Psychiatry and Behavioral Sciences at Stanford Medicine in California. Shah specializes in reproductive psychiatry and was not associated with the study.

“What’s interesting about endometriosis though is that genome-wide association studies have shown that there may be a genetic predisposition for some women to develop both endometriosis and a mood disorder,” said Shah.

A 2023 study suggested that endometriosis, anxiety, and depression may be connected through a shared genetic basis.

But the experience patients with endometriosis go through also lends itself to the development of mood disorders, said Daniel Ginn, DO, assistant clinical professor of Obstetrics and Gynecology at the David Geffen School of Medicine at the University of California, Los Angeles. Ginn specializes in the treatment of endometriosis and was not a part of the study.

Beyond postpartum depression, Ginn wasn’t surprised by the association of endometriosis with anxiety or OCD because what he hears from patients “on a daily basis is the telling of a history that has been hallmarked by not being listened to, not being believed, and not having symptoms managed well.”

As a result, he said many patients focus heavily on learning about their condition, coming into office visits with binders full of test results and information in an effort to understand and manage it themselves. This “does lead to a certain sense of a need to grasp for control because no one else is helping them [treat their condition effectively].”

He added: “I find it hard to believe that anxiety and OCD were preexisting of the conditions rather than the consequence of a long-term suboptimally managed disease.”

The authors reported no disclosures or sources of funding.

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

Women with endometriosis have a much higher risk of being diagnosed with several psychiatric disorders during the postpartum period according to an oral abstract presented at the American Society for Reproductive Medicine’s 2024 Scientific Congress and Expo in Denver, Colorado.

Researchers compared rates of postpartum depression, anxiety, mood disturbance (temporary low or anxious mood requiring no treatment), and obsessive-compulsive disorder (OCD) diagnoses among over 200 million adult women from 67 healthcare organizations who had a child between 2005 and 2023.

Within a year after giving birth, women with prepregnancy endometriosis were 25% more likely to be diagnosed with postpartum depression, 85% more likely to be diagnosed with postpartum mood disturbance, 44% more likely to be diagnosed with anxiety, and 1.26 times more likely to be diagnosed with OCD.

About 75% of women studied had no preexisting depression. This population had a 17% higher risk of receiving a postpartum depression diagnosis, a 95% higher risk of receiving an OCD diagnosis, a 72% higher risk of receiving a postpartum mood disturbance diagnosis, and a 38% risk of receiving an anxiety diagnosis.

Among women without preexisting depression, the risk increased by 64% for OCD, 42% for postpartum mood disturbance, and 25% for anxiety, while the risk for postpartum depression was negligible, indicating that women already experiencing depression likely have a higher baseline risk for worsening symptoms postpartum, said the study’s lead author Tina Yi-Jin Hsieh, MD, MPH, biomedical researcher at Harvard Medical School in Boston, Massachusetts.

“We think that because preexisting depression is the more dominant risk factor, it doesn’t really matter if you have another additional risk factor like endometriosis to really change the risk of postpartum depression,” said Hsieh.

Endometriosis is a debilitating condition in which tissue similar to uterine lining grows on the outside of the uterus, causing chronic pain and infertility. It affects between 6% and 10% of women worldwide and takes an average of between 4 and 11 years to be diagnosed. It has been linked to depression and anxiety disorders, yet the study authors say there’s little research examining its impact on women in the year after giving birth.

“Endometriosis is a complex condition that can affect both physical and mental health over much of a person’s life,” said Anna Modest, PhD, assistant professor of Obstetrics, Gynecology, and Reproductive Biology at Harvard Medical School and a study author. “Perinatal and maternal mental health can have a huge impact on children and their family — we need to better understand who is at risk for challenges in the postpartum period.”

“Most chronic medical illnesses, particularly those causing pain, have been shown to increase the risk of mood disorders,” said Ripal Shah, MD, MPH, clinical associate professor of Psychiatry and Behavioral Sciences at Stanford Medicine in California. Shah specializes in reproductive psychiatry and was not associated with the study.

“What’s interesting about endometriosis though is that genome-wide association studies have shown that there may be a genetic predisposition for some women to develop both endometriosis and a mood disorder,” said Shah.

A 2023 study suggested that endometriosis, anxiety, and depression may be connected through a shared genetic basis.

But the experience patients with endometriosis go through also lends itself to the development of mood disorders, said Daniel Ginn, DO, assistant clinical professor of Obstetrics and Gynecology at the David Geffen School of Medicine at the University of California, Los Angeles. Ginn specializes in the treatment of endometriosis and was not a part of the study.

Beyond postpartum depression, Ginn wasn’t surprised by the association of endometriosis with anxiety or OCD because what he hears from patients “on a daily basis is the telling of a history that has been hallmarked by not being listened to, not being believed, and not having symptoms managed well.”

As a result, he said many patients focus heavily on learning about their condition, coming into office visits with binders full of test results and information in an effort to understand and manage it themselves. This “does lead to a certain sense of a need to grasp for control because no one else is helping them [treat their condition effectively].”

He added: “I find it hard to believe that anxiety and OCD were preexisting of the conditions rather than the consequence of a long-term suboptimally managed disease.”

The authors reported no disclosures or sources of funding.

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

Podcasts, websites, and large “Parenting” sections in bookstores testify to the large demand for parent guidance and support, but also to the fact that there is no one universally accepted guidebook, such as Benjamin Spock provided for parents almost 80 years ago with Baby and Child Care. The Positive Parenting Program — “Triple P” — is a curriculum for parents that focuses on five areas of parental competence and can be applied at different levels of intensity to address different needs, from preventing common problems and promoting healthy development to addressing substantial child behavioral problems.

We will describe the basic components of this curriculum so that you may determine whether it might be useful to the families in your practice. Then we will expand upon the domains that have proven essential for parents to nurture healthy development in their children. Even if you do not have the time or resources to provide the full Triple P curriculum, you can offer these principles directly to parents and decide when to refer them to access more formal parent training and coaching.

Triple P was developed by psychologist Matthew Sanders, to “promote positive, caring relationships between parents and their children and to help parents develop effective management strategies for dealing with a variety of childhood behavior problems and common developmental issues” as his doctoral project in Australia in the 1980s. Research in the 1990s suggested substantial efficacy, and it was packaged for broader adoption in the early 2000s. It is a tiered approach, meaning there is content for universal education (level 1), up through more intensive, specialized, and individualized content to be delivered in group or individual settings focused on building specific skills or addressing select problems. It was originally developed for the parents of 0- to 11-year-old children, with additional curricula for parents of teenagers created later. It always is delivered to parents only, through a mix of video and reading, or in-person groups or individual coaching. While the universal education resources are available for free to families of children under 12 in Australia, resources and training are available for a fee in the United states (triplep.net). Research has demonstrated considerable efficacy at reducing some of the common behavioral problems of childhood, improving parental confidence and family harmony, and decreasing rates of parental depression. It has even demonstrated efficacy in reducing the incidence of child maltreatment.

• 1. Creating a safe and engaging environment for children
• 2. Providing a positive learning environment for children
• 3. Assertive discipline
• 4. Having realistic expectations
• 5. Parental self-care.

The educational materials and more intensive parent trainings are all focused on developing knowledge and skills in the parents that will promote a positive relationship with their children, teach the children new skills while encouraging desirable behaviors, and managing problematic behaviors. The training happens with written or video scenarios, up through individualized skill coaching with homework and direct feedback from trained clinicians. While information about the universally helpful knowledge and skills can be found online or accessed through some local programs in the United States, the higher levels of intervention are less consistently available. You should explore what is available in your community, but even if you don’t have the resources for your own training, you are already offering parent guidance at every visit.

Practical Strategies

Below are practical strategies to offer parents the knowledge and support that are essential to “positive parenting,” so they may nurture their children’s healthiest development.

Attunement: Attunement is simply a parent’s ability to know who their child is and where their child is at any given time. This covers an appreciation of the child’s temperament, style, interests, strengths, and vulnerabilities. Where their child is at includes being able to read that particular child’s cues: Are they hungry? Sleepy? Sick? Frustrated? Parents are the experts on their children, but their children are also always changing. You can help the parents in your practice be intentional about being attuned to their children, so they can always be deepening their understanding of who their children are (becoming) and where they are at in any given moment. This requires protecting regular, unstructured time when they can give their children their full attention: reading, doing an art project, practicing music, or basketball. Schedules are often packed with work and school, driving between many structured activities. Reassure the parents in your practice that time spent in play is just as important. When a parent is present, attentive, and curious, asking questions, learning about the child’s thoughts, feelings and ideas, they are doing some of the most essential (and delightful) work of raising children.

Positive Environment: A “positive environment” is child-centered, with access to age-appropriate activities of a wide range. Offering first-time parents written resources about child development and age-appropriate games, books, and activities is an easy way to support positive parenting. A positive environment also has structure and routines, so children can play and explore with the comfort of knowing what to expect and what is expected of them. Do they have a regular bedtime and bedtime routines? Do they consistently eat dinner together and clean up as a family? Do they have reliable unstructured time together, maybe playing board games or kickball after dinner? These varying but predictable routines provide opportunities for children to practice helping, following through, sharing, and tolerating frustration or failure, and they give parents low-stakes opportunities to offer praise for their effort, compassion when they struggle, and affection for no reason at all. They lower the chances of parent-child interactions being predominantly reactive, demanding, pleading, or angry.

Effective Discipline: A positive environment includes reasonable and consistent consequences for rule breaking and poor behavior, and an essential part of predictability includes clear ground rules for what is expected of children at home, around chores, getting ready for school and bedtime, and their behavior. Parents need to agree on and children should understand what the consequences will be for breaking rules. Parents should also have a clear strategy for consistently and calmly enforcing rules. This is not easy, but is just as important as affection and play. If parents are struggling with discipline, it is worth asking for a specific example to learn about where the trouble lies. Are parents not on the same page? Are they worried about their children’s distress? Do they lose their temper and the matter escalates? Clear ground rules and a game plan can help them to stay calm instead of resorting to pleading and yelling. Speaking with them about the value of planning and communicating about these expectations and rules during a quiet time, not in the midst of conflict, might be enough to help them with effective discipline. Others may need more support. Books like 123 Magic with more detail on how to manage time outs can be helpful. For those parents who are managing greater difficulty, a referral to parent coaching (with a modality such as Triple P, Parent-Child Interaction Training or Collaborative Problem Solving) may be needed.

Parental Well-Being: Being aligned with one’s spouse (or other caregiver) in how to manage challenging child behaviors is essential to a healthy relationship, and overall well-being is an essential ingredient in creating a nurturing, positive environment at home. How is the parents’ communication with each other overall? Do they have time together that is not focused on the children? Does each parent have time for outside interests or hobbies? How about other important relationships? Do they prioritize their own sleep, regular exercise, and good nutrition? It can be powerful if they plan family activities that are centered on their own passions and interests as well as their children’s. It is powerful for parents to hear from you that when they protect some of their time and energy to simply care for their own health and well-being, they are building a positive environment for their children, both in how they will show up for their family and in what they model.
 

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

Suggested Reading

Sanders MR et al. The Development and Dissemination of the Triple P – Positive Parenting Program: A Multilevel Evidence-Based System of Parenting and Family Support. Prev Sci. 2002 Sep;3(3):173-89. doi: 10.1023/a:1019942516231.

Sanders MR. The Triple P System of Evidence-Based Parenting Support: Past, Present, and Future Directions. Clin Child Fam Psychol Rev. 2023 Dec;26(4):880-903. doi: 10.1007/s10567-023-00441-8.

Podcasts, websites, and large “Parenting” sections in bookstores testify to the large demand for parent guidance and support, but also to the fact that there is no one universally accepted guidebook, such as Benjamin Spock provided for parents almost 80 years ago with Baby and Child Care. The Positive Parenting Program — “Triple P” — is a curriculum for parents that focuses on five areas of parental competence and can be applied at different levels of intensity to address different needs, from preventing common problems and promoting healthy development to addressing substantial child behavioral problems.

We will describe the basic components of this curriculum so that you may determine whether it might be useful to the families in your practice. Then we will expand upon the domains that have proven essential for parents to nurture healthy development in their children. Even if you do not have the time or resources to provide the full Triple P curriculum, you can offer these principles directly to parents and decide when to refer them to access more formal parent training and coaching.

Triple P was developed by psychologist Matthew Sanders, to “promote positive, caring relationships between parents and their children and to help parents develop effective management strategies for dealing with a variety of childhood behavior problems and common developmental issues” as his doctoral project in Australia in the 1980s. Research in the 1990s suggested substantial efficacy, and it was packaged for broader adoption in the early 2000s. It is a tiered approach, meaning there is content for universal education (level 1), up through more intensive, specialized, and individualized content to be delivered in group or individual settings focused on building specific skills or addressing select problems. It was originally developed for the parents of 0- to 11-year-old children, with additional curricula for parents of teenagers created later. It always is delivered to parents only, through a mix of video and reading, or in-person groups or individual coaching. While the universal education resources are available for free to families of children under 12 in Australia, resources and training are available for a fee in the United states (triplep.net). Research has demonstrated considerable efficacy at reducing some of the common behavioral problems of childhood, improving parental confidence and family harmony, and decreasing rates of parental depression. It has even demonstrated efficacy in reducing the incidence of child maltreatment.

• 1. Creating a safe and engaging environment for children
• 2. Providing a positive learning environment for children
• 3. Assertive discipline
• 4. Having realistic expectations
• 5. Parental self-care.

The educational materials and more intensive parent trainings are all focused on developing knowledge and skills in the parents that will promote a positive relationship with their children, teach the children new skills while encouraging desirable behaviors, and managing problematic behaviors. The training happens with written or video scenarios, up through individualized skill coaching with homework and direct feedback from trained clinicians. While information about the universally helpful knowledge and skills can be found online or accessed through some local programs in the United States, the higher levels of intervention are less consistently available. You should explore what is available in your community, but even if you don’t have the resources for your own training, you are already offering parent guidance at every visit.

Practical Strategies

Below are practical strategies to offer parents the knowledge and support that are essential to “positive parenting,” so they may nurture their children’s healthiest development.

Attunement: Attunement is simply a parent’s ability to know who their child is and where their child is at any given time. This covers an appreciation of the child’s temperament, style, interests, strengths, and vulnerabilities. Where their child is at includes being able to read that particular child’s cues: Are they hungry? Sleepy? Sick? Frustrated? Parents are the experts on their children, but their children are also always changing. You can help the parents in your practice be intentional about being attuned to their children, so they can always be deepening their understanding of who their children are (becoming) and where they are at in any given moment. This requires protecting regular, unstructured time when they can give their children their full attention: reading, doing an art project, practicing music, or basketball. Schedules are often packed with work and school, driving between many structured activities. Reassure the parents in your practice that time spent in play is just as important. When a parent is present, attentive, and curious, asking questions, learning about the child’s thoughts, feelings and ideas, they are doing some of the most essential (and delightful) work of raising children.

Positive Environment: A “positive environment” is child-centered, with access to age-appropriate activities of a wide range. Offering first-time parents written resources about child development and age-appropriate games, books, and activities is an easy way to support positive parenting. A positive environment also has structure and routines, so children can play and explore with the comfort of knowing what to expect and what is expected of them. Do they have a regular bedtime and bedtime routines? Do they consistently eat dinner together and clean up as a family? Do they have reliable unstructured time together, maybe playing board games or kickball after dinner? These varying but predictable routines provide opportunities for children to practice helping, following through, sharing, and tolerating frustration or failure, and they give parents low-stakes opportunities to offer praise for their effort, compassion when they struggle, and affection for no reason at all. They lower the chances of parent-child interactions being predominantly reactive, demanding, pleading, or angry.

Effective Discipline: A positive environment includes reasonable and consistent consequences for rule breaking and poor behavior, and an essential part of predictability includes clear ground rules for what is expected of children at home, around chores, getting ready for school and bedtime, and their behavior. Parents need to agree on and children should understand what the consequences will be for breaking rules. Parents should also have a clear strategy for consistently and calmly enforcing rules. This is not easy, but is just as important as affection and play. If parents are struggling with discipline, it is worth asking for a specific example to learn about where the trouble lies. Are parents not on the same page? Are they worried about their children’s distress? Do they lose their temper and the matter escalates? Clear ground rules and a game plan can help them to stay calm instead of resorting to pleading and yelling. Speaking with them about the value of planning and communicating about these expectations and rules during a quiet time, not in the midst of conflict, might be enough to help them with effective discipline. Others may need more support. Books like 123 Magic with more detail on how to manage time outs can be helpful. For those parents who are managing greater difficulty, a referral to parent coaching (with a modality such as Triple P, Parent-Child Interaction Training or Collaborative Problem Solving) may be needed.

Parental Well-Being: Being aligned with one’s spouse (or other caregiver) in how to manage challenging child behaviors is essential to a healthy relationship, and overall well-being is an essential ingredient in creating a nurturing, positive environment at home. How is the parents’ communication with each other overall? Do they have time together that is not focused on the children? Does each parent have time for outside interests or hobbies? How about other important relationships? Do they prioritize their own sleep, regular exercise, and good nutrition? It can be powerful if they plan family activities that are centered on their own passions and interests as well as their children’s. It is powerful for parents to hear from you that when they protect some of their time and energy to simply care for their own health and well-being, they are building a positive environment for their children, both in how they will show up for their family and in what they model.
 

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

Suggested Reading

Sanders MR et al. The Development and Dissemination of the Triple P – Positive Parenting Program: A Multilevel Evidence-Based System of Parenting and Family Support. Prev Sci. 2002 Sep;3(3):173-89. doi: 10.1023/a:1019942516231.

Sanders MR. The Triple P System of Evidence-Based Parenting Support: Past, Present, and Future Directions. Clin Child Fam Psychol Rev. 2023 Dec;26(4):880-903. doi: 10.1007/s10567-023-00441-8.

Podcasts, websites, and large “Parenting” sections in bookstores testify to the large demand for parent guidance and support, but also to the fact that there is no one universally accepted guidebook, such as Benjamin Spock provided for parents almost 80 years ago with Baby and Child Care. The Positive Parenting Program — “Triple P” — is a curriculum for parents that focuses on five areas of parental competence and can be applied at different levels of intensity to address different needs, from preventing common problems and promoting healthy development to addressing substantial child behavioral problems.

We will describe the basic components of this curriculum so that you may determine whether it might be useful to the families in your practice. Then we will expand upon the domains that have proven essential for parents to nurture healthy development in their children. Even if you do not have the time or resources to provide the full Triple P curriculum, you can offer these principles directly to parents and decide when to refer them to access more formal parent training and coaching.

Triple P was developed by psychologist Matthew Sanders, to “promote positive, caring relationships between parents and their children and to help parents develop effective management strategies for dealing with a variety of childhood behavior problems and common developmental issues” as his doctoral project in Australia in the 1980s. Research in the 1990s suggested substantial efficacy, and it was packaged for broader adoption in the early 2000s. It is a tiered approach, meaning there is content for universal education (level 1), up through more intensive, specialized, and individualized content to be delivered in group or individual settings focused on building specific skills or addressing select problems. It was originally developed for the parents of 0- to 11-year-old children, with additional curricula for parents of teenagers created later. It always is delivered to parents only, through a mix of video and reading, or in-person groups or individual coaching. While the universal education resources are available for free to families of children under 12 in Australia, resources and training are available for a fee in the United states (triplep.net). Research has demonstrated considerable efficacy at reducing some of the common behavioral problems of childhood, improving parental confidence and family harmony, and decreasing rates of parental depression. It has even demonstrated efficacy in reducing the incidence of child maltreatment.

• 1. Creating a safe and engaging environment for children
• 2. Providing a positive learning environment for children
• 3. Assertive discipline
• 4. Having realistic expectations
• 5. Parental self-care.

The educational materials and more intensive parent trainings are all focused on developing knowledge and skills in the parents that will promote a positive relationship with their children, teach the children new skills while encouraging desirable behaviors, and managing problematic behaviors. The training happens with written or video scenarios, up through individualized skill coaching with homework and direct feedback from trained clinicians. While information about the universally helpful knowledge and skills can be found online or accessed through some local programs in the United States, the higher levels of intervention are less consistently available. You should explore what is available in your community, but even if you don’t have the resources for your own training, you are already offering parent guidance at every visit.

Practical Strategies

Below are practical strategies to offer parents the knowledge and support that are essential to “positive parenting,” so they may nurture their children’s healthiest development.

Attunement: Attunement is simply a parent’s ability to know who their child is and where their child is at any given time. This covers an appreciation of the child’s temperament, style, interests, strengths, and vulnerabilities. Where their child is at includes being able to read that particular child’s cues: Are they hungry? Sleepy? Sick? Frustrated? Parents are the experts on their children, but their children are also always changing. You can help the parents in your practice be intentional about being attuned to their children, so they can always be deepening their understanding of who their children are (becoming) and where they are at in any given moment. This requires protecting regular, unstructured time when they can give their children their full attention: reading, doing an art project, practicing music, or basketball. Schedules are often packed with work and school, driving between many structured activities. Reassure the parents in your practice that time spent in play is just as important. When a parent is present, attentive, and curious, asking questions, learning about the child’s thoughts, feelings and ideas, they are doing some of the most essential (and delightful) work of raising children.

Positive Environment: A “positive environment” is child-centered, with access to age-appropriate activities of a wide range. Offering first-time parents written resources about child development and age-appropriate games, books, and activities is an easy way to support positive parenting. A positive environment also has structure and routines, so children can play and explore with the comfort of knowing what to expect and what is expected of them. Do they have a regular bedtime and bedtime routines? Do they consistently eat dinner together and clean up as a family? Do they have reliable unstructured time together, maybe playing board games or kickball after dinner? These varying but predictable routines provide opportunities for children to practice helping, following through, sharing, and tolerating frustration or failure, and they give parents low-stakes opportunities to offer praise for their effort, compassion when they struggle, and affection for no reason at all. They lower the chances of parent-child interactions being predominantly reactive, demanding, pleading, or angry.

Effective Discipline: A positive environment includes reasonable and consistent consequences for rule breaking and poor behavior, and an essential part of predictability includes clear ground rules for what is expected of children at home, around chores, getting ready for school and bedtime, and their behavior. Parents need to agree on and children should understand what the consequences will be for breaking rules. Parents should also have a clear strategy for consistently and calmly enforcing rules. This is not easy, but is just as important as affection and play. If parents are struggling with discipline, it is worth asking for a specific example to learn about where the trouble lies. Are parents not on the same page? Are they worried about their children’s distress? Do they lose their temper and the matter escalates? Clear ground rules and a game plan can help them to stay calm instead of resorting to pleading and yelling. Speaking with them about the value of planning and communicating about these expectations and rules during a quiet time, not in the midst of conflict, might be enough to help them with effective discipline. Others may need more support. Books like 123 Magic with more detail on how to manage time outs can be helpful. For those parents who are managing greater difficulty, a referral to parent coaching (with a modality such as Triple P, Parent-Child Interaction Training or Collaborative Problem Solving) may be needed.

Parental Well-Being: Being aligned with one’s spouse (or other caregiver) in how to manage challenging child behaviors is essential to a healthy relationship, and overall well-being is an essential ingredient in creating a nurturing, positive environment at home. How is the parents’ communication with each other overall? Do they have time together that is not focused on the children? Does each parent have time for outside interests or hobbies? How about other important relationships? Do they prioritize their own sleep, regular exercise, and good nutrition? It can be powerful if they plan family activities that are centered on their own passions and interests as well as their children’s. It is powerful for parents to hear from you that when they protect some of their time and energy to simply care for their own health and well-being, they are building a positive environment for their children, both in how they will show up for their family and in what they model.
 

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

Suggested Reading

Sanders MR et al. The Development and Dissemination of the Triple P – Positive Parenting Program: A Multilevel Evidence-Based System of Parenting and Family Support. Prev Sci. 2002 Sep;3(3):173-89. doi: 10.1023/a:1019942516231.

Sanders MR. The Triple P System of Evidence-Based Parenting Support: Past, Present, and Future Directions. Clin Child Fam Psychol Rev. 2023 Dec;26(4):880-903. doi: 10.1007/s10567-023-00441-8.

TOPLINE:

Postpartum exercise reduces the severity of depressive and anxiety symptoms. Initiating exercise within 12 weeks post partum is linked to greater reductions in depressive symptoms.

METHODOLOGY:

• Researchers conducted a systematic review and meta-analysis including 35 studies with a total of 4072 participants.
• The review included randomized controlled trials and nonrandomized interventions examining the impact of postpartum exercise on depression and anxiety.
• Participants were postpartum individuals within the first year after childbirth, with interventions including various types of exercise.
• Data sources included online databases with data up to January 2024, reference lists, and hand searches.
• The Grading of Recommendations, Assessment, Development, and Evaluation framework was used to assess the certainty of evidence.

TAKEAWAY:

• Postpartum exercise-only interventions resulted in a moderate reduction in the severity of depressive symptoms (standardized mean difference [SMD], –0.52; 95% CI, –0.80 to –0.24).
• Exercise-only interventions were associated with a small reduction in the severity of anxiety symptoms (SMD, –0.25; 95% CI, –0.43 to –0.08).
• Initiating exercise within 12 weeks post partum was associated with a greater reduction in depressive symptoms, compared with starting later.
• Postpartum exercise was associated with a 45% reduction in the odds of developing depression (odds ratio, 0.55; 95% CI, 0.32-0.95).

IN PRACTICE:

“Further investigation should aim to investigate the effects of postpartum exercise in individuals who experienced perinatal complications and in those who had limitations to exercise during pregnancy. Additionally, more investigation is required to address the possible lasting effects of postpartum exercise on maternal mental health as there were very limited studies reporting on this outcome,” the authors of the study wrote.

SOURCE:

This study was led by Margie H. Davenport, University of Alberta in Edmonton, Canada. It was published online in British Journal of Sports Medicine.

LIMITATIONS:

This study’s limitations included high heterogeneity among included studies, small sample sizes in some studies, and the combination of exercise with other interventions in some cases. These factors may have affected the generalizability and precision of the findings.

DISCLOSURES:

This study was funded by the Christenson Professorship in Active Healthy Living. Davenport is funded by a Christenson Professorship in Active Healthy Living. One coauthor is funded by the Université du Québec à Trois-Rivières research chair in physical activity and maternal and neonatal health. No relevant conflicts of interest were disclosed by the authors.

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

TOPLINE:

Postpartum exercise reduces the severity of depressive and anxiety symptoms. Initiating exercise within 12 weeks post partum is linked to greater reductions in depressive symptoms.

METHODOLOGY:

• Researchers conducted a systematic review and meta-analysis including 35 studies with a total of 4072 participants.
• The review included randomized controlled trials and nonrandomized interventions examining the impact of postpartum exercise on depression and anxiety.
• Participants were postpartum individuals within the first year after childbirth, with interventions including various types of exercise.
• Data sources included online databases with data up to January 2024, reference lists, and hand searches.
• The Grading of Recommendations, Assessment, Development, and Evaluation framework was used to assess the certainty of evidence.

TAKEAWAY:

• Postpartum exercise-only interventions resulted in a moderate reduction in the severity of depressive symptoms (standardized mean difference [SMD], –0.52; 95% CI, –0.80 to –0.24).
• Exercise-only interventions were associated with a small reduction in the severity of anxiety symptoms (SMD, –0.25; 95% CI, –0.43 to –0.08).
• Initiating exercise within 12 weeks post partum was associated with a greater reduction in depressive symptoms, compared with starting later.
• Postpartum exercise was associated with a 45% reduction in the odds of developing depression (odds ratio, 0.55; 95% CI, 0.32-0.95).

IN PRACTICE:

“Further investigation should aim to investigate the effects of postpartum exercise in individuals who experienced perinatal complications and in those who had limitations to exercise during pregnancy. Additionally, more investigation is required to address the possible lasting effects of postpartum exercise on maternal mental health as there were very limited studies reporting on this outcome,” the authors of the study wrote.

SOURCE:

This study was led by Margie H. Davenport, University of Alberta in Edmonton, Canada. It was published online in British Journal of Sports Medicine.

LIMITATIONS:

This study’s limitations included high heterogeneity among included studies, small sample sizes in some studies, and the combination of exercise with other interventions in some cases. These factors may have affected the generalizability and precision of the findings.

DISCLOSURES:

This study was funded by the Christenson Professorship in Active Healthy Living. Davenport is funded by a Christenson Professorship in Active Healthy Living. One coauthor is funded by the Université du Québec à Trois-Rivières research chair in physical activity and maternal and neonatal health. No relevant conflicts of interest were disclosed by the authors.

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

TOPLINE:

Postpartum exercise reduces the severity of depressive and anxiety symptoms. Initiating exercise within 12 weeks post partum is linked to greater reductions in depressive symptoms.

METHODOLOGY:

• Researchers conducted a systematic review and meta-analysis including 35 studies with a total of 4072 participants.
• The review included randomized controlled trials and nonrandomized interventions examining the impact of postpartum exercise on depression and anxiety.
• Participants were postpartum individuals within the first year after childbirth, with interventions including various types of exercise.
• Data sources included online databases with data up to January 2024, reference lists, and hand searches.
• The Grading of Recommendations, Assessment, Development, and Evaluation framework was used to assess the certainty of evidence.

TAKEAWAY:

• Postpartum exercise-only interventions resulted in a moderate reduction in the severity of depressive symptoms (standardized mean difference [SMD], –0.52; 95% CI, –0.80 to –0.24).
• Exercise-only interventions were associated with a small reduction in the severity of anxiety symptoms (SMD, –0.25; 95% CI, –0.43 to –0.08).
• Initiating exercise within 12 weeks post partum was associated with a greater reduction in depressive symptoms, compared with starting later.
• Postpartum exercise was associated with a 45% reduction in the odds of developing depression (odds ratio, 0.55; 95% CI, 0.32-0.95).

IN PRACTICE:

“Further investigation should aim to investigate the effects of postpartum exercise in individuals who experienced perinatal complications and in those who had limitations to exercise during pregnancy. Additionally, more investigation is required to address the possible lasting effects of postpartum exercise on maternal mental health as there were very limited studies reporting on this outcome,” the authors of the study wrote.

SOURCE:

This study was led by Margie H. Davenport, University of Alberta in Edmonton, Canada. It was published online in British Journal of Sports Medicine.

LIMITATIONS:

This study’s limitations included high heterogeneity among included studies, small sample sizes in some studies, and the combination of exercise with other interventions in some cases. These factors may have affected the generalizability and precision of the findings.

DISCLOSURES:

This study was funded by the Christenson Professorship in Active Healthy Living. Davenport is funded by a Christenson Professorship in Active Healthy Living. One coauthor is funded by the Université du Québec à Trois-Rivières research chair in physical activity and maternal and neonatal health. No relevant conflicts of interest were disclosed by the authors.

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

SAN ANTONIO — Several types of anti-obesity medications (AOMs), including glucagon-like peptide 1s (GLP-1s), are associated with decreased alcohol use, new research suggests.

The findings, from surveys of more than 14,000 participants in WeightWatchers’ telehealth weight management program, were presented on November 6 at the Obesity Society’s Obesity Week 2024 meeting by the company’s Chief Nutrition Officer, Michelle I. Cardel, PhD, RD, based in Gainesville, Florida.

Similar reductions in alcohol consumption were seen in people taking different classes of AOMs, suggesting “an additional mechanism by which AOMs reduce energy intake, and also signal a potential role for these medications to reduce alcohol use,” Cardel said, adding “Clinicians treating individuals for obesity may consider anti-obesity medications particularly among those who report higher alcohol intake.”

Asked to comment, session moderator and obesity researcher Joseph A. Skelton, MD, professor of pediatrics at Wake Forest University School of Medicine, Winston-Salem, North Carolina, said, “I think there are some overlapping pathways there, possibly a reward system or something like that in the brain. I don’t think we know exactly what the end result will be as a potential use of the medications. But there’s a signal that needs to be investigated more.”

Cardel noted that there was one previous large cohort study finding that semaglutide was associated with a lower risk for alcohol use disorder, and another study that analyzed social media threads of people saying they’d quit drinking after starting a GLP-1 drug. But this new study is the first to examine the relationship with different classes of AOMs and to quantify the amount of alcohol consumed.
 

About Half Reported Reduced Alcohol Consumption, Regardless the AOM Class

The study included 14,053 WeightWatchers’ telehealth program participants who initiated an AOM between January 2022 and August 2023 and refilled the same AOM between October and November 2023. Those who had previously used AOMs before coming to the program or who had undergone bariatric surgery were excluded.

Participants had a mean age of 43 years, were 86% women, were 60% White, and had a mean body mass index of 36. They were surveyed about their weekly alcohol use prior to AOM initiation and again at the time of AOM refill.

At baseline, they were divided into categories of 0 (no alcohol use; n = 6562), category 1 (one to three drinks for women and one to six for men; n = 5948), category 2 (4-6 for women and 7-14 for men; n = 1216), and category 3 (≥ 7 for women and ≥ 15 for men; n = 327).

At the second survey, 24% reported decreased drinking after starting an AOM, 71% reported no change, and 4% reported increased drinking (P < .0001). But when just the 7491 individuals who reported any alcohol use at baseline were included, 45% reported decreased drinking after starting an AOM, 52% reported no change, and only 2% reported increased drinking.

The decrease in drinking with AOM use rose with greater alcohol use at baseline, from 37% for category 1, 76% for category 2, and 91% for category 3. The proportions reporting increased drinking were just 3%, 1%, and 0%, respectively. The adjusted odds ratios (ORs) for decreasing drinking were 5.97 for category 2 (P < .0001) and 19.18 for category 3 (P < .0001) vs category 1.

The proportions reporting reduced drinking were similar across AOM classes: 51% for metformin, 46% for bupropion/naltrexone, 46% for first-generation GLP-1s (Saxenda, Trulicity, and Victoza), and 45% for the second-generation GLP-1 drugs (Mounjaro, Ozempic, Rybelsus, Wegovy, and Zepbound). All were statistically significant at P < .0001.

The highest proportion reporting increased drinking was 4% for bupropion/naltrexone. Compared with women, men were significantly more likely to report decreased drinking with AOM use (adjusted OR, 0.74; P < .001), but there were no differences by race/ethnicity or age.

Compared with those who had overweight, those in obesity classes I, II, and III were all more likely to decrease drinking with AOM use, with adjusted ORs of 1.26 (P = .0045), 1.49 (P < .001), and 1.63 (P < .001), respectively.
 

Mechanisms Appear Both Biological and Behavioral

During the discussion, Cardel said that qualitative assessments with participants suggest that there are at least two mechanisms behind this phenomenon: One biological and the other intentional.

“What we hear from them is twofold, one, particularly amongst those folks on GLP-1 medications, we’re hearing that physiologically, they feel different with the medications, that their cravings for alcohol are decreased, and that when they do choose to drink that there’s often a very much a negative reinforcement ... I’ve had a patient tell me, ‘I used to be able to have two or three margaritas, and maybe I didn’t feel like the best I’d ever felt in the morning, but I was okay. And now if I have two or three drinks, I will be throwing up for 5 hours, and it’s the worst hangover I’ve ever had in my life.’ And so it very much creates that negative reinforcement loop.”

But at the same time, “folks who are coming to us and seeking these medications are very much on a on a health-based journey. That’s what they tell us. The majority of our patients are there to improve their health. We rarely hear about the vanity or aesthetic part of it. So perhaps it’s that, in terms of trying to improve their health, they’re also trying to reduce their alcohol consumption, either just for their overall health or also as a means of trying to decrease their overall calorie consumption.”

In future research, Cardel said, “we want to examine whether the anti-obesity medications are more successful at reducing alcohol use compared to non-pharmacological weight management interventions, as we know that people often reduce their alcohol consumption on a weight management journey as a means of prioritizing their calories for food and decreasing the calories from alcohol.”

Cardel and all the study coauthors were employees and shareholders at WeightWatchers at the time the research was conducted. Skelton is editor in chief of the journal Childhood Obesity.
 

A version of this article appeared on Medscape.com.

SAN ANTONIO — Several types of anti-obesity medications (AOMs), including glucagon-like peptide 1s (GLP-1s), are associated with decreased alcohol use, new research suggests.

The findings, from surveys of more than 14,000 participants in WeightWatchers’ telehealth weight management program, were presented on November 6 at the Obesity Society’s Obesity Week 2024 meeting by the company’s Chief Nutrition Officer, Michelle I. Cardel, PhD, RD, based in Gainesville, Florida.

Similar reductions in alcohol consumption were seen in people taking different classes of AOMs, suggesting “an additional mechanism by which AOMs reduce energy intake, and also signal a potential role for these medications to reduce alcohol use,” Cardel said, adding “Clinicians treating individuals for obesity may consider anti-obesity medications particularly among those who report higher alcohol intake.”

Asked to comment, session moderator and obesity researcher Joseph A. Skelton, MD, professor of pediatrics at Wake Forest University School of Medicine, Winston-Salem, North Carolina, said, “I think there are some overlapping pathways there, possibly a reward system or something like that in the brain. I don’t think we know exactly what the end result will be as a potential use of the medications. But there’s a signal that needs to be investigated more.”

Cardel noted that there was one previous large cohort study finding that semaglutide was associated with a lower risk for alcohol use disorder, and another study that analyzed social media threads of people saying they’d quit drinking after starting a GLP-1 drug. But this new study is the first to examine the relationship with different classes of AOMs and to quantify the amount of alcohol consumed.
 

About Half Reported Reduced Alcohol Consumption, Regardless the AOM Class

The study included 14,053 WeightWatchers’ telehealth program participants who initiated an AOM between January 2022 and August 2023 and refilled the same AOM between October and November 2023. Those who had previously used AOMs before coming to the program or who had undergone bariatric surgery were excluded.

Participants had a mean age of 43 years, were 86% women, were 60% White, and had a mean body mass index of 36. They were surveyed about their weekly alcohol use prior to AOM initiation and again at the time of AOM refill.

At baseline, they were divided into categories of 0 (no alcohol use; n = 6562), category 1 (one to three drinks for women and one to six for men; n = 5948), category 2 (4-6 for women and 7-14 for men; n = 1216), and category 3 (≥ 7 for women and ≥ 15 for men; n = 327).

At the second survey, 24% reported decreased drinking after starting an AOM, 71% reported no change, and 4% reported increased drinking (P < .0001). But when just the 7491 individuals who reported any alcohol use at baseline were included, 45% reported decreased drinking after starting an AOM, 52% reported no change, and only 2% reported increased drinking.

The decrease in drinking with AOM use rose with greater alcohol use at baseline, from 37% for category 1, 76% for category 2, and 91% for category 3. The proportions reporting increased drinking were just 3%, 1%, and 0%, respectively. The adjusted odds ratios (ORs) for decreasing drinking were 5.97 for category 2 (P < .0001) and 19.18 for category 3 (P < .0001) vs category 1.

The proportions reporting reduced drinking were similar across AOM classes: 51% for metformin, 46% for bupropion/naltrexone, 46% for first-generation GLP-1s (Saxenda, Trulicity, and Victoza), and 45% for the second-generation GLP-1 drugs (Mounjaro, Ozempic, Rybelsus, Wegovy, and Zepbound). All were statistically significant at P < .0001.

The highest proportion reporting increased drinking was 4% for bupropion/naltrexone. Compared with women, men were significantly more likely to report decreased drinking with AOM use (adjusted OR, 0.74; P < .001), but there were no differences by race/ethnicity or age.

Compared with those who had overweight, those in obesity classes I, II, and III were all more likely to decrease drinking with AOM use, with adjusted ORs of 1.26 (P = .0045), 1.49 (P < .001), and 1.63 (P < .001), respectively.
 

Mechanisms Appear Both Biological and Behavioral

During the discussion, Cardel said that qualitative assessments with participants suggest that there are at least two mechanisms behind this phenomenon: One biological and the other intentional.

“What we hear from them is twofold, one, particularly amongst those folks on GLP-1 medications, we’re hearing that physiologically, they feel different with the medications, that their cravings for alcohol are decreased, and that when they do choose to drink that there’s often a very much a negative reinforcement ... I’ve had a patient tell me, ‘I used to be able to have two or three margaritas, and maybe I didn’t feel like the best I’d ever felt in the morning, but I was okay. And now if I have two or three drinks, I will be throwing up for 5 hours, and it’s the worst hangover I’ve ever had in my life.’ And so it very much creates that negative reinforcement loop.”

But at the same time, “folks who are coming to us and seeking these medications are very much on a on a health-based journey. That’s what they tell us. The majority of our patients are there to improve their health. We rarely hear about the vanity or aesthetic part of it. So perhaps it’s that, in terms of trying to improve their health, they’re also trying to reduce their alcohol consumption, either just for their overall health or also as a means of trying to decrease their overall calorie consumption.”

In future research, Cardel said, “we want to examine whether the anti-obesity medications are more successful at reducing alcohol use compared to non-pharmacological weight management interventions, as we know that people often reduce their alcohol consumption on a weight management journey as a means of prioritizing their calories for food and decreasing the calories from alcohol.”

Cardel and all the study coauthors were employees and shareholders at WeightWatchers at the time the research was conducted. Skelton is editor in chief of the journal Childhood Obesity.
 

A version of this article appeared on Medscape.com.

SAN ANTONIO — Several types of anti-obesity medications (AOMs), including glucagon-like peptide 1s (GLP-1s), are associated with decreased alcohol use, new research suggests.

The findings, from surveys of more than 14,000 participants in WeightWatchers’ telehealth weight management program, were presented on November 6 at the Obesity Society’s Obesity Week 2024 meeting by the company’s Chief Nutrition Officer, Michelle I. Cardel, PhD, RD, based in Gainesville, Florida.

Similar reductions in alcohol consumption were seen in people taking different classes of AOMs, suggesting “an additional mechanism by which AOMs reduce energy intake, and also signal a potential role for these medications to reduce alcohol use,” Cardel said, adding “Clinicians treating individuals for obesity may consider anti-obesity medications particularly among those who report higher alcohol intake.”

Asked to comment, session moderator and obesity researcher Joseph A. Skelton, MD, professor of pediatrics at Wake Forest University School of Medicine, Winston-Salem, North Carolina, said, “I think there are some overlapping pathways there, possibly a reward system or something like that in the brain. I don’t think we know exactly what the end result will be as a potential use of the medications. But there’s a signal that needs to be investigated more.”

Cardel noted that there was one previous large cohort study finding that semaglutide was associated with a lower risk for alcohol use disorder, and another study that analyzed social media threads of people saying they’d quit drinking after starting a GLP-1 drug. But this new study is the first to examine the relationship with different classes of AOMs and to quantify the amount of alcohol consumed.
 

About Half Reported Reduced Alcohol Consumption, Regardless the AOM Class

The study included 14,053 WeightWatchers’ telehealth program participants who initiated an AOM between January 2022 and August 2023 and refilled the same AOM between October and November 2023. Those who had previously used AOMs before coming to the program or who had undergone bariatric surgery were excluded.

Participants had a mean age of 43 years, were 86% women, were 60% White, and had a mean body mass index of 36. They were surveyed about their weekly alcohol use prior to AOM initiation and again at the time of AOM refill.

At baseline, they were divided into categories of 0 (no alcohol use; n = 6562), category 1 (one to three drinks for women and one to six for men; n = 5948), category 2 (4-6 for women and 7-14 for men; n = 1216), and category 3 (≥ 7 for women and ≥ 15 for men; n = 327).

At the second survey, 24% reported decreased drinking after starting an AOM, 71% reported no change, and 4% reported increased drinking (P < .0001). But when just the 7491 individuals who reported any alcohol use at baseline were included, 45% reported decreased drinking after starting an AOM, 52% reported no change, and only 2% reported increased drinking.

The decrease in drinking with AOM use rose with greater alcohol use at baseline, from 37% for category 1, 76% for category 2, and 91% for category 3. The proportions reporting increased drinking were just 3%, 1%, and 0%, respectively. The adjusted odds ratios (ORs) for decreasing drinking were 5.97 for category 2 (P < .0001) and 19.18 for category 3 (P < .0001) vs category 1.

The proportions reporting reduced drinking were similar across AOM classes: 51% for metformin, 46% for bupropion/naltrexone, 46% for first-generation GLP-1s (Saxenda, Trulicity, and Victoza), and 45% for the second-generation GLP-1 drugs (Mounjaro, Ozempic, Rybelsus, Wegovy, and Zepbound). All were statistically significant at P < .0001.

The highest proportion reporting increased drinking was 4% for bupropion/naltrexone. Compared with women, men were significantly more likely to report decreased drinking with AOM use (adjusted OR, 0.74; P < .001), but there were no differences by race/ethnicity or age.

Compared with those who had overweight, those in obesity classes I, II, and III were all more likely to decrease drinking with AOM use, with adjusted ORs of 1.26 (P = .0045), 1.49 (P < .001), and 1.63 (P < .001), respectively.
 

Mechanisms Appear Both Biological and Behavioral

During the discussion, Cardel said that qualitative assessments with participants suggest that there are at least two mechanisms behind this phenomenon: One biological and the other intentional.

“What we hear from them is twofold, one, particularly amongst those folks on GLP-1 medications, we’re hearing that physiologically, they feel different with the medications, that their cravings for alcohol are decreased, and that when they do choose to drink that there’s often a very much a negative reinforcement ... I’ve had a patient tell me, ‘I used to be able to have two or three margaritas, and maybe I didn’t feel like the best I’d ever felt in the morning, but I was okay. And now if I have two or three drinks, I will be throwing up for 5 hours, and it’s the worst hangover I’ve ever had in my life.’ And so it very much creates that negative reinforcement loop.”

But at the same time, “folks who are coming to us and seeking these medications are very much on a on a health-based journey. That’s what they tell us. The majority of our patients are there to improve their health. We rarely hear about the vanity or aesthetic part of it. So perhaps it’s that, in terms of trying to improve their health, they’re also trying to reduce their alcohol consumption, either just for their overall health or also as a means of trying to decrease their overall calorie consumption.”

In future research, Cardel said, “we want to examine whether the anti-obesity medications are more successful at reducing alcohol use compared to non-pharmacological weight management interventions, as we know that people often reduce their alcohol consumption on a weight management journey as a means of prioritizing their calories for food and decreasing the calories from alcohol.”

Cardel and all the study coauthors were employees and shareholders at WeightWatchers at the time the research was conducted. Skelton is editor in chief of the journal Childhood Obesity.
 

A version of this article appeared on Medscape.com.

TOPLINE:

Children of mothers who had obesity or eating disorders before or during pregnancy may face higher risks for neurodevelopmental and psychiatric disorders.

METHODOLOGY:

• Researchers conducted a population-based cohort study to investigate the association of maternal eating disorders and high prepregnancy body mass index (BMI) with psychiatric disorder and neurodevelopmental diagnoses in offspring.
• They used Finnish national registers to assess all live births from 2004 through 2014, with follow-up until 2021.
• Data of 392,098 mothers (mean age, 30.15 years) and 649,956 offspring (48.86% girls) were included.
• Maternal eating disorders and prepregnancy BMI were the main exposures, with 1.60% of mothers having a history of eating disorders; 5.89% were underweight and 53.13% had obesity.
• Diagnoses of children were identified and grouped by ICD-10 codes of mental, behavioral, and neurodevelopmental disorders, mood disorders, anxiety disorders, sleep disorders, attention-deficit/hyperactivity disorder, and conduct disorders, among several others.

TAKEAWAY:

• From birth until 7-17 years of age, 16.43% of offspring were diagnosed with a neurodevelopmental or psychiatric disorder.
• Maternal eating disorders were associated with psychiatric disorders in the offspring, with the largest effect sizes observed for sleep disorders (hazard ratio [HR], 2.36) and social functioning and tic disorders (HR, 2.18; P < .001 for both).
• The offspring of mothers with severe prepregnancy obesity had a more than twofold increased risk for intellectual disabilities (HR, 2.04; 95% CI, 1.83-2.28); being underweight before pregnancy was also linked to many psychiatric disorders in offspring.
• The occurrence of adverse birth outcomes along with maternal eating disorders or high BMI further increased the risk for neurodevelopmental and psychiatric disorders in the offspring.

IN PRACTICE:

“The findings underline the risk of offspring mental illness associated with maternal eating disorders and prepregnancy BMI and suggest the need to consider these exposures clinically to help prevent offspring mental illness,” the authors wrote.

SOURCE:

This study was led by Ida A.K. Nilsson, PhD, of the Department of Molecular Medicine and Surgery at the Karolinska Institutet in Stockholm, Sweden, and was published online in JAMA Network Open.

LIMITATIONS:

A limitation of the study was the relatively short follow-up time, which restricted the inclusion of late-onset psychiatric disorder diagnoses, such as schizophrenia spectrum disorders. Paternal data and genetic information, which may have influenced the interpretation of the data, were not available. Another potential bias was that mothers with eating disorders may have been more perceptive to their child’s eating behavior, leading to greater access to care and diagnosis for these children.

DISCLOSURES:

This work was supported by the Swedish Research Council, the regional agreement on medical training and clinical research between Region Stockholm and the Karolinska Institutet, the Swedish Brain Foundation, and other sources. The authors declared no conflicts of interest.

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

TOPLINE:

Children of mothers who had obesity or eating disorders before or during pregnancy may face higher risks for neurodevelopmental and psychiatric disorders.

METHODOLOGY:

• Researchers conducted a population-based cohort study to investigate the association of maternal eating disorders and high prepregnancy body mass index (BMI) with psychiatric disorder and neurodevelopmental diagnoses in offspring.
• They used Finnish national registers to assess all live births from 2004 through 2014, with follow-up until 2021.
• Data of 392,098 mothers (mean age, 30.15 years) and 649,956 offspring (48.86% girls) were included.
• Maternal eating disorders and prepregnancy BMI were the main exposures, with 1.60% of mothers having a history of eating disorders; 5.89% were underweight and 53.13% had obesity.
• Diagnoses of children were identified and grouped by ICD-10 codes of mental, behavioral, and neurodevelopmental disorders, mood disorders, anxiety disorders, sleep disorders, attention-deficit/hyperactivity disorder, and conduct disorders, among several others.

TAKEAWAY:

• From birth until 7-17 years of age, 16.43% of offspring were diagnosed with a neurodevelopmental or psychiatric disorder.
• Maternal eating disorders were associated with psychiatric disorders in the offspring, with the largest effect sizes observed for sleep disorders (hazard ratio [HR], 2.36) and social functioning and tic disorders (HR, 2.18; P < .001 for both).
• The offspring of mothers with severe prepregnancy obesity had a more than twofold increased risk for intellectual disabilities (HR, 2.04; 95% CI, 1.83-2.28); being underweight before pregnancy was also linked to many psychiatric disorders in offspring.
• The occurrence of adverse birth outcomes along with maternal eating disorders or high BMI further increased the risk for neurodevelopmental and psychiatric disorders in the offspring.

IN PRACTICE:

“The findings underline the risk of offspring mental illness associated with maternal eating disorders and prepregnancy BMI and suggest the need to consider these exposures clinically to help prevent offspring mental illness,” the authors wrote.

SOURCE:

This study was led by Ida A.K. Nilsson, PhD, of the Department of Molecular Medicine and Surgery at the Karolinska Institutet in Stockholm, Sweden, and was published online in JAMA Network Open.

LIMITATIONS:

A limitation of the study was the relatively short follow-up time, which restricted the inclusion of late-onset psychiatric disorder diagnoses, such as schizophrenia spectrum disorders. Paternal data and genetic information, which may have influenced the interpretation of the data, were not available. Another potential bias was that mothers with eating disorders may have been more perceptive to their child’s eating behavior, leading to greater access to care and diagnosis for these children.

DISCLOSURES:

This work was supported by the Swedish Research Council, the regional agreement on medical training and clinical research between Region Stockholm and the Karolinska Institutet, the Swedish Brain Foundation, and other sources. The authors declared no conflicts of interest.

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

TOPLINE:

Children of mothers who had obesity or eating disorders before or during pregnancy may face higher risks for neurodevelopmental and psychiatric disorders.

METHODOLOGY:

• Researchers conducted a population-based cohort study to investigate the association of maternal eating disorders and high prepregnancy body mass index (BMI) with psychiatric disorder and neurodevelopmental diagnoses in offspring.
• They used Finnish national registers to assess all live births from 2004 through 2014, with follow-up until 2021.
• Data of 392,098 mothers (mean age, 30.15 years) and 649,956 offspring (48.86% girls) were included.
• Maternal eating disorders and prepregnancy BMI were the main exposures, with 1.60% of mothers having a history of eating disorders; 5.89% were underweight and 53.13% had obesity.
• Diagnoses of children were identified and grouped by ICD-10 codes of mental, behavioral, and neurodevelopmental disorders, mood disorders, anxiety disorders, sleep disorders, attention-deficit/hyperactivity disorder, and conduct disorders, among several others.

TAKEAWAY:

• From birth until 7-17 years of age, 16.43% of offspring were diagnosed with a neurodevelopmental or psychiatric disorder.
• Maternal eating disorders were associated with psychiatric disorders in the offspring, with the largest effect sizes observed for sleep disorders (hazard ratio [HR], 2.36) and social functioning and tic disorders (HR, 2.18; P < .001 for both).
• The offspring of mothers with severe prepregnancy obesity had a more than twofold increased risk for intellectual disabilities (HR, 2.04; 95% CI, 1.83-2.28); being underweight before pregnancy was also linked to many psychiatric disorders in offspring.
• The occurrence of adverse birth outcomes along with maternal eating disorders or high BMI further increased the risk for neurodevelopmental and psychiatric disorders in the offspring.

IN PRACTICE:

“The findings underline the risk of offspring mental illness associated with maternal eating disorders and prepregnancy BMI and suggest the need to consider these exposures clinically to help prevent offspring mental illness,” the authors wrote.

SOURCE:

This study was led by Ida A.K. Nilsson, PhD, of the Department of Molecular Medicine and Surgery at the Karolinska Institutet in Stockholm, Sweden, and was published online in JAMA Network Open.

LIMITATIONS:

A limitation of the study was the relatively short follow-up time, which restricted the inclusion of late-onset psychiatric disorder diagnoses, such as schizophrenia spectrum disorders. Paternal data and genetic information, which may have influenced the interpretation of the data, were not available. Another potential bias was that mothers with eating disorders may have been more perceptive to their child’s eating behavior, leading to greater access to care and diagnosis for these children.

DISCLOSURES:

This work was supported by the Swedish Research Council, the regional agreement on medical training and clinical research between Region Stockholm and the Karolinska Institutet, the Swedish Brain Foundation, and other sources. The authors declared no conflicts of interest.

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

When she was 5 years old, Katherine Edson, LCSW, tried to end her life by drowning herself. “I was enduring severe physical and sexual abuse, and it had become unbearable,” she said. “I waded into a lake, knowing there was a point when it would become too deep and I’d go under.”

As she was walking toward the deeper water, it occurred to her that if she died, she wouldn’t be able to eat Rice Krispies again. “I thought, ‘no more Snap, Crackle, and Pop’ — the three little mascots on the cereal box — and I felt sad,” said Edson, a New York–based retired therapist. “But I still kept walking.”

A man on the shore saw her disappear under the water and pulled her out. “I remember vomiting a lot of water and I remember that the man had tattoos, but I don’t remember how I felt to be alive. I was just numb.”

Edson thinks there were clues her pediatrician missed. “We lived in a small Southern town. Everyone knew my parents were alcoholics. I was very dissociated and withdrawn in general and during pediatric visits. My affect broadcasted that something was wrong, but no one asked if I was okay.”

She acknowledged that professionals in those days “weren’t tuned in to mental health issues in kids. At least there’s more awareness today and hopefully more training — especially since it seems like more kids are trying to end their lives today than when I was growing up.”
 

Alarming Statistics

According to the American Academy of Pediatrics (AAP), suicide is the second leading cause of death for people aged 10-24 years. Data from Children’s Hospital Association’s Pediatric Health Information System revealed that suicide attempts, ideation, and self-injury have become the most common mental health conditions seen in the emergency departments (EDs) of children’s hospitals, with a 166% increase in ED visits for suicide attempts in children aged 5-18 years, between 2016 and 2022.

Psychiatrist Helen Egger, MD, chief medical officer and co-founder of Little Otter, a specialty pediatric and whole family digital mental health company, recently coauthored a report analyzing data on 1434 children who completed a screening session and comprehensive diagnostic assessment at Little Otter from May 2023 to February 2024 (n = 1016 children aged 8-14 years and n = 418 aged 3-7 years).

Little Otter

Points of Contact

“It’s known that most children who die by suicide had a recent visit with a health professional — a pediatrician or child mental health professional. It’s unlikely that the child was fine and then, a few weeks later, stopped being fine. The likelihood is that the child wasn’t fine during that visit, but the clinician didn’t ask about mental health,” Egger said.

Christine Crawford, MD, MPH, associate medical director of the National Alliance on Mental Illness (NAMI), said that awareness of pediatric and adolescent suicidality is relevant to all physicians who treat children. “When you’re working with kids, anything can come up. Be prepared to navigate the conversation. You can never predict who the patient will feel most comfortable disclosing these thoughts to.”

NAMI

Don’t Be Afraid to Ask

According to the AAP, all children aged 12 years or older should be screened for suicidal risk, and children aged 8-11 years should be screened “when clinically indicated.” AAP also recommends annual screening for depression in children aged 12 years or older. However, Egger thinks that screening for depression should start sooner.

Katherine Kay Greydanus

It can be tempting to screen by merely giving a youngster a form to fill out in the waiting room, but Greydanus strongly advises against this approach. “The important thing is having rapport with the child, being in the same room together. You can ask some simple questions. ‘How are you doing? How are things at school? How are things with your family?’”

“When you’re screening for depression and have a kid who’s talking about sadness or low mood for more than 2 weeks and endorsing other symptoms, such as problems with sleep or appetite, difficulty concentrating, anhedonia, losing interest in things they’d usually enjoy, feeling they’re a burden to others, hopelessness about the future, being unable to function the way they used to — that person meets criteria for depression and you should have a high suspicion and concern about potential suicide,” said Crawford, assistant professor of psychiatry, Boston University School of Medicine.

She suggested probing further and being direct. “It sounds like you’ve been having a tough time. You talk about being sad. I wonder if you’re feeling so sad that you might not want to be alive anymore.” Some healthcare providers “tiptoe around when it comes to suicide, but it’s better to be direct and communicate the question in simple, plain language: ‘Have you ever had thoughts about hurting or killing yourself, that life is no longer worth living, or life would be easier for your family if you weren’t alive?’”

It’s a common myth that asking about depression or suicidality will “plant a seed” or “put ideas in people’s heads,” potentially leading to suicidality. “What we know to be true is that asking about suicide doesn’t put lives at risk. In fact, the contrary is true,” according to Crawford. Several studies have refuted this myth.

Two screening tools that might be helpful in ascertaining the presence of depression and suicidality are the PHQ-9 modified for Adolescents and the four-question Ask Suicide-Screening Questions.
 

Probe for More Details

If a child or adolescent affirms suicidal ideation, it’s important to ask if they have a plan, Crawford advised. “If they say, ‘yes,’ don’t run out of the office or shut down the conversation by picking up the phone and calling the closest child psychiatrist. We want kids to open up as much as possible when they’ve already opened up a little. So continue the conversation.”

If a child has a plan, the risk for following through on that plan is “high,” Crawford emphasized. “You want the maximum amount of information at your fingertips because this will equip you to navigate the next step in getting the child help.”

The suicide plan may not be realistic and, if carried out, might not actually end in death, especially in younger children. “A 6-year-old might say, ‘I’m gonna drink a whole bottle of apple juice and my belly will explode.’ Or ‘I’ll take 10 extra vitamins.’ The objective lethality of the plan doesn’t matter in that moment. What matters is that the child believes it’s going to work, and it provides a window into how depressed that child is.”

Greydanus added that it’s important to understand what might be going on in the child’s life. Could there be abuse in the family? Is the child being bullied? Bullying can take place at school or online, he noted. The overall risk for suicidal thoughts is elevated for youth who are involved in bullying, whether they’re the bully or the one being bullied.

Kirk Smalley, president and co-founder of Stand for the Silent, an organization designed to bring awareness about the devastating effects of bullying, agreed that pediatricians a should ask children if they’re being bullied. “Sometimes, kids will open up to someone who isn’t a parent or a teacher, who might be seen as ‘too close’ to the situation,” Smalley said.

“Let them know you’re a trusted adult they can confide in and you’re willing to help them navigate this — and then follow through,” advised Smalley, whose 11-year-old son died by suicide after being subjected to bullying.
 

Painting a Complete Picture

Crawford advises clinicians to “look at the whole picture and piece it together.”

For example, “if the child is functioning, going to school, maintaining relationships with other people, and not experiencing symptoms of depression but discloses the desire to kill him/herself, understand the context.” Sometimes, adolescents can be impulsive. Decision-making “can be driven by emotion.” The teen may have experienced emotional distress, such as “conflict with a peer, arguments with a parent, or romantic heartbreak. She might say, ‘I’m going to kill myself if I ever see him holding hands with another girl.’”

In the setting of an acute stressor, such as a breakup, the child might not need a higher level of care such as hospitalization. “But for non-psychiatry providers, it’s unclear if the child might act on it, so it’s important to have the child evaluated; talk to collateral supports, such as parents, teachers, or a therapist if they have one; and see what makes sense for that specific child.”

She also recommended “getting a sense if the kid is future-oriented in thinking. If they’re talking about an upcoming concert this weekend, or wanting to get to basketball practice, that’s reassuring. It suggests the likelihood of following through [on suicide] is low.”

And assess coping strategies. “You can say, ‘I see you’re really going through a lot. I worry that these thoughts will come up in school. What do you think you’d do in the moment if these thoughts come up?’ If there’s a coping strategy — for example, ‘I’d talk to my friend during lunch’ — that’s also reassuring,” Crawford said.

Of course, that doesn’t mean the statement should be ignored or dismissed. Rather, it informs the next preventive steps and how intensive the level of care should be.
 

Next Steps: Involving the Family, Getting Help

It’s particularly concerning if the child is unable to identify strategies other than suicide, said Crawford. “You can say, ‘I’m concerned because it’s highly likely that you’ll run into this guy and I wouldn’t want you to die. You have so much to live for.’”

Then, you can ask if it’s okay to bring in the parent or caregiver to talk about what the child just revealed. “If the kid says no — especially a teen — you can respond, ‘I hear what you’re saying, but I actually do have to bring your parent in because of your safety and we can discuss together how to keep you safe.’”

In advance, Crawford tells the patient what she plans to share with the parent. “That way, we’re on the same page and the kid has a sense of agency about how the conversation with the parent will go.” If the teen doesn’t want certain information revealed, “you can ask, ‘What would you leave out, and why?’ This lends itself to a helpful conversation about what the child is thinking about.”

Once the provider has received the green light, it’s time to bring the parent into the room. “Especially in the primary care or pediatric setting, the parent is often shocked, worried, and caught off-guard,” Crawford said.

“You can start by thanking the patient for being open and honest. Then you can tell the parent, ‘Your daughter shared she’s been having some difficult emotions and experiences, and she’s thought of ending her life because she doesn’t know how to cope. I wanted to talk to you about this because it’s important to look at resources we can connect her to and effective coping strategies.’”

Further interventions can include referring the patient to a child psychiatrist or therapist, or both. “Have a list of referrals readily available,” Greydanus advised. If you suspect or if the child reveals abuse, you’re a mandated reporter and need to inform Child Protective Services (CPS). “But don’t stop there,” he warned. “Make sure the child is indeed getting help through CPS and appropriate intervention has been taken regarding the abuse and potential suicide attempt.” Or you may send the child to the ED, where ED physicians are “trained in what to do if they suspect abuse. But make sure that when you ‘throw the ball,’ there’s someone who can ‘catch’ it and accept responsibility for the child’s safety.”

Crawford noted that many primary care settings — especially in under-resourced areas — lack child psychiatrists or therapists. “You need to know what’s feasible in the community you’re practicing in,” she advised. “Be aware of the local crisis line — 988 — and mental health resources in the school and community. There are often school psychologists, social workers, or counselors who can become involved.”

Greydanus emphasized that it’s critical to assess for the presence of firearms in the home and address it with the parents. “If a child is sad or angry and gets impulsive, it’s amazingly common for them to get their hands in a firearm and use it.”

As previously reported, pediatricians and other healthcare providers have a valuable role to play in screening parents for firearm ownership and offering counseling on safe storage practices, according to research presented on September 28 at the AAP 2024 National Conference.
 

Sometimes, Even the Best Efforts Aren’t Successful

“Suicide is complicated, and parents or doctors can take all the ‘right’ steps to get counseling for the child — hospitalization, medication, and support — and children might still take their lives,” said Ronnie Susan Walker, MS, LCPC, founder and executive director of Alliance of Hope for Suicide Loss Survivors. The organization was launched as a “postvention campaign” 7 years ago to provide support to survivors of suicide loss, who are themselves a high-risk population for suicide.

Walker alluded to the concept of a “ suicide trance” — a term coined by Richard Heckler, PhD, in his book Waking Up, Alive. This trance “is a state of mind and body that receives only the kind of input that reinforces the pain and corroborates the person’s conviction that the only way out is through death,” Heckler wrote.

Walker, whose stepson died by suicide, said physicians and other healthcare professionals who have lost a patient to suicide “should focus on postvention — finding support from other professionals and managing their own grief and guilt.”

It’s natural to feel guilt and second-guess yourself, Greydanus said. “You question whether you missed something or could have done more, so acknowledge that even with the best care and intentions, some suicides aren’t preventable,” he said.

Walker recommends reaching out to the family. “When I lost my stepson, his doctor came to the funeral and wrote us a very meaningful note. That meant so much to us.”

Greydanus agreed it’s appropriate for the clinician to offer comfort to the family “if he or she feels it necessary or feels moved to do so.” However, he cautioned, there’s “often a fear of malpractice charges that may interfere in certain cases.”

Egger added that records should always be “very detailed,” with clear documentation of how you interacted with the child and the rationale behind your interventions. “I’m not a legal expert, but I would always err on the side of connecting with family and sharing grief and compassion. My experience with physician-patient relationships is that the more connected, transparent, and empathetic they are, the better the outcome will be for everyone.”

Losing a patient to suicide is traumatic, so give yourself time to grieve, Egger advised. “Unfortunately, this is an experience that almost everyone in the field will likely go through at some point. Reach out for professional counseling or peer support.”

Physicians who have lost a patient to suicide may turn to an online forum, the Coalition of Clinician Survivors, designed to create a safe anonymous space for discussion, education, testimonials, and one-on-one support.

Greydanus emphasized that the most important role in working with suicidal youngsters is to provide hope. “Yes, you can’t help everyone, but you can help most of them. That’s why you’re there.”

Greydanus, Crawford, Egger, Edson, Smalley, and Walker reported no financial conflicts of interest.
 

A version of this article appeared on Medscape.com.

When she was 5 years old, Katherine Edson, LCSW, tried to end her life by drowning herself. “I was enduring severe physical and sexual abuse, and it had become unbearable,” she said. “I waded into a lake, knowing there was a point when it would become too deep and I’d go under.”

As she was walking toward the deeper water, it occurred to her that if she died, she wouldn’t be able to eat Rice Krispies again. “I thought, ‘no more Snap, Crackle, and Pop’ — the three little mascots on the cereal box — and I felt sad,” said Edson, a New York–based retired therapist. “But I still kept walking.”

A man on the shore saw her disappear under the water and pulled her out. “I remember vomiting a lot of water and I remember that the man had tattoos, but I don’t remember how I felt to be alive. I was just numb.”

Edson thinks there were clues her pediatrician missed. “We lived in a small Southern town. Everyone knew my parents were alcoholics. I was very dissociated and withdrawn in general and during pediatric visits. My affect broadcasted that something was wrong, but no one asked if I was okay.”

She acknowledged that professionals in those days “weren’t tuned in to mental health issues in kids. At least there’s more awareness today and hopefully more training — especially since it seems like more kids are trying to end their lives today than when I was growing up.”
 

Alarming Statistics

According to the American Academy of Pediatrics (AAP), suicide is the second leading cause of death for people aged 10-24 years. Data from Children’s Hospital Association’s Pediatric Health Information System revealed that suicide attempts, ideation, and self-injury have become the most common mental health conditions seen in the emergency departments (EDs) of children’s hospitals, with a 166% increase in ED visits for suicide attempts in children aged 5-18 years, between 2016 and 2022.

Psychiatrist Helen Egger, MD, chief medical officer and co-founder of Little Otter, a specialty pediatric and whole family digital mental health company, recently coauthored a report analyzing data on 1434 children who completed a screening session and comprehensive diagnostic assessment at Little Otter from May 2023 to February 2024 (n = 1016 children aged 8-14 years and n = 418 aged 3-7 years).

Little Otter

Points of Contact

“It’s known that most children who die by suicide had a recent visit with a health professional — a pediatrician or child mental health professional. It’s unlikely that the child was fine and then, a few weeks later, stopped being fine. The likelihood is that the child wasn’t fine during that visit, but the clinician didn’t ask about mental health,” Egger said.

Christine Crawford, MD, MPH, associate medical director of the National Alliance on Mental Illness (NAMI), said that awareness of pediatric and adolescent suicidality is relevant to all physicians who treat children. “When you’re working with kids, anything can come up. Be prepared to navigate the conversation. You can never predict who the patient will feel most comfortable disclosing these thoughts to.”

NAMI

Don’t Be Afraid to Ask

According to the AAP, all children aged 12 years or older should be screened for suicidal risk, and children aged 8-11 years should be screened “when clinically indicated.” AAP also recommends annual screening for depression in children aged 12 years or older. However, Egger thinks that screening for depression should start sooner.

Katherine Kay Greydanus

It can be tempting to screen by merely giving a youngster a form to fill out in the waiting room, but Greydanus strongly advises against this approach. “The important thing is having rapport with the child, being in the same room together. You can ask some simple questions. ‘How are you doing? How are things at school? How are things with your family?’”

“When you’re screening for depression and have a kid who’s talking about sadness or low mood for more than 2 weeks and endorsing other symptoms, such as problems with sleep or appetite, difficulty concentrating, anhedonia, losing interest in things they’d usually enjoy, feeling they’re a burden to others, hopelessness about the future, being unable to function the way they used to — that person meets criteria for depression and you should have a high suspicion and concern about potential suicide,” said Crawford, assistant professor of psychiatry, Boston University School of Medicine.

She suggested probing further and being direct. “It sounds like you’ve been having a tough time. You talk about being sad. I wonder if you’re feeling so sad that you might not want to be alive anymore.” Some healthcare providers “tiptoe around when it comes to suicide, but it’s better to be direct and communicate the question in simple, plain language: ‘Have you ever had thoughts about hurting or killing yourself, that life is no longer worth living, or life would be easier for your family if you weren’t alive?’”

It’s a common myth that asking about depression or suicidality will “plant a seed” or “put ideas in people’s heads,” potentially leading to suicidality. “What we know to be true is that asking about suicide doesn’t put lives at risk. In fact, the contrary is true,” according to Crawford. Several studies have refuted this myth.

Two screening tools that might be helpful in ascertaining the presence of depression and suicidality are the PHQ-9 modified for Adolescents and the four-question Ask Suicide-Screening Questions.
 

Probe for More Details

If a child or adolescent affirms suicidal ideation, it’s important to ask if they have a plan, Crawford advised. “If they say, ‘yes,’ don’t run out of the office or shut down the conversation by picking up the phone and calling the closest child psychiatrist. We want kids to open up as much as possible when they’ve already opened up a little. So continue the conversation.”

If a child has a plan, the risk for following through on that plan is “high,” Crawford emphasized. “You want the maximum amount of information at your fingertips because this will equip you to navigate the next step in getting the child help.”

The suicide plan may not be realistic and, if carried out, might not actually end in death, especially in younger children. “A 6-year-old might say, ‘I’m gonna drink a whole bottle of apple juice and my belly will explode.’ Or ‘I’ll take 10 extra vitamins.’ The objective lethality of the plan doesn’t matter in that moment. What matters is that the child believes it’s going to work, and it provides a window into how depressed that child is.”

Greydanus added that it’s important to understand what might be going on in the child’s life. Could there be abuse in the family? Is the child being bullied? Bullying can take place at school or online, he noted. The overall risk for suicidal thoughts is elevated for youth who are involved in bullying, whether they’re the bully or the one being bullied.

Kirk Smalley, president and co-founder of Stand for the Silent, an organization designed to bring awareness about the devastating effects of bullying, agreed that pediatricians a should ask children if they’re being bullied. “Sometimes, kids will open up to someone who isn’t a parent or a teacher, who might be seen as ‘too close’ to the situation,” Smalley said.

“Let them know you’re a trusted adult they can confide in and you’re willing to help them navigate this — and then follow through,” advised Smalley, whose 11-year-old son died by suicide after being subjected to bullying.
 

Painting a Complete Picture

Crawford advises clinicians to “look at the whole picture and piece it together.”

For example, “if the child is functioning, going to school, maintaining relationships with other people, and not experiencing symptoms of depression but discloses the desire to kill him/herself, understand the context.” Sometimes, adolescents can be impulsive. Decision-making “can be driven by emotion.” The teen may have experienced emotional distress, such as “conflict with a peer, arguments with a parent, or romantic heartbreak. She might say, ‘I’m going to kill myself if I ever see him holding hands with another girl.’”

In the setting of an acute stressor, such as a breakup, the child might not need a higher level of care such as hospitalization. “But for non-psychiatry providers, it’s unclear if the child might act on it, so it’s important to have the child evaluated; talk to collateral supports, such as parents, teachers, or a therapist if they have one; and see what makes sense for that specific child.”

She also recommended “getting a sense if the kid is future-oriented in thinking. If they’re talking about an upcoming concert this weekend, or wanting to get to basketball practice, that’s reassuring. It suggests the likelihood of following through [on suicide] is low.”

And assess coping strategies. “You can say, ‘I see you’re really going through a lot. I worry that these thoughts will come up in school. What do you think you’d do in the moment if these thoughts come up?’ If there’s a coping strategy — for example, ‘I’d talk to my friend during lunch’ — that’s also reassuring,” Crawford said.

Of course, that doesn’t mean the statement should be ignored or dismissed. Rather, it informs the next preventive steps and how intensive the level of care should be.
 

Next Steps: Involving the Family, Getting Help

It’s particularly concerning if the child is unable to identify strategies other than suicide, said Crawford. “You can say, ‘I’m concerned because it’s highly likely that you’ll run into this guy and I wouldn’t want you to die. You have so much to live for.’”

Then, you can ask if it’s okay to bring in the parent or caregiver to talk about what the child just revealed. “If the kid says no — especially a teen — you can respond, ‘I hear what you’re saying, but I actually do have to bring your parent in because of your safety and we can discuss together how to keep you safe.’”

In advance, Crawford tells the patient what she plans to share with the parent. “That way, we’re on the same page and the kid has a sense of agency about how the conversation with the parent will go.” If the teen doesn’t want certain information revealed, “you can ask, ‘What would you leave out, and why?’ This lends itself to a helpful conversation about what the child is thinking about.”

Once the provider has received the green light, it’s time to bring the parent into the room. “Especially in the primary care or pediatric setting, the parent is often shocked, worried, and caught off-guard,” Crawford said.

“You can start by thanking the patient for being open and honest. Then you can tell the parent, ‘Your daughter shared she’s been having some difficult emotions and experiences, and she’s thought of ending her life because she doesn’t know how to cope. I wanted to talk to you about this because it’s important to look at resources we can connect her to and effective coping strategies.’”

Further interventions can include referring the patient to a child psychiatrist or therapist, or both. “Have a list of referrals readily available,” Greydanus advised. If you suspect or if the child reveals abuse, you’re a mandated reporter and need to inform Child Protective Services (CPS). “But don’t stop there,” he warned. “Make sure the child is indeed getting help through CPS and appropriate intervention has been taken regarding the abuse and potential suicide attempt.” Or you may send the child to the ED, where ED physicians are “trained in what to do if they suspect abuse. But make sure that when you ‘throw the ball,’ there’s someone who can ‘catch’ it and accept responsibility for the child’s safety.”

Crawford noted that many primary care settings — especially in under-resourced areas — lack child psychiatrists or therapists. “You need to know what’s feasible in the community you’re practicing in,” she advised. “Be aware of the local crisis line — 988 — and mental health resources in the school and community. There are often school psychologists, social workers, or counselors who can become involved.”

Greydanus emphasized that it’s critical to assess for the presence of firearms in the home and address it with the parents. “If a child is sad or angry and gets impulsive, it’s amazingly common for them to get their hands in a firearm and use it.”

As previously reported, pediatricians and other healthcare providers have a valuable role to play in screening parents for firearm ownership and offering counseling on safe storage practices, according to research presented on September 28 at the AAP 2024 National Conference.
 

Sometimes, Even the Best Efforts Aren’t Successful

“Suicide is complicated, and parents or doctors can take all the ‘right’ steps to get counseling for the child — hospitalization, medication, and support — and children might still take their lives,” said Ronnie Susan Walker, MS, LCPC, founder and executive director of Alliance of Hope for Suicide Loss Survivors. The organization was launched as a “postvention campaign” 7 years ago to provide support to survivors of suicide loss, who are themselves a high-risk population for suicide.

Walker alluded to the concept of a “ suicide trance” — a term coined by Richard Heckler, PhD, in his book Waking Up, Alive. This trance “is a state of mind and body that receives only the kind of input that reinforces the pain and corroborates the person’s conviction that the only way out is through death,” Heckler wrote.

Walker, whose stepson died by suicide, said physicians and other healthcare professionals who have lost a patient to suicide “should focus on postvention — finding support from other professionals and managing their own grief and guilt.”

It’s natural to feel guilt and second-guess yourself, Greydanus said. “You question whether you missed something or could have done more, so acknowledge that even with the best care and intentions, some suicides aren’t preventable,” he said.

Walker recommends reaching out to the family. “When I lost my stepson, his doctor came to the funeral and wrote us a very meaningful note. That meant so much to us.”

Greydanus agreed it’s appropriate for the clinician to offer comfort to the family “if he or she feels it necessary or feels moved to do so.” However, he cautioned, there’s “often a fear of malpractice charges that may interfere in certain cases.”

Egger added that records should always be “very detailed,” with clear documentation of how you interacted with the child and the rationale behind your interventions. “I’m not a legal expert, but I would always err on the side of connecting with family and sharing grief and compassion. My experience with physician-patient relationships is that the more connected, transparent, and empathetic they are, the better the outcome will be for everyone.”

Losing a patient to suicide is traumatic, so give yourself time to grieve, Egger advised. “Unfortunately, this is an experience that almost everyone in the field will likely go through at some point. Reach out for professional counseling or peer support.”

Physicians who have lost a patient to suicide may turn to an online forum, the Coalition of Clinician Survivors, designed to create a safe anonymous space for discussion, education, testimonials, and one-on-one support.

Greydanus emphasized that the most important role in working with suicidal youngsters is to provide hope. “Yes, you can’t help everyone, but you can help most of them. That’s why you’re there.”

Greydanus, Crawford, Egger, Edson, Smalley, and Walker reported no financial conflicts of interest.
 

A version of this article appeared on Medscape.com.

When she was 5 years old, Katherine Edson, LCSW, tried to end her life by drowning herself. “I was enduring severe physical and sexual abuse, and it had become unbearable,” she said. “I waded into a lake, knowing there was a point when it would become too deep and I’d go under.”

As she was walking toward the deeper water, it occurred to her that if she died, she wouldn’t be able to eat Rice Krispies again. “I thought, ‘no more Snap, Crackle, and Pop’ — the three little mascots on the cereal box — and I felt sad,” said Edson, a New York–based retired therapist. “But I still kept walking.”

A man on the shore saw her disappear under the water and pulled her out. “I remember vomiting a lot of water and I remember that the man had tattoos, but I don’t remember how I felt to be alive. I was just numb.”

Edson thinks there were clues her pediatrician missed. “We lived in a small Southern town. Everyone knew my parents were alcoholics. I was very dissociated and withdrawn in general and during pediatric visits. My affect broadcasted that something was wrong, but no one asked if I was okay.”

She acknowledged that professionals in those days “weren’t tuned in to mental health issues in kids. At least there’s more awareness today and hopefully more training — especially since it seems like more kids are trying to end their lives today than when I was growing up.”
 

Alarming Statistics

According to the American Academy of Pediatrics (AAP), suicide is the second leading cause of death for people aged 10-24 years. Data from Children’s Hospital Association’s Pediatric Health Information System revealed that suicide attempts, ideation, and self-injury have become the most common mental health conditions seen in the emergency departments (EDs) of children’s hospitals, with a 166% increase in ED visits for suicide attempts in children aged 5-18 years, between 2016 and 2022.

Psychiatrist Helen Egger, MD, chief medical officer and co-founder of Little Otter, a specialty pediatric and whole family digital mental health company, recently coauthored a report analyzing data on 1434 children who completed a screening session and comprehensive diagnostic assessment at Little Otter from May 2023 to February 2024 (n = 1016 children aged 8-14 years and n = 418 aged 3-7 years).

Little Otter

Points of Contact

“It’s known that most children who die by suicide had a recent visit with a health professional — a pediatrician or child mental health professional. It’s unlikely that the child was fine and then, a few weeks later, stopped being fine. The likelihood is that the child wasn’t fine during that visit, but the clinician didn’t ask about mental health,” Egger said.

Christine Crawford, MD, MPH, associate medical director of the National Alliance on Mental Illness (NAMI), said that awareness of pediatric and adolescent suicidality is relevant to all physicians who treat children. “When you’re working with kids, anything can come up. Be prepared to navigate the conversation. You can never predict who the patient will feel most comfortable disclosing these thoughts to.”

NAMI

Don’t Be Afraid to Ask

According to the AAP, all children aged 12 years or older should be screened for suicidal risk, and children aged 8-11 years should be screened “when clinically indicated.” AAP also recommends annual screening for depression in children aged 12 years or older. However, Egger thinks that screening for depression should start sooner.

Katherine Kay Greydanus

It can be tempting to screen by merely giving a youngster a form to fill out in the waiting room, but Greydanus strongly advises against this approach. “The important thing is having rapport with the child, being in the same room together. You can ask some simple questions. ‘How are you doing? How are things at school? How are things with your family?’”

“When you’re screening for depression and have a kid who’s talking about sadness or low mood for more than 2 weeks and endorsing other symptoms, such as problems with sleep or appetite, difficulty concentrating, anhedonia, losing interest in things they’d usually enjoy, feeling they’re a burden to others, hopelessness about the future, being unable to function the way they used to — that person meets criteria for depression and you should have a high suspicion and concern about potential suicide,” said Crawford, assistant professor of psychiatry, Boston University School of Medicine.

She suggested probing further and being direct. “It sounds like you’ve been having a tough time. You talk about being sad. I wonder if you’re feeling so sad that you might not want to be alive anymore.” Some healthcare providers “tiptoe around when it comes to suicide, but it’s better to be direct and communicate the question in simple, plain language: ‘Have you ever had thoughts about hurting or killing yourself, that life is no longer worth living, or life would be easier for your family if you weren’t alive?’”

It’s a common myth that asking about depression or suicidality will “plant a seed” or “put ideas in people’s heads,” potentially leading to suicidality. “What we know to be true is that asking about suicide doesn’t put lives at risk. In fact, the contrary is true,” according to Crawford. Several studies have refuted this myth.

Two screening tools that might be helpful in ascertaining the presence of depression and suicidality are the PHQ-9 modified for Adolescents and the four-question Ask Suicide-Screening Questions.
 

Probe for More Details

If a child or adolescent affirms suicidal ideation, it’s important to ask if they have a plan, Crawford advised. “If they say, ‘yes,’ don’t run out of the office or shut down the conversation by picking up the phone and calling the closest child psychiatrist. We want kids to open up as much as possible when they’ve already opened up a little. So continue the conversation.”

If a child has a plan, the risk for following through on that plan is “high,” Crawford emphasized. “You want the maximum amount of information at your fingertips because this will equip you to navigate the next step in getting the child help.”

The suicide plan may not be realistic and, if carried out, might not actually end in death, especially in younger children. “A 6-year-old might say, ‘I’m gonna drink a whole bottle of apple juice and my belly will explode.’ Or ‘I’ll take 10 extra vitamins.’ The objective lethality of the plan doesn’t matter in that moment. What matters is that the child believes it’s going to work, and it provides a window into how depressed that child is.”

Greydanus added that it’s important to understand what might be going on in the child’s life. Could there be abuse in the family? Is the child being bullied? Bullying can take place at school or online, he noted. The overall risk for suicidal thoughts is elevated for youth who are involved in bullying, whether they’re the bully or the one being bullied.

Kirk Smalley, president and co-founder of Stand for the Silent, an organization designed to bring awareness about the devastating effects of bullying, agreed that pediatricians a should ask children if they’re being bullied. “Sometimes, kids will open up to someone who isn’t a parent or a teacher, who might be seen as ‘too close’ to the situation,” Smalley said.

“Let them know you’re a trusted adult they can confide in and you’re willing to help them navigate this — and then follow through,” advised Smalley, whose 11-year-old son died by suicide after being subjected to bullying.
 

Painting a Complete Picture

Crawford advises clinicians to “look at the whole picture and piece it together.”

For example, “if the child is functioning, going to school, maintaining relationships with other people, and not experiencing symptoms of depression but discloses the desire to kill him/herself, understand the context.” Sometimes, adolescents can be impulsive. Decision-making “can be driven by emotion.” The teen may have experienced emotional distress, such as “conflict with a peer, arguments with a parent, or romantic heartbreak. She might say, ‘I’m going to kill myself if I ever see him holding hands with another girl.’”

In the setting of an acute stressor, such as a breakup, the child might not need a higher level of care such as hospitalization. “But for non-psychiatry providers, it’s unclear if the child might act on it, so it’s important to have the child evaluated; talk to collateral supports, such as parents, teachers, or a therapist if they have one; and see what makes sense for that specific child.”

She also recommended “getting a sense if the kid is future-oriented in thinking. If they’re talking about an upcoming concert this weekend, or wanting to get to basketball practice, that’s reassuring. It suggests the likelihood of following through [on suicide] is low.”

And assess coping strategies. “You can say, ‘I see you’re really going through a lot. I worry that these thoughts will come up in school. What do you think you’d do in the moment if these thoughts come up?’ If there’s a coping strategy — for example, ‘I’d talk to my friend during lunch’ — that’s also reassuring,” Crawford said.

Of course, that doesn’t mean the statement should be ignored or dismissed. Rather, it informs the next preventive steps and how intensive the level of care should be.
 

Next Steps: Involving the Family, Getting Help

It’s particularly concerning if the child is unable to identify strategies other than suicide, said Crawford. “You can say, ‘I’m concerned because it’s highly likely that you’ll run into this guy and I wouldn’t want you to die. You have so much to live for.’”

Then, you can ask if it’s okay to bring in the parent or caregiver to talk about what the child just revealed. “If the kid says no — especially a teen — you can respond, ‘I hear what you’re saying, but I actually do have to bring your parent in because of your safety and we can discuss together how to keep you safe.’”

In advance, Crawford tells the patient what she plans to share with the parent. “That way, we’re on the same page and the kid has a sense of agency about how the conversation with the parent will go.” If the teen doesn’t want certain information revealed, “you can ask, ‘What would you leave out, and why?’ This lends itself to a helpful conversation about what the child is thinking about.”

Once the provider has received the green light, it’s time to bring the parent into the room. “Especially in the primary care or pediatric setting, the parent is often shocked, worried, and caught off-guard,” Crawford said.

“You can start by thanking the patient for being open and honest. Then you can tell the parent, ‘Your daughter shared she’s been having some difficult emotions and experiences, and she’s thought of ending her life because she doesn’t know how to cope. I wanted to talk to you about this because it’s important to look at resources we can connect her to and effective coping strategies.’”

Further interventions can include referring the patient to a child psychiatrist or therapist, or both. “Have a list of referrals readily available,” Greydanus advised. If you suspect or if the child reveals abuse, you’re a mandated reporter and need to inform Child Protective Services (CPS). “But don’t stop there,” he warned. “Make sure the child is indeed getting help through CPS and appropriate intervention has been taken regarding the abuse and potential suicide attempt.” Or you may send the child to the ED, where ED physicians are “trained in what to do if they suspect abuse. But make sure that when you ‘throw the ball,’ there’s someone who can ‘catch’ it and accept responsibility for the child’s safety.”

Crawford noted that many primary care settings — especially in under-resourced areas — lack child psychiatrists or therapists. “You need to know what’s feasible in the community you’re practicing in,” she advised. “Be aware of the local crisis line — 988 — and mental health resources in the school and community. There are often school psychologists, social workers, or counselors who can become involved.”

Greydanus emphasized that it’s critical to assess for the presence of firearms in the home and address it with the parents. “If a child is sad or angry and gets impulsive, it’s amazingly common for them to get their hands in a firearm and use it.”

As previously reported, pediatricians and other healthcare providers have a valuable role to play in screening parents for firearm ownership and offering counseling on safe storage practices, according to research presented on September 28 at the AAP 2024 National Conference.
 

Sometimes, Even the Best Efforts Aren’t Successful

“Suicide is complicated, and parents or doctors can take all the ‘right’ steps to get counseling for the child — hospitalization, medication, and support — and children might still take their lives,” said Ronnie Susan Walker, MS, LCPC, founder and executive director of Alliance of Hope for Suicide Loss Survivors. The organization was launched as a “postvention campaign” 7 years ago to provide support to survivors of suicide loss, who are themselves a high-risk population for suicide.

Walker alluded to the concept of a “ suicide trance” — a term coined by Richard Heckler, PhD, in his book Waking Up, Alive. This trance “is a state of mind and body that receives only the kind of input that reinforces the pain and corroborates the person’s conviction that the only way out is through death,” Heckler wrote.

Walker, whose stepson died by suicide, said physicians and other healthcare professionals who have lost a patient to suicide “should focus on postvention — finding support from other professionals and managing their own grief and guilt.”

It’s natural to feel guilt and second-guess yourself, Greydanus said. “You question whether you missed something or could have done more, so acknowledge that even with the best care and intentions, some suicides aren’t preventable,” he said.

Walker recommends reaching out to the family. “When I lost my stepson, his doctor came to the funeral and wrote us a very meaningful note. That meant so much to us.”

Greydanus agreed it’s appropriate for the clinician to offer comfort to the family “if he or she feels it necessary or feels moved to do so.” However, he cautioned, there’s “often a fear of malpractice charges that may interfere in certain cases.”

Egger added that records should always be “very detailed,” with clear documentation of how you interacted with the child and the rationale behind your interventions. “I’m not a legal expert, but I would always err on the side of connecting with family and sharing grief and compassion. My experience with physician-patient relationships is that the more connected, transparent, and empathetic they are, the better the outcome will be for everyone.”

Losing a patient to suicide is traumatic, so give yourself time to grieve, Egger advised. “Unfortunately, this is an experience that almost everyone in the field will likely go through at some point. Reach out for professional counseling or peer support.”

Physicians who have lost a patient to suicide may turn to an online forum, the Coalition of Clinician Survivors, designed to create a safe anonymous space for discussion, education, testimonials, and one-on-one support.

Greydanus emphasized that the most important role in working with suicidal youngsters is to provide hope. “Yes, you can’t help everyone, but you can help most of them. That’s why you’re there.”

Greydanus, Crawford, Egger, Edson, Smalley, and Walker reported no financial conflicts of interest.
 

A version of this article appeared on Medscape.com.

With tens of millions of Euros in the offing, researchers across the European Union have eagerly taken up the gauntlet to find novel interventions for difficult-to-treat mental health and pain conditions. Their target is psychedelics, including classic compounds like psilocybin and atypical ones like ketamine and MDMA. Some of these still carry a stigma as party drugs and spiritual gateways to holotropic experiences.

Twelve groups make up the European College of Neuropsychopharmacology’s psychedelic research network. Along with several affiliates, the groups span nine countries (Denmark, Sweden, Finland, Switzerland, Germany, the Netherlands, the Czech Republic, Greece, and the United Kingdom) and are focused on the use of psychedelic compounds as potential treatments for psychiatric conditions like treatment-resistant depression, addiction, attention-deficit/hyperactivity disorder, anorexia, and obsessive-compulsive disorder.

One of the largest endeavors is PsyPal, a 4-year, randomized controlled trial investigating the potential of psilocybin for treating psychological distress in palliative care patients with life-limiting conditions. PsyPal is the first multisite clinical trial funded by the European Union to explore psychedelic-assisted therapy.

At PsyPal’s helm is Robert Schoevers, MD, PhD, professor of psychiatry and Department Head at University Medical Center Groningen (UMCG), Groningen, the Netherlands, a major hub for psychedelic research.

Schoevers is a bit of a pioneer who said he entered psychedelic research somewhat reluctantly. A decade ago, a colleague showed him a few papers on ketamine and depression. Because UMCG has a large population of patients with treatment-resistant depression, he agreed to do a pilot study. Since then, he has put together an interdisciplinary team of 25 researchers, published numerous papers, and currently has seven studies, including PsyPal, in various stages of progress.

Schoevers is also building a large national consortium that aims to investigate and, if shown effective, implement novel psychiatry treatments much more rapidly and efficiently than current drug development and approval processes, which can take 12 years or longer. He has just secured millions in government funding to start this process.

Next year, Schoevers and his team will decide to test either MDMA for posttraumatic stress disorder (PTSD) or psilocybin for depression in a large clinical trial, with the aim of getting a treatment as near to formal registration as possible. This will involve working with the European Medicines Agency and its Dutch counterpart, talking to experts who are familiar with the US Food and Drug Administration’s rejection of Lykos Therapeutics’ MDMA treatment for PTSD, and working directly with patients through the National Patient Alliance. The team is also talking to insurers and pharma companies.

The ultimate goal is to “see if we can build a platform in the Netherlands that would have a European perspective, serve as a point of entry for researchers with good ideas, and [attract] public funding as well as companies who have interesting compounds we think would be worthwhile to study,” Schoevers said.

His multiple endeavors emphasize a transdisciplinary and transdiagnostic approach he has been honing for decades. He and his colleagues are investigating the clinical, psychological, and neurobiological parallels between different treatment- resistant conditions and seeking to understand how contextual factors might influence patients, experiences, and outcomes.
 

Connecting the Dots

Jens H. van Dalfsen, PhD, a postdoctoral researcher in biological psychiatry, is the principal investigator of another UMCG group looking into the neurobiological mechanisms of major depressive disorder and treatment-resistant depression. His team’s strategy entails an elaborate coordination between the preclinical and clinical research settings.

For example, Sarah Massetti, a PhD candidate in biological psychiatry, is using blood samples collected in clinical trials to investigate the molecular mechanisms underpinning the neuroplasticity and immune-modulating effects produced by psychedelic compounds.

Another line of research spearheaded by Rutger Boesjes, a PhD candidate in biological psychiatry, is exploring the interactions between drugs like ketamine and the circadian system and how they might relate to antidepressant responses in animal models. It could be that the timing of administration of these drugs is relevant, he explained.
 

The Patient Factor

How psychedelics work and in whom is a big question for the UMCG team and across the research landscape.

“When researchers and the general public talk about psychedelics, they frequently refer to how they promote synaptic plasticity and new connections in the brain,” said van Dalfsen. “But traditional compounds also do that. So the ultimate question that we’ve been exploring is whether findings reflect an actual pharmacological effect or if expectancy also plays a role. In other words: How can we explain why psychedelics might or might not be effective in treatment-resistant patients?” he explained.

This is where the connection to the clinical experience becomes paramount and Joost Breeksema, PhD, comes in.

Breeksema divides his time between UMCG research and his role as executive director and co-founder of the Open Foundation, a nonprofit dedicated to advancing scientific psychedelic research. The work he’s doing outside the university is helping to frame the investigations of the wider group.

So far he has conducted two qualitative studies.

One was an off-label study in which patients with treatment-resistant depression were administered esketamine.

The other was a randomized clinical trial in which participants were blinded to a single 10- or 25-mg dose of psilocybin versus a 1-mg psilocybin microdose placebo that is too small to invoke any effects.

A key insight was the degree to which participants were unprepared for the intensity of their experiences, especially with regards to ketamine. Breeksema said the sessions might not have been so intense or negative for some participants had they been informed beforehand to expect the drugs could provoke “quite overwhelming experiences” and had they been accompanied by an experienced guide providing reassurance and support.

The format for the psilocybin trial met part of this criteria. Participants received a micro (placebo), medium, or high dose in a single session accompanied by two trained therapists. They then engaged in two sessions afterward to process their experiences. A single psilocybin experience appeared to be not enough or too much depending on the dose they were assigned and if they had prior experience with the compound.

Trial participants also felt they needed more help making sense of the experience. “This is a common and important theme,” said Breeksema. “Think about it. If you’ve been depressed for 10, 15 years and … you uncover something and break through something that’s been stuck, you need to process it.”

Jeanine Kamphuis, PhD, a psychiatrist and senior researcher at UMCG and one of the trial study co-authors, explained that they want to find a way to identify who will be too overwhelmed by these experiences if the dose should be adjusted or if some time needs to pass between dosing sessions. They also want to spend more time preparing patients for these sessions.

She emphasized that the studies have provided a reality check. “These are not wonder pills or wonder experiences. And in these types of patients, they’re not intended for a personal growth experience,” she said. “You have a patient who is sitting in front of you who seeks therapy and relief from very severe mood complaints, and the suffering is high,” she said, adding that expectancy bias further complicates patient participation and, likely, outcomes.
 

The Challenges

For all the potential and opportunity that psychedelics may hold for treatment, UMCG’s work has underscored some challenges.

The field of psychedelic research is characterized by methodological issues, explained van Dalfsen, such as blinding, expectancy, and overestimation of treatment effects. When looking at efficacy, “Is it the compound or the expectancy and promise? This is why it’s important to study how the drugs differ from each other in their biological effects and why they are or are not effective,” he said.

The team has also experienced issues with trial recruitment.

Martijn Godschalk, MD, a PhD candidate in psychiatry, has been addressing this problem while working on RESET-TRD, a phase 3, randomized controlled trial comparing an oral esketamine drink with electroconvulsive therapy in patients with treatment-resistant depression.

He’s been coordinating with local university hospitals, general hospitals, and municipal healthcare clinics to meet inclusion criteria and ensure the trial has enough power to demonstrate effectiveness. In turn, these sites are able to participate in a trial they wouldn’t normally be involved in due to lack of resources.

But Godschalk said he was concerned that many patients have gotten wind of the hype surrounding psychedelic treatments within psychiatry — a factor that has contributed to recruitment challenges. “There are a lot of patients who are interested in the non-registered drug and don’t necessarily have an interest in the other [control] arm,” he said.

Despite the challenges, the classic psychedelics such as MDMA and psilocybin “seem to catalyze a psychological process that may be harder to get with regular psychotherapies,” said Schoevers.

He remains cautious, noting there are still unanswered questions, such as who are the best candidates for these drugs and whether they might cause harm in certain patients while benefiting others. “I do think that this is the first time in 20 or 30 years that there is a group of potential treatments that would really make a difference.”

Schoevers received grants and other funding from The Netherlands Organisation for Health Research & Development, Horizon 2020, Horizon 2023, the National Institute of Mental Health (USA), UMCG, Stichting tot Steun VCVGZ, Nationaal programma Groningen, Healthcare Innovation Funds, Janssen Pharmaceuticals, Novartis, Compass Pathways, Clexio Biosciences, and GH research.
 

A version of this article appeared on Medscape.com.

With tens of millions of Euros in the offing, researchers across the European Union have eagerly taken up the gauntlet to find novel interventions for difficult-to-treat mental health and pain conditions. Their target is psychedelics, including classic compounds like psilocybin and atypical ones like ketamine and MDMA. Some of these still carry a stigma as party drugs and spiritual gateways to holotropic experiences.

Twelve groups make up the European College of Neuropsychopharmacology’s psychedelic research network. Along with several affiliates, the groups span nine countries (Denmark, Sweden, Finland, Switzerland, Germany, the Netherlands, the Czech Republic, Greece, and the United Kingdom) and are focused on the use of psychedelic compounds as potential treatments for psychiatric conditions like treatment-resistant depression, addiction, attention-deficit/hyperactivity disorder, anorexia, and obsessive-compulsive disorder.

One of the largest endeavors is PsyPal, a 4-year, randomized controlled trial investigating the potential of psilocybin for treating psychological distress in palliative care patients with life-limiting conditions. PsyPal is the first multisite clinical trial funded by the European Union to explore psychedelic-assisted therapy.

At PsyPal’s helm is Robert Schoevers, MD, PhD, professor of psychiatry and Department Head at University Medical Center Groningen (UMCG), Groningen, the Netherlands, a major hub for psychedelic research.

Schoevers is a bit of a pioneer who said he entered psychedelic research somewhat reluctantly. A decade ago, a colleague showed him a few papers on ketamine and depression. Because UMCG has a large population of patients with treatment-resistant depression, he agreed to do a pilot study. Since then, he has put together an interdisciplinary team of 25 researchers, published numerous papers, and currently has seven studies, including PsyPal, in various stages of progress.

Schoevers is also building a large national consortium that aims to investigate and, if shown effective, implement novel psychiatry treatments much more rapidly and efficiently than current drug development and approval processes, which can take 12 years or longer. He has just secured millions in government funding to start this process.

Next year, Schoevers and his team will decide to test either MDMA for posttraumatic stress disorder (PTSD) or psilocybin for depression in a large clinical trial, with the aim of getting a treatment as near to formal registration as possible. This will involve working with the European Medicines Agency and its Dutch counterpart, talking to experts who are familiar with the US Food and Drug Administration’s rejection of Lykos Therapeutics’ MDMA treatment for PTSD, and working directly with patients through the National Patient Alliance. The team is also talking to insurers and pharma companies.

The ultimate goal is to “see if we can build a platform in the Netherlands that would have a European perspective, serve as a point of entry for researchers with good ideas, and [attract] public funding as well as companies who have interesting compounds we think would be worthwhile to study,” Schoevers said.

His multiple endeavors emphasize a transdisciplinary and transdiagnostic approach he has been honing for decades. He and his colleagues are investigating the clinical, psychological, and neurobiological parallels between different treatment- resistant conditions and seeking to understand how contextual factors might influence patients, experiences, and outcomes.
 

Connecting the Dots

Jens H. van Dalfsen, PhD, a postdoctoral researcher in biological psychiatry, is the principal investigator of another UMCG group looking into the neurobiological mechanisms of major depressive disorder and treatment-resistant depression. His team’s strategy entails an elaborate coordination between the preclinical and clinical research settings.

For example, Sarah Massetti, a PhD candidate in biological psychiatry, is using blood samples collected in clinical trials to investigate the molecular mechanisms underpinning the neuroplasticity and immune-modulating effects produced by psychedelic compounds.

Another line of research spearheaded by Rutger Boesjes, a PhD candidate in biological psychiatry, is exploring the interactions between drugs like ketamine and the circadian system and how they might relate to antidepressant responses in animal models. It could be that the timing of administration of these drugs is relevant, he explained.
 

The Patient Factor

How psychedelics work and in whom is a big question for the UMCG team and across the research landscape.

“When researchers and the general public talk about psychedelics, they frequently refer to how they promote synaptic plasticity and new connections in the brain,” said van Dalfsen. “But traditional compounds also do that. So the ultimate question that we’ve been exploring is whether findings reflect an actual pharmacological effect or if expectancy also plays a role. In other words: How can we explain why psychedelics might or might not be effective in treatment-resistant patients?” he explained.

This is where the connection to the clinical experience becomes paramount and Joost Breeksema, PhD, comes in.

Breeksema divides his time between UMCG research and his role as executive director and co-founder of the Open Foundation, a nonprofit dedicated to advancing scientific psychedelic research. The work he’s doing outside the university is helping to frame the investigations of the wider group.

So far he has conducted two qualitative studies.

One was an off-label study in which patients with treatment-resistant depression were administered esketamine.

The other was a randomized clinical trial in which participants were blinded to a single 10- or 25-mg dose of psilocybin versus a 1-mg psilocybin microdose placebo that is too small to invoke any effects.

A key insight was the degree to which participants were unprepared for the intensity of their experiences, especially with regards to ketamine. Breeksema said the sessions might not have been so intense or negative for some participants had they been informed beforehand to expect the drugs could provoke “quite overwhelming experiences” and had they been accompanied by an experienced guide providing reassurance and support.

The format for the psilocybin trial met part of this criteria. Participants received a micro (placebo), medium, or high dose in a single session accompanied by two trained therapists. They then engaged in two sessions afterward to process their experiences. A single psilocybin experience appeared to be not enough or too much depending on the dose they were assigned and if they had prior experience with the compound.

Trial participants also felt they needed more help making sense of the experience. “This is a common and important theme,” said Breeksema. “Think about it. If you’ve been depressed for 10, 15 years and … you uncover something and break through something that’s been stuck, you need to process it.”

Jeanine Kamphuis, PhD, a psychiatrist and senior researcher at UMCG and one of the trial study co-authors, explained that they want to find a way to identify who will be too overwhelmed by these experiences if the dose should be adjusted or if some time needs to pass between dosing sessions. They also want to spend more time preparing patients for these sessions.

She emphasized that the studies have provided a reality check. “These are not wonder pills or wonder experiences. And in these types of patients, they’re not intended for a personal growth experience,” she said. “You have a patient who is sitting in front of you who seeks therapy and relief from very severe mood complaints, and the suffering is high,” she said, adding that expectancy bias further complicates patient participation and, likely, outcomes.
 

The Challenges

For all the potential and opportunity that psychedelics may hold for treatment, UMCG’s work has underscored some challenges.

The field of psychedelic research is characterized by methodological issues, explained van Dalfsen, such as blinding, expectancy, and overestimation of treatment effects. When looking at efficacy, “Is it the compound or the expectancy and promise? This is why it’s important to study how the drugs differ from each other in their biological effects and why they are or are not effective,” he said.

The team has also experienced issues with trial recruitment.

Martijn Godschalk, MD, a PhD candidate in psychiatry, has been addressing this problem while working on RESET-TRD, a phase 3, randomized controlled trial comparing an oral esketamine drink with electroconvulsive therapy in patients with treatment-resistant depression.

He’s been coordinating with local university hospitals, general hospitals, and municipal healthcare clinics to meet inclusion criteria and ensure the trial has enough power to demonstrate effectiveness. In turn, these sites are able to participate in a trial they wouldn’t normally be involved in due to lack of resources.

But Godschalk said he was concerned that many patients have gotten wind of the hype surrounding psychedelic treatments within psychiatry — a factor that has contributed to recruitment challenges. “There are a lot of patients who are interested in the non-registered drug and don’t necessarily have an interest in the other [control] arm,” he said.

Despite the challenges, the classic psychedelics such as MDMA and psilocybin “seem to catalyze a psychological process that may be harder to get with regular psychotherapies,” said Schoevers.

He remains cautious, noting there are still unanswered questions, such as who are the best candidates for these drugs and whether they might cause harm in certain patients while benefiting others. “I do think that this is the first time in 20 or 30 years that there is a group of potential treatments that would really make a difference.”

Schoevers received grants and other funding from The Netherlands Organisation for Health Research & Development, Horizon 2020, Horizon 2023, the National Institute of Mental Health (USA), UMCG, Stichting tot Steun VCVGZ, Nationaal programma Groningen, Healthcare Innovation Funds, Janssen Pharmaceuticals, Novartis, Compass Pathways, Clexio Biosciences, and GH research.
 

A version of this article appeared on Medscape.com.

With tens of millions of Euros in the offing, researchers across the European Union have eagerly taken up the gauntlet to find novel interventions for difficult-to-treat mental health and pain conditions. Their target is psychedelics, including classic compounds like psilocybin and atypical ones like ketamine and MDMA. Some of these still carry a stigma as party drugs and spiritual gateways to holotropic experiences.

Twelve groups make up the European College of Neuropsychopharmacology’s psychedelic research network. Along with several affiliates, the groups span nine countries (Denmark, Sweden, Finland, Switzerland, Germany, the Netherlands, the Czech Republic, Greece, and the United Kingdom) and are focused on the use of psychedelic compounds as potential treatments for psychiatric conditions like treatment-resistant depression, addiction, attention-deficit/hyperactivity disorder, anorexia, and obsessive-compulsive disorder.

One of the largest endeavors is PsyPal, a 4-year, randomized controlled trial investigating the potential of psilocybin for treating psychological distress in palliative care patients with life-limiting conditions. PsyPal is the first multisite clinical trial funded by the European Union to explore psychedelic-assisted therapy.

At PsyPal’s helm is Robert Schoevers, MD, PhD, professor of psychiatry and Department Head at University Medical Center Groningen (UMCG), Groningen, the Netherlands, a major hub for psychedelic research.

Schoevers is a bit of a pioneer who said he entered psychedelic research somewhat reluctantly. A decade ago, a colleague showed him a few papers on ketamine and depression. Because UMCG has a large population of patients with treatment-resistant depression, he agreed to do a pilot study. Since then, he has put together an interdisciplinary team of 25 researchers, published numerous papers, and currently has seven studies, including PsyPal, in various stages of progress.

Schoevers is also building a large national consortium that aims to investigate and, if shown effective, implement novel psychiatry treatments much more rapidly and efficiently than current drug development and approval processes, which can take 12 years or longer. He has just secured millions in government funding to start this process.

Next year, Schoevers and his team will decide to test either MDMA for posttraumatic stress disorder (PTSD) or psilocybin for depression in a large clinical trial, with the aim of getting a treatment as near to formal registration as possible. This will involve working with the European Medicines Agency and its Dutch counterpart, talking to experts who are familiar with the US Food and Drug Administration’s rejection of Lykos Therapeutics’ MDMA treatment for PTSD, and working directly with patients through the National Patient Alliance. The team is also talking to insurers and pharma companies.

The ultimate goal is to “see if we can build a platform in the Netherlands that would have a European perspective, serve as a point of entry for researchers with good ideas, and [attract] public funding as well as companies who have interesting compounds we think would be worthwhile to study,” Schoevers said.

His multiple endeavors emphasize a transdisciplinary and transdiagnostic approach he has been honing for decades. He and his colleagues are investigating the clinical, psychological, and neurobiological parallels between different treatment- resistant conditions and seeking to understand how contextual factors might influence patients, experiences, and outcomes.
 

Connecting the Dots

Jens H. van Dalfsen, PhD, a postdoctoral researcher in biological psychiatry, is the principal investigator of another UMCG group looking into the neurobiological mechanisms of major depressive disorder and treatment-resistant depression. His team’s strategy entails an elaborate coordination between the preclinical and clinical research settings.

For example, Sarah Massetti, a PhD candidate in biological psychiatry, is using blood samples collected in clinical trials to investigate the molecular mechanisms underpinning the neuroplasticity and immune-modulating effects produced by psychedelic compounds.

Another line of research spearheaded by Rutger Boesjes, a PhD candidate in biological psychiatry, is exploring the interactions between drugs like ketamine and the circadian system and how they might relate to antidepressant responses in animal models. It could be that the timing of administration of these drugs is relevant, he explained.
 

The Patient Factor

How psychedelics work and in whom is a big question for the UMCG team and across the research landscape.

“When researchers and the general public talk about psychedelics, they frequently refer to how they promote synaptic plasticity and new connections in the brain,” said van Dalfsen. “But traditional compounds also do that. So the ultimate question that we’ve been exploring is whether findings reflect an actual pharmacological effect or if expectancy also plays a role. In other words: How can we explain why psychedelics might or might not be effective in treatment-resistant patients?” he explained.

This is where the connection to the clinical experience becomes paramount and Joost Breeksema, PhD, comes in.

Breeksema divides his time between UMCG research and his role as executive director and co-founder of the Open Foundation, a nonprofit dedicated to advancing scientific psychedelic research. The work he’s doing outside the university is helping to frame the investigations of the wider group.

So far he has conducted two qualitative studies.

One was an off-label study in which patients with treatment-resistant depression were administered esketamine.

The other was a randomized clinical trial in which participants were blinded to a single 10- or 25-mg dose of psilocybin versus a 1-mg psilocybin microdose placebo that is too small to invoke any effects.

A key insight was the degree to which participants were unprepared for the intensity of their experiences, especially with regards to ketamine. Breeksema said the sessions might not have been so intense or negative for some participants had they been informed beforehand to expect the drugs could provoke “quite overwhelming experiences” and had they been accompanied by an experienced guide providing reassurance and support.

The format for the psilocybin trial met part of this criteria. Participants received a micro (placebo), medium, or high dose in a single session accompanied by two trained therapists. They then engaged in two sessions afterward to process their experiences. A single psilocybin experience appeared to be not enough or too much depending on the dose they were assigned and if they had prior experience with the compound.

Trial participants also felt they needed more help making sense of the experience. “This is a common and important theme,” said Breeksema. “Think about it. If you’ve been depressed for 10, 15 years and … you uncover something and break through something that’s been stuck, you need to process it.”

Jeanine Kamphuis, PhD, a psychiatrist and senior researcher at UMCG and one of the trial study co-authors, explained that they want to find a way to identify who will be too overwhelmed by these experiences if the dose should be adjusted or if some time needs to pass between dosing sessions. They also want to spend more time preparing patients for these sessions.

She emphasized that the studies have provided a reality check. “These are not wonder pills or wonder experiences. And in these types of patients, they’re not intended for a personal growth experience,” she said. “You have a patient who is sitting in front of you who seeks therapy and relief from very severe mood complaints, and the suffering is high,” she said, adding that expectancy bias further complicates patient participation and, likely, outcomes.
 

The Challenges

For all the potential and opportunity that psychedelics may hold for treatment, UMCG’s work has underscored some challenges.

The field of psychedelic research is characterized by methodological issues, explained van Dalfsen, such as blinding, expectancy, and overestimation of treatment effects. When looking at efficacy, “Is it the compound or the expectancy and promise? This is why it’s important to study how the drugs differ from each other in their biological effects and why they are or are not effective,” he said.

The team has also experienced issues with trial recruitment.

Martijn Godschalk, MD, a PhD candidate in psychiatry, has been addressing this problem while working on RESET-TRD, a phase 3, randomized controlled trial comparing an oral esketamine drink with electroconvulsive therapy in patients with treatment-resistant depression.

He’s been coordinating with local university hospitals, general hospitals, and municipal healthcare clinics to meet inclusion criteria and ensure the trial has enough power to demonstrate effectiveness. In turn, these sites are able to participate in a trial they wouldn’t normally be involved in due to lack of resources.

But Godschalk said he was concerned that many patients have gotten wind of the hype surrounding psychedelic treatments within psychiatry — a factor that has contributed to recruitment challenges. “There are a lot of patients who are interested in the non-registered drug and don’t necessarily have an interest in the other [control] arm,” he said.

Despite the challenges, the classic psychedelics such as MDMA and psilocybin “seem to catalyze a psychological process that may be harder to get with regular psychotherapies,” said Schoevers.

He remains cautious, noting there are still unanswered questions, such as who are the best candidates for these drugs and whether they might cause harm in certain patients while benefiting others. “I do think that this is the first time in 20 or 30 years that there is a group of potential treatments that would really make a difference.”

Schoevers received grants and other funding from The Netherlands Organisation for Health Research & Development, Horizon 2020, Horizon 2023, the National Institute of Mental Health (USA), UMCG, Stichting tot Steun VCVGZ, Nationaal programma Groningen, Healthcare Innovation Funds, Janssen Pharmaceuticals, Novartis, Compass Pathways, Clexio Biosciences, and GH research.
 

A version of this article appeared on Medscape.com.

The US Food and Drug Administration (FDA) has announced a voluntary manufacturer-initiated recall of more than 7000 bottles of duloxetine delayed-release capsules due to unacceptable levels of a potential carcinogen.

Duloxetine (Cymbalta) is a serotonin-norepinephrine reuptake inhibitor used to treat major depressive disorder, generalized anxiety disorder, fibromyalgia, chronic musculoskeletal pain, and neuropathic pain associated with diabetic peripheral neuropathy.

The recall is due to the detection of the nitrosamine impurity, N-nitroso duloxetine, above the proposed interim limit.

Nitrosamines are common in water and foods, and exposure to some levels of the chemical is common. Exposure to nitrosamine impurities above acceptable levels and over long periods may increase cancer risk, the FDA reported.

“If drugs contain levels of nitrosamines above the acceptable daily intake limits, FDA recommends these drugs be recalled by the manufacturer as appropriate,” the agency noted on its website.

The recall was initiated by Breckenridge Pharmaceutical and covers 7107 bottles of 500-count, 20 mg duloxetine delayed-release capsules. The drug is manufactured by Towa Pharmaceutical Europe and distributed nationwide by BPI.

The affected bottles are from lot number 220128 with an expiration date of 12/2024 and NDC of 51991-746-05.

The recall was initiated on October 10 and is ongoing.

“Healthcare professionals can educate patients about alternative treatment options to medications with potential nitrosamine impurities if available and clinically appropriate,” the FDA advises. “If a medication has been recalled, pharmacists may be able to dispense the same medication from a manufacturing lot that has not been recalled. Prescribers may also determine whether there is an alternative treatment option for patients.”

The FDA has labeled this a “class II” recall, which the agency defines as “a situation in which use of or exposure to a violative product may cause temporary or medically reversible adverse health consequences or where the probability of serious adverse health consequences is remote.”

Nitrosamine impurities have prompted a number of drug recalls in recent years, including oral anticoagulants, metformin, and skeletal muscle relaxants.

The impurities may be found in drugs for a number of reasons, the agency reported. The source may be from a drug’s manufacturing process, chemical structure, or the conditions under which it is stored or packaged.
 

A version of this article appeared on Medscape.com.

The US Food and Drug Administration (FDA) has announced a voluntary manufacturer-initiated recall of more than 7000 bottles of duloxetine delayed-release capsules due to unacceptable levels of a potential carcinogen.

Duloxetine (Cymbalta) is a serotonin-norepinephrine reuptake inhibitor used to treat major depressive disorder, generalized anxiety disorder, fibromyalgia, chronic musculoskeletal pain, and neuropathic pain associated with diabetic peripheral neuropathy.

The recall is due to the detection of the nitrosamine impurity, N-nitroso duloxetine, above the proposed interim limit.

Nitrosamines are common in water and foods, and exposure to some levels of the chemical is common. Exposure to nitrosamine impurities above acceptable levels and over long periods may increase cancer risk, the FDA reported.

“If drugs contain levels of nitrosamines above the acceptable daily intake limits, FDA recommends these drugs be recalled by the manufacturer as appropriate,” the agency noted on its website.

The recall was initiated by Breckenridge Pharmaceutical and covers 7107 bottles of 500-count, 20 mg duloxetine delayed-release capsules. The drug is manufactured by Towa Pharmaceutical Europe and distributed nationwide by BPI.

The affected bottles are from lot number 220128 with an expiration date of 12/2024 and NDC of 51991-746-05.

The recall was initiated on October 10 and is ongoing.

“Healthcare professionals can educate patients about alternative treatment options to medications with potential nitrosamine impurities if available and clinically appropriate,” the FDA advises. “If a medication has been recalled, pharmacists may be able to dispense the same medication from a manufacturing lot that has not been recalled. Prescribers may also determine whether there is an alternative treatment option for patients.”

The FDA has labeled this a “class II” recall, which the agency defines as “a situation in which use of or exposure to a violative product may cause temporary or medically reversible adverse health consequences or where the probability of serious adverse health consequences is remote.”

Nitrosamine impurities have prompted a number of drug recalls in recent years, including oral anticoagulants, metformin, and skeletal muscle relaxants.

The impurities may be found in drugs for a number of reasons, the agency reported. The source may be from a drug’s manufacturing process, chemical structure, or the conditions under which it is stored or packaged.
 

A version of this article appeared on Medscape.com.

The US Food and Drug Administration (FDA) has announced a voluntary manufacturer-initiated recall of more than 7000 bottles of duloxetine delayed-release capsules due to unacceptable levels of a potential carcinogen.

Duloxetine (Cymbalta) is a serotonin-norepinephrine reuptake inhibitor used to treat major depressive disorder, generalized anxiety disorder, fibromyalgia, chronic musculoskeletal pain, and neuropathic pain associated with diabetic peripheral neuropathy.

The recall is due to the detection of the nitrosamine impurity, N-nitroso duloxetine, above the proposed interim limit.

Nitrosamines are common in water and foods, and exposure to some levels of the chemical is common. Exposure to nitrosamine impurities above acceptable levels and over long periods may increase cancer risk, the FDA reported.

“If drugs contain levels of nitrosamines above the acceptable daily intake limits, FDA recommends these drugs be recalled by the manufacturer as appropriate,” the agency noted on its website.

The recall was initiated by Breckenridge Pharmaceutical and covers 7107 bottles of 500-count, 20 mg duloxetine delayed-release capsules. The drug is manufactured by Towa Pharmaceutical Europe and distributed nationwide by BPI.

The affected bottles are from lot number 220128 with an expiration date of 12/2024 and NDC of 51991-746-05.

The recall was initiated on October 10 and is ongoing.

“Healthcare professionals can educate patients about alternative treatment options to medications with potential nitrosamine impurities if available and clinically appropriate,” the FDA advises. “If a medication has been recalled, pharmacists may be able to dispense the same medication from a manufacturing lot that has not been recalled. Prescribers may also determine whether there is an alternative treatment option for patients.”

The FDA has labeled this a “class II” recall, which the agency defines as “a situation in which use of or exposure to a violative product may cause temporary or medically reversible adverse health consequences or where the probability of serious adverse health consequences is remote.”

Nitrosamine impurities have prompted a number of drug recalls in recent years, including oral anticoagulants, metformin, and skeletal muscle relaxants.

The impurities may be found in drugs for a number of reasons, the agency reported. The source may be from a drug’s manufacturing process, chemical structure, or the conditions under which it is stored or packaged.
 

A version of this article appeared on Medscape.com.

About 7 of every 10 veterans who die by suicide involve the use of a firearm. A reason for this high rate is access, as half of veterans report owning ≥ 1 personal firearms. Of those individuals, more than half report storing firearms loaded and/or unsecured and one-third of veterans who store their firearms loaded and unlocked do not own a lockbox or safe. 

Suicide death prevention has improved as firearms have become more difficult to obtain. That’s why Navy veteran Rep. Chris Deluzio (D-PA), former FBI Special Agent and federal prosecutor Rep. Brian Fitzpatrick (R-PA), and Rep. Greg Landsman (D-OH) have teamed up to introduce the Saving Our Veterans Lives Act of 2024. Under the proposed act, any veteran would be able to get a free lockbox from the US Department of Veterans Affairs (VA).

Suicidal crises can be brief. According to the VA, if a person experiencing a suicidal crisis can’t access the method they planned to use, they generally do not seek out other lethal means. Lockboxes are a way of “putting space between thought and trigger,” the VA said.

The VA Suicide Prevention Program distributes free firearm cable locks to any veteran who requests one. However, many veterans favor lockboxes and safes to secure their guns. A VA pilot program offers free lockboxes to veterans enrolled in the Veterans Health Administration who are at an elevated risk for suicide. The program is set to launch in late 2024 and is a collaboration between the Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, VA National Prosthetics Service, and VA Office of Suicide Prevention.

The proposed bill would make the lockboxes (which typically cost between $25 and $350) free to any veteran, regardless of VA enrollment status or diagnosis. It ensures “sufficient funding for many tens of thousands of lockboxes to be distributed.” The bill would also direct the VA to create a public education campaign on the availability of lockboxes and the importance of secure firearm storage in suicide prevention.

“The alarming and tragic reality is that our veterans face a suicide rate 57% higher than that of civilians,” Rep. Fitzpatrick said. “This commonsense, bipartisan initiative is more than a solution—it's a lifeline.”

The representatives report that the bill has been endorsed by an “unprecedented” number of organizations, including the National Shooting Sports Foundation, Disabled American Veterans, The American Legion, GIFFORDS, Everytown for Gun Safety, Brady, American Psychological Association, American Foundation for Suicide Prevention, and Association of VA Psychologist Leaders.

“Did you know that in some cases only 10 minutes elapse between an individual having suicidal ideation and acting?” American Legion National Commander James LaCoursiere said in the representatives’ press release. “The Saving Our Veterans Lives Act is an important part of preventing suicide as it will provide veterans with the information and means to securely store their firearms to prevent suicide, while still protecting their Second Amendment rights. The Legion commends Rep. Deluzio and his team for bringing this bill forward and for their continued dedication to the welfare of our nation’s veterans.” 

"I hear colleagues all the time talk about veteran suicide," Rep. Deluzio said in an interview with Military.com. "It is a problem in my community. It's a problem across the country. Let's take action. This is a chance where we can do it that I think can cut through the politics that normally divide us on these [gun] issues. And I think the coalition supporting the bill tells you, we've got a path to pass it."

About 7 of every 10 veterans who die by suicide involve the use of a firearm. A reason for this high rate is access, as half of veterans report owning ≥ 1 personal firearms. Of those individuals, more than half report storing firearms loaded and/or unsecured and one-third of veterans who store their firearms loaded and unlocked do not own a lockbox or safe. 

Suicide death prevention has improved as firearms have become more difficult to obtain. That’s why Navy veteran Rep. Chris Deluzio (D-PA), former FBI Special Agent and federal prosecutor Rep. Brian Fitzpatrick (R-PA), and Rep. Greg Landsman (D-OH) have teamed up to introduce the Saving Our Veterans Lives Act of 2024. Under the proposed act, any veteran would be able to get a free lockbox from the US Department of Veterans Affairs (VA).

Suicidal crises can be brief. According to the VA, if a person experiencing a suicidal crisis can’t access the method they planned to use, they generally do not seek out other lethal means. Lockboxes are a way of “putting space between thought and trigger,” the VA said.

The VA Suicide Prevention Program distributes free firearm cable locks to any veteran who requests one. However, many veterans favor lockboxes and safes to secure their guns. A VA pilot program offers free lockboxes to veterans enrolled in the Veterans Health Administration who are at an elevated risk for suicide. The program is set to launch in late 2024 and is a collaboration between the Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, VA National Prosthetics Service, and VA Office of Suicide Prevention.

The proposed bill would make the lockboxes (which typically cost between $25 and $350) free to any veteran, regardless of VA enrollment status or diagnosis. It ensures “sufficient funding for many tens of thousands of lockboxes to be distributed.” The bill would also direct the VA to create a public education campaign on the availability of lockboxes and the importance of secure firearm storage in suicide prevention.

“The alarming and tragic reality is that our veterans face a suicide rate 57% higher than that of civilians,” Rep. Fitzpatrick said. “This commonsense, bipartisan initiative is more than a solution—it's a lifeline.”

The representatives report that the bill has been endorsed by an “unprecedented” number of organizations, including the National Shooting Sports Foundation, Disabled American Veterans, The American Legion, GIFFORDS, Everytown for Gun Safety, Brady, American Psychological Association, American Foundation for Suicide Prevention, and Association of VA Psychologist Leaders.

“Did you know that in some cases only 10 minutes elapse between an individual having suicidal ideation and acting?” American Legion National Commander James LaCoursiere said in the representatives’ press release. “The Saving Our Veterans Lives Act is an important part of preventing suicide as it will provide veterans with the information and means to securely store their firearms to prevent suicide, while still protecting their Second Amendment rights. The Legion commends Rep. Deluzio and his team for bringing this bill forward and for their continued dedication to the welfare of our nation’s veterans.” 

"I hear colleagues all the time talk about veteran suicide," Rep. Deluzio said in an interview with Military.com. "It is a problem in my community. It's a problem across the country. Let's take action. This is a chance where we can do it that I think can cut through the politics that normally divide us on these [gun] issues. And I think the coalition supporting the bill tells you, we've got a path to pass it."

About 7 of every 10 veterans who die by suicide involve the use of a firearm. A reason for this high rate is access, as half of veterans report owning ≥ 1 personal firearms. Of those individuals, more than half report storing firearms loaded and/or unsecured and one-third of veterans who store their firearms loaded and unlocked do not own a lockbox or safe. 

Suicide death prevention has improved as firearms have become more difficult to obtain. That’s why Navy veteran Rep. Chris Deluzio (D-PA), former FBI Special Agent and federal prosecutor Rep. Brian Fitzpatrick (R-PA), and Rep. Greg Landsman (D-OH) have teamed up to introduce the Saving Our Veterans Lives Act of 2024. Under the proposed act, any veteran would be able to get a free lockbox from the US Department of Veterans Affairs (VA).

Suicidal crises can be brief. According to the VA, if a person experiencing a suicidal crisis can’t access the method they planned to use, they generally do not seek out other lethal means. Lockboxes are a way of “putting space between thought and trigger,” the VA said.

The VA Suicide Prevention Program distributes free firearm cable locks to any veteran who requests one. However, many veterans favor lockboxes and safes to secure their guns. A VA pilot program offers free lockboxes to veterans enrolled in the Veterans Health Administration who are at an elevated risk for suicide. The program is set to launch in late 2024 and is a collaboration between the Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, VA National Prosthetics Service, and VA Office of Suicide Prevention.

The proposed bill would make the lockboxes (which typically cost between $25 and $350) free to any veteran, regardless of VA enrollment status or diagnosis. It ensures “sufficient funding for many tens of thousands of lockboxes to be distributed.” The bill would also direct the VA to create a public education campaign on the availability of lockboxes and the importance of secure firearm storage in suicide prevention.

“The alarming and tragic reality is that our veterans face a suicide rate 57% higher than that of civilians,” Rep. Fitzpatrick said. “This commonsense, bipartisan initiative is more than a solution—it's a lifeline.”

The representatives report that the bill has been endorsed by an “unprecedented” number of organizations, including the National Shooting Sports Foundation, Disabled American Veterans, The American Legion, GIFFORDS, Everytown for Gun Safety, Brady, American Psychological Association, American Foundation for Suicide Prevention, and Association of VA Psychologist Leaders.

“Did you know that in some cases only 10 minutes elapse between an individual having suicidal ideation and acting?” American Legion National Commander James LaCoursiere said in the representatives’ press release. “The Saving Our Veterans Lives Act is an important part of preventing suicide as it will provide veterans with the information and means to securely store their firearms to prevent suicide, while still protecting their Second Amendment rights. The Legion commends Rep. Deluzio and his team for bringing this bill forward and for their continued dedication to the welfare of our nation’s veterans.” 

"I hear colleagues all the time talk about veteran suicide," Rep. Deluzio said in an interview with Military.com. "It is a problem in my community. It's a problem across the country. Let's take action. This is a chance where we can do it that I think can cut through the politics that normally divide us on these [gun] issues. And I think the coalition supporting the bill tells you, we've got a path to pass it."

TOPLINE:

Patients with dry eye disease are more than three times as likely to have mental health conditions, such as depression and anxiety, as those without the condition.

METHODOLOGY:

• Researchers used a database from the National Institutes of Health to investigate the association between dry eye disease and mental health disorders in a large and diverse nationwide population of American adults.
• They identified 18,257 patients (mean age, 64.9 years; 67% women) with dry eye disease who were propensity score–matched with 54,765 participants without the condition.
• The cases of dry eye disease were identified using Systematized Nomenclature of Medicine codes for dry eyes, meibomian gland dysfunction, and tear film insufficiency.
• The outcome measures for mental health conditions were clinical diagnoses of depressive disorders, anxiety-related disorders, bipolar disorder, and schizophrenia spectrum disorders.

TAKEAWAY:

• Patients with dry eye disease had more than triple the risk for mental health conditions than participants without the condition (adjusted odds ratio [aOR], 3.21; P < .001).
• Patients with dry eye disease had a higher risk for a depressive disorder (aOR, 3.47), anxiety-related disorder (aOR, 2.74), bipolar disorder (aOR, 2.23), and schizophrenia spectrum disorder (aOR, 2.48; P < .001 for all) than participants without the condition.
• The associations between dry eye disease and mental health conditions were significantly stronger among Black individuals than among White individuals, except for bipolar disorder.
• Dry eye disease was associated with two- to threefold higher odds of depressive disorders, anxiety-related disorders, bipolar disorder, and schizophrenia spectrum disorders even in participants who never used medications for mental health (P < .001 for all).

IN PRACTICE:

“Greater efforts should be undertaken to screen patients with DED [dry eye disease] for mental health conditions, particularly in historically medically underserved populations,” the authors of the study wrote.

SOURCE:

This study was led by Aaron T. Zhao, of the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, and was published online on October 15, 2024, in the American Journal of Ophthalmology.

LIMITATIONS:

This study relied on electronic health record data, which may have led to the inclusion of participants with undiagnosed dry eye disease as control participants. Moreover, the study did not evaluate the severity of dry eye disease or the severity and duration of mental health conditions, which may have affected the results. The database analyzed in this study may not have fully captured the complete demographic profile of the nationwide population, which may have affected the generalizability of the findings.

DISCLOSURES:

This study was supported by funding from the National Institutes of Health and Research to Prevent Blindness. The authors declared having no conflicts of interest.

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

TOPLINE:

Patients with dry eye disease are more than three times as likely to have mental health conditions, such as depression and anxiety, as those without the condition.

METHODOLOGY:

• Researchers used a database from the National Institutes of Health to investigate the association between dry eye disease and mental health disorders in a large and diverse nationwide population of American adults.
• They identified 18,257 patients (mean age, 64.9 years; 67% women) with dry eye disease who were propensity score–matched with 54,765 participants without the condition.
• The cases of dry eye disease were identified using Systematized Nomenclature of Medicine codes for dry eyes, meibomian gland dysfunction, and tear film insufficiency.
• The outcome measures for mental health conditions were clinical diagnoses of depressive disorders, anxiety-related disorders, bipolar disorder, and schizophrenia spectrum disorders.

TAKEAWAY:

• Patients with dry eye disease had more than triple the risk for mental health conditions than participants without the condition (adjusted odds ratio [aOR], 3.21; P < .001).
• Patients with dry eye disease had a higher risk for a depressive disorder (aOR, 3.47), anxiety-related disorder (aOR, 2.74), bipolar disorder (aOR, 2.23), and schizophrenia spectrum disorder (aOR, 2.48; P < .001 for all) than participants without the condition.
• The associations between dry eye disease and mental health conditions were significantly stronger among Black individuals than among White individuals, except for bipolar disorder.
• Dry eye disease was associated with two- to threefold higher odds of depressive disorders, anxiety-related disorders, bipolar disorder, and schizophrenia spectrum disorders even in participants who never used medications for mental health (P < .001 for all).

IN PRACTICE:

“Greater efforts should be undertaken to screen patients with DED [dry eye disease] for mental health conditions, particularly in historically medically underserved populations,” the authors of the study wrote.

SOURCE:

This study was led by Aaron T. Zhao, of the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, and was published online on October 15, 2024, in the American Journal of Ophthalmology.

LIMITATIONS:

This study relied on electronic health record data, which may have led to the inclusion of participants with undiagnosed dry eye disease as control participants. Moreover, the study did not evaluate the severity of dry eye disease or the severity and duration of mental health conditions, which may have affected the results. The database analyzed in this study may not have fully captured the complete demographic profile of the nationwide population, which may have affected the generalizability of the findings.

DISCLOSURES:

This study was supported by funding from the National Institutes of Health and Research to Prevent Blindness. The authors declared having no conflicts of interest.

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

TOPLINE:

Patients with dry eye disease are more than three times as likely to have mental health conditions, such as depression and anxiety, as those without the condition.

METHODOLOGY:

• Researchers used a database from the National Institutes of Health to investigate the association between dry eye disease and mental health disorders in a large and diverse nationwide population of American adults.
• They identified 18,257 patients (mean age, 64.9 years; 67% women) with dry eye disease who were propensity score–matched with 54,765 participants without the condition.
• The cases of dry eye disease were identified using Systematized Nomenclature of Medicine codes for dry eyes, meibomian gland dysfunction, and tear film insufficiency.
• The outcome measures for mental health conditions were clinical diagnoses of depressive disorders, anxiety-related disorders, bipolar disorder, and schizophrenia spectrum disorders.

TAKEAWAY:

• Patients with dry eye disease had more than triple the risk for mental health conditions than participants without the condition (adjusted odds ratio [aOR], 3.21; P < .001).
• Patients with dry eye disease had a higher risk for a depressive disorder (aOR, 3.47), anxiety-related disorder (aOR, 2.74), bipolar disorder (aOR, 2.23), and schizophrenia spectrum disorder (aOR, 2.48; P < .001 for all) than participants without the condition.
• The associations between dry eye disease and mental health conditions were significantly stronger among Black individuals than among White individuals, except for bipolar disorder.
• Dry eye disease was associated with two- to threefold higher odds of depressive disorders, anxiety-related disorders, bipolar disorder, and schizophrenia spectrum disorders even in participants who never used medications for mental health (P < .001 for all).

IN PRACTICE:

“Greater efforts should be undertaken to screen patients with DED [dry eye disease] for mental health conditions, particularly in historically medically underserved populations,” the authors of the study wrote.

SOURCE:

This study was led by Aaron T. Zhao, of the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, and was published online on October 15, 2024, in the American Journal of Ophthalmology.

LIMITATIONS:

This study relied on electronic health record data, which may have led to the inclusion of participants with undiagnosed dry eye disease as control participants. Moreover, the study did not evaluate the severity of dry eye disease or the severity and duration of mental health conditions, which may have affected the results. The database analyzed in this study may not have fully captured the complete demographic profile of the nationwide population, which may have affected the generalizability of the findings.

DISCLOSURES:

This study was supported by funding from the National Institutes of Health and Research to Prevent Blindness. The authors declared having no conflicts of interest.

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