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Watching TV, using computer have opposite ties to dementia risk
The relationship to dementia with these activities remained strong no matter how much physical activity a person did, the authors wrote in Proceedings of the National Academy of Sciences.
Both watching TV and using a computer have been linked to increased risk of chronic disease and mortality, while exercise and physical activity (PA) have shown benefit in reducing cognitive decline, structural brain atrophy, and dementia risk in older adults, the authors wrote.
The authors said they wanted to try to understand the effects of watching TV and using computers on dementia risk, because people in the United States and Europe have been engaging in both of these activities more often.
They concluded that it’s not the sitting part of sedentary behavior (SB) that potentially has the effect on dementia but what people are doing while sitting.
Some of the results were surprising, lead author David Raichlen, PhD, professor of Human and Evolutionary Biology at University of Southern California, Los Angeles, said in an interview.
Previous literature on sedentary behaviors have documented their negative effects on a wide range of health outcomes, rather than finding positive associations, he explained.
More than 140,000 included in study
The researchers conducted their prospective cohort study using data from the United Kingdom Biobank. After excluding people younger than 60, those with prevalent dementia at the start of follow-up, and those without complete data, 146,651 participants were included.
The participants were followed from their baseline visit until they received a dementia diagnosis, died, were lost to follow-up, or were last admitted to the hospital.
TV-watching time was linked with an increased risk of incident dementia (HR [95% confidence interval] = 1.31 [1.23-1.40]), and computer use was linked with a reduced risk of incident dementia HR [95% CI] = 0.80 [0.76-0.85]).
TV’s link with higher dementia risk increased in those who had the highest use, compared with those who had the lowest use (HR [95% CI] = 1.28 [1.18-1.39].
Similarly, the link with risk reduction for dementia with computer use increased with more use.
Both medium and high computer time were associated with reduced risk of incident dementia (HR [95% CI] = 0.70 [0.64-0.76] and HR [95% CI] = 0.76 [0.70-0.83] respectively).
Dr. Raichlen pointed out that the high use of TV in this study was 4 or more hours a day and computer use – which included leisure use, not work use – had benefits on dementia risk after just half an hour.
These results remained significant after researchers adjusted for demographic, health, and lifestyle variables, including time spent on physical activity, sleeping, obesity, alcohol consumption, smoking status, diet scores, education level, body mass index, and employment type.
Physical is still better than sedentary activity
One potential reason for the different effects on dementia risk in the two activities studied, the authors write, is that sitting down to watch TV is associated with “uniquely low levels of muscle activity and energy expenditure, compared with sitting to use a computer.”
Andrew Budson, MD, chief of Cognitive & Behavioral Neurology and Associate Chief of Staff for Education for the VA Boston Healthcare System, Mass., who was not part of the study, said he thinks a more likely explanation for the study findings lies in the active versus passive tasks required in the two kinds of viewing that the authors reference.
“When we’re doing cognitive activity involving using the computer, we’re using large parts of our cortex to carry out that activity, whereas when we’re watching TV, there are probably relatively small amounts of our brain that are actually active,” Dr. Budson, author of Seven Steps to Managing Your Memory, explained in an interview.
“This is one of the first times I’ve been convinced that even when the computer activity isn’t completely new and novel, it may be beneficial,” Dr. Budson said.
It would be much better to do physical activity, but if the choice is sedentary activity, active cognitive activities, such as computer use, are better than TV watching, he continued.
The results of the current study are consistent with previous work showing that the type of sedentary behavior matters, according to the authors.
“Several studies have shown that TV time is associated with mortality and poor cardiometabolic biomarkers, whereas computer time is not,” they wrote.
A limitation of the study is that sedentary behaviors were self-reported via questionnaires, and there may be errors in recall.
“The use of objective methods for measuring both SB and PA are needed in future studies,” they write.
The authors receive support from the National Institutes of Health, the State of Arizona, the Arizona Department of Health Services, and the McKnight Brain Research Foundation. Neither the authors nor Dr. Budson declared relevant financial relationships.
The relationship to dementia with these activities remained strong no matter how much physical activity a person did, the authors wrote in Proceedings of the National Academy of Sciences.
Both watching TV and using a computer have been linked to increased risk of chronic disease and mortality, while exercise and physical activity (PA) have shown benefit in reducing cognitive decline, structural brain atrophy, and dementia risk in older adults, the authors wrote.
The authors said they wanted to try to understand the effects of watching TV and using computers on dementia risk, because people in the United States and Europe have been engaging in both of these activities more often.
They concluded that it’s not the sitting part of sedentary behavior (SB) that potentially has the effect on dementia but what people are doing while sitting.
Some of the results were surprising, lead author David Raichlen, PhD, professor of Human and Evolutionary Biology at University of Southern California, Los Angeles, said in an interview.
Previous literature on sedentary behaviors have documented their negative effects on a wide range of health outcomes, rather than finding positive associations, he explained.
More than 140,000 included in study
The researchers conducted their prospective cohort study using data from the United Kingdom Biobank. After excluding people younger than 60, those with prevalent dementia at the start of follow-up, and those without complete data, 146,651 participants were included.
The participants were followed from their baseline visit until they received a dementia diagnosis, died, were lost to follow-up, or were last admitted to the hospital.
TV-watching time was linked with an increased risk of incident dementia (HR [95% confidence interval] = 1.31 [1.23-1.40]), and computer use was linked with a reduced risk of incident dementia HR [95% CI] = 0.80 [0.76-0.85]).
TV’s link with higher dementia risk increased in those who had the highest use, compared with those who had the lowest use (HR [95% CI] = 1.28 [1.18-1.39].
Similarly, the link with risk reduction for dementia with computer use increased with more use.
Both medium and high computer time were associated with reduced risk of incident dementia (HR [95% CI] = 0.70 [0.64-0.76] and HR [95% CI] = 0.76 [0.70-0.83] respectively).
Dr. Raichlen pointed out that the high use of TV in this study was 4 or more hours a day and computer use – which included leisure use, not work use – had benefits on dementia risk after just half an hour.
These results remained significant after researchers adjusted for demographic, health, and lifestyle variables, including time spent on physical activity, sleeping, obesity, alcohol consumption, smoking status, diet scores, education level, body mass index, and employment type.
Physical is still better than sedentary activity
One potential reason for the different effects on dementia risk in the two activities studied, the authors write, is that sitting down to watch TV is associated with “uniquely low levels of muscle activity and energy expenditure, compared with sitting to use a computer.”
Andrew Budson, MD, chief of Cognitive & Behavioral Neurology and Associate Chief of Staff for Education for the VA Boston Healthcare System, Mass., who was not part of the study, said he thinks a more likely explanation for the study findings lies in the active versus passive tasks required in the two kinds of viewing that the authors reference.
“When we’re doing cognitive activity involving using the computer, we’re using large parts of our cortex to carry out that activity, whereas when we’re watching TV, there are probably relatively small amounts of our brain that are actually active,” Dr. Budson, author of Seven Steps to Managing Your Memory, explained in an interview.
“This is one of the first times I’ve been convinced that even when the computer activity isn’t completely new and novel, it may be beneficial,” Dr. Budson said.
It would be much better to do physical activity, but if the choice is sedentary activity, active cognitive activities, such as computer use, are better than TV watching, he continued.
The results of the current study are consistent with previous work showing that the type of sedentary behavior matters, according to the authors.
“Several studies have shown that TV time is associated with mortality and poor cardiometabolic biomarkers, whereas computer time is not,” they wrote.
A limitation of the study is that sedentary behaviors were self-reported via questionnaires, and there may be errors in recall.
“The use of objective methods for measuring both SB and PA are needed in future studies,” they write.
The authors receive support from the National Institutes of Health, the State of Arizona, the Arizona Department of Health Services, and the McKnight Brain Research Foundation. Neither the authors nor Dr. Budson declared relevant financial relationships.
The relationship to dementia with these activities remained strong no matter how much physical activity a person did, the authors wrote in Proceedings of the National Academy of Sciences.
Both watching TV and using a computer have been linked to increased risk of chronic disease and mortality, while exercise and physical activity (PA) have shown benefit in reducing cognitive decline, structural brain atrophy, and dementia risk in older adults, the authors wrote.
The authors said they wanted to try to understand the effects of watching TV and using computers on dementia risk, because people in the United States and Europe have been engaging in both of these activities more often.
They concluded that it’s not the sitting part of sedentary behavior (SB) that potentially has the effect on dementia but what people are doing while sitting.
Some of the results were surprising, lead author David Raichlen, PhD, professor of Human and Evolutionary Biology at University of Southern California, Los Angeles, said in an interview.
Previous literature on sedentary behaviors have documented their negative effects on a wide range of health outcomes, rather than finding positive associations, he explained.
More than 140,000 included in study
The researchers conducted their prospective cohort study using data from the United Kingdom Biobank. After excluding people younger than 60, those with prevalent dementia at the start of follow-up, and those without complete data, 146,651 participants were included.
The participants were followed from their baseline visit until they received a dementia diagnosis, died, were lost to follow-up, or were last admitted to the hospital.
TV-watching time was linked with an increased risk of incident dementia (HR [95% confidence interval] = 1.31 [1.23-1.40]), and computer use was linked with a reduced risk of incident dementia HR [95% CI] = 0.80 [0.76-0.85]).
TV’s link with higher dementia risk increased in those who had the highest use, compared with those who had the lowest use (HR [95% CI] = 1.28 [1.18-1.39].
Similarly, the link with risk reduction for dementia with computer use increased with more use.
Both medium and high computer time were associated with reduced risk of incident dementia (HR [95% CI] = 0.70 [0.64-0.76] and HR [95% CI] = 0.76 [0.70-0.83] respectively).
Dr. Raichlen pointed out that the high use of TV in this study was 4 or more hours a day and computer use – which included leisure use, not work use – had benefits on dementia risk after just half an hour.
These results remained significant after researchers adjusted for demographic, health, and lifestyle variables, including time spent on physical activity, sleeping, obesity, alcohol consumption, smoking status, diet scores, education level, body mass index, and employment type.
Physical is still better than sedentary activity
One potential reason for the different effects on dementia risk in the two activities studied, the authors write, is that sitting down to watch TV is associated with “uniquely low levels of muscle activity and energy expenditure, compared with sitting to use a computer.”
Andrew Budson, MD, chief of Cognitive & Behavioral Neurology and Associate Chief of Staff for Education for the VA Boston Healthcare System, Mass., who was not part of the study, said he thinks a more likely explanation for the study findings lies in the active versus passive tasks required in the two kinds of viewing that the authors reference.
“When we’re doing cognitive activity involving using the computer, we’re using large parts of our cortex to carry out that activity, whereas when we’re watching TV, there are probably relatively small amounts of our brain that are actually active,” Dr. Budson, author of Seven Steps to Managing Your Memory, explained in an interview.
“This is one of the first times I’ve been convinced that even when the computer activity isn’t completely new and novel, it may be beneficial,” Dr. Budson said.
It would be much better to do physical activity, but if the choice is sedentary activity, active cognitive activities, such as computer use, are better than TV watching, he continued.
The results of the current study are consistent with previous work showing that the type of sedentary behavior matters, according to the authors.
“Several studies have shown that TV time is associated with mortality and poor cardiometabolic biomarkers, whereas computer time is not,” they wrote.
A limitation of the study is that sedentary behaviors were self-reported via questionnaires, and there may be errors in recall.
“The use of objective methods for measuring both SB and PA are needed in future studies,” they write.
The authors receive support from the National Institutes of Health, the State of Arizona, the Arizona Department of Health Services, and the McKnight Brain Research Foundation. Neither the authors nor Dr. Budson declared relevant financial relationships.
FROM PROCEEDINGS OF THE NATIONAL ACADEMY OF SCIENCES
New panic disorder model flags risk for recurrence, persistence
Investigators based in France and the United States analyzed data for almost 800 patients with DSM-IV–diagnosed PD.
Results showed that having a “general psychopathology factor,” defined as the shared effects of all comorbid conditions, or PD liability, significantly and independently predicted 3-year recurrence or persistence of PD symptoms.
Having a lower physical health-related quality of life (QOL), a greater number of stressful life events, and not seeking treatment at baseline were also significant and independent predictors.
“This integrative model could help clinicians to identify individuals at high risk of recurrence or persistence of panic disorder and provide content for future research,” Valentin Scheer, MD, MPH, a resident in psychiatry at AP-HP, Assistance Publique, Hôpitaux de Paris, and colleagues wrote.
The findings were published online in the Journal of Clinical Psychiatry.
Integration needed
PD is a disabling disorder with a “chronic course” – and a recurrence rate ranging from 25% to 50%, the investigators noted.
“Because of the heterogeneous course of PD, there is a need to develop a comprehensive predictive model of recurrence or persistence,” they wrote. This could “help practitioners adapt therapeutic strategies and develop prevention strategies in high-risk individuals.”
Most previous studies that have investigated risk factors for PD recurrence and persistence have relied on clinical samples, often with limited sample sizes.
Moreover, each risk factor, when considered individually, accounts for only a “small proportion” of the variance in risk, the researchers noted. The co-occurrence of these risk factors “suggests the need to combine them into a broad multivariable model.”
However, currently proposed integrative models do not identify independent predictors or mitigate the influence of confounding variables. To fill this gap, the investigators conducted a study using structural equation modeling “to take into account multiple correlations across predictors.”
They drew on data from 775 participants (mean age, 40 years) in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). For the current analysis, they examined two waves of NESARC (2001-2002 and 2004-2005) to “build a comprehensive model” of the 3-year recurrence or persistence of PD.
The researchers used a “latent variable approach” that simultaneously examined the effect of the following five groups of potential predictors of recurrence or persistence: PD severity, severity of comorbidity, family history of psychiatric disorders, sociodemographic characteristics, and treatment-seeking behavior.
They also distinguished between risk factors responsible for recurrence and those responsible for persistence.
Psychiatric diagnoses were determined on the basis of the Alcohol Use Disorder and Associated Disabilities Interview Schedule-IV. Participants also completed Version 2 of the Short Form 12-Item Health Survey, which assesses both mental and physical QOL over the previous 4 weeks.
Early treatment needed
Among participants with a 12-month diagnosis of PD at wave 1, 13% had persistent PD and 27.6% had recurrent PD during the 3-year period. The mean duration of illness was 9.5 years.
A greater number of lifetime panic attacks, the presence of any Axis I or II comorbid disorder, and any Axis I disorder, especially social anxiety disorder, were significantly associated with 3-year risk for recurrence and for persistence.
Sweating, choking, paresthesias, the comorbid disorders of mania/hypomania and general anxiety disorder, nicotine dependence, lower mental and physical QOL scores, and exposure to a greater number of stressful life events in the previous year were all significantly associated with 3-year risk for recurrence.
Only variables shown with a P value were statistically significant, “with the a priori fixed at .05,” the researchers noted.
A combination of psychopathology factors, such as the shared effect of all comorbid psychiatric conditions, PD liability, lower physical health-related QOL, more life stressors during the past year, and not seeking treatment at baseline “significantly and independently” predicted recurrence or persistence of symptoms between the two waves (all Ps < .05), the investigators reported.
One study limitation cited was that several psychiatric disorders known to be associated with PD recurrence or persistence, such as borderline personality disorder, were not examined. Additionally, the study used a 3-year follow-up period – and the results might have differed for other follow-up time frames, the researchers noted.
Nevertheless, the findings constitute a “comprehensive model” to predict recurrence and persistence of PD, they wrote. Moreover, early treatment-seeking behavior “should be promoted, as it may reduce the risk of recurrence.”
Not much new?
Commenting on the study, Peter Roy-Byrne, MD, professor of psychiatry, University of Washington, Seattle, noted, “there is not much that is new here.”
Dr. Roy-Byrne, who was not involved with the study, said that a “general theme for years has been that more severe illness, whether you measure it by greater number of other Axis I disorders or symptom severity or a general psychopathology factor, usually predicts worse outcome – here codified as persistence and recurrence.”
Greater stress and reluctance to seek treatment may also predict worse outcomes, he noted.
In addition, the study “did not examine another very important factor: the degree of social connection/social support that someone has,” Dr. Roy-Byrne said. However, “perhaps some of this was contained in specific life events.”
A version of this article first appeared on Medscape.com.
Investigators based in France and the United States analyzed data for almost 800 patients with DSM-IV–diagnosed PD.
Results showed that having a “general psychopathology factor,” defined as the shared effects of all comorbid conditions, or PD liability, significantly and independently predicted 3-year recurrence or persistence of PD symptoms.
Having a lower physical health-related quality of life (QOL), a greater number of stressful life events, and not seeking treatment at baseline were also significant and independent predictors.
“This integrative model could help clinicians to identify individuals at high risk of recurrence or persistence of panic disorder and provide content for future research,” Valentin Scheer, MD, MPH, a resident in psychiatry at AP-HP, Assistance Publique, Hôpitaux de Paris, and colleagues wrote.
The findings were published online in the Journal of Clinical Psychiatry.
Integration needed
PD is a disabling disorder with a “chronic course” – and a recurrence rate ranging from 25% to 50%, the investigators noted.
“Because of the heterogeneous course of PD, there is a need to develop a comprehensive predictive model of recurrence or persistence,” they wrote. This could “help practitioners adapt therapeutic strategies and develop prevention strategies in high-risk individuals.”
Most previous studies that have investigated risk factors for PD recurrence and persistence have relied on clinical samples, often with limited sample sizes.
Moreover, each risk factor, when considered individually, accounts for only a “small proportion” of the variance in risk, the researchers noted. The co-occurrence of these risk factors “suggests the need to combine them into a broad multivariable model.”
However, currently proposed integrative models do not identify independent predictors or mitigate the influence of confounding variables. To fill this gap, the investigators conducted a study using structural equation modeling “to take into account multiple correlations across predictors.”
They drew on data from 775 participants (mean age, 40 years) in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). For the current analysis, they examined two waves of NESARC (2001-2002 and 2004-2005) to “build a comprehensive model” of the 3-year recurrence or persistence of PD.
The researchers used a “latent variable approach” that simultaneously examined the effect of the following five groups of potential predictors of recurrence or persistence: PD severity, severity of comorbidity, family history of psychiatric disorders, sociodemographic characteristics, and treatment-seeking behavior.
They also distinguished between risk factors responsible for recurrence and those responsible for persistence.
Psychiatric diagnoses were determined on the basis of the Alcohol Use Disorder and Associated Disabilities Interview Schedule-IV. Participants also completed Version 2 of the Short Form 12-Item Health Survey, which assesses both mental and physical QOL over the previous 4 weeks.
Early treatment needed
Among participants with a 12-month diagnosis of PD at wave 1, 13% had persistent PD and 27.6% had recurrent PD during the 3-year period. The mean duration of illness was 9.5 years.
A greater number of lifetime panic attacks, the presence of any Axis I or II comorbid disorder, and any Axis I disorder, especially social anxiety disorder, were significantly associated with 3-year risk for recurrence and for persistence.
Sweating, choking, paresthesias, the comorbid disorders of mania/hypomania and general anxiety disorder, nicotine dependence, lower mental and physical QOL scores, and exposure to a greater number of stressful life events in the previous year were all significantly associated with 3-year risk for recurrence.
Only variables shown with a P value were statistically significant, “with the a priori fixed at .05,” the researchers noted.
A combination of psychopathology factors, such as the shared effect of all comorbid psychiatric conditions, PD liability, lower physical health-related QOL, more life stressors during the past year, and not seeking treatment at baseline “significantly and independently” predicted recurrence or persistence of symptoms between the two waves (all Ps < .05), the investigators reported.
One study limitation cited was that several psychiatric disorders known to be associated with PD recurrence or persistence, such as borderline personality disorder, were not examined. Additionally, the study used a 3-year follow-up period – and the results might have differed for other follow-up time frames, the researchers noted.
Nevertheless, the findings constitute a “comprehensive model” to predict recurrence and persistence of PD, they wrote. Moreover, early treatment-seeking behavior “should be promoted, as it may reduce the risk of recurrence.”
Not much new?
Commenting on the study, Peter Roy-Byrne, MD, professor of psychiatry, University of Washington, Seattle, noted, “there is not much that is new here.”
Dr. Roy-Byrne, who was not involved with the study, said that a “general theme for years has been that more severe illness, whether you measure it by greater number of other Axis I disorders or symptom severity or a general psychopathology factor, usually predicts worse outcome – here codified as persistence and recurrence.”
Greater stress and reluctance to seek treatment may also predict worse outcomes, he noted.
In addition, the study “did not examine another very important factor: the degree of social connection/social support that someone has,” Dr. Roy-Byrne said. However, “perhaps some of this was contained in specific life events.”
A version of this article first appeared on Medscape.com.
Investigators based in France and the United States analyzed data for almost 800 patients with DSM-IV–diagnosed PD.
Results showed that having a “general psychopathology factor,” defined as the shared effects of all comorbid conditions, or PD liability, significantly and independently predicted 3-year recurrence or persistence of PD symptoms.
Having a lower physical health-related quality of life (QOL), a greater number of stressful life events, and not seeking treatment at baseline were also significant and independent predictors.
“This integrative model could help clinicians to identify individuals at high risk of recurrence or persistence of panic disorder and provide content for future research,” Valentin Scheer, MD, MPH, a resident in psychiatry at AP-HP, Assistance Publique, Hôpitaux de Paris, and colleagues wrote.
The findings were published online in the Journal of Clinical Psychiatry.
Integration needed
PD is a disabling disorder with a “chronic course” – and a recurrence rate ranging from 25% to 50%, the investigators noted.
“Because of the heterogeneous course of PD, there is a need to develop a comprehensive predictive model of recurrence or persistence,” they wrote. This could “help practitioners adapt therapeutic strategies and develop prevention strategies in high-risk individuals.”
Most previous studies that have investigated risk factors for PD recurrence and persistence have relied on clinical samples, often with limited sample sizes.
Moreover, each risk factor, when considered individually, accounts for only a “small proportion” of the variance in risk, the researchers noted. The co-occurrence of these risk factors “suggests the need to combine them into a broad multivariable model.”
However, currently proposed integrative models do not identify independent predictors or mitigate the influence of confounding variables. To fill this gap, the investigators conducted a study using structural equation modeling “to take into account multiple correlations across predictors.”
They drew on data from 775 participants (mean age, 40 years) in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). For the current analysis, they examined two waves of NESARC (2001-2002 and 2004-2005) to “build a comprehensive model” of the 3-year recurrence or persistence of PD.
The researchers used a “latent variable approach” that simultaneously examined the effect of the following five groups of potential predictors of recurrence or persistence: PD severity, severity of comorbidity, family history of psychiatric disorders, sociodemographic characteristics, and treatment-seeking behavior.
They also distinguished between risk factors responsible for recurrence and those responsible for persistence.
Psychiatric diagnoses were determined on the basis of the Alcohol Use Disorder and Associated Disabilities Interview Schedule-IV. Participants also completed Version 2 of the Short Form 12-Item Health Survey, which assesses both mental and physical QOL over the previous 4 weeks.
Early treatment needed
Among participants with a 12-month diagnosis of PD at wave 1, 13% had persistent PD and 27.6% had recurrent PD during the 3-year period. The mean duration of illness was 9.5 years.
A greater number of lifetime panic attacks, the presence of any Axis I or II comorbid disorder, and any Axis I disorder, especially social anxiety disorder, were significantly associated with 3-year risk for recurrence and for persistence.
Sweating, choking, paresthesias, the comorbid disorders of mania/hypomania and general anxiety disorder, nicotine dependence, lower mental and physical QOL scores, and exposure to a greater number of stressful life events in the previous year were all significantly associated with 3-year risk for recurrence.
Only variables shown with a P value were statistically significant, “with the a priori fixed at .05,” the researchers noted.
A combination of psychopathology factors, such as the shared effect of all comorbid psychiatric conditions, PD liability, lower physical health-related QOL, more life stressors during the past year, and not seeking treatment at baseline “significantly and independently” predicted recurrence or persistence of symptoms between the two waves (all Ps < .05), the investigators reported.
One study limitation cited was that several psychiatric disorders known to be associated with PD recurrence or persistence, such as borderline personality disorder, were not examined. Additionally, the study used a 3-year follow-up period – and the results might have differed for other follow-up time frames, the researchers noted.
Nevertheless, the findings constitute a “comprehensive model” to predict recurrence and persistence of PD, they wrote. Moreover, early treatment-seeking behavior “should be promoted, as it may reduce the risk of recurrence.”
Not much new?
Commenting on the study, Peter Roy-Byrne, MD, professor of psychiatry, University of Washington, Seattle, noted, “there is not much that is new here.”
Dr. Roy-Byrne, who was not involved with the study, said that a “general theme for years has been that more severe illness, whether you measure it by greater number of other Axis I disorders or symptom severity or a general psychopathology factor, usually predicts worse outcome – here codified as persistence and recurrence.”
Greater stress and reluctance to seek treatment may also predict worse outcomes, he noted.
In addition, the study “did not examine another very important factor: the degree of social connection/social support that someone has,” Dr. Roy-Byrne said. However, “perhaps some of this was contained in specific life events.”
A version of this article first appeared on Medscape.com.
FROM THE JOURNAL OF CLINICAL PSYCHIATRY
Siblings of children with chronic health conditions may have increased mental health risks
Siblings of children with chronic health conditions could be at an increased risk for depression, according to a new report.
In a systematic review of 34 studies, siblings of children with chronic health conditions had significantly higher scores on depressive rating scales than individuals without a sibling with a chronic health condition (standardized mean difference = 0.53; P < .001). Findings related to other clinical health outcomes, such as physical health conditions or mortality, were inconsistent.
“We’ve known for a long time that siblings of kids with chronic conditions undergo stress, and there have been conflicting data on how that stress is manifested in terms of their own health,” senior study author Eyal Cohen, MD, program head for child health evaluative sciences at the Hospital for Sick Children, Toronto, told this news organization.
“For some siblings, having the experience of being raised with a child with a chronic condition may be an asset and build resiliency, while other siblings may feel strong negative emotions, such as sadness, anger, and fear,” he said. “Although we know that this experience is stressful for many siblings, it is important to know whether it changes their health outcomes, so that appropriate support can be put in place for those who need it.”
The study was published online in the Journal of Pediatrics.
Risk for psychological challenges
About a quarter of children in the United States have a mental, emotional, developmental, or behavioral condition, and more than a third have at least one current or lifelong health condition, the study authors write. A childhood chronic health condition can affect family members through worse mental health outcomes, increased stress, and poorer health-related quality of life.
Dr. Cohen and colleagues conducted a systematic review and meta-analysis to assess the clinical mental and physical health outcomes of siblings of children with chronic health conditions in comparison with siblings of healthy children or normative data.
The research team included English-language studies that reported on clinically diagnosable mental or physical health outcomes among siblings of persons younger than 18 years who had a chronic health condition. They included a comparison group and used an experimental or observational design for their study. The researchers analyzed 34 studies, including 28 that reported on mental health, 3 that reported on physical health, and 3 that reported on mortality.
Overall, siblings of children with chronic health conditions had significantly higher scores on depression rating scales than their comparison groups. Siblings’ anxiety scores weren’t substantially higher, however (standard mean difference = 0.21; P = .07).
The effects for confirmed psychiatric diagnoses, physical health outcomes, and mortality could not be included in the meta-analysis, owing to the limited number of studies and the high level of heterogeneity among the studies.
Dr. Cohen noted that although the researchers weren’t surprised that siblings may be at increased risk of mental health challenges, they were surprised by the limited data regarding physical health.
“At a minimum, our findings support the importance of asking open-ended questions about how a family is doing during clinical encounters,” he said. “These siblings may also benefit from programs such as support groups or summer camps, which have been shown to improve mental health and behavioral outcomes in siblings of children with chronic health conditions, such as cancer and neurodevelopmental disabilities.”
Future studies should assess the specific risk factors for mental health problems in siblings of children with chronic health conditions, Dr. Cohen said. Additional research could also investigate the design and effectiveness of interventions that address these concerns.
Message of inclusiveness
“The message that resonates with me is about the interventions and resources needed to support siblings,” Linda Nguyen, a doctoral student in rehabilitation science and researcher with the CanChild Center for Childhood Disability Research at McMaster University in Hamilton, Ont., told this news organization.
Ms. Nguyen, who wasn’t involved with this study, has researched the resources available to siblings in Canada and has found a lack of support options, particularly when it comes to specific health care management roles.
“Consistently throughout my research, I’ve seen the need for resources that go beyond a focus on siblings’ well-being and instead support them in their different roles,” she said. “Some want to be friends, mentors, supporters, and caregivers for their siblings in the future.”
Siblings often adopt different roles as they form their own identity, Ms. Nguyen noted, which becomes a larger part of the health care conversation as children with chronic conditions make the transition from pediatric to adult health care. Siblings want to be asked how they’d like to be involved, she said. Some would like to be involved with health care appointments, the chronic condition community, research, and policy making.
“At the societal level and public level, there’s also a message of inclusiveness and making sure that we’re welcoming youth with disabilities and chronic conditions,” Jan Willem Gorter, MD, PhD, a professor of pediatrics and scientist for CanChild at McMaster University, told this news organization.
Dr. Gorter, who also was not involved with this study, noted that children with chronic conditions often feel left behind, which can influence the involvement of their siblings as well.
“There are a lot of places in the world where children with disabilities go to special schools, and they spend a lot of time in a different world, with different experiences than their siblings,” he said. “At the public health level, we want to advocate for an inclusive society and support the whole family, which benefits everybody.”
The study was funded by the Canadian Institutes of Health Research and the CHILD-BRIGHT Network summer studentship, which is supported by the Canadian Institute for Health Research Strategy for Patient-Oriented Research. Dr. Cohen, Ms. Nguyen, and Dr. Gorter have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Siblings of children with chronic health conditions could be at an increased risk for depression, according to a new report.
In a systematic review of 34 studies, siblings of children with chronic health conditions had significantly higher scores on depressive rating scales than individuals without a sibling with a chronic health condition (standardized mean difference = 0.53; P < .001). Findings related to other clinical health outcomes, such as physical health conditions or mortality, were inconsistent.
“We’ve known for a long time that siblings of kids with chronic conditions undergo stress, and there have been conflicting data on how that stress is manifested in terms of their own health,” senior study author Eyal Cohen, MD, program head for child health evaluative sciences at the Hospital for Sick Children, Toronto, told this news organization.
“For some siblings, having the experience of being raised with a child with a chronic condition may be an asset and build resiliency, while other siblings may feel strong negative emotions, such as sadness, anger, and fear,” he said. “Although we know that this experience is stressful for many siblings, it is important to know whether it changes their health outcomes, so that appropriate support can be put in place for those who need it.”
The study was published online in the Journal of Pediatrics.
Risk for psychological challenges
About a quarter of children in the United States have a mental, emotional, developmental, or behavioral condition, and more than a third have at least one current or lifelong health condition, the study authors write. A childhood chronic health condition can affect family members through worse mental health outcomes, increased stress, and poorer health-related quality of life.
Dr. Cohen and colleagues conducted a systematic review and meta-analysis to assess the clinical mental and physical health outcomes of siblings of children with chronic health conditions in comparison with siblings of healthy children or normative data.
The research team included English-language studies that reported on clinically diagnosable mental or physical health outcomes among siblings of persons younger than 18 years who had a chronic health condition. They included a comparison group and used an experimental or observational design for their study. The researchers analyzed 34 studies, including 28 that reported on mental health, 3 that reported on physical health, and 3 that reported on mortality.
Overall, siblings of children with chronic health conditions had significantly higher scores on depression rating scales than their comparison groups. Siblings’ anxiety scores weren’t substantially higher, however (standard mean difference = 0.21; P = .07).
The effects for confirmed psychiatric diagnoses, physical health outcomes, and mortality could not be included in the meta-analysis, owing to the limited number of studies and the high level of heterogeneity among the studies.
Dr. Cohen noted that although the researchers weren’t surprised that siblings may be at increased risk of mental health challenges, they were surprised by the limited data regarding physical health.
“At a minimum, our findings support the importance of asking open-ended questions about how a family is doing during clinical encounters,” he said. “These siblings may also benefit from programs such as support groups or summer camps, which have been shown to improve mental health and behavioral outcomes in siblings of children with chronic health conditions, such as cancer and neurodevelopmental disabilities.”
Future studies should assess the specific risk factors for mental health problems in siblings of children with chronic health conditions, Dr. Cohen said. Additional research could also investigate the design and effectiveness of interventions that address these concerns.
Message of inclusiveness
“The message that resonates with me is about the interventions and resources needed to support siblings,” Linda Nguyen, a doctoral student in rehabilitation science and researcher with the CanChild Center for Childhood Disability Research at McMaster University in Hamilton, Ont., told this news organization.
Ms. Nguyen, who wasn’t involved with this study, has researched the resources available to siblings in Canada and has found a lack of support options, particularly when it comes to specific health care management roles.
“Consistently throughout my research, I’ve seen the need for resources that go beyond a focus on siblings’ well-being and instead support them in their different roles,” she said. “Some want to be friends, mentors, supporters, and caregivers for their siblings in the future.”
Siblings often adopt different roles as they form their own identity, Ms. Nguyen noted, which becomes a larger part of the health care conversation as children with chronic conditions make the transition from pediatric to adult health care. Siblings want to be asked how they’d like to be involved, she said. Some would like to be involved with health care appointments, the chronic condition community, research, and policy making.
“At the societal level and public level, there’s also a message of inclusiveness and making sure that we’re welcoming youth with disabilities and chronic conditions,” Jan Willem Gorter, MD, PhD, a professor of pediatrics and scientist for CanChild at McMaster University, told this news organization.
Dr. Gorter, who also was not involved with this study, noted that children with chronic conditions often feel left behind, which can influence the involvement of their siblings as well.
“There are a lot of places in the world where children with disabilities go to special schools, and they spend a lot of time in a different world, with different experiences than their siblings,” he said. “At the public health level, we want to advocate for an inclusive society and support the whole family, which benefits everybody.”
The study was funded by the Canadian Institutes of Health Research and the CHILD-BRIGHT Network summer studentship, which is supported by the Canadian Institute for Health Research Strategy for Patient-Oriented Research. Dr. Cohen, Ms. Nguyen, and Dr. Gorter have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Siblings of children with chronic health conditions could be at an increased risk for depression, according to a new report.
In a systematic review of 34 studies, siblings of children with chronic health conditions had significantly higher scores on depressive rating scales than individuals without a sibling with a chronic health condition (standardized mean difference = 0.53; P < .001). Findings related to other clinical health outcomes, such as physical health conditions or mortality, were inconsistent.
“We’ve known for a long time that siblings of kids with chronic conditions undergo stress, and there have been conflicting data on how that stress is manifested in terms of their own health,” senior study author Eyal Cohen, MD, program head for child health evaluative sciences at the Hospital for Sick Children, Toronto, told this news organization.
“For some siblings, having the experience of being raised with a child with a chronic condition may be an asset and build resiliency, while other siblings may feel strong negative emotions, such as sadness, anger, and fear,” he said. “Although we know that this experience is stressful for many siblings, it is important to know whether it changes their health outcomes, so that appropriate support can be put in place for those who need it.”
The study was published online in the Journal of Pediatrics.
Risk for psychological challenges
About a quarter of children in the United States have a mental, emotional, developmental, or behavioral condition, and more than a third have at least one current or lifelong health condition, the study authors write. A childhood chronic health condition can affect family members through worse mental health outcomes, increased stress, and poorer health-related quality of life.
Dr. Cohen and colleagues conducted a systematic review and meta-analysis to assess the clinical mental and physical health outcomes of siblings of children with chronic health conditions in comparison with siblings of healthy children or normative data.
The research team included English-language studies that reported on clinically diagnosable mental or physical health outcomes among siblings of persons younger than 18 years who had a chronic health condition. They included a comparison group and used an experimental or observational design for their study. The researchers analyzed 34 studies, including 28 that reported on mental health, 3 that reported on physical health, and 3 that reported on mortality.
Overall, siblings of children with chronic health conditions had significantly higher scores on depression rating scales than their comparison groups. Siblings’ anxiety scores weren’t substantially higher, however (standard mean difference = 0.21; P = .07).
The effects for confirmed psychiatric diagnoses, physical health outcomes, and mortality could not be included in the meta-analysis, owing to the limited number of studies and the high level of heterogeneity among the studies.
Dr. Cohen noted that although the researchers weren’t surprised that siblings may be at increased risk of mental health challenges, they were surprised by the limited data regarding physical health.
“At a minimum, our findings support the importance of asking open-ended questions about how a family is doing during clinical encounters,” he said. “These siblings may also benefit from programs such as support groups or summer camps, which have been shown to improve mental health and behavioral outcomes in siblings of children with chronic health conditions, such as cancer and neurodevelopmental disabilities.”
Future studies should assess the specific risk factors for mental health problems in siblings of children with chronic health conditions, Dr. Cohen said. Additional research could also investigate the design and effectiveness of interventions that address these concerns.
Message of inclusiveness
“The message that resonates with me is about the interventions and resources needed to support siblings,” Linda Nguyen, a doctoral student in rehabilitation science and researcher with the CanChild Center for Childhood Disability Research at McMaster University in Hamilton, Ont., told this news organization.
Ms. Nguyen, who wasn’t involved with this study, has researched the resources available to siblings in Canada and has found a lack of support options, particularly when it comes to specific health care management roles.
“Consistently throughout my research, I’ve seen the need for resources that go beyond a focus on siblings’ well-being and instead support them in their different roles,” she said. “Some want to be friends, mentors, supporters, and caregivers for their siblings in the future.”
Siblings often adopt different roles as they form their own identity, Ms. Nguyen noted, which becomes a larger part of the health care conversation as children with chronic conditions make the transition from pediatric to adult health care. Siblings want to be asked how they’d like to be involved, she said. Some would like to be involved with health care appointments, the chronic condition community, research, and policy making.
“At the societal level and public level, there’s also a message of inclusiveness and making sure that we’re welcoming youth with disabilities and chronic conditions,” Jan Willem Gorter, MD, PhD, a professor of pediatrics and scientist for CanChild at McMaster University, told this news organization.
Dr. Gorter, who also was not involved with this study, noted that children with chronic conditions often feel left behind, which can influence the involvement of their siblings as well.
“There are a lot of places in the world where children with disabilities go to special schools, and they spend a lot of time in a different world, with different experiences than their siblings,” he said. “At the public health level, we want to advocate for an inclusive society and support the whole family, which benefits everybody.”
The study was funded by the Canadian Institutes of Health Research and the CHILD-BRIGHT Network summer studentship, which is supported by the Canadian Institute for Health Research Strategy for Patient-Oriented Research. Dr. Cohen, Ms. Nguyen, and Dr. Gorter have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM JOURNAL OF PEDIATRICS
Postpartum depression risk higher with family psych history
Mothers who have a family history of any psychiatric disorder have almost two times the risk of postpartum depression as do mothers without such history, according to a new study.
Mette-Marie Zacher Kjeldsen, MSc, with the National Centre for Register-based Research at Aarhus (Denmark) University, led the study, a meta-analysis that included 26 studies with information on 100,877 women.
Findings were published online in JAMA Psychiatry.
When mothers had a family history of psychiatric disorders, the odds ratio for PPD was 2.08 (95% confidence interval, 1.67-2.59). That corresponds to a risk ratio of 1.79 (95% CI, 1.52-2.09), assuming a 15% postpartum depression prevalence in the general population.
Not doomed to develop PPD
Polina Teslyar, MD, a perinatal psychiatrist at Brigham and Women’s Hospital in Boston told this news organization it’s important to point out that though the risk is higher, women with a family psychiatric history should not feel as though they are destined to develop PPD.
“You are still more likely to not have postpartum depression, but it is important to be aware of personal risk factors so that if a person is experiencing that, they ask for help quickly rather than suffering and not knowing something is amiss,” she emphasized. Dr. Teslyar says she does see the higher risk for PPD, which is preventable and treatable, in her own practice when women have had a family history of psychiatric disorders.
The association makes sense, but literature on why that is has been varied, she said, and likely involves both genetics and socioeconomic factors. It’s difficult to tease apart how big a part each plays.
In her perinatal practice she sees women even before they are pregnant to discuss risk factors for PPD so she does ask about family history of psychiatric disorders, specifically about history of PPD and anxiety.
The researchers suggest routine perinatal care should include an easy low-cost, two-part question about both personal and family history of psychiatric disorders.
“As the assessment is possible even prior to conception, this would leave time for planning preventive efforts, such as psychosocial and psychological interventions targeting these at-risk women,” the authors write.
Asking about family history a challenge
Dr. Teslyar noted though that one of the challenges in asking about family history is that families may not have openly shared psychiatric history details with offspring. Family members may also report conditions they suspect a family member had rather than having a documented diagnosis.
In places where there is universal health care, she noted, finding documented diagnoses is easier, but otherwise “you’re really taking a subjective interpretation.”
The researchers found that subgroup, sensitivity, and meta–regression analyses aligned with the primary findings. The overall certainty of evidence was graded as moderate.
This study was not able to make clear how the specific diagnoses of family members affect the risk of developing PPD because much of the data from the studies came from self-report and questions were not consistent across the studies.
For instance, only 7 studies asked specifically about first-degree family members and 10 asked about specific diagnoses. Diagnoses ranged from mild affective disorders to more intrusive disorders, such as schizophrenia.
And while this study doesn’t seek to determine why the family history and risk of PPD appear to be connected, the authors offer some possible explanations.
“Growing up in an environment with parents struggling with mental health problems potentially influences the social support received from these parents when going into motherhood,” the authors write. “This particular explanation is supported by umbrella reviews concluding that lack of social support is a significant PPD risk factor.”
Screening, extraction, and assessment of studies included was done independently by two reviewers, increasing validity, the authors note.
The authors state that approximately 10%-15% of new mothers experience PPD, but Dr. Teslyar points out the numbers in the United States are typically quoted at up to 20%-30%. PPD ranges from mild to severe episodes and includes symptoms like those for major depression outside the postpartum period.
Study authors received funding from The Lundbeck Foundation and the European Union’s Horizon 2020 Research and Innovation Programme. A coauthor, Vibe G. Frokjaer, MD, PhD, has served as consultant and lecturer for H. Lundbeck and Sage Therapeutics. No other disclosures were reported. Dr. Teslyar reports no relevant financial relationships.
Mothers who have a family history of any psychiatric disorder have almost two times the risk of postpartum depression as do mothers without such history, according to a new study.
Mette-Marie Zacher Kjeldsen, MSc, with the National Centre for Register-based Research at Aarhus (Denmark) University, led the study, a meta-analysis that included 26 studies with information on 100,877 women.
Findings were published online in JAMA Psychiatry.
When mothers had a family history of psychiatric disorders, the odds ratio for PPD was 2.08 (95% confidence interval, 1.67-2.59). That corresponds to a risk ratio of 1.79 (95% CI, 1.52-2.09), assuming a 15% postpartum depression prevalence in the general population.
Not doomed to develop PPD
Polina Teslyar, MD, a perinatal psychiatrist at Brigham and Women’s Hospital in Boston told this news organization it’s important to point out that though the risk is higher, women with a family psychiatric history should not feel as though they are destined to develop PPD.
“You are still more likely to not have postpartum depression, but it is important to be aware of personal risk factors so that if a person is experiencing that, they ask for help quickly rather than suffering and not knowing something is amiss,” she emphasized. Dr. Teslyar says she does see the higher risk for PPD, which is preventable and treatable, in her own practice when women have had a family history of psychiatric disorders.
The association makes sense, but literature on why that is has been varied, she said, and likely involves both genetics and socioeconomic factors. It’s difficult to tease apart how big a part each plays.
In her perinatal practice she sees women even before they are pregnant to discuss risk factors for PPD so she does ask about family history of psychiatric disorders, specifically about history of PPD and anxiety.
The researchers suggest routine perinatal care should include an easy low-cost, two-part question about both personal and family history of psychiatric disorders.
“As the assessment is possible even prior to conception, this would leave time for planning preventive efforts, such as psychosocial and psychological interventions targeting these at-risk women,” the authors write.
Asking about family history a challenge
Dr. Teslyar noted though that one of the challenges in asking about family history is that families may not have openly shared psychiatric history details with offspring. Family members may also report conditions they suspect a family member had rather than having a documented diagnosis.
In places where there is universal health care, she noted, finding documented diagnoses is easier, but otherwise “you’re really taking a subjective interpretation.”
The researchers found that subgroup, sensitivity, and meta–regression analyses aligned with the primary findings. The overall certainty of evidence was graded as moderate.
This study was not able to make clear how the specific diagnoses of family members affect the risk of developing PPD because much of the data from the studies came from self-report and questions were not consistent across the studies.
For instance, only 7 studies asked specifically about first-degree family members and 10 asked about specific diagnoses. Diagnoses ranged from mild affective disorders to more intrusive disorders, such as schizophrenia.
And while this study doesn’t seek to determine why the family history and risk of PPD appear to be connected, the authors offer some possible explanations.
“Growing up in an environment with parents struggling with mental health problems potentially influences the social support received from these parents when going into motherhood,” the authors write. “This particular explanation is supported by umbrella reviews concluding that lack of social support is a significant PPD risk factor.”
Screening, extraction, and assessment of studies included was done independently by two reviewers, increasing validity, the authors note.
The authors state that approximately 10%-15% of new mothers experience PPD, but Dr. Teslyar points out the numbers in the United States are typically quoted at up to 20%-30%. PPD ranges from mild to severe episodes and includes symptoms like those for major depression outside the postpartum period.
Study authors received funding from The Lundbeck Foundation and the European Union’s Horizon 2020 Research and Innovation Programme. A coauthor, Vibe G. Frokjaer, MD, PhD, has served as consultant and lecturer for H. Lundbeck and Sage Therapeutics. No other disclosures were reported. Dr. Teslyar reports no relevant financial relationships.
Mothers who have a family history of any psychiatric disorder have almost two times the risk of postpartum depression as do mothers without such history, according to a new study.
Mette-Marie Zacher Kjeldsen, MSc, with the National Centre for Register-based Research at Aarhus (Denmark) University, led the study, a meta-analysis that included 26 studies with information on 100,877 women.
Findings were published online in JAMA Psychiatry.
When mothers had a family history of psychiatric disorders, the odds ratio for PPD was 2.08 (95% confidence interval, 1.67-2.59). That corresponds to a risk ratio of 1.79 (95% CI, 1.52-2.09), assuming a 15% postpartum depression prevalence in the general population.
Not doomed to develop PPD
Polina Teslyar, MD, a perinatal psychiatrist at Brigham and Women’s Hospital in Boston told this news organization it’s important to point out that though the risk is higher, women with a family psychiatric history should not feel as though they are destined to develop PPD.
“You are still more likely to not have postpartum depression, but it is important to be aware of personal risk factors so that if a person is experiencing that, they ask for help quickly rather than suffering and not knowing something is amiss,” she emphasized. Dr. Teslyar says she does see the higher risk for PPD, which is preventable and treatable, in her own practice when women have had a family history of psychiatric disorders.
The association makes sense, but literature on why that is has been varied, she said, and likely involves both genetics and socioeconomic factors. It’s difficult to tease apart how big a part each plays.
In her perinatal practice she sees women even before they are pregnant to discuss risk factors for PPD so she does ask about family history of psychiatric disorders, specifically about history of PPD and anxiety.
The researchers suggest routine perinatal care should include an easy low-cost, two-part question about both personal and family history of psychiatric disorders.
“As the assessment is possible even prior to conception, this would leave time for planning preventive efforts, such as psychosocial and psychological interventions targeting these at-risk women,” the authors write.
Asking about family history a challenge
Dr. Teslyar noted though that one of the challenges in asking about family history is that families may not have openly shared psychiatric history details with offspring. Family members may also report conditions they suspect a family member had rather than having a documented diagnosis.
In places where there is universal health care, she noted, finding documented diagnoses is easier, but otherwise “you’re really taking a subjective interpretation.”
The researchers found that subgroup, sensitivity, and meta–regression analyses aligned with the primary findings. The overall certainty of evidence was graded as moderate.
This study was not able to make clear how the specific diagnoses of family members affect the risk of developing PPD because much of the data from the studies came from self-report and questions were not consistent across the studies.
For instance, only 7 studies asked specifically about first-degree family members and 10 asked about specific diagnoses. Diagnoses ranged from mild affective disorders to more intrusive disorders, such as schizophrenia.
And while this study doesn’t seek to determine why the family history and risk of PPD appear to be connected, the authors offer some possible explanations.
“Growing up in an environment with parents struggling with mental health problems potentially influences the social support received from these parents when going into motherhood,” the authors write. “This particular explanation is supported by umbrella reviews concluding that lack of social support is a significant PPD risk factor.”
Screening, extraction, and assessment of studies included was done independently by two reviewers, increasing validity, the authors note.
The authors state that approximately 10%-15% of new mothers experience PPD, but Dr. Teslyar points out the numbers in the United States are typically quoted at up to 20%-30%. PPD ranges from mild to severe episodes and includes symptoms like those for major depression outside the postpartum period.
Study authors received funding from The Lundbeck Foundation and the European Union’s Horizon 2020 Research and Innovation Programme. A coauthor, Vibe G. Frokjaer, MD, PhD, has served as consultant and lecturer for H. Lundbeck and Sage Therapeutics. No other disclosures were reported. Dr. Teslyar reports no relevant financial relationships.
FROM JAMA PSYCHIATRY
Early dementia but no specialists: Reinforcements needed?
Patients in rural areas are also less likely to see psychologists and undergo neuropsychological testing, according to the study, published in JAMA Network Open.
Patients who forgo such specialist visits and testing may be missing information about their condition that could help them prepare for changes in job responsibilities and future care decisions, said Wendy Yi Xu, PhD, of The Ohio State University, Columbus, who led the research.
“A lot of them are still in the workforce,” Dr. Xu said. Patients in the study were an average age of 56 years, well before the conventional age of retirement.
Location, location, location
To examine rural versus urban differences in the use of diagnostic tests and health care visits for early onset Alzheimer’s disease and related dementias, Dr. Xu and colleagues analyzed commercial claims data from 2012-2018. They identified more than 71,000 patients aged 40-64 years with those conditions and focused on health care use by 7,311 patients in urban areas and 1,119 in rural areas within 90 days of a new dementia diagnosis.
The proportion who received neuropsychological testing was 19% among urban patients and 16% among rural patients. Psychological assessments, which are less specialized and detailed than neuropsychological testing, and brain imaging occurred at similar rates in both groups. Similar proportions of rural and urban patients visited neurologists (17.7% and 17.96%, respectively) and psychiatrists (6.02% and 6.47%).
But more urban patients than rural patients visited a psychologist, at 19% versus 15%, according to the researchers.
Approximately 18% of patients in rural areas saw a primary care provider without visiting other specialists, compared with 13% in urban areas.
The researchers found that rural patients were significantly less likely to undergo neuropsychological testing (odds ratio, 0.83; 95% confidence interval, 0.70-0.98) or see a psychologist (OR, 0.72; 95% CI, 0.60-0.85).
Similarly, rural patients had significantly higher odds of having only primary care providers involved in the diagnosis of dementia and symptom management (OR, 1.40; 95% CI, 1.19-1.66).
Addressing workforce deficiencies
More primary care training in dementia care and collaboration with specialist colleagues could help address differences in care, Dr. Xu’s group writes. Such efforts are already underway.
In 2018, the Alzheimer’s Association launched telementoring programs focused on dementia care using the Project ECHO (Extension for Community Healthcare Outcomes) model. Researchers originally developed Project ECHO at the University of New Mexico in 2003 to teach primary care clinicians in remote settings how to treat patients infected with the hepatitis C virus.
With the Alzheimer’s and Dementia Care ECHO Program for Clinicians, primary care clinicians can participate in interactive case-based video conferencing sessions to better understand dementia and how to provide high-quality care in community settings, according to the association.
The program covers guidelines for diagnosis, disclosure, and follow-up; the initiation of care planning; managing disease-related challenges; and resources for patients and caregivers.
Since 2018, nearly 100 primary care practices in the United States have completed training in dementia care using Project ECHO, said Morgan Daven, vice president of health systems for the Alzheimer’s Association. Many cases featured in the program are challenging, he added.
“With primary care being on the front lines, it is really important that primary care physicians are equipped to do what they can to detect or diagnose and know when to refer,” Mr. Daven said.
The association has compiled other resources for clinicians as well.
A 2020 report from the association examined the role that primary care physicians play in dementia care. One survey found that 82% of primary care physicians consider themselves on the front lines of providing care for patients with dementia.
Meanwhile, about half say medical professionals are not prepared to meet rising demands associated with Alzheimer’s disease and dementia care.
Mr. Daven said the geographic disparities Dr. Xu and colleagues found are unsurprising. More than half of primary care physicians who care for people with Alzheimer’s disease say dementia specialists in their communities cannot meet demand. The problem is more urgent in rural areas. Roughly half of nonmetropolitan counties in the United States lack a practicing psychologist, according to a 2018 study published in the American Journal of Preventive Medicine.
“We really need to approach this on both sides – build the capacity in primary care, but we also need to address the dementia care specialty shortages,” Mr. Daven said.
The lack of obvious differences in access to neurologists in the new study “was surprising, given the more than fourfold difference between urban and rural areas in the supply of neurologists,” the researchers note. Health plans may maintain more access to neurologists than psychologists because of relatively higher reimbursement for neurologists, they observed.
One of the study coauthors disclosed ties to Aveanna Healthcare, a company that delivers home health and hospice care.
A version of this article first appeared on Medscape.com.
Patients in rural areas are also less likely to see psychologists and undergo neuropsychological testing, according to the study, published in JAMA Network Open.
Patients who forgo such specialist visits and testing may be missing information about their condition that could help them prepare for changes in job responsibilities and future care decisions, said Wendy Yi Xu, PhD, of The Ohio State University, Columbus, who led the research.
“A lot of them are still in the workforce,” Dr. Xu said. Patients in the study were an average age of 56 years, well before the conventional age of retirement.
Location, location, location
To examine rural versus urban differences in the use of diagnostic tests and health care visits for early onset Alzheimer’s disease and related dementias, Dr. Xu and colleagues analyzed commercial claims data from 2012-2018. They identified more than 71,000 patients aged 40-64 years with those conditions and focused on health care use by 7,311 patients in urban areas and 1,119 in rural areas within 90 days of a new dementia diagnosis.
The proportion who received neuropsychological testing was 19% among urban patients and 16% among rural patients. Psychological assessments, which are less specialized and detailed than neuropsychological testing, and brain imaging occurred at similar rates in both groups. Similar proportions of rural and urban patients visited neurologists (17.7% and 17.96%, respectively) and psychiatrists (6.02% and 6.47%).
But more urban patients than rural patients visited a psychologist, at 19% versus 15%, according to the researchers.
Approximately 18% of patients in rural areas saw a primary care provider without visiting other specialists, compared with 13% in urban areas.
The researchers found that rural patients were significantly less likely to undergo neuropsychological testing (odds ratio, 0.83; 95% confidence interval, 0.70-0.98) or see a psychologist (OR, 0.72; 95% CI, 0.60-0.85).
Similarly, rural patients had significantly higher odds of having only primary care providers involved in the diagnosis of dementia and symptom management (OR, 1.40; 95% CI, 1.19-1.66).
Addressing workforce deficiencies
More primary care training in dementia care and collaboration with specialist colleagues could help address differences in care, Dr. Xu’s group writes. Such efforts are already underway.
In 2018, the Alzheimer’s Association launched telementoring programs focused on dementia care using the Project ECHO (Extension for Community Healthcare Outcomes) model. Researchers originally developed Project ECHO at the University of New Mexico in 2003 to teach primary care clinicians in remote settings how to treat patients infected with the hepatitis C virus.
With the Alzheimer’s and Dementia Care ECHO Program for Clinicians, primary care clinicians can participate in interactive case-based video conferencing sessions to better understand dementia and how to provide high-quality care in community settings, according to the association.
The program covers guidelines for diagnosis, disclosure, and follow-up; the initiation of care planning; managing disease-related challenges; and resources for patients and caregivers.
Since 2018, nearly 100 primary care practices in the United States have completed training in dementia care using Project ECHO, said Morgan Daven, vice president of health systems for the Alzheimer’s Association. Many cases featured in the program are challenging, he added.
“With primary care being on the front lines, it is really important that primary care physicians are equipped to do what they can to detect or diagnose and know when to refer,” Mr. Daven said.
The association has compiled other resources for clinicians as well.
A 2020 report from the association examined the role that primary care physicians play in dementia care. One survey found that 82% of primary care physicians consider themselves on the front lines of providing care for patients with dementia.
Meanwhile, about half say medical professionals are not prepared to meet rising demands associated with Alzheimer’s disease and dementia care.
Mr. Daven said the geographic disparities Dr. Xu and colleagues found are unsurprising. More than half of primary care physicians who care for people with Alzheimer’s disease say dementia specialists in their communities cannot meet demand. The problem is more urgent in rural areas. Roughly half of nonmetropolitan counties in the United States lack a practicing psychologist, according to a 2018 study published in the American Journal of Preventive Medicine.
“We really need to approach this on both sides – build the capacity in primary care, but we also need to address the dementia care specialty shortages,” Mr. Daven said.
The lack of obvious differences in access to neurologists in the new study “was surprising, given the more than fourfold difference between urban and rural areas in the supply of neurologists,” the researchers note. Health plans may maintain more access to neurologists than psychologists because of relatively higher reimbursement for neurologists, they observed.
One of the study coauthors disclosed ties to Aveanna Healthcare, a company that delivers home health and hospice care.
A version of this article first appeared on Medscape.com.
Patients in rural areas are also less likely to see psychologists and undergo neuropsychological testing, according to the study, published in JAMA Network Open.
Patients who forgo such specialist visits and testing may be missing information about their condition that could help them prepare for changes in job responsibilities and future care decisions, said Wendy Yi Xu, PhD, of The Ohio State University, Columbus, who led the research.
“A lot of them are still in the workforce,” Dr. Xu said. Patients in the study were an average age of 56 years, well before the conventional age of retirement.
Location, location, location
To examine rural versus urban differences in the use of diagnostic tests and health care visits for early onset Alzheimer’s disease and related dementias, Dr. Xu and colleagues analyzed commercial claims data from 2012-2018. They identified more than 71,000 patients aged 40-64 years with those conditions and focused on health care use by 7,311 patients in urban areas and 1,119 in rural areas within 90 days of a new dementia diagnosis.
The proportion who received neuropsychological testing was 19% among urban patients and 16% among rural patients. Psychological assessments, which are less specialized and detailed than neuropsychological testing, and brain imaging occurred at similar rates in both groups. Similar proportions of rural and urban patients visited neurologists (17.7% and 17.96%, respectively) and psychiatrists (6.02% and 6.47%).
But more urban patients than rural patients visited a psychologist, at 19% versus 15%, according to the researchers.
Approximately 18% of patients in rural areas saw a primary care provider without visiting other specialists, compared with 13% in urban areas.
The researchers found that rural patients were significantly less likely to undergo neuropsychological testing (odds ratio, 0.83; 95% confidence interval, 0.70-0.98) or see a psychologist (OR, 0.72; 95% CI, 0.60-0.85).
Similarly, rural patients had significantly higher odds of having only primary care providers involved in the diagnosis of dementia and symptom management (OR, 1.40; 95% CI, 1.19-1.66).
Addressing workforce deficiencies
More primary care training in dementia care and collaboration with specialist colleagues could help address differences in care, Dr. Xu’s group writes. Such efforts are already underway.
In 2018, the Alzheimer’s Association launched telementoring programs focused on dementia care using the Project ECHO (Extension for Community Healthcare Outcomes) model. Researchers originally developed Project ECHO at the University of New Mexico in 2003 to teach primary care clinicians in remote settings how to treat patients infected with the hepatitis C virus.
With the Alzheimer’s and Dementia Care ECHO Program for Clinicians, primary care clinicians can participate in interactive case-based video conferencing sessions to better understand dementia and how to provide high-quality care in community settings, according to the association.
The program covers guidelines for diagnosis, disclosure, and follow-up; the initiation of care planning; managing disease-related challenges; and resources for patients and caregivers.
Since 2018, nearly 100 primary care practices in the United States have completed training in dementia care using Project ECHO, said Morgan Daven, vice president of health systems for the Alzheimer’s Association. Many cases featured in the program are challenging, he added.
“With primary care being on the front lines, it is really important that primary care physicians are equipped to do what they can to detect or diagnose and know when to refer,” Mr. Daven said.
The association has compiled other resources for clinicians as well.
A 2020 report from the association examined the role that primary care physicians play in dementia care. One survey found that 82% of primary care physicians consider themselves on the front lines of providing care for patients with dementia.
Meanwhile, about half say medical professionals are not prepared to meet rising demands associated with Alzheimer’s disease and dementia care.
Mr. Daven said the geographic disparities Dr. Xu and colleagues found are unsurprising. More than half of primary care physicians who care for people with Alzheimer’s disease say dementia specialists in their communities cannot meet demand. The problem is more urgent in rural areas. Roughly half of nonmetropolitan counties in the United States lack a practicing psychologist, according to a 2018 study published in the American Journal of Preventive Medicine.
“We really need to approach this on both sides – build the capacity in primary care, but we also need to address the dementia care specialty shortages,” Mr. Daven said.
The lack of obvious differences in access to neurologists in the new study “was surprising, given the more than fourfold difference between urban and rural areas in the supply of neurologists,” the researchers note. Health plans may maintain more access to neurologists than psychologists because of relatively higher reimbursement for neurologists, they observed.
One of the study coauthors disclosed ties to Aveanna Healthcare, a company that delivers home health and hospice care.
A version of this article first appeared on Medscape.com.
FROM JAMA NETWORK OPEN
What ketamine and psilocybin can and cannot do in depression
Recent studies with hallucinogens have raised hopes for an effective drug-based therapy to treat chronic depression. At the German Congress of Psychosomatic Medicine and Psychotherapy, Torsten Passie, MD, PhD, professor of psychiatry and psychotherapy at the Hannover (Germay) Medical School, gave a presentation on the current state of psilocybin and ketamine/esketamine research.
Dr. Passie, who also is head physician of the specialist unit for addiction and addiction prevention at the Diakonisches Werk in Hannover, has been investigating hallucinogenic substances and their application in psychotherapy for decades.
New therapies sought
In depression, gloom extends beyond the patient’s mood. For some time there has been little cause for joy with regard to chronic depression therapy. Established drug therapies hardly perform any better than placebo in meta-analyses, as a study recently confirmed. The pharmaceutical industry pulled out of psycho-pharmaceutical development more than 10 years ago. What’s more, the number of cases is rising, especially among young people, and there are long waiting times for psychotherapy appointments.
It is no wonder that some are welcoming new drug-based approaches with lysergic acid diethylamide (LSD)–like hallucinogens. In 2016, a study on psilocybin was published in The Lancet Psychiatry, although the study was unblinded and included only 24 patients.
Evoking emotions
A range of substances can be classed as hallucinogens, including psilocybin, mescaline, LSD, 3,4-methylenedioxy-methamphetamine (MDMA, also known as ecstasy), and ketamine.
Taking hallucinogens can cause a release of serotonin and dopamine, an increase in activity levels in the brain, a shift in stimulus filtering, an increase in the production of internal stimuli (inner experiences), and a change in sensory integration (for example, synesthesia).
Besides falling into a dreamlike state, patients can achieve an expansion or narrowing of consciousness if they focus on an inner experience. Internal perception increases. Perceptual routines are broken apart. Thought processes become more image-based and are more associative than normal.
Patients therefore are more capable of making new and unusual connections between different biographical or current situations. Previously unconscious ideas can become conscious. At higher doses, ego loss can occur, which can be associated with a mystical feeling of connectedness.
Hallucinogens mainly evoke and heighten emotions. Those effects may be experienced strongly as internal visions or in physical manifestations (for example, crying or laughing). In contrast, conventional antidepressants work by suppressing emotions (that is, emotional blunting).
These different mechanisms result in two contrasting management strategies. For example, SSRI antidepressants cause a patient to perceive workplace bullying as less severe and to do nothing to change the situation; the patient remains passive.
In contrast, a therapeutically guided, emotionally activating experience on hallucinogens can help the patient to try more actively to change the stressful situation.
Ketamine has a special place among hallucinogens. Unlike other hallucinogens, ketamine causes a strong clouding of consciousness, a reduction in physical sensory perception, and significant disruption in thinking and memory. It is therefore only suitable as a short-term intervention and is therapeutically impractical over the long term.
Ketamine’s effects
Ketamine, a racemic mixture of the enantiomers S-ketamine and R-ketamine, was originally used only as an analgesic and anesthetic. Owing to its rapid antidepressant effect, it has since also been used as an emergency medication for severe depression, sometimes in combination with SSRIs or serotonin noradrenaline reuptake inhibitors.
Approximately 60% of patients respond to the treatment. Whereas with conventional antidepressants, onset of action requires 10-14 days, ketamine is effective within a few hours. However, relapse always occurs, usually very quickly. After 2-3 days, the effect is usually approximately that of a placebo. An administration interval of about 2 days is optimal. However, “resistance” to the effect often develops after some time: the drug’s antidepressant effect diminishes.
Ketamine also has some unpleasant side effects, such as depersonalization, dissociation, impaired thinking, nystagmus, and psychotomimetic effects. Nausea and vomiting also occur. Interestingly, the latter does not bother the patient much, owing to the drug’s psychological effects, and it does not lead to treatment discontinuation, said Dr. Passie, who described his clinical experiences with ketamine.
Since ketamine causes a considerable clouding of consciousness, sensory disorders, and significant memory problems, it is not suitable for psychedelic-assisted psychotherapy, unlike LSD or psilocybin, he emphasized.
Ketamine 2.0?
Esketamine, the pure S-enantiomer of ketamine, has been on the market since 2019 in the form of a nasal spray (Spravato). Esketamine has been approved in combination with oral antidepressant therapy for adults with a moderate to severe episode of major depression for acute treatment of a psychiatric emergency.
A meta-analysis from 2022 concluded that the original racemic ketamine is better than the new esketamine in reducing symptoms of depression.
In his own comprehensive study, Dr. Passie concluded that the mental impairments that occur during therapy did not differ significantly between substances. The patients even felt that the side effects from esketamine therapy were much more mentally unpleasant, said Dr. Passie. He concluded that the R-enantiomer may have a kind of protective effect against some of the psychopathological effects of the S-enantiomer (esketamine).
In addition, preclinical studies have indicated that the antidepressant effects of R-enantiomer, which is not contained in esketamine, are longer lasting and stronger.
Another problem is absorption, which can be inconsistent with a nasal spray. It may differ, for example, depending on the ambient humidity or whether the patient has recently had a cold. In addition, the spray is far more expensive than the ketamine injection, said Dr. Passie. Patients must also use the nasal spray under supervision at a medical practice (as with the intravenous application) and must receive follow-up care there. It therefore offers no advantage over the ketamine injection.
According to the Institute for Quality and Efficiency in Healthcare, no additional benefit has been proven for esketamine over standard therapies for adults who have experienced a moderate to severe depressive episode when used as short-term treatment for the rapid reduction of depressive symptoms in a psychiatric emergency. The German Medical Association agreed with this evaluation in October 2021.
In the United Kingdom, the medication was never approved, owing to the fact that it was too expensive and that no studies comparing it with psychotherapy were available.
Add-on psilocybin?
What was experienced under the influence of psilocybin can also be subsequently processed and used in psychotherapy.
The acute effect of psilocybin begins after approximately 40 minutes and lasts for 4-6 hours. The antidepressant effect, if it occurs at all, is of immediate onset. Unlike ketamine/esketamine, psilocybin hardly has any physical side effects.
The neurologic mechanism of action has been investigated recently using fMRI and PET techniques. According to the investigations, the substance causes individual networks of activity in the patient’s brain to interconnect more strongly, said Dr. Passie. The thalamus, the filter station for sensory information, as well as the limbic and paralimbic structures, which generate emotions, and the cortex are all activated more strongly.
Two therapeutic settings
Psilocybin, at least in the context of studies, is used in two settings: psycholytic therapy and psychedelic therapy. Both settings originated in the 1950s and were also used with LSD as the active substance.
Psycholytic therapy with psilocybin entails multiple administrations at low doses (for example, 10-18 mg), incorporated into a longer, mostly psychodynamic therapy of around 50-100 hours (often on an inpatient basis at the beginning). It results in what is described as an extended encounter with oneself. The focus is on psychodynamic experiences, such as memories and internal conflicts. In addition, novel experiences with oneself and self-recognition are important.
Psychedelic therapy generally entails one or two sessions with a high dose (for example, 25-35 mg psilocybin). The preparation and follow-up are limited to a few sessions. These methods refer to so-called transpersonal psychology, which addresses extraordinary states of consciousness in line with religious experiences. It often leads to an intense self-confrontation as well as to new evaluations of self and world. The central element to this therapy is the experience of a mystical ego loss and the concomitant feeling of connectedness, which should help to expand one’s perspective.
Euphoria and disillusionment
The first promising studies with a few patients suffering from depression were followed by others in which the euphoria was allowed to fade away somewhat. In the first direct comparison in a methodically high-grade double-blind study, psilocybin was inferior to the SSRI antidepressant escitalopram.
“There is a great variation in response from person to person,” said Dr. Passie. “The better the study is methodically controlled, the worse the results,” he hypothesized.
“Since the method is up to 50 times more expensive in practice, compared to SSRI therapy over 6-12 weeks, the question clearly must be asked as to whether it really has any great future.”
Outlook for psilocybin
Nevertheless, Dr. Passie still sees potential in psilocybin. He considers an approach in which psilocybin therapy is more firmly incorporated into psychotherapy, with between four and 10 therapy sessions before and after administration of a lower therapeutic dose of the substance, to be more promising.
“With this kind of intensive preparation and follow-up, as well as the repeated psilocybin sessions, the patient can benefit much more than is possible with one or two high-dose sessions,” said Dr. Passie, who also is chair of the International Society for Substance-Assisted Psychotherapy. “The constant ‘in-depth work on the ego’ required for drastic therapeutic changes can be more effective and lead to permanent improvements. I have no doubt about this.”
In Dr. Passie’s opinion, the best approach would involve a dignified inpatient setting with a longer period of follow-up care and consistent posttreatment care, including group therapy. The shape of future psilocybin therapy depends on whether the rather abrupt change seen with high-dose psychedelic therapy is permanent. The answer to this question will be decisive for the method and manner of its future clinical use.
Because of the somewhat negative study results, however, the initial investors are pulling out. Dr. Passie is therefore skeptical about whether the necessary larger studies will take place and whether psilocybin will make it onto the market.
In Switzerland, which is not subject to EU restrictions, more than 30 physicians have been authorized to use psilocybin, LSD, and MDMA in psychotherapy sessions. Still, in some respects this is a special case that cannot be transferred easily to other countries, said Dr. Passie.
Possible psilocybin improvement?
Various chemical derivatives of psychoactive substances have been researched, including a psilocybin variant with the label CYB003. With CYB003, the length of the acute psychedelic experience is reduced from around 6 hours (such as with psilocybin) to 1 hour. The plasma concentration of the substance is less variable between different patients. It is assumed that its effects will also differ less from person to person.
In July, researchers began a study of the use of CYB003 in the treatment of major depression. In the randomized, double-blind, placebo-controlled study with 40 patients, multiple doses of the substance will be administered.
When asked, Dr. Passie was rather skeptical about the study. He considers the approaches with psilocybin derivatives to be the consequences of a “gold-rush atmosphere” and expects there will be no real additional benefit, especially not a reduction in the period of action.
A version of this article first appeared on Medscape.com.
Recent studies with hallucinogens have raised hopes for an effective drug-based therapy to treat chronic depression. At the German Congress of Psychosomatic Medicine and Psychotherapy, Torsten Passie, MD, PhD, professor of psychiatry and psychotherapy at the Hannover (Germay) Medical School, gave a presentation on the current state of psilocybin and ketamine/esketamine research.
Dr. Passie, who also is head physician of the specialist unit for addiction and addiction prevention at the Diakonisches Werk in Hannover, has been investigating hallucinogenic substances and their application in psychotherapy for decades.
New therapies sought
In depression, gloom extends beyond the patient’s mood. For some time there has been little cause for joy with regard to chronic depression therapy. Established drug therapies hardly perform any better than placebo in meta-analyses, as a study recently confirmed. The pharmaceutical industry pulled out of psycho-pharmaceutical development more than 10 years ago. What’s more, the number of cases is rising, especially among young people, and there are long waiting times for psychotherapy appointments.
It is no wonder that some are welcoming new drug-based approaches with lysergic acid diethylamide (LSD)–like hallucinogens. In 2016, a study on psilocybin was published in The Lancet Psychiatry, although the study was unblinded and included only 24 patients.
Evoking emotions
A range of substances can be classed as hallucinogens, including psilocybin, mescaline, LSD, 3,4-methylenedioxy-methamphetamine (MDMA, also known as ecstasy), and ketamine.
Taking hallucinogens can cause a release of serotonin and dopamine, an increase in activity levels in the brain, a shift in stimulus filtering, an increase in the production of internal stimuli (inner experiences), and a change in sensory integration (for example, synesthesia).
Besides falling into a dreamlike state, patients can achieve an expansion or narrowing of consciousness if they focus on an inner experience. Internal perception increases. Perceptual routines are broken apart. Thought processes become more image-based and are more associative than normal.
Patients therefore are more capable of making new and unusual connections between different biographical or current situations. Previously unconscious ideas can become conscious. At higher doses, ego loss can occur, which can be associated with a mystical feeling of connectedness.
Hallucinogens mainly evoke and heighten emotions. Those effects may be experienced strongly as internal visions or in physical manifestations (for example, crying or laughing). In contrast, conventional antidepressants work by suppressing emotions (that is, emotional blunting).
These different mechanisms result in two contrasting management strategies. For example, SSRI antidepressants cause a patient to perceive workplace bullying as less severe and to do nothing to change the situation; the patient remains passive.
In contrast, a therapeutically guided, emotionally activating experience on hallucinogens can help the patient to try more actively to change the stressful situation.
Ketamine has a special place among hallucinogens. Unlike other hallucinogens, ketamine causes a strong clouding of consciousness, a reduction in physical sensory perception, and significant disruption in thinking and memory. It is therefore only suitable as a short-term intervention and is therapeutically impractical over the long term.
Ketamine’s effects
Ketamine, a racemic mixture of the enantiomers S-ketamine and R-ketamine, was originally used only as an analgesic and anesthetic. Owing to its rapid antidepressant effect, it has since also been used as an emergency medication for severe depression, sometimes in combination with SSRIs or serotonin noradrenaline reuptake inhibitors.
Approximately 60% of patients respond to the treatment. Whereas with conventional antidepressants, onset of action requires 10-14 days, ketamine is effective within a few hours. However, relapse always occurs, usually very quickly. After 2-3 days, the effect is usually approximately that of a placebo. An administration interval of about 2 days is optimal. However, “resistance” to the effect often develops after some time: the drug’s antidepressant effect diminishes.
Ketamine also has some unpleasant side effects, such as depersonalization, dissociation, impaired thinking, nystagmus, and psychotomimetic effects. Nausea and vomiting also occur. Interestingly, the latter does not bother the patient much, owing to the drug’s psychological effects, and it does not lead to treatment discontinuation, said Dr. Passie, who described his clinical experiences with ketamine.
Since ketamine causes a considerable clouding of consciousness, sensory disorders, and significant memory problems, it is not suitable for psychedelic-assisted psychotherapy, unlike LSD or psilocybin, he emphasized.
Ketamine 2.0?
Esketamine, the pure S-enantiomer of ketamine, has been on the market since 2019 in the form of a nasal spray (Spravato). Esketamine has been approved in combination with oral antidepressant therapy for adults with a moderate to severe episode of major depression for acute treatment of a psychiatric emergency.
A meta-analysis from 2022 concluded that the original racemic ketamine is better than the new esketamine in reducing symptoms of depression.
In his own comprehensive study, Dr. Passie concluded that the mental impairments that occur during therapy did not differ significantly between substances. The patients even felt that the side effects from esketamine therapy were much more mentally unpleasant, said Dr. Passie. He concluded that the R-enantiomer may have a kind of protective effect against some of the psychopathological effects of the S-enantiomer (esketamine).
In addition, preclinical studies have indicated that the antidepressant effects of R-enantiomer, which is not contained in esketamine, are longer lasting and stronger.
Another problem is absorption, which can be inconsistent with a nasal spray. It may differ, for example, depending on the ambient humidity or whether the patient has recently had a cold. In addition, the spray is far more expensive than the ketamine injection, said Dr. Passie. Patients must also use the nasal spray under supervision at a medical practice (as with the intravenous application) and must receive follow-up care there. It therefore offers no advantage over the ketamine injection.
According to the Institute for Quality and Efficiency in Healthcare, no additional benefit has been proven for esketamine over standard therapies for adults who have experienced a moderate to severe depressive episode when used as short-term treatment for the rapid reduction of depressive symptoms in a psychiatric emergency. The German Medical Association agreed with this evaluation in October 2021.
In the United Kingdom, the medication was never approved, owing to the fact that it was too expensive and that no studies comparing it with psychotherapy were available.
Add-on psilocybin?
What was experienced under the influence of psilocybin can also be subsequently processed and used in psychotherapy.
The acute effect of psilocybin begins after approximately 40 minutes and lasts for 4-6 hours. The antidepressant effect, if it occurs at all, is of immediate onset. Unlike ketamine/esketamine, psilocybin hardly has any physical side effects.
The neurologic mechanism of action has been investigated recently using fMRI and PET techniques. According to the investigations, the substance causes individual networks of activity in the patient’s brain to interconnect more strongly, said Dr. Passie. The thalamus, the filter station for sensory information, as well as the limbic and paralimbic structures, which generate emotions, and the cortex are all activated more strongly.
Two therapeutic settings
Psilocybin, at least in the context of studies, is used in two settings: psycholytic therapy and psychedelic therapy. Both settings originated in the 1950s and were also used with LSD as the active substance.
Psycholytic therapy with psilocybin entails multiple administrations at low doses (for example, 10-18 mg), incorporated into a longer, mostly psychodynamic therapy of around 50-100 hours (often on an inpatient basis at the beginning). It results in what is described as an extended encounter with oneself. The focus is on psychodynamic experiences, such as memories and internal conflicts. In addition, novel experiences with oneself and self-recognition are important.
Psychedelic therapy generally entails one or two sessions with a high dose (for example, 25-35 mg psilocybin). The preparation and follow-up are limited to a few sessions. These methods refer to so-called transpersonal psychology, which addresses extraordinary states of consciousness in line with religious experiences. It often leads to an intense self-confrontation as well as to new evaluations of self and world. The central element to this therapy is the experience of a mystical ego loss and the concomitant feeling of connectedness, which should help to expand one’s perspective.
Euphoria and disillusionment
The first promising studies with a few patients suffering from depression were followed by others in which the euphoria was allowed to fade away somewhat. In the first direct comparison in a methodically high-grade double-blind study, psilocybin was inferior to the SSRI antidepressant escitalopram.
“There is a great variation in response from person to person,” said Dr. Passie. “The better the study is methodically controlled, the worse the results,” he hypothesized.
“Since the method is up to 50 times more expensive in practice, compared to SSRI therapy over 6-12 weeks, the question clearly must be asked as to whether it really has any great future.”
Outlook for psilocybin
Nevertheless, Dr. Passie still sees potential in psilocybin. He considers an approach in which psilocybin therapy is more firmly incorporated into psychotherapy, with between four and 10 therapy sessions before and after administration of a lower therapeutic dose of the substance, to be more promising.
“With this kind of intensive preparation and follow-up, as well as the repeated psilocybin sessions, the patient can benefit much more than is possible with one or two high-dose sessions,” said Dr. Passie, who also is chair of the International Society for Substance-Assisted Psychotherapy. “The constant ‘in-depth work on the ego’ required for drastic therapeutic changes can be more effective and lead to permanent improvements. I have no doubt about this.”
In Dr. Passie’s opinion, the best approach would involve a dignified inpatient setting with a longer period of follow-up care and consistent posttreatment care, including group therapy. The shape of future psilocybin therapy depends on whether the rather abrupt change seen with high-dose psychedelic therapy is permanent. The answer to this question will be decisive for the method and manner of its future clinical use.
Because of the somewhat negative study results, however, the initial investors are pulling out. Dr. Passie is therefore skeptical about whether the necessary larger studies will take place and whether psilocybin will make it onto the market.
In Switzerland, which is not subject to EU restrictions, more than 30 physicians have been authorized to use psilocybin, LSD, and MDMA in psychotherapy sessions. Still, in some respects this is a special case that cannot be transferred easily to other countries, said Dr. Passie.
Possible psilocybin improvement?
Various chemical derivatives of psychoactive substances have been researched, including a psilocybin variant with the label CYB003. With CYB003, the length of the acute psychedelic experience is reduced from around 6 hours (such as with psilocybin) to 1 hour. The plasma concentration of the substance is less variable between different patients. It is assumed that its effects will also differ less from person to person.
In July, researchers began a study of the use of CYB003 in the treatment of major depression. In the randomized, double-blind, placebo-controlled study with 40 patients, multiple doses of the substance will be administered.
When asked, Dr. Passie was rather skeptical about the study. He considers the approaches with psilocybin derivatives to be the consequences of a “gold-rush atmosphere” and expects there will be no real additional benefit, especially not a reduction in the period of action.
A version of this article first appeared on Medscape.com.
Recent studies with hallucinogens have raised hopes for an effective drug-based therapy to treat chronic depression. At the German Congress of Psychosomatic Medicine and Psychotherapy, Torsten Passie, MD, PhD, professor of psychiatry and psychotherapy at the Hannover (Germay) Medical School, gave a presentation on the current state of psilocybin and ketamine/esketamine research.
Dr. Passie, who also is head physician of the specialist unit for addiction and addiction prevention at the Diakonisches Werk in Hannover, has been investigating hallucinogenic substances and their application in psychotherapy for decades.
New therapies sought
In depression, gloom extends beyond the patient’s mood. For some time there has been little cause for joy with regard to chronic depression therapy. Established drug therapies hardly perform any better than placebo in meta-analyses, as a study recently confirmed. The pharmaceutical industry pulled out of psycho-pharmaceutical development more than 10 years ago. What’s more, the number of cases is rising, especially among young people, and there are long waiting times for psychotherapy appointments.
It is no wonder that some are welcoming new drug-based approaches with lysergic acid diethylamide (LSD)–like hallucinogens. In 2016, a study on psilocybin was published in The Lancet Psychiatry, although the study was unblinded and included only 24 patients.
Evoking emotions
A range of substances can be classed as hallucinogens, including psilocybin, mescaline, LSD, 3,4-methylenedioxy-methamphetamine (MDMA, also known as ecstasy), and ketamine.
Taking hallucinogens can cause a release of serotonin and dopamine, an increase in activity levels in the brain, a shift in stimulus filtering, an increase in the production of internal stimuli (inner experiences), and a change in sensory integration (for example, synesthesia).
Besides falling into a dreamlike state, patients can achieve an expansion or narrowing of consciousness if they focus on an inner experience. Internal perception increases. Perceptual routines are broken apart. Thought processes become more image-based and are more associative than normal.
Patients therefore are more capable of making new and unusual connections between different biographical or current situations. Previously unconscious ideas can become conscious. At higher doses, ego loss can occur, which can be associated with a mystical feeling of connectedness.
Hallucinogens mainly evoke and heighten emotions. Those effects may be experienced strongly as internal visions or in physical manifestations (for example, crying or laughing). In contrast, conventional antidepressants work by suppressing emotions (that is, emotional blunting).
These different mechanisms result in two contrasting management strategies. For example, SSRI antidepressants cause a patient to perceive workplace bullying as less severe and to do nothing to change the situation; the patient remains passive.
In contrast, a therapeutically guided, emotionally activating experience on hallucinogens can help the patient to try more actively to change the stressful situation.
Ketamine has a special place among hallucinogens. Unlike other hallucinogens, ketamine causes a strong clouding of consciousness, a reduction in physical sensory perception, and significant disruption in thinking and memory. It is therefore only suitable as a short-term intervention and is therapeutically impractical over the long term.
Ketamine’s effects
Ketamine, a racemic mixture of the enantiomers S-ketamine and R-ketamine, was originally used only as an analgesic and anesthetic. Owing to its rapid antidepressant effect, it has since also been used as an emergency medication for severe depression, sometimes in combination with SSRIs or serotonin noradrenaline reuptake inhibitors.
Approximately 60% of patients respond to the treatment. Whereas with conventional antidepressants, onset of action requires 10-14 days, ketamine is effective within a few hours. However, relapse always occurs, usually very quickly. After 2-3 days, the effect is usually approximately that of a placebo. An administration interval of about 2 days is optimal. However, “resistance” to the effect often develops after some time: the drug’s antidepressant effect diminishes.
Ketamine also has some unpleasant side effects, such as depersonalization, dissociation, impaired thinking, nystagmus, and psychotomimetic effects. Nausea and vomiting also occur. Interestingly, the latter does not bother the patient much, owing to the drug’s psychological effects, and it does not lead to treatment discontinuation, said Dr. Passie, who described his clinical experiences with ketamine.
Since ketamine causes a considerable clouding of consciousness, sensory disorders, and significant memory problems, it is not suitable for psychedelic-assisted psychotherapy, unlike LSD or psilocybin, he emphasized.
Ketamine 2.0?
Esketamine, the pure S-enantiomer of ketamine, has been on the market since 2019 in the form of a nasal spray (Spravato). Esketamine has been approved in combination with oral antidepressant therapy for adults with a moderate to severe episode of major depression for acute treatment of a psychiatric emergency.
A meta-analysis from 2022 concluded that the original racemic ketamine is better than the new esketamine in reducing symptoms of depression.
In his own comprehensive study, Dr. Passie concluded that the mental impairments that occur during therapy did not differ significantly between substances. The patients even felt that the side effects from esketamine therapy were much more mentally unpleasant, said Dr. Passie. He concluded that the R-enantiomer may have a kind of protective effect against some of the psychopathological effects of the S-enantiomer (esketamine).
In addition, preclinical studies have indicated that the antidepressant effects of R-enantiomer, which is not contained in esketamine, are longer lasting and stronger.
Another problem is absorption, which can be inconsistent with a nasal spray. It may differ, for example, depending on the ambient humidity or whether the patient has recently had a cold. In addition, the spray is far more expensive than the ketamine injection, said Dr. Passie. Patients must also use the nasal spray under supervision at a medical practice (as with the intravenous application) and must receive follow-up care there. It therefore offers no advantage over the ketamine injection.
According to the Institute for Quality and Efficiency in Healthcare, no additional benefit has been proven for esketamine over standard therapies for adults who have experienced a moderate to severe depressive episode when used as short-term treatment for the rapid reduction of depressive symptoms in a psychiatric emergency. The German Medical Association agreed with this evaluation in October 2021.
In the United Kingdom, the medication was never approved, owing to the fact that it was too expensive and that no studies comparing it with psychotherapy were available.
Add-on psilocybin?
What was experienced under the influence of psilocybin can also be subsequently processed and used in psychotherapy.
The acute effect of psilocybin begins after approximately 40 minutes and lasts for 4-6 hours. The antidepressant effect, if it occurs at all, is of immediate onset. Unlike ketamine/esketamine, psilocybin hardly has any physical side effects.
The neurologic mechanism of action has been investigated recently using fMRI and PET techniques. According to the investigations, the substance causes individual networks of activity in the patient’s brain to interconnect more strongly, said Dr. Passie. The thalamus, the filter station for sensory information, as well as the limbic and paralimbic structures, which generate emotions, and the cortex are all activated more strongly.
Two therapeutic settings
Psilocybin, at least in the context of studies, is used in two settings: psycholytic therapy and psychedelic therapy. Both settings originated in the 1950s and were also used with LSD as the active substance.
Psycholytic therapy with psilocybin entails multiple administrations at low doses (for example, 10-18 mg), incorporated into a longer, mostly psychodynamic therapy of around 50-100 hours (often on an inpatient basis at the beginning). It results in what is described as an extended encounter with oneself. The focus is on psychodynamic experiences, such as memories and internal conflicts. In addition, novel experiences with oneself and self-recognition are important.
Psychedelic therapy generally entails one or two sessions with a high dose (for example, 25-35 mg psilocybin). The preparation and follow-up are limited to a few sessions. These methods refer to so-called transpersonal psychology, which addresses extraordinary states of consciousness in line with religious experiences. It often leads to an intense self-confrontation as well as to new evaluations of self and world. The central element to this therapy is the experience of a mystical ego loss and the concomitant feeling of connectedness, which should help to expand one’s perspective.
Euphoria and disillusionment
The first promising studies with a few patients suffering from depression were followed by others in which the euphoria was allowed to fade away somewhat. In the first direct comparison in a methodically high-grade double-blind study, psilocybin was inferior to the SSRI antidepressant escitalopram.
“There is a great variation in response from person to person,” said Dr. Passie. “The better the study is methodically controlled, the worse the results,” he hypothesized.
“Since the method is up to 50 times more expensive in practice, compared to SSRI therapy over 6-12 weeks, the question clearly must be asked as to whether it really has any great future.”
Outlook for psilocybin
Nevertheless, Dr. Passie still sees potential in psilocybin. He considers an approach in which psilocybin therapy is more firmly incorporated into psychotherapy, with between four and 10 therapy sessions before and after administration of a lower therapeutic dose of the substance, to be more promising.
“With this kind of intensive preparation and follow-up, as well as the repeated psilocybin sessions, the patient can benefit much more than is possible with one or two high-dose sessions,” said Dr. Passie, who also is chair of the International Society for Substance-Assisted Psychotherapy. “The constant ‘in-depth work on the ego’ required for drastic therapeutic changes can be more effective and lead to permanent improvements. I have no doubt about this.”
In Dr. Passie’s opinion, the best approach would involve a dignified inpatient setting with a longer period of follow-up care and consistent posttreatment care, including group therapy. The shape of future psilocybin therapy depends on whether the rather abrupt change seen with high-dose psychedelic therapy is permanent. The answer to this question will be decisive for the method and manner of its future clinical use.
Because of the somewhat negative study results, however, the initial investors are pulling out. Dr. Passie is therefore skeptical about whether the necessary larger studies will take place and whether psilocybin will make it onto the market.
In Switzerland, which is not subject to EU restrictions, more than 30 physicians have been authorized to use psilocybin, LSD, and MDMA in psychotherapy sessions. Still, in some respects this is a special case that cannot be transferred easily to other countries, said Dr. Passie.
Possible psilocybin improvement?
Various chemical derivatives of psychoactive substances have been researched, including a psilocybin variant with the label CYB003. With CYB003, the length of the acute psychedelic experience is reduced from around 6 hours (such as with psilocybin) to 1 hour. The plasma concentration of the substance is less variable between different patients. It is assumed that its effects will also differ less from person to person.
In July, researchers began a study of the use of CYB003 in the treatment of major depression. In the randomized, double-blind, placebo-controlled study with 40 patients, multiple doses of the substance will be administered.
When asked, Dr. Passie was rather skeptical about the study. He considers the approaches with psilocybin derivatives to be the consequences of a “gold-rush atmosphere” and expects there will be no real additional benefit, especially not a reduction in the period of action.
A version of this article first appeared on Medscape.com.
What’s in a mother’s song?
How do a baby’s body and brain respond when their mother sings a lullaby?
Shannon de l’Etoile, PhD, is hoping to find out. Dr. de l’Etoile, professor of music therapy at the University of Miami, began watching interactions between typically functioning mothers and infants, mothers with postpartum depression and their babies, and mothers and infants with Down Syndrome.
The infants she studied became highly attentive to their mothers’ singing and showed “a contented state of arousal,” she said. Mothers, meanwhile, became more engaged with their babies.
To examine the issue more scientifically, Dr. de l’Etoile has launched a study of infant-directed singing, a method connecting babies and mothers through song. With the help of a nearly $20,000 grant from the Grammy Museum – a Los Angeles nonprofit that hosts and funds exhibits and other music programs – Dr. de l’Etoile plans to recruit 20 women whose children attend programming at the Linda Ray Intervention Center at the University of Miami. The early intervention program targets children under age 2 who have disabilities or slower development, or who may have been exposed to drugs in utero. The study will last 1 year, with plans for an extension.
“By helping the mothers to become more sensitive, we are simultaneously helping infants learn how to regulate, so that by the time they’re in preschool, they can manage their behavior and have a successful, positive experience,” Dr. de l’Etoile said. She hopes her project will help women gain the confidence they need for families emotionally.
Mothers who practice infant-directed singing communicate with their babies through a variety of songs, from happy, playful versions of the ABCs, to more somber, drawn-out lullabies. In turn, their babies learn the emotional cues that go along with songs, potentially going from crying to playing, or watching their mother attentively.
Later in life, children raised with infant-directed singing might sing to themselves when they are stressed or need to go to sleep, Dr. de l’Etoile said.
A caregiving method like singing may be less intuitive for women facing basic survival challenges, like maintaining safe housing or putting food on the table, Dr. d’Etoile said.
Interest in studying infant-directed singing has grown in the past few years, although according to Sandra Trehub, PhD, an expert in infant-directed singing, studies of the phenomenon began in the early 1990s. In her own work, Dr. Trehub found that infants appear to be more engaged with parents who sing directly to them than those who sing around but not at them.
Dr. Trehub said singing can be an additional resource for a mother to overcome socioeconomic hardships and bond with their child.
“Songs sung to an infant repeatedly become almost like a special signal between mother and child, a way for them to bond with each other,” she said.
Isabel Santana Chica, MS, executive director of the Linda Ray Intervention Center, expressed enthusiasm for the project.
“Music is a great way to support language, social, and emotional development,” Ms. Chica said. “My hope is that through infant-directed singing, mothers will have one additional tool to connect to their infants and enhance development.”
A version of this article first appeared on Medscape.com.
How do a baby’s body and brain respond when their mother sings a lullaby?
Shannon de l’Etoile, PhD, is hoping to find out. Dr. de l’Etoile, professor of music therapy at the University of Miami, began watching interactions between typically functioning mothers and infants, mothers with postpartum depression and their babies, and mothers and infants with Down Syndrome.
The infants she studied became highly attentive to their mothers’ singing and showed “a contented state of arousal,” she said. Mothers, meanwhile, became more engaged with their babies.
To examine the issue more scientifically, Dr. de l’Etoile has launched a study of infant-directed singing, a method connecting babies and mothers through song. With the help of a nearly $20,000 grant from the Grammy Museum – a Los Angeles nonprofit that hosts and funds exhibits and other music programs – Dr. de l’Etoile plans to recruit 20 women whose children attend programming at the Linda Ray Intervention Center at the University of Miami. The early intervention program targets children under age 2 who have disabilities or slower development, or who may have been exposed to drugs in utero. The study will last 1 year, with plans for an extension.
“By helping the mothers to become more sensitive, we are simultaneously helping infants learn how to regulate, so that by the time they’re in preschool, they can manage their behavior and have a successful, positive experience,” Dr. de l’Etoile said. She hopes her project will help women gain the confidence they need for families emotionally.
Mothers who practice infant-directed singing communicate with their babies through a variety of songs, from happy, playful versions of the ABCs, to more somber, drawn-out lullabies. In turn, their babies learn the emotional cues that go along with songs, potentially going from crying to playing, or watching their mother attentively.
Later in life, children raised with infant-directed singing might sing to themselves when they are stressed or need to go to sleep, Dr. de l’Etoile said.
A caregiving method like singing may be less intuitive for women facing basic survival challenges, like maintaining safe housing or putting food on the table, Dr. d’Etoile said.
Interest in studying infant-directed singing has grown in the past few years, although according to Sandra Trehub, PhD, an expert in infant-directed singing, studies of the phenomenon began in the early 1990s. In her own work, Dr. Trehub found that infants appear to be more engaged with parents who sing directly to them than those who sing around but not at them.
Dr. Trehub said singing can be an additional resource for a mother to overcome socioeconomic hardships and bond with their child.
“Songs sung to an infant repeatedly become almost like a special signal between mother and child, a way for them to bond with each other,” she said.
Isabel Santana Chica, MS, executive director of the Linda Ray Intervention Center, expressed enthusiasm for the project.
“Music is a great way to support language, social, and emotional development,” Ms. Chica said. “My hope is that through infant-directed singing, mothers will have one additional tool to connect to their infants and enhance development.”
A version of this article first appeared on Medscape.com.
How do a baby’s body and brain respond when their mother sings a lullaby?
Shannon de l’Etoile, PhD, is hoping to find out. Dr. de l’Etoile, professor of music therapy at the University of Miami, began watching interactions between typically functioning mothers and infants, mothers with postpartum depression and their babies, and mothers and infants with Down Syndrome.
The infants she studied became highly attentive to their mothers’ singing and showed “a contented state of arousal,” she said. Mothers, meanwhile, became more engaged with their babies.
To examine the issue more scientifically, Dr. de l’Etoile has launched a study of infant-directed singing, a method connecting babies and mothers through song. With the help of a nearly $20,000 grant from the Grammy Museum – a Los Angeles nonprofit that hosts and funds exhibits and other music programs – Dr. de l’Etoile plans to recruit 20 women whose children attend programming at the Linda Ray Intervention Center at the University of Miami. The early intervention program targets children under age 2 who have disabilities or slower development, or who may have been exposed to drugs in utero. The study will last 1 year, with plans for an extension.
“By helping the mothers to become more sensitive, we are simultaneously helping infants learn how to regulate, so that by the time they’re in preschool, they can manage their behavior and have a successful, positive experience,” Dr. de l’Etoile said. She hopes her project will help women gain the confidence they need for families emotionally.
Mothers who practice infant-directed singing communicate with their babies through a variety of songs, from happy, playful versions of the ABCs, to more somber, drawn-out lullabies. In turn, their babies learn the emotional cues that go along with songs, potentially going from crying to playing, or watching their mother attentively.
Later in life, children raised with infant-directed singing might sing to themselves when they are stressed or need to go to sleep, Dr. de l’Etoile said.
A caregiving method like singing may be less intuitive for women facing basic survival challenges, like maintaining safe housing or putting food on the table, Dr. d’Etoile said.
Interest in studying infant-directed singing has grown in the past few years, although according to Sandra Trehub, PhD, an expert in infant-directed singing, studies of the phenomenon began in the early 1990s. In her own work, Dr. Trehub found that infants appear to be more engaged with parents who sing directly to them than those who sing around but not at them.
Dr. Trehub said singing can be an additional resource for a mother to overcome socioeconomic hardships and bond with their child.
“Songs sung to an infant repeatedly become almost like a special signal between mother and child, a way for them to bond with each other,” she said.
Isabel Santana Chica, MS, executive director of the Linda Ray Intervention Center, expressed enthusiasm for the project.
“Music is a great way to support language, social, and emotional development,” Ms. Chica said. “My hope is that through infant-directed singing, mothers will have one additional tool to connect to their infants and enhance development.”
A version of this article first appeared on Medscape.com.
Postpartum psychosis: Does longitudinal course inform treatment?
The last 15 years have brought increased effort to screen for postpartum psychiatric illness. That’s exceedingly welcome given the morbidity and potential mortality associated with postpartum psychiatric disorders across the country.
From small community hospitals to major academic centers, screening for postpartum depression is part of the clinical fabric of routine obstetrical care. There is a growing appreciation for the complexity of perinatal psychiatric illness, particularly with respect to the commingling of both mood and anxiety disorders during the postpartum period. However, willingness to treat and appreciation of the urgency to treat with both pharmacologic and nonpharmacologic interventions can vary. For women who suffer from postpartum depression and their families, there are real-world implications of both treating and failing to treat this illness, and there is an urgent need to really help these women “climb out of the darkness” that is and defines postpartum depression.
Less common but of great clinical importance is postpartum psychosis, which occurs in approximately 1 in 1,000-2,000 women based on estimates from several studies. As noted in previous columns, the presentation is a dramatic one, with the typical onset of psychotic symptoms in the first days to weeks post partum. The disorder typically has a mood component and is not an exacerbation of underlying chronic psychotic illness. While there have been few systematic treatment studies, the clinical consensus is treatment usually includes hospitalization to ensure the safety of both the patient and infant. Use of medications, including mood stabilizers, antipsychotics, and benzodiazepines may be appropriate when expeditious treatment is needed.
Appropriate treatment by informed clinical staff is essential, as untreated or incompletely treated postpartum psychosis with its attendant morbidity and potential mortality is a very real concern. As I speak with women across the country with histories of postpartum psychosis, I’m often told of the difficult exchanges that women and their partners have at EDs in various clinical settings where diagnosis was delayed, or treatment was incomplete because of staff without expertise in postpartum psychosis management.
Another dilemma that patients and clinicians face after acute treatment is treatment duration, which is derived from how we conceptualize the illness. Even for experts in the area, there is not a consensus on whether postpartum psychosis should be considered as bipolar disorder or whether it is a circumscribed diagnostic entity. This issue has been hotly debated for many years and is one of the reasons why the illness is not included in the DSM classification system.
At Massachusetts General Hospital, we are systematically studying a large cohort of women with histories of postpartum psychosis as part of the MGH Postpartum Psychosis Project to better understand the phenomenology of postpartum psychosis, and also to understand the possible genomic underpinning of the illness. Most recently, we are conducting a neuroimaging study of women with histories of postpartum psychosis, compared with women in a healthy control group. We hope the results of this novel investigation will help to answer whether there is a neural signature identifiable with neuroimaging techniques such as functional MRI, if those findings are similar to other findings of neural circuitry we see in other forms of psychotic illness, or if the illness has a more distinct neural signature.
A question patients and colleagues often ask is what is the long-term nature of postpartum psychosis. If one considers it clearly to be bipolar disorder, the most intuitive approach would be long-term treatment with mood stabilizers. We now have a growing amount of data on the longitudinal course of postpartum psychosis. In one meta-analysis, 64% of women who had an episode of postpartum psychosis developed episodes of recurrent psychiatric disorder mostly consistent with bipolar illness. However, 36% of women appear to have more circumscribed illness without recurrence. In those women with recurrent disease, the presumption was those patients who had bipolar disorder and their presentation postpartum was simply their index episode of bipolar illness. However, there were other women who looked as if they had developed subsequent illness over the 11-26 years of follow-up, and those women did not receive long-term treatment.
A more recent prospective study of 106 women with postpartum psychosis who had their medication tapered and discontinued showed that 32% of women went on to have recurrent disease with a median time to illness of 20.3 months, and those patients presented primarily with illness that looked like bipolar disorder.
These accumulating data support the impression we’ve had for years that there’s a very strong relationship between bipolar disorder and postpartum psychiatric illness. Regardless of what side of the debate you fall on, the acute treatment is really the same. The real question for the clinician is what to do over the long term. Frequently, patients feel very strongly about a taper and discontinuation of medicine, and even the data show between 30% and 45% of women seem to have relatively circumscribed disease. There may be an issue in terms of prophylaxis if a patient gets pregnant and delivers another child, but that’s a separate issue. The issue is really whether there is a way to “thread the clinical needle” and meet patients where they are who do not want to continue long-term treatment.
I think we are at a point where we could argue the clinical treatment algorithm for patients who present with a new-onset manic-like psychosis postpartum is clear: initial treatment to stabilize, and then treatment with mood stabilizers for at least 12 months to follow is indicated. However, it may also be reasonable to taper treatment at 12-18 months, particularly for patients who have discussed this option with their clinician and who have been totally well for a year. (Women with previously documented bipolar disorder who have episodes of postpartum psychosis should obviously be treated with longer-term treatment aimed at maintenance of euthymia, as discontinuation of mood stabilizer is well known to be associated with risk for relapse.)
It should be noted that the longitudinal course and the treatment implications for women with postpartum psychosis are not etched in stone absent a clear evidence base driving care guidelines. Treatment must still be individualized. Women with underlying mood diatheses will typically declare themselves over time, and others may do well if they discontinue treatment, particularly if they are followed closely and instructed to present to a clinician at the earliest symptoms of mood dysregulation. The good news is we’ve seen an evolution of both interest and expertise in acute management of postpartum psychosis and a richer appreciation of the potential heterogeneity of this sample of women. There may be some variability in terms of long-term course requiring personalized treatment and obviously close follow-up of these women.
Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. Email Dr. Cohen at obnews@mdedge.com.
The last 15 years have brought increased effort to screen for postpartum psychiatric illness. That’s exceedingly welcome given the morbidity and potential mortality associated with postpartum psychiatric disorders across the country.
From small community hospitals to major academic centers, screening for postpartum depression is part of the clinical fabric of routine obstetrical care. There is a growing appreciation for the complexity of perinatal psychiatric illness, particularly with respect to the commingling of both mood and anxiety disorders during the postpartum period. However, willingness to treat and appreciation of the urgency to treat with both pharmacologic and nonpharmacologic interventions can vary. For women who suffer from postpartum depression and their families, there are real-world implications of both treating and failing to treat this illness, and there is an urgent need to really help these women “climb out of the darkness” that is and defines postpartum depression.
Less common but of great clinical importance is postpartum psychosis, which occurs in approximately 1 in 1,000-2,000 women based on estimates from several studies. As noted in previous columns, the presentation is a dramatic one, with the typical onset of psychotic symptoms in the first days to weeks post partum. The disorder typically has a mood component and is not an exacerbation of underlying chronic psychotic illness. While there have been few systematic treatment studies, the clinical consensus is treatment usually includes hospitalization to ensure the safety of both the patient and infant. Use of medications, including mood stabilizers, antipsychotics, and benzodiazepines may be appropriate when expeditious treatment is needed.
Appropriate treatment by informed clinical staff is essential, as untreated or incompletely treated postpartum psychosis with its attendant morbidity and potential mortality is a very real concern. As I speak with women across the country with histories of postpartum psychosis, I’m often told of the difficult exchanges that women and their partners have at EDs in various clinical settings where diagnosis was delayed, or treatment was incomplete because of staff without expertise in postpartum psychosis management.
Another dilemma that patients and clinicians face after acute treatment is treatment duration, which is derived from how we conceptualize the illness. Even for experts in the area, there is not a consensus on whether postpartum psychosis should be considered as bipolar disorder or whether it is a circumscribed diagnostic entity. This issue has been hotly debated for many years and is one of the reasons why the illness is not included in the DSM classification system.
At Massachusetts General Hospital, we are systematically studying a large cohort of women with histories of postpartum psychosis as part of the MGH Postpartum Psychosis Project to better understand the phenomenology of postpartum psychosis, and also to understand the possible genomic underpinning of the illness. Most recently, we are conducting a neuroimaging study of women with histories of postpartum psychosis, compared with women in a healthy control group. We hope the results of this novel investigation will help to answer whether there is a neural signature identifiable with neuroimaging techniques such as functional MRI, if those findings are similar to other findings of neural circuitry we see in other forms of psychotic illness, or if the illness has a more distinct neural signature.
A question patients and colleagues often ask is what is the long-term nature of postpartum psychosis. If one considers it clearly to be bipolar disorder, the most intuitive approach would be long-term treatment with mood stabilizers. We now have a growing amount of data on the longitudinal course of postpartum psychosis. In one meta-analysis, 64% of women who had an episode of postpartum psychosis developed episodes of recurrent psychiatric disorder mostly consistent with bipolar illness. However, 36% of women appear to have more circumscribed illness without recurrence. In those women with recurrent disease, the presumption was those patients who had bipolar disorder and their presentation postpartum was simply their index episode of bipolar illness. However, there were other women who looked as if they had developed subsequent illness over the 11-26 years of follow-up, and those women did not receive long-term treatment.
A more recent prospective study of 106 women with postpartum psychosis who had their medication tapered and discontinued showed that 32% of women went on to have recurrent disease with a median time to illness of 20.3 months, and those patients presented primarily with illness that looked like bipolar disorder.
These accumulating data support the impression we’ve had for years that there’s a very strong relationship between bipolar disorder and postpartum psychiatric illness. Regardless of what side of the debate you fall on, the acute treatment is really the same. The real question for the clinician is what to do over the long term. Frequently, patients feel very strongly about a taper and discontinuation of medicine, and even the data show between 30% and 45% of women seem to have relatively circumscribed disease. There may be an issue in terms of prophylaxis if a patient gets pregnant and delivers another child, but that’s a separate issue. The issue is really whether there is a way to “thread the clinical needle” and meet patients where they are who do not want to continue long-term treatment.
I think we are at a point where we could argue the clinical treatment algorithm for patients who present with a new-onset manic-like psychosis postpartum is clear: initial treatment to stabilize, and then treatment with mood stabilizers for at least 12 months to follow is indicated. However, it may also be reasonable to taper treatment at 12-18 months, particularly for patients who have discussed this option with their clinician and who have been totally well for a year. (Women with previously documented bipolar disorder who have episodes of postpartum psychosis should obviously be treated with longer-term treatment aimed at maintenance of euthymia, as discontinuation of mood stabilizer is well known to be associated with risk for relapse.)
It should be noted that the longitudinal course and the treatment implications for women with postpartum psychosis are not etched in stone absent a clear evidence base driving care guidelines. Treatment must still be individualized. Women with underlying mood diatheses will typically declare themselves over time, and others may do well if they discontinue treatment, particularly if they are followed closely and instructed to present to a clinician at the earliest symptoms of mood dysregulation. The good news is we’ve seen an evolution of both interest and expertise in acute management of postpartum psychosis and a richer appreciation of the potential heterogeneity of this sample of women. There may be some variability in terms of long-term course requiring personalized treatment and obviously close follow-up of these women.
Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. Email Dr. Cohen at obnews@mdedge.com.
The last 15 years have brought increased effort to screen for postpartum psychiatric illness. That’s exceedingly welcome given the morbidity and potential mortality associated with postpartum psychiatric disorders across the country.
From small community hospitals to major academic centers, screening for postpartum depression is part of the clinical fabric of routine obstetrical care. There is a growing appreciation for the complexity of perinatal psychiatric illness, particularly with respect to the commingling of both mood and anxiety disorders during the postpartum period. However, willingness to treat and appreciation of the urgency to treat with both pharmacologic and nonpharmacologic interventions can vary. For women who suffer from postpartum depression and their families, there are real-world implications of both treating and failing to treat this illness, and there is an urgent need to really help these women “climb out of the darkness” that is and defines postpartum depression.
Less common but of great clinical importance is postpartum psychosis, which occurs in approximately 1 in 1,000-2,000 women based on estimates from several studies. As noted in previous columns, the presentation is a dramatic one, with the typical onset of psychotic symptoms in the first days to weeks post partum. The disorder typically has a mood component and is not an exacerbation of underlying chronic psychotic illness. While there have been few systematic treatment studies, the clinical consensus is treatment usually includes hospitalization to ensure the safety of both the patient and infant. Use of medications, including mood stabilizers, antipsychotics, and benzodiazepines may be appropriate when expeditious treatment is needed.
Appropriate treatment by informed clinical staff is essential, as untreated or incompletely treated postpartum psychosis with its attendant morbidity and potential mortality is a very real concern. As I speak with women across the country with histories of postpartum psychosis, I’m often told of the difficult exchanges that women and their partners have at EDs in various clinical settings where diagnosis was delayed, or treatment was incomplete because of staff without expertise in postpartum psychosis management.
Another dilemma that patients and clinicians face after acute treatment is treatment duration, which is derived from how we conceptualize the illness. Even for experts in the area, there is not a consensus on whether postpartum psychosis should be considered as bipolar disorder or whether it is a circumscribed diagnostic entity. This issue has been hotly debated for many years and is one of the reasons why the illness is not included in the DSM classification system.
At Massachusetts General Hospital, we are systematically studying a large cohort of women with histories of postpartum psychosis as part of the MGH Postpartum Psychosis Project to better understand the phenomenology of postpartum psychosis, and also to understand the possible genomic underpinning of the illness. Most recently, we are conducting a neuroimaging study of women with histories of postpartum psychosis, compared with women in a healthy control group. We hope the results of this novel investigation will help to answer whether there is a neural signature identifiable with neuroimaging techniques such as functional MRI, if those findings are similar to other findings of neural circuitry we see in other forms of psychotic illness, or if the illness has a more distinct neural signature.
A question patients and colleagues often ask is what is the long-term nature of postpartum psychosis. If one considers it clearly to be bipolar disorder, the most intuitive approach would be long-term treatment with mood stabilizers. We now have a growing amount of data on the longitudinal course of postpartum psychosis. In one meta-analysis, 64% of women who had an episode of postpartum psychosis developed episodes of recurrent psychiatric disorder mostly consistent with bipolar illness. However, 36% of women appear to have more circumscribed illness without recurrence. In those women with recurrent disease, the presumption was those patients who had bipolar disorder and their presentation postpartum was simply their index episode of bipolar illness. However, there were other women who looked as if they had developed subsequent illness over the 11-26 years of follow-up, and those women did not receive long-term treatment.
A more recent prospective study of 106 women with postpartum psychosis who had their medication tapered and discontinued showed that 32% of women went on to have recurrent disease with a median time to illness of 20.3 months, and those patients presented primarily with illness that looked like bipolar disorder.
These accumulating data support the impression we’ve had for years that there’s a very strong relationship between bipolar disorder and postpartum psychiatric illness. Regardless of what side of the debate you fall on, the acute treatment is really the same. The real question for the clinician is what to do over the long term. Frequently, patients feel very strongly about a taper and discontinuation of medicine, and even the data show between 30% and 45% of women seem to have relatively circumscribed disease. There may be an issue in terms of prophylaxis if a patient gets pregnant and delivers another child, but that’s a separate issue. The issue is really whether there is a way to “thread the clinical needle” and meet patients where they are who do not want to continue long-term treatment.
I think we are at a point where we could argue the clinical treatment algorithm for patients who present with a new-onset manic-like psychosis postpartum is clear: initial treatment to stabilize, and then treatment with mood stabilizers for at least 12 months to follow is indicated. However, it may also be reasonable to taper treatment at 12-18 months, particularly for patients who have discussed this option with their clinician and who have been totally well for a year. (Women with previously documented bipolar disorder who have episodes of postpartum psychosis should obviously be treated with longer-term treatment aimed at maintenance of euthymia, as discontinuation of mood stabilizer is well known to be associated with risk for relapse.)
It should be noted that the longitudinal course and the treatment implications for women with postpartum psychosis are not etched in stone absent a clear evidence base driving care guidelines. Treatment must still be individualized. Women with underlying mood diatheses will typically declare themselves over time, and others may do well if they discontinue treatment, particularly if they are followed closely and instructed to present to a clinician at the earliest symptoms of mood dysregulation. The good news is we’ve seen an evolution of both interest and expertise in acute management of postpartum psychosis and a richer appreciation of the potential heterogeneity of this sample of women. There may be some variability in terms of long-term course requiring personalized treatment and obviously close follow-up of these women.
Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. Email Dr. Cohen at obnews@mdedge.com.
Managing maternal and infant mental health
An overwhelmed mother presents to your office with her 2-month-old son for his check-up. She seems distant and dysphoric, often shrugging her shoulders with an empty stare when asked about her son’s development. Her baby cries loudly in her arms and you can see that she is uncomfortable soothing him as she frantically rocks him back and forth. He appears to have gained little weight since the last appointment occurring 6 days post partum and his mother describes him as “difficult and fussy all the time.” The father was unable to attend the appointment due to work obligations and often leaves the baby alone with the mother for 10 hours per day. As you examine her son, you counsel the mother on how to care for her baby while also caring for herself. The mother immediately begins to sob into her hands and states: “I can’t do this anymore. I am not meant to be a mother.”
Major depressive disorder with peripartum onset – also known as postpartum depression – is a major public health concern that affects approximately 20% of women in industrial societies like the United States. It is among the most prevalent psychiatric disorders in the world and remains largely underdiagnosed because of lack of access to care, symptom underreporting secondary to stigma, and lack of education regarding illness.1 Adequate treatment of perinatal depression is of paramount importance, as this condition can have significant negative consequences for both mother and child.
Infants raised by depressed mothers show early disruptions in social and emotional development, including diminished security of attachment with their mothers and reduced ability to self-regulate.2 Later in development, the offspring of depressed mothers are at greater risk for psychopathology – most notably anxiety and depression as well as impaired social behavior. 3,4 Rates of depression in school-aged and adolescent children of depressed mothers have been reported to be between 20% and 41%.4 Not only are rates of depression higher, but depression in children of depressed parents, relative to depression in same-age children of nondepressed parents, has an earlier age of onset, longer duration, and is associated with greater functional impairment and risk of relapse.5
In addition, evidence shows that infants of depressed mothers show more negative affect and more self-directed regulatory behaviors, while toddlers show more dysregulated aggression and heightened mood lability.6 Given that these infants also already have an increased genetic risk for depression and anxiety, it is essential that mothers are identified and treated early to prevent these early disruptions to the parent-child relationship.
Pediatricians sit at the intersection of motherhood and infant development. This offers a unique opportunity to influence the trajectory of the child through bolstering supports for the mother. Understandably, time is limited during these brief touchpoints occurring over the first postpartum year, although a heartfelt “How are you?” can make all the difference. In asking this simple question in a disarming way, you may prevent multiple adverse childhood experiences for your tiniest patients.
Further, evidence has shown that toxic stress experienced during sensitive periods of brain development in infants and young children can negatively affect brain architecture. Brain pathways that are rarely used are pruned away, whereas pathways that are readily accessed grow stronger. If children are exposed to toxic stress, whether it be from abuse, mental illness of a caregiver such as severe maternal depression, witnessed domestic violence, or worse, they may begin to experience the world as dangerous and uncertain. This can strengthen connections in parts of the brain associated with fear, arousal, and emotional regulation at the cost of other parts of the brain associated with learning and safety.
Particularly focusing on infancy through preschool, children depend on sensitive, responsive caregivers to learn how to understand emotions and begin to self-soothe. Pediatricians have access to this critical period and can help lead the way toward secure attachment between mother and child. Through taking this dyadic, integrated approach, not only can downstream problems in the child be attenuated or even prevented (that is, disrupted social-emotional development and depression/anxiety), but a mother’s identity can form around her strengths in parenting rather than negative cognitive distortions. Here are some ways to quickly assess a mother for major depressive disorder with peripartum onset so that treatment can be secured, allowing children to develop and learn in a safe, supportive, loving environment:
- Add a standardized instrument to the check-in process during baby’s first year of life. The Edinburgh Postnatal Depression Scale (EPDS) is the most commonly used screening tool, consisting of 10 questions with a score of 10 or greater suggestive of maternal depression. Recently, it was found that the EPDS may be further abbreviated to a three-question version with a sensitivity of 95% and a negative predictive value of 98%.
- Dedicate 5 minutes during each appointment to ask the mother, in earnest, how she is doing and to create space to hear her concerns. This high-yield discussion can be the catalyst the mother needs to identify that something is not right.
- Obtain collateral information from the mother’s partner, if available, in a way that feels collaborative and supportive. You may ask the partner during the appointment if they have any concerns about how both parents are coping with their new parenting roles.
- If the mother has multiple risk factors for major depressive disorder with peripartum onset – past history of depression, family history of perinatal depression, lack of social supports, or past history of major depressive disorder with peripartum onset with an earlier child (elevating their risk to about 50%) – you may dedicate a bit more time to assess the patient and/or provide mental health resources directly upon wrapping up the appointment.
- Finally, you may add an educational blurb about major depressive disorder with peripartum onset in all after-visit summaries for new parents and infants with a list of mental health resources that includes reproductive psychiatrists, therapists, and a link to robust resources like Postpartum Support International.
By taking the extra step to leverage the relationship between mother and infant at this highly vulnerable time, you have the ability to positively affect the trajectory of a family. And, at the end of the day, this dyadic approach to patient care is the secret ingredient to improved outcomes all around.
References
1. Muzik M and Hamilton SE. Matern Child Health J. 2016;20(11):2268-79.
2. Granat A et al. Emotion. 2017;17(1):11-27.
3. Conroy S et al. J Am Acad Child Adolesc Psychiatry. 2012;51(1):51-61.
4. Goodman SH. Annu Rev Clin Psychol. 2007;3:107-35.
5. Keller MB et al. Arch Gen Psychiatry. 1986;43(10):930-7.
6. Tronick EZ and Gianino AF. New Dir Child Dev. 1986;34:5-11.
Dr. Richards is assistant clinical professor in the department of psychiatry and biobehavioral sciences, program director of the child and adolescent psychiatry fellowship, and associate medical director of the perinatal program at the UCLA Semel Institute for Neuroscience and Human Behavior in Los Angeles.
An overwhelmed mother presents to your office with her 2-month-old son for his check-up. She seems distant and dysphoric, often shrugging her shoulders with an empty stare when asked about her son’s development. Her baby cries loudly in her arms and you can see that she is uncomfortable soothing him as she frantically rocks him back and forth. He appears to have gained little weight since the last appointment occurring 6 days post partum and his mother describes him as “difficult and fussy all the time.” The father was unable to attend the appointment due to work obligations and often leaves the baby alone with the mother for 10 hours per day. As you examine her son, you counsel the mother on how to care for her baby while also caring for herself. The mother immediately begins to sob into her hands and states: “I can’t do this anymore. I am not meant to be a mother.”
Major depressive disorder with peripartum onset – also known as postpartum depression – is a major public health concern that affects approximately 20% of women in industrial societies like the United States. It is among the most prevalent psychiatric disorders in the world and remains largely underdiagnosed because of lack of access to care, symptom underreporting secondary to stigma, and lack of education regarding illness.1 Adequate treatment of perinatal depression is of paramount importance, as this condition can have significant negative consequences for both mother and child.
Infants raised by depressed mothers show early disruptions in social and emotional development, including diminished security of attachment with their mothers and reduced ability to self-regulate.2 Later in development, the offspring of depressed mothers are at greater risk for psychopathology – most notably anxiety and depression as well as impaired social behavior. 3,4 Rates of depression in school-aged and adolescent children of depressed mothers have been reported to be between 20% and 41%.4 Not only are rates of depression higher, but depression in children of depressed parents, relative to depression in same-age children of nondepressed parents, has an earlier age of onset, longer duration, and is associated with greater functional impairment and risk of relapse.5
In addition, evidence shows that infants of depressed mothers show more negative affect and more self-directed regulatory behaviors, while toddlers show more dysregulated aggression and heightened mood lability.6 Given that these infants also already have an increased genetic risk for depression and anxiety, it is essential that mothers are identified and treated early to prevent these early disruptions to the parent-child relationship.
Pediatricians sit at the intersection of motherhood and infant development. This offers a unique opportunity to influence the trajectory of the child through bolstering supports for the mother. Understandably, time is limited during these brief touchpoints occurring over the first postpartum year, although a heartfelt “How are you?” can make all the difference. In asking this simple question in a disarming way, you may prevent multiple adverse childhood experiences for your tiniest patients.
Further, evidence has shown that toxic stress experienced during sensitive periods of brain development in infants and young children can negatively affect brain architecture. Brain pathways that are rarely used are pruned away, whereas pathways that are readily accessed grow stronger. If children are exposed to toxic stress, whether it be from abuse, mental illness of a caregiver such as severe maternal depression, witnessed domestic violence, or worse, they may begin to experience the world as dangerous and uncertain. This can strengthen connections in parts of the brain associated with fear, arousal, and emotional regulation at the cost of other parts of the brain associated with learning and safety.
Particularly focusing on infancy through preschool, children depend on sensitive, responsive caregivers to learn how to understand emotions and begin to self-soothe. Pediatricians have access to this critical period and can help lead the way toward secure attachment between mother and child. Through taking this dyadic, integrated approach, not only can downstream problems in the child be attenuated or even prevented (that is, disrupted social-emotional development and depression/anxiety), but a mother’s identity can form around her strengths in parenting rather than negative cognitive distortions. Here are some ways to quickly assess a mother for major depressive disorder with peripartum onset so that treatment can be secured, allowing children to develop and learn in a safe, supportive, loving environment:
- Add a standardized instrument to the check-in process during baby’s first year of life. The Edinburgh Postnatal Depression Scale (EPDS) is the most commonly used screening tool, consisting of 10 questions with a score of 10 or greater suggestive of maternal depression. Recently, it was found that the EPDS may be further abbreviated to a three-question version with a sensitivity of 95% and a negative predictive value of 98%.
- Dedicate 5 minutes during each appointment to ask the mother, in earnest, how she is doing and to create space to hear her concerns. This high-yield discussion can be the catalyst the mother needs to identify that something is not right.
- Obtain collateral information from the mother’s partner, if available, in a way that feels collaborative and supportive. You may ask the partner during the appointment if they have any concerns about how both parents are coping with their new parenting roles.
- If the mother has multiple risk factors for major depressive disorder with peripartum onset – past history of depression, family history of perinatal depression, lack of social supports, or past history of major depressive disorder with peripartum onset with an earlier child (elevating their risk to about 50%) – you may dedicate a bit more time to assess the patient and/or provide mental health resources directly upon wrapping up the appointment.
- Finally, you may add an educational blurb about major depressive disorder with peripartum onset in all after-visit summaries for new parents and infants with a list of mental health resources that includes reproductive psychiatrists, therapists, and a link to robust resources like Postpartum Support International.
By taking the extra step to leverage the relationship between mother and infant at this highly vulnerable time, you have the ability to positively affect the trajectory of a family. And, at the end of the day, this dyadic approach to patient care is the secret ingredient to improved outcomes all around.
References
1. Muzik M and Hamilton SE. Matern Child Health J. 2016;20(11):2268-79.
2. Granat A et al. Emotion. 2017;17(1):11-27.
3. Conroy S et al. J Am Acad Child Adolesc Psychiatry. 2012;51(1):51-61.
4. Goodman SH. Annu Rev Clin Psychol. 2007;3:107-35.
5. Keller MB et al. Arch Gen Psychiatry. 1986;43(10):930-7.
6. Tronick EZ and Gianino AF. New Dir Child Dev. 1986;34:5-11.
Dr. Richards is assistant clinical professor in the department of psychiatry and biobehavioral sciences, program director of the child and adolescent psychiatry fellowship, and associate medical director of the perinatal program at the UCLA Semel Institute for Neuroscience and Human Behavior in Los Angeles.
An overwhelmed mother presents to your office with her 2-month-old son for his check-up. She seems distant and dysphoric, often shrugging her shoulders with an empty stare when asked about her son’s development. Her baby cries loudly in her arms and you can see that she is uncomfortable soothing him as she frantically rocks him back and forth. He appears to have gained little weight since the last appointment occurring 6 days post partum and his mother describes him as “difficult and fussy all the time.” The father was unable to attend the appointment due to work obligations and often leaves the baby alone with the mother for 10 hours per day. As you examine her son, you counsel the mother on how to care for her baby while also caring for herself. The mother immediately begins to sob into her hands and states: “I can’t do this anymore. I am not meant to be a mother.”
Major depressive disorder with peripartum onset – also known as postpartum depression – is a major public health concern that affects approximately 20% of women in industrial societies like the United States. It is among the most prevalent psychiatric disorders in the world and remains largely underdiagnosed because of lack of access to care, symptom underreporting secondary to stigma, and lack of education regarding illness.1 Adequate treatment of perinatal depression is of paramount importance, as this condition can have significant negative consequences for both mother and child.
Infants raised by depressed mothers show early disruptions in social and emotional development, including diminished security of attachment with their mothers and reduced ability to self-regulate.2 Later in development, the offspring of depressed mothers are at greater risk for psychopathology – most notably anxiety and depression as well as impaired social behavior. 3,4 Rates of depression in school-aged and adolescent children of depressed mothers have been reported to be between 20% and 41%.4 Not only are rates of depression higher, but depression in children of depressed parents, relative to depression in same-age children of nondepressed parents, has an earlier age of onset, longer duration, and is associated with greater functional impairment and risk of relapse.5
In addition, evidence shows that infants of depressed mothers show more negative affect and more self-directed regulatory behaviors, while toddlers show more dysregulated aggression and heightened mood lability.6 Given that these infants also already have an increased genetic risk for depression and anxiety, it is essential that mothers are identified and treated early to prevent these early disruptions to the parent-child relationship.
Pediatricians sit at the intersection of motherhood and infant development. This offers a unique opportunity to influence the trajectory of the child through bolstering supports for the mother. Understandably, time is limited during these brief touchpoints occurring over the first postpartum year, although a heartfelt “How are you?” can make all the difference. In asking this simple question in a disarming way, you may prevent multiple adverse childhood experiences for your tiniest patients.
Further, evidence has shown that toxic stress experienced during sensitive periods of brain development in infants and young children can negatively affect brain architecture. Brain pathways that are rarely used are pruned away, whereas pathways that are readily accessed grow stronger. If children are exposed to toxic stress, whether it be from abuse, mental illness of a caregiver such as severe maternal depression, witnessed domestic violence, or worse, they may begin to experience the world as dangerous and uncertain. This can strengthen connections in parts of the brain associated with fear, arousal, and emotional regulation at the cost of other parts of the brain associated with learning and safety.
Particularly focusing on infancy through preschool, children depend on sensitive, responsive caregivers to learn how to understand emotions and begin to self-soothe. Pediatricians have access to this critical period and can help lead the way toward secure attachment between mother and child. Through taking this dyadic, integrated approach, not only can downstream problems in the child be attenuated or even prevented (that is, disrupted social-emotional development and depression/anxiety), but a mother’s identity can form around her strengths in parenting rather than negative cognitive distortions. Here are some ways to quickly assess a mother for major depressive disorder with peripartum onset so that treatment can be secured, allowing children to develop and learn in a safe, supportive, loving environment:
- Add a standardized instrument to the check-in process during baby’s first year of life. The Edinburgh Postnatal Depression Scale (EPDS) is the most commonly used screening tool, consisting of 10 questions with a score of 10 or greater suggestive of maternal depression. Recently, it was found that the EPDS may be further abbreviated to a three-question version with a sensitivity of 95% and a negative predictive value of 98%.
- Dedicate 5 minutes during each appointment to ask the mother, in earnest, how she is doing and to create space to hear her concerns. This high-yield discussion can be the catalyst the mother needs to identify that something is not right.
- Obtain collateral information from the mother’s partner, if available, in a way that feels collaborative and supportive. You may ask the partner during the appointment if they have any concerns about how both parents are coping with their new parenting roles.
- If the mother has multiple risk factors for major depressive disorder with peripartum onset – past history of depression, family history of perinatal depression, lack of social supports, or past history of major depressive disorder with peripartum onset with an earlier child (elevating their risk to about 50%) – you may dedicate a bit more time to assess the patient and/or provide mental health resources directly upon wrapping up the appointment.
- Finally, you may add an educational blurb about major depressive disorder with peripartum onset in all after-visit summaries for new parents and infants with a list of mental health resources that includes reproductive psychiatrists, therapists, and a link to robust resources like Postpartum Support International.
By taking the extra step to leverage the relationship between mother and infant at this highly vulnerable time, you have the ability to positively affect the trajectory of a family. And, at the end of the day, this dyadic approach to patient care is the secret ingredient to improved outcomes all around.
References
1. Muzik M and Hamilton SE. Matern Child Health J. 2016;20(11):2268-79.
2. Granat A et al. Emotion. 2017;17(1):11-27.
3. Conroy S et al. J Am Acad Child Adolesc Psychiatry. 2012;51(1):51-61.
4. Goodman SH. Annu Rev Clin Psychol. 2007;3:107-35.
5. Keller MB et al. Arch Gen Psychiatry. 1986;43(10):930-7.
6. Tronick EZ and Gianino AF. New Dir Child Dev. 1986;34:5-11.
Dr. Richards is assistant clinical professor in the department of psychiatry and biobehavioral sciences, program director of the child and adolescent psychiatry fellowship, and associate medical director of the perinatal program at the UCLA Semel Institute for Neuroscience and Human Behavior in Los Angeles.
Mindfulness ‘changes the biology’ of pain
In a randomized trial, more than 100 healthy individuals were assigned to an 8-week mindfulness-based stress reduction (MBSR) program, a health improvement program (HEP) of the same length, or a waiting list.
Scanning participants’ brains during a heat-based stimulus pain task showed those who completed the MBSR had a reduction in a brain signature linked to the sensory intensity of pain.
“Our finding supports the idea that for new practitioners, mindfulness training directly affects how sensory signals from the body are converted into a brain response,” lead investigator Joseph Wielgosz, PhD, of the Center for Healthy Minds, University of Wisconsin–Madison, said in a release.
Further analysis in long-term meditation practitioners showed the total time spent on intensive retreats was associated with neural changes associated with the perceived stress of pain.
“Just like an experienced athlete plays a sport differently than a first-timer, experienced mindfulness practitioners seem to use their mental ‘muscles’ differently in response to pain than first-time meditators,” Dr. Wielgosz noted.
The findings were published online in the American Journal of Psychiatry.
A complex condition
Dr. Wielgosz told this news organization that pain is “complex,” with multiple stages and several phases between the time signals are sent from pain receptors and the experience of pain.
“The way that mindfulness affects pain processing has more to do with the way the brain interprets pain signals.”
The investigators note that understanding the neurocognitive mechanisms underlying the efficacy of nonpharmacologic pain interventions is a “high-priority objective for improving pain treatment.”
Evidence from brief laboratory interventions and cross-sectional studies suggests that mindfulness training is associated with alterations in both sensory processing and cognitive-emotional regulatory networks, the investigators note.
“However, no such study has yet been conducted on a standardized, full-length, and widely used clinical intervention, such as MBSR,” they add.
Thermal pain task
The randomized, active-control trial included 115 healthy, meditation-naive individuals (61.7% women; average age, 48.3 years). Just over half (58%) had a graduate degree and their mean score on the Hollingshead index was 58.3, indicting a higher socioeconomic status.
All were randomly assigned to an 8-week MBSR course, an 8-week HEP course as an active control group, or a waiting-list control group with no intervention.
The MBSR involved instruction and practice in continuous focused attention on the breath, bodily sensations, and mental content while in seated postures, walking, and doing yoga.
The HEP matched the MBSR in terms of its length, structure, and nonspecific therapeutic elements, which included a supportive group atmosphere, expert instruction, and positive expectancy for benefit.
To examine the interventions’ effect on the pain experience, participants underwent a pain task in which they had 20 thermal stimuli applied to the inside of the left wrist for 12 seconds, including 8 seconds at peak temperature.
The stimuli were separated by a distractor task and intervals for cued anticipation, recovery, and subjective ratings of intensity and unpleasantness on a scale of 0-20.
During the task, participants underwent MRI to assess the neurologic pain signature (NPS) and the stimulus intensity independent pain signature-1 (SIIPS-1) within the brain.
The NPS is activated by various types of pain stimuli, while responding minimally or not at all to “emotionally evocative stimuli” relating to pain or to placebo treatment, the researchers note.
In contrast, the SIIPS-1 is activated in response to aspects of pain unrelated to the stimulus itself. It incorporates a “broader range of cognitive and emotional modulatory circuits,” including those related to expectancy and cognitive processes to modulate the pain experience.
Neural signatures
Results showed that in all groups, age was significantly negatively associated with both NPS (P = .001) and SIIPS-1 response (P < .001), although not subjective pain reports, and was subsequently included in all analyses of neural signatures.
Persons in the MBSR group had a significant decrease in the NPS, compared with those in the HEP group (P = .05), and from pre- to postintervention assessments (P = .023).
Those in the MBSR group also had “marginal” decreases in the NPS vs. the waiting list group (P = .096), and in the SIIPS-1 relative to both the HEP (P = .089) and waiting list groups (P = .087).
In subjective pain ratings, the MBSR group showed a marginal decrease, compared with the waiting list group (P = .078), and from the pre- to postintervention assessments (P = .028).
The HEP group also had marginal decreases in pain unpleasantness vs. the waiting list group (P = .043), and from the pre- to postintervention assessments for pain intensity (P = .046) and unpleasantness (P = .007).
The researchers also assessed 30 long-term meditators who had undertaken at least 3 years of formal experience with meditation, including participating in multiple intensive retreats and ongoing daily practice, and compared them with meditation-naive individuals.
Long-term meditators reported significantly less pain intensity and unpleasantness than those who had not undergone the training (P < .001).
In addition, a higher number of practice hours during a retreat was linked to a greater reduction in pain ratings. This association remained even after adjustment for gender and respiration rate.
However, the number of daily practice hours was not significantly associated with pain ratings among long-term meditators.
Although there were no average differences in neural signature responses between long-term meditators and individuals who were naive to the technique, there was an inverse relationship between hours on retreat and SIIPS-1 response (P = .027).
‘We’re seeing the biology change’
Commenting for this news organization, Fadel Zeidan, PhD, associate professor of anesthesiology, University of California, San Diego, said that in attenuating the experience of pain, mindfulness engages “very novel” mechanisms.
However, the “most remarkable thing about this study” is that the pain effect occurred when the participants were not meditating, “which gives rise to the notion that mental training is just like physical training,” said Dr. Zeidan, who was not involved with the research.
He noted that the notion was not appreciated previously, “because we weren’t able to see the changes,” as they were based on self-report alone.
However, combining those reports with brain imaging and other objective methods means that “we’re actually seeing the biology change,” Dr. Zeidan said.
He added that mindfulness is different from other techniques for modulating the pain experience, because it is self-facilitated.
“People can learn this technique, ideally, for free online. They can learn the recipe, and it’s one of the only techniques out there that can be used immediately to assuage one’s own pain,” he said.
“There’s nothing else out there on this planet that could immediately reduce one’s own pain. You have to wait 45 minutes for Tylenol, distraction can only work for so long, and you can’t really placebo yourself,” Dr. Zeidan added.
The study was funded by a National Center for Complementary and Alternative Medicine grant, National Institute of Mental Health grants, a Fetzer Institute grant, and a John Templeton Foundation grant, as well as a core grant to the Waisman Center from the National Institute of Child Health and Human Development to Albee Messing. Dr. Wielgosz and Dr. Zeidan have reported no relevant financial relationships. Disclosures for the coinvestigators are listed in the original article.
A version of this article first appeared on Medscape.com.
In a randomized trial, more than 100 healthy individuals were assigned to an 8-week mindfulness-based stress reduction (MBSR) program, a health improvement program (HEP) of the same length, or a waiting list.
Scanning participants’ brains during a heat-based stimulus pain task showed those who completed the MBSR had a reduction in a brain signature linked to the sensory intensity of pain.
“Our finding supports the idea that for new practitioners, mindfulness training directly affects how sensory signals from the body are converted into a brain response,” lead investigator Joseph Wielgosz, PhD, of the Center for Healthy Minds, University of Wisconsin–Madison, said in a release.
Further analysis in long-term meditation practitioners showed the total time spent on intensive retreats was associated with neural changes associated with the perceived stress of pain.
“Just like an experienced athlete plays a sport differently than a first-timer, experienced mindfulness practitioners seem to use their mental ‘muscles’ differently in response to pain than first-time meditators,” Dr. Wielgosz noted.
The findings were published online in the American Journal of Psychiatry.
A complex condition
Dr. Wielgosz told this news organization that pain is “complex,” with multiple stages and several phases between the time signals are sent from pain receptors and the experience of pain.
“The way that mindfulness affects pain processing has more to do with the way the brain interprets pain signals.”
The investigators note that understanding the neurocognitive mechanisms underlying the efficacy of nonpharmacologic pain interventions is a “high-priority objective for improving pain treatment.”
Evidence from brief laboratory interventions and cross-sectional studies suggests that mindfulness training is associated with alterations in both sensory processing and cognitive-emotional regulatory networks, the investigators note.
“However, no such study has yet been conducted on a standardized, full-length, and widely used clinical intervention, such as MBSR,” they add.
Thermal pain task
The randomized, active-control trial included 115 healthy, meditation-naive individuals (61.7% women; average age, 48.3 years). Just over half (58%) had a graduate degree and their mean score on the Hollingshead index was 58.3, indicting a higher socioeconomic status.
All were randomly assigned to an 8-week MBSR course, an 8-week HEP course as an active control group, or a waiting-list control group with no intervention.
The MBSR involved instruction and practice in continuous focused attention on the breath, bodily sensations, and mental content while in seated postures, walking, and doing yoga.
The HEP matched the MBSR in terms of its length, structure, and nonspecific therapeutic elements, which included a supportive group atmosphere, expert instruction, and positive expectancy for benefit.
To examine the interventions’ effect on the pain experience, participants underwent a pain task in which they had 20 thermal stimuli applied to the inside of the left wrist for 12 seconds, including 8 seconds at peak temperature.
The stimuli were separated by a distractor task and intervals for cued anticipation, recovery, and subjective ratings of intensity and unpleasantness on a scale of 0-20.
During the task, participants underwent MRI to assess the neurologic pain signature (NPS) and the stimulus intensity independent pain signature-1 (SIIPS-1) within the brain.
The NPS is activated by various types of pain stimuli, while responding minimally or not at all to “emotionally evocative stimuli” relating to pain or to placebo treatment, the researchers note.
In contrast, the SIIPS-1 is activated in response to aspects of pain unrelated to the stimulus itself. It incorporates a “broader range of cognitive and emotional modulatory circuits,” including those related to expectancy and cognitive processes to modulate the pain experience.
Neural signatures
Results showed that in all groups, age was significantly negatively associated with both NPS (P = .001) and SIIPS-1 response (P < .001), although not subjective pain reports, and was subsequently included in all analyses of neural signatures.
Persons in the MBSR group had a significant decrease in the NPS, compared with those in the HEP group (P = .05), and from pre- to postintervention assessments (P = .023).
Those in the MBSR group also had “marginal” decreases in the NPS vs. the waiting list group (P = .096), and in the SIIPS-1 relative to both the HEP (P = .089) and waiting list groups (P = .087).
In subjective pain ratings, the MBSR group showed a marginal decrease, compared with the waiting list group (P = .078), and from the pre- to postintervention assessments (P = .028).
The HEP group also had marginal decreases in pain unpleasantness vs. the waiting list group (P = .043), and from the pre- to postintervention assessments for pain intensity (P = .046) and unpleasantness (P = .007).
The researchers also assessed 30 long-term meditators who had undertaken at least 3 years of formal experience with meditation, including participating in multiple intensive retreats and ongoing daily practice, and compared them with meditation-naive individuals.
Long-term meditators reported significantly less pain intensity and unpleasantness than those who had not undergone the training (P < .001).
In addition, a higher number of practice hours during a retreat was linked to a greater reduction in pain ratings. This association remained even after adjustment for gender and respiration rate.
However, the number of daily practice hours was not significantly associated with pain ratings among long-term meditators.
Although there were no average differences in neural signature responses between long-term meditators and individuals who were naive to the technique, there was an inverse relationship between hours on retreat and SIIPS-1 response (P = .027).
‘We’re seeing the biology change’
Commenting for this news organization, Fadel Zeidan, PhD, associate professor of anesthesiology, University of California, San Diego, said that in attenuating the experience of pain, mindfulness engages “very novel” mechanisms.
However, the “most remarkable thing about this study” is that the pain effect occurred when the participants were not meditating, “which gives rise to the notion that mental training is just like physical training,” said Dr. Zeidan, who was not involved with the research.
He noted that the notion was not appreciated previously, “because we weren’t able to see the changes,” as they were based on self-report alone.
However, combining those reports with brain imaging and other objective methods means that “we’re actually seeing the biology change,” Dr. Zeidan said.
He added that mindfulness is different from other techniques for modulating the pain experience, because it is self-facilitated.
“People can learn this technique, ideally, for free online. They can learn the recipe, and it’s one of the only techniques out there that can be used immediately to assuage one’s own pain,” he said.
“There’s nothing else out there on this planet that could immediately reduce one’s own pain. You have to wait 45 minutes for Tylenol, distraction can only work for so long, and you can’t really placebo yourself,” Dr. Zeidan added.
The study was funded by a National Center for Complementary and Alternative Medicine grant, National Institute of Mental Health grants, a Fetzer Institute grant, and a John Templeton Foundation grant, as well as a core grant to the Waisman Center from the National Institute of Child Health and Human Development to Albee Messing. Dr. Wielgosz and Dr. Zeidan have reported no relevant financial relationships. Disclosures for the coinvestigators are listed in the original article.
A version of this article first appeared on Medscape.com.
In a randomized trial, more than 100 healthy individuals were assigned to an 8-week mindfulness-based stress reduction (MBSR) program, a health improvement program (HEP) of the same length, or a waiting list.
Scanning participants’ brains during a heat-based stimulus pain task showed those who completed the MBSR had a reduction in a brain signature linked to the sensory intensity of pain.
“Our finding supports the idea that for new practitioners, mindfulness training directly affects how sensory signals from the body are converted into a brain response,” lead investigator Joseph Wielgosz, PhD, of the Center for Healthy Minds, University of Wisconsin–Madison, said in a release.
Further analysis in long-term meditation practitioners showed the total time spent on intensive retreats was associated with neural changes associated with the perceived stress of pain.
“Just like an experienced athlete plays a sport differently than a first-timer, experienced mindfulness practitioners seem to use their mental ‘muscles’ differently in response to pain than first-time meditators,” Dr. Wielgosz noted.
The findings were published online in the American Journal of Psychiatry.
A complex condition
Dr. Wielgosz told this news organization that pain is “complex,” with multiple stages and several phases between the time signals are sent from pain receptors and the experience of pain.
“The way that mindfulness affects pain processing has more to do with the way the brain interprets pain signals.”
The investigators note that understanding the neurocognitive mechanisms underlying the efficacy of nonpharmacologic pain interventions is a “high-priority objective for improving pain treatment.”
Evidence from brief laboratory interventions and cross-sectional studies suggests that mindfulness training is associated with alterations in both sensory processing and cognitive-emotional regulatory networks, the investigators note.
“However, no such study has yet been conducted on a standardized, full-length, and widely used clinical intervention, such as MBSR,” they add.
Thermal pain task
The randomized, active-control trial included 115 healthy, meditation-naive individuals (61.7% women; average age, 48.3 years). Just over half (58%) had a graduate degree and their mean score on the Hollingshead index was 58.3, indicting a higher socioeconomic status.
All were randomly assigned to an 8-week MBSR course, an 8-week HEP course as an active control group, or a waiting-list control group with no intervention.
The MBSR involved instruction and practice in continuous focused attention on the breath, bodily sensations, and mental content while in seated postures, walking, and doing yoga.
The HEP matched the MBSR in terms of its length, structure, and nonspecific therapeutic elements, which included a supportive group atmosphere, expert instruction, and positive expectancy for benefit.
To examine the interventions’ effect on the pain experience, participants underwent a pain task in which they had 20 thermal stimuli applied to the inside of the left wrist for 12 seconds, including 8 seconds at peak temperature.
The stimuli were separated by a distractor task and intervals for cued anticipation, recovery, and subjective ratings of intensity and unpleasantness on a scale of 0-20.
During the task, participants underwent MRI to assess the neurologic pain signature (NPS) and the stimulus intensity independent pain signature-1 (SIIPS-1) within the brain.
The NPS is activated by various types of pain stimuli, while responding minimally or not at all to “emotionally evocative stimuli” relating to pain or to placebo treatment, the researchers note.
In contrast, the SIIPS-1 is activated in response to aspects of pain unrelated to the stimulus itself. It incorporates a “broader range of cognitive and emotional modulatory circuits,” including those related to expectancy and cognitive processes to modulate the pain experience.
Neural signatures
Results showed that in all groups, age was significantly negatively associated with both NPS (P = .001) and SIIPS-1 response (P < .001), although not subjective pain reports, and was subsequently included in all analyses of neural signatures.
Persons in the MBSR group had a significant decrease in the NPS, compared with those in the HEP group (P = .05), and from pre- to postintervention assessments (P = .023).
Those in the MBSR group also had “marginal” decreases in the NPS vs. the waiting list group (P = .096), and in the SIIPS-1 relative to both the HEP (P = .089) and waiting list groups (P = .087).
In subjective pain ratings, the MBSR group showed a marginal decrease, compared with the waiting list group (P = .078), and from the pre- to postintervention assessments (P = .028).
The HEP group also had marginal decreases in pain unpleasantness vs. the waiting list group (P = .043), and from the pre- to postintervention assessments for pain intensity (P = .046) and unpleasantness (P = .007).
The researchers also assessed 30 long-term meditators who had undertaken at least 3 years of formal experience with meditation, including participating in multiple intensive retreats and ongoing daily practice, and compared them with meditation-naive individuals.
Long-term meditators reported significantly less pain intensity and unpleasantness than those who had not undergone the training (P < .001).
In addition, a higher number of practice hours during a retreat was linked to a greater reduction in pain ratings. This association remained even after adjustment for gender and respiration rate.
However, the number of daily practice hours was not significantly associated with pain ratings among long-term meditators.
Although there were no average differences in neural signature responses between long-term meditators and individuals who were naive to the technique, there was an inverse relationship between hours on retreat and SIIPS-1 response (P = .027).
‘We’re seeing the biology change’
Commenting for this news organization, Fadel Zeidan, PhD, associate professor of anesthesiology, University of California, San Diego, said that in attenuating the experience of pain, mindfulness engages “very novel” mechanisms.
However, the “most remarkable thing about this study” is that the pain effect occurred when the participants were not meditating, “which gives rise to the notion that mental training is just like physical training,” said Dr. Zeidan, who was not involved with the research.
He noted that the notion was not appreciated previously, “because we weren’t able to see the changes,” as they were based on self-report alone.
However, combining those reports with brain imaging and other objective methods means that “we’re actually seeing the biology change,” Dr. Zeidan said.
He added that mindfulness is different from other techniques for modulating the pain experience, because it is self-facilitated.
“People can learn this technique, ideally, for free online. They can learn the recipe, and it’s one of the only techniques out there that can be used immediately to assuage one’s own pain,” he said.
“There’s nothing else out there on this planet that could immediately reduce one’s own pain. You have to wait 45 minutes for Tylenol, distraction can only work for so long, and you can’t really placebo yourself,” Dr. Zeidan added.
The study was funded by a National Center for Complementary and Alternative Medicine grant, National Institute of Mental Health grants, a Fetzer Institute grant, and a John Templeton Foundation grant, as well as a core grant to the Waisman Center from the National Institute of Child Health and Human Development to Albee Messing. Dr. Wielgosz and Dr. Zeidan have reported no relevant financial relationships. Disclosures for the coinvestigators are listed in the original article.
A version of this article first appeared on Medscape.com.
FROM AMERICAN JOURNAL OF PSYCHIATRY