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Help! More Clinicians Are Needed to Manage Care for Children With Autism. How About You?
Almost all primary care providers (PCPs) have taken on diagnosing and managing ADHD. With about 12% of school aged children affected, typical PCPs can expect about 240 children with ADHD under their care. Adopting this primary care function has been helped by having clear diagnostic criteria for the three DMS 5 “presentations” of ADHD, open source tools (e.g. Vanderbilts), expectation of collaboration by educators, American Academy of Pediatrics (AAP) guidelines for diagnosis and management, Society for Developmental–Behavioral Pediatrics guidelines for “complex ADHD,” and access to effective medication treatments PCPs can provide (although less so for behavioral ones), cultural acceptance of individuals with ADHD, and especially reliable payment by insurers.
Screening
But what about PCP management of autism spectrum disorder (ASD), now affecting 2.8%, for an expected 60 children under care for each of us? It is more essential because very early detection and entry into evidence-based intervention has long-term benefits for the child and family that are not as crucial for ADHD. While ADHD symptoms may not impact functioning until age 7 or even 12 years of age, signs of ASD usually emerge earlier (by 18 months) but gradually and about 30% after apparently normal development even to age 2 years.
Screening is crucial, but unfortunately not perfect. Recent AAP surveys show that most PCPs screen for autism at the recommended 18 and 24 months. But what happens after that? How many offices are tracking referrals for positive screens for needed evaluations and early intervention? Our data shows that tracking is rarely done and children do not start to get the benefit of early intervention until 4.5 years of age, on average.
Diagnostic Testing
And screening is the easiest part of addressing ASD. Wait times for diagnostic testing can be agonizing months to years. Multiple programs are training PCPs to perform hands-on 10- to 30-minute secondary screening with considerable success. You can become proficient on tools such as STAT (Screening Tool for Autism in Two-Year-Olds), RITA-T (Rapid Interactive Screening Test for Autism in Toddlers), BISCUIT (Baby and Infant Screen for Children with Autism Traits), SORF (Systematic Observation of Red Flags), ADEC (Autism Detection in Early Childhood) or CARS (Childhood Autism Rating Scale) with a few hours of training. Even secondary assessments done virtually by PCPs such as TELE-ASD-PEDS quite accurately predict a verifiable ASD diagnosis for those referred by concerns. Some problems of the reported accuracy of these secondary screening processes have to do with validation in samples of children for whom parents or clinicians already had concern and generally not including many younger children in whom it is so important to detect. Level of confidence of developmental and behavioral pediatricians of the presence of ASD is highly related to ultimate diagnosis. But success with PCPs’ mastering secondary screening has not yet been reported to convince insurers to approve payment for intervention services such as Applied Behavior Analysis (ABA).
Comorbidity
Co-existing conditions affect the majority of patients with ASD (70%), compared with ADHD, but with a broader range and more debilitating and difficult to manage conditions. More medical co-existing issues such as intellectual disability (25%-75%), seizures (12%-26%), motor incoordination (51%), GI conditions (9%-91%), sleep difficulty (50%-80%), sleep apnea, congenital heart disease, avoidant-restrictive food intake disorder, autoimmune disorders, and genetic syndromes (e.g. Fragile X, tuberous sclerosis, Down, Angelman’s, untreated PKU, neurofibromatosis, Klinefelter syndrome) reflect the range of underpinnings of ASD. The need to detect and manage these co-existing issues, besides assessing hearing and vision, makes our skilled involvement and vigilance in ASD care essential. Referring for help from OTs, PTs, speech pathologists, neurologists, psychologists, and special educators as issues in their domains are prioritized is also our responsibility. We must also help families balance utilizing these resources so as to avoid overwhelm.
Anxiety (50%), ADHD (37%-85%), depression (54%), bipolar (7.3%), suicidal ideation (40% starting < 8 years), and emotion dysregulation, familiar to us from our management of ADHD, may develop but are often less well defined and more intractable in ASD, making use of screening tools essential. Using a system like CHADIS that has online pre-visit and monitoring screens delivered based on algorithms for the numerous co-existing conditions, automated handouts, and functions to make and track referral success can facilitate care for this complex chronic condition. Identifying mental health providers with ASD expertise is more difficult, so more management is on us. While medications for these conditions can be beneficial, we need to learn to use lower doses, slower dose increases, and employ problem-solving of side effects with more parent collaboration than for ADHD as children with ASD often cannot self-report effectively. We need to ask about the common ad hoc use of complementary medications and substances (32%-87%) that may be complicating. Of course, these conditions and the caveats of management require more of our time with the patient and family as well as communication with the many other professionals involved. It is important to set our own and our families’ expectations (and schedules) for much more frequent contact and also to bill appropriately with chronic care (99487,89,90) and collaborative care CPT codes (99492,3,4 or G2214).
Behavioral Manifestations
During our care, the often extreme behavioral manifestations of ASD may be the most pressing issues. We need new understanding and skills to sort out and counsel on inflexible, explosive, and sensory triggered behaviors. Just as for ADHD, using the approach of Functional Behavioral Assessment and plans for home as well as school behavior can be key. More difficult in ASD is looking for physical causes, since the child may not provide clear cues because of communication and sensory differences. Conditions common in children with ASD such as constipation, dental caries, otitis, dietary intolerances, allergies, migraine, sleep deficits, menstrual cramps, or fears and changes from puberty manifesting behaviorally are often tricky to sort out.
While the diagnosis of ASD, as for ADHD, does not require any laboratory testing, looking for possible causes is important information for the family and someday may also lead to genetic or other therapies. We need to know that recommendations include screening for Ferritin, Pb, chromosomal microarray and FMR I testing as well as checking that PKU was normal; MECP 2 is indicated in females and symptomatic males; and PTENS testing for children with head circumference greater than 2.5-3 SD. Metabolic and mitochondrial assays are indicated only when symptoms suggest. We need to develop confidence to reserve MRIs or EEGs for cases with abnormal neuro. exams, regression, or history of seizures. It is demanding to keep up with AAP recommendations in this very active area of research.
Interventions
The interventions for ADHD are generally school accommodations and therapies for comorbidities. In contrast, since core social communication skills are the main deficit in ASD, all children screened positive for ASD should be referred for early intervention while awaiting, as well as after, diagnosis. While all states have no or low-cost early intervention, quality and quantity (of hours offered) varies. We should also recommend and try to determine if evidence-based intervention is being provided, such as pivotal response training, UCLA discrete trial therapy, Carbone’s verbal behavior, applied behavior analysis (ABA), Early Start Denver Model, and sometimes music and social skills trainings (effect size 0.42-0.76). Such professional interventions have best evidence with more than 25 hours/week but 15 hours has benefit for higher functioning children. CBT can help anxiety even in younger children. One way for families to provide more hours and more generalizable intervention is coaching by the PLAY Project or DIRFloortime, parent mediated interventions with evidence, some with training both in person or online. Alternative communication training and other condition specific assistance are often needed (e.g. Picture Exchange Communication System for nonverbal children).
While we should already be familiar with writing 504 plan and IEP requests to schools, which also apply to children with ASD, in addition we need to be ready to advise about other legal rights including autism waivers, wraparound services, guardianship, and trust accounts. We can share quality educational materials available online (e.g. from Autism Speaks, SPARK, and Autism Navigator). Social media groups may be supportive, but also may contain disinformation we need to dispel.
Unfortunately, templates, questionnaires, and lack of interdisciplinary referral and communication functions of EHRs don’t support the complexities of care for ASD. While the AAP has guidelines for diagnosis and management and an online toolkit, consider adding a system with an autism-specific module like CHADIS and joining the Autism Care Network or ECHO Autism sessions to get both information and support to take on the evolving critical role of autism care.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at pdnews@mdedge.com.
Almost all primary care providers (PCPs) have taken on diagnosing and managing ADHD. With about 12% of school aged children affected, typical PCPs can expect about 240 children with ADHD under their care. Adopting this primary care function has been helped by having clear diagnostic criteria for the three DMS 5 “presentations” of ADHD, open source tools (e.g. Vanderbilts), expectation of collaboration by educators, American Academy of Pediatrics (AAP) guidelines for diagnosis and management, Society for Developmental–Behavioral Pediatrics guidelines for “complex ADHD,” and access to effective medication treatments PCPs can provide (although less so for behavioral ones), cultural acceptance of individuals with ADHD, and especially reliable payment by insurers.
Screening
But what about PCP management of autism spectrum disorder (ASD), now affecting 2.8%, for an expected 60 children under care for each of us? It is more essential because very early detection and entry into evidence-based intervention has long-term benefits for the child and family that are not as crucial for ADHD. While ADHD symptoms may not impact functioning until age 7 or even 12 years of age, signs of ASD usually emerge earlier (by 18 months) but gradually and about 30% after apparently normal development even to age 2 years.
Screening is crucial, but unfortunately not perfect. Recent AAP surveys show that most PCPs screen for autism at the recommended 18 and 24 months. But what happens after that? How many offices are tracking referrals for positive screens for needed evaluations and early intervention? Our data shows that tracking is rarely done and children do not start to get the benefit of early intervention until 4.5 years of age, on average.
Diagnostic Testing
And screening is the easiest part of addressing ASD. Wait times for diagnostic testing can be agonizing months to years. Multiple programs are training PCPs to perform hands-on 10- to 30-minute secondary screening with considerable success. You can become proficient on tools such as STAT (Screening Tool for Autism in Two-Year-Olds), RITA-T (Rapid Interactive Screening Test for Autism in Toddlers), BISCUIT (Baby and Infant Screen for Children with Autism Traits), SORF (Systematic Observation of Red Flags), ADEC (Autism Detection in Early Childhood) or CARS (Childhood Autism Rating Scale) with a few hours of training. Even secondary assessments done virtually by PCPs such as TELE-ASD-PEDS quite accurately predict a verifiable ASD diagnosis for those referred by concerns. Some problems of the reported accuracy of these secondary screening processes have to do with validation in samples of children for whom parents or clinicians already had concern and generally not including many younger children in whom it is so important to detect. Level of confidence of developmental and behavioral pediatricians of the presence of ASD is highly related to ultimate diagnosis. But success with PCPs’ mastering secondary screening has not yet been reported to convince insurers to approve payment for intervention services such as Applied Behavior Analysis (ABA).
Comorbidity
Co-existing conditions affect the majority of patients with ASD (70%), compared with ADHD, but with a broader range and more debilitating and difficult to manage conditions. More medical co-existing issues such as intellectual disability (25%-75%), seizures (12%-26%), motor incoordination (51%), GI conditions (9%-91%), sleep difficulty (50%-80%), sleep apnea, congenital heart disease, avoidant-restrictive food intake disorder, autoimmune disorders, and genetic syndromes (e.g. Fragile X, tuberous sclerosis, Down, Angelman’s, untreated PKU, neurofibromatosis, Klinefelter syndrome) reflect the range of underpinnings of ASD. The need to detect and manage these co-existing issues, besides assessing hearing and vision, makes our skilled involvement and vigilance in ASD care essential. Referring for help from OTs, PTs, speech pathologists, neurologists, psychologists, and special educators as issues in their domains are prioritized is also our responsibility. We must also help families balance utilizing these resources so as to avoid overwhelm.
Anxiety (50%), ADHD (37%-85%), depression (54%), bipolar (7.3%), suicidal ideation (40% starting < 8 years), and emotion dysregulation, familiar to us from our management of ADHD, may develop but are often less well defined and more intractable in ASD, making use of screening tools essential. Using a system like CHADIS that has online pre-visit and monitoring screens delivered based on algorithms for the numerous co-existing conditions, automated handouts, and functions to make and track referral success can facilitate care for this complex chronic condition. Identifying mental health providers with ASD expertise is more difficult, so more management is on us. While medications for these conditions can be beneficial, we need to learn to use lower doses, slower dose increases, and employ problem-solving of side effects with more parent collaboration than for ADHD as children with ASD often cannot self-report effectively. We need to ask about the common ad hoc use of complementary medications and substances (32%-87%) that may be complicating. Of course, these conditions and the caveats of management require more of our time with the patient and family as well as communication with the many other professionals involved. It is important to set our own and our families’ expectations (and schedules) for much more frequent contact and also to bill appropriately with chronic care (99487,89,90) and collaborative care CPT codes (99492,3,4 or G2214).
Behavioral Manifestations
During our care, the often extreme behavioral manifestations of ASD may be the most pressing issues. We need new understanding and skills to sort out and counsel on inflexible, explosive, and sensory triggered behaviors. Just as for ADHD, using the approach of Functional Behavioral Assessment and plans for home as well as school behavior can be key. More difficult in ASD is looking for physical causes, since the child may not provide clear cues because of communication and sensory differences. Conditions common in children with ASD such as constipation, dental caries, otitis, dietary intolerances, allergies, migraine, sleep deficits, menstrual cramps, or fears and changes from puberty manifesting behaviorally are often tricky to sort out.
While the diagnosis of ASD, as for ADHD, does not require any laboratory testing, looking for possible causes is important information for the family and someday may also lead to genetic or other therapies. We need to know that recommendations include screening for Ferritin, Pb, chromosomal microarray and FMR I testing as well as checking that PKU was normal; MECP 2 is indicated in females and symptomatic males; and PTENS testing for children with head circumference greater than 2.5-3 SD. Metabolic and mitochondrial assays are indicated only when symptoms suggest. We need to develop confidence to reserve MRIs or EEGs for cases with abnormal neuro. exams, regression, or history of seizures. It is demanding to keep up with AAP recommendations in this very active area of research.
Interventions
The interventions for ADHD are generally school accommodations and therapies for comorbidities. In contrast, since core social communication skills are the main deficit in ASD, all children screened positive for ASD should be referred for early intervention while awaiting, as well as after, diagnosis. While all states have no or low-cost early intervention, quality and quantity (of hours offered) varies. We should also recommend and try to determine if evidence-based intervention is being provided, such as pivotal response training, UCLA discrete trial therapy, Carbone’s verbal behavior, applied behavior analysis (ABA), Early Start Denver Model, and sometimes music and social skills trainings (effect size 0.42-0.76). Such professional interventions have best evidence with more than 25 hours/week but 15 hours has benefit for higher functioning children. CBT can help anxiety even in younger children. One way for families to provide more hours and more generalizable intervention is coaching by the PLAY Project or DIRFloortime, parent mediated interventions with evidence, some with training both in person or online. Alternative communication training and other condition specific assistance are often needed (e.g. Picture Exchange Communication System for nonverbal children).
While we should already be familiar with writing 504 plan and IEP requests to schools, which also apply to children with ASD, in addition we need to be ready to advise about other legal rights including autism waivers, wraparound services, guardianship, and trust accounts. We can share quality educational materials available online (e.g. from Autism Speaks, SPARK, and Autism Navigator). Social media groups may be supportive, but also may contain disinformation we need to dispel.
Unfortunately, templates, questionnaires, and lack of interdisciplinary referral and communication functions of EHRs don’t support the complexities of care for ASD. While the AAP has guidelines for diagnosis and management and an online toolkit, consider adding a system with an autism-specific module like CHADIS and joining the Autism Care Network or ECHO Autism sessions to get both information and support to take on the evolving critical role of autism care.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at pdnews@mdedge.com.
Almost all primary care providers (PCPs) have taken on diagnosing and managing ADHD. With about 12% of school aged children affected, typical PCPs can expect about 240 children with ADHD under their care. Adopting this primary care function has been helped by having clear diagnostic criteria for the three DMS 5 “presentations” of ADHD, open source tools (e.g. Vanderbilts), expectation of collaboration by educators, American Academy of Pediatrics (AAP) guidelines for diagnosis and management, Society for Developmental–Behavioral Pediatrics guidelines for “complex ADHD,” and access to effective medication treatments PCPs can provide (although less so for behavioral ones), cultural acceptance of individuals with ADHD, and especially reliable payment by insurers.
Screening
But what about PCP management of autism spectrum disorder (ASD), now affecting 2.8%, for an expected 60 children under care for each of us? It is more essential because very early detection and entry into evidence-based intervention has long-term benefits for the child and family that are not as crucial for ADHD. While ADHD symptoms may not impact functioning until age 7 or even 12 years of age, signs of ASD usually emerge earlier (by 18 months) but gradually and about 30% after apparently normal development even to age 2 years.
Screening is crucial, but unfortunately not perfect. Recent AAP surveys show that most PCPs screen for autism at the recommended 18 and 24 months. But what happens after that? How many offices are tracking referrals for positive screens for needed evaluations and early intervention? Our data shows that tracking is rarely done and children do not start to get the benefit of early intervention until 4.5 years of age, on average.
Diagnostic Testing
And screening is the easiest part of addressing ASD. Wait times for diagnostic testing can be agonizing months to years. Multiple programs are training PCPs to perform hands-on 10- to 30-minute secondary screening with considerable success. You can become proficient on tools such as STAT (Screening Tool for Autism in Two-Year-Olds), RITA-T (Rapid Interactive Screening Test for Autism in Toddlers), BISCUIT (Baby and Infant Screen for Children with Autism Traits), SORF (Systematic Observation of Red Flags), ADEC (Autism Detection in Early Childhood) or CARS (Childhood Autism Rating Scale) with a few hours of training. Even secondary assessments done virtually by PCPs such as TELE-ASD-PEDS quite accurately predict a verifiable ASD diagnosis for those referred by concerns. Some problems of the reported accuracy of these secondary screening processes have to do with validation in samples of children for whom parents or clinicians already had concern and generally not including many younger children in whom it is so important to detect. Level of confidence of developmental and behavioral pediatricians of the presence of ASD is highly related to ultimate diagnosis. But success with PCPs’ mastering secondary screening has not yet been reported to convince insurers to approve payment for intervention services such as Applied Behavior Analysis (ABA).
Comorbidity
Co-existing conditions affect the majority of patients with ASD (70%), compared with ADHD, but with a broader range and more debilitating and difficult to manage conditions. More medical co-existing issues such as intellectual disability (25%-75%), seizures (12%-26%), motor incoordination (51%), GI conditions (9%-91%), sleep difficulty (50%-80%), sleep apnea, congenital heart disease, avoidant-restrictive food intake disorder, autoimmune disorders, and genetic syndromes (e.g. Fragile X, tuberous sclerosis, Down, Angelman’s, untreated PKU, neurofibromatosis, Klinefelter syndrome) reflect the range of underpinnings of ASD. The need to detect and manage these co-existing issues, besides assessing hearing and vision, makes our skilled involvement and vigilance in ASD care essential. Referring for help from OTs, PTs, speech pathologists, neurologists, psychologists, and special educators as issues in their domains are prioritized is also our responsibility. We must also help families balance utilizing these resources so as to avoid overwhelm.
Anxiety (50%), ADHD (37%-85%), depression (54%), bipolar (7.3%), suicidal ideation (40% starting < 8 years), and emotion dysregulation, familiar to us from our management of ADHD, may develop but are often less well defined and more intractable in ASD, making use of screening tools essential. Using a system like CHADIS that has online pre-visit and monitoring screens delivered based on algorithms for the numerous co-existing conditions, automated handouts, and functions to make and track referral success can facilitate care for this complex chronic condition. Identifying mental health providers with ASD expertise is more difficult, so more management is on us. While medications for these conditions can be beneficial, we need to learn to use lower doses, slower dose increases, and employ problem-solving of side effects with more parent collaboration than for ADHD as children with ASD often cannot self-report effectively. We need to ask about the common ad hoc use of complementary medications and substances (32%-87%) that may be complicating. Of course, these conditions and the caveats of management require more of our time with the patient and family as well as communication with the many other professionals involved. It is important to set our own and our families’ expectations (and schedules) for much more frequent contact and also to bill appropriately with chronic care (99487,89,90) and collaborative care CPT codes (99492,3,4 or G2214).
Behavioral Manifestations
During our care, the often extreme behavioral manifestations of ASD may be the most pressing issues. We need new understanding and skills to sort out and counsel on inflexible, explosive, and sensory triggered behaviors. Just as for ADHD, using the approach of Functional Behavioral Assessment and plans for home as well as school behavior can be key. More difficult in ASD is looking for physical causes, since the child may not provide clear cues because of communication and sensory differences. Conditions common in children with ASD such as constipation, dental caries, otitis, dietary intolerances, allergies, migraine, sleep deficits, menstrual cramps, or fears and changes from puberty manifesting behaviorally are often tricky to sort out.
While the diagnosis of ASD, as for ADHD, does not require any laboratory testing, looking for possible causes is important information for the family and someday may also lead to genetic or other therapies. We need to know that recommendations include screening for Ferritin, Pb, chromosomal microarray and FMR I testing as well as checking that PKU was normal; MECP 2 is indicated in females and symptomatic males; and PTENS testing for children with head circumference greater than 2.5-3 SD. Metabolic and mitochondrial assays are indicated only when symptoms suggest. We need to develop confidence to reserve MRIs or EEGs for cases with abnormal neuro. exams, regression, or history of seizures. It is demanding to keep up with AAP recommendations in this very active area of research.
Interventions
The interventions for ADHD are generally school accommodations and therapies for comorbidities. In contrast, since core social communication skills are the main deficit in ASD, all children screened positive for ASD should be referred for early intervention while awaiting, as well as after, diagnosis. While all states have no or low-cost early intervention, quality and quantity (of hours offered) varies. We should also recommend and try to determine if evidence-based intervention is being provided, such as pivotal response training, UCLA discrete trial therapy, Carbone’s verbal behavior, applied behavior analysis (ABA), Early Start Denver Model, and sometimes music and social skills trainings (effect size 0.42-0.76). Such professional interventions have best evidence with more than 25 hours/week but 15 hours has benefit for higher functioning children. CBT can help anxiety even in younger children. One way for families to provide more hours and more generalizable intervention is coaching by the PLAY Project or DIRFloortime, parent mediated interventions with evidence, some with training both in person or online. Alternative communication training and other condition specific assistance are often needed (e.g. Picture Exchange Communication System for nonverbal children).
While we should already be familiar with writing 504 plan and IEP requests to schools, which also apply to children with ASD, in addition we need to be ready to advise about other legal rights including autism waivers, wraparound services, guardianship, and trust accounts. We can share quality educational materials available online (e.g. from Autism Speaks, SPARK, and Autism Navigator). Social media groups may be supportive, but also may contain disinformation we need to dispel.
Unfortunately, templates, questionnaires, and lack of interdisciplinary referral and communication functions of EHRs don’t support the complexities of care for ASD. While the AAP has guidelines for diagnosis and management and an online toolkit, consider adding a system with an autism-specific module like CHADIS and joining the Autism Care Network or ECHO Autism sessions to get both information and support to take on the evolving critical role of autism care.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at pdnews@mdedge.com.
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HOWARD, MD </bylineFull> <bylineTitleText/> <USOrGlobal/> <wireDocType/> <newsDocType>Column</newsDocType> <journalDocType/> <linkLabel/> <pageRange/> <citation/> <quizID/> <indexIssueDate/> <itemClass qcode="ninat:text"/> <provider qcode="provider:imng"> <name>IMNG Medical Media</name> <rightsInfo> <copyrightHolder> <name>Frontline Medical News</name> </copyrightHolder> <copyrightNotice>Copyright (c) 2015 Frontline Medical News, a Frontline Medical Communications Inc. company. All rights reserved. This material may not be published, broadcast, copied, or otherwise reproduced or distributed without the prior written permission of Frontline Medical Communications Inc.</copyrightNotice> </rightsInfo> </provider> <abstract/> <metaDescription>PCP detection and care for children with ASD is more complex than ADHD, but even more essential, so we need to learn the skills.</metaDescription> <articlePDF/> <teaserImage>300295</teaserImage> <teaser>PCP detection and care for children with ASD is complex, so pediatricians need to learn the skills.</teaser> <title>Help! More Clinicians Are Needed to Manage Care for Children With Autism. 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Howard</description> <description role="drol:credit"/> </link> </links> </header> <itemSet> <newsItem> <itemMeta> <itemRole>Main</itemRole> <itemClass>text</itemClass> <title>Help! More Clinicians Are Needed to Manage Care for Children With Autism. How About You?</title> <deck/> </itemMeta> <itemContent> <p>Almost all primary care providers (PCPs) have taken on diagnosing and managing ADHD. With about 12% of school aged children affected, typical PCPs can expect about 240 children with ADHD under their care. Adopting this primary care function has been helped by having clear diagnostic criteria for the three DMS 5 “presentations” of ADHD, open source tools (e.g. Vanderbilts), expectation of collaboration by educators, American Academy of Pediatrics (AAP) guidelines for diagnosis and management, Society for Developmental–Behavioral Pediatrics guidelines for “complex ADHD,” and access to effective medication treatments PCPs can provide (although less so for behavioral ones), cultural acceptance of individuals with ADHD, and especially reliable payment by insurers. </p> <h2>Screening</h2> <p>But what about PCP management of autism spectrum disorder (ASD), now affecting 2.8%, for an expected 60 children under care for each of us? <span class="tag metaDescription">PCP detection and care for children with ASD is more complex than ADHD, but even more essential, so we need to learn the skills.</span> It is more essential because very early detection and entry into evidence-based intervention has long-term benefits for the child and family that are not as crucial for ADHD. While ADHD symptoms may not impact functioning until age 7 or even 12 years of age, signs of ASD usually emerge earlier (by 18 months) but gradually and about 30% after apparently normal development even to age 2 years.</p> <p>[[{"fid":"300295","view_mode":"medstat_image_flush_right","fields":{"format":"medstat_image_flush_right","field_file_image_alt_text[und][0][value]":"Barbara J. Howard, MD, is an assistant professor of pediatrics at The Johns Hopkins School of Medicine and president of CHADIS.","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][value]":"Dr. Barbara J. Howard"},"type":"media","attributes":{"class":"media-element file-medstat_image_flush_right"}}]]Screening is crucial, but unfortunately not perfect. Recent AAP surveys show that most PCPs screen for autism at the recommended 18 and 24 months. But what happens after that? How many offices are tracking referrals for positive screens for needed evaluations and early intervention? Our data shows that tracking is rarely done and children do not start to get the benefit of early intervention until 4.5 years of age, on average. <br/><br/></p> <h2>Diagnostic Testing</h2> <p>And screening is the easiest part of addressing ASD. Wait times for diagnostic testing can be agonizing months to years. Multiple programs are training PCPs to perform hands-on 10- to 30-minute secondary screening with considerable success. You can become proficient on tools such as STAT (Screening Tool for Autism in Two-Year-Olds), RITA-T (Rapid Interactive Screening Test for Autism in Toddlers), BISCUIT (Baby and Infant Screen for Children with Autism Traits), SORF (Systematic Observation of Red Flags), ADEC (Autism Detection in Early Childhood) or CARS (Childhood Autism Rating Scale) with a few hours of training. Even secondary assessments done virtually by PCPs such as TELE-ASD-PEDS quite accurately predict a verifiable ASD diagnosis for those referred by concerns. Some problems of the reported accuracy of these secondary screening processes have to do with validation in samples of children for whom parents or clinicians already had concern and generally not including many younger children in whom it is so important to detect. Level of confidence of developmental and behavioral pediatricians of the presence of ASD is highly related to ultimate diagnosis. But success with PCPs’ mastering secondary screening has not yet been reported to convince insurers to approve payment for intervention services such as Applied Behavior Analysis (ABA). </p> <h2>Comorbidity</h2> <p>Co-existing conditions affect the majority of patients with ASD (70%), compared with ADHD, but with a broader range and more debilitating and difficult to manage conditions. More medical co-existing issues such as intellectual disability (25%-75%), seizures (12%-26%), motor incoordination (51%), GI conditions (9%-91%), sleep difficulty (50%-80%), sleep apnea, congenital heart disease, avoidant-restrictive food intake disorder, autoimmune disorders, and genetic syndromes (e.g. Fragile X, tuberous sclerosis, Down, Angelman’s, untreated PKU, neurofibromatosis, Klinefelter syndrome) reflect the range of underpinnings of ASD. The need to detect and manage these co-existing issues, besides assessing hearing and vision, makes our skilled involvement and vigilance in ASD care essential. Referring for help from OTs, PTs, speech pathologists, neurologists, psychologists, and special educators as issues in their domains are prioritized is also our responsibility. We must also help families balance utilizing these resources so as to avoid overwhelm. </p> <p>Anxiety (50%), ADHD (37%-85%), depression (54%), bipolar (7.3%), suicidal ideation (40% starting < 8 years), and emotion dysregulation, familiar to us from our management of ADHD, may develop but are often less well defined and more intractable in ASD, making use of screening tools essential. Using a system like CHADIS that has online pre-visit and monitoring screens delivered based on algorithms for the numerous co-existing conditions, automated handouts, and functions to make and track referral success can facilitate care for this complex chronic condition. Identifying mental health providers with ASD expertise is more difficult, so more management is on us. While medications for these conditions can be beneficial, we need to learn to use lower doses, slower dose increases, and employ problem-solving of side effects with more parent collaboration than for ADHD as children with ASD often cannot self-report effectively. We need to ask about the common ad hoc use of complementary medications and substances (32%-87%) that may be complicating. Of course, these conditions and the caveats of management require more of our time with the patient and family as well as communication with the many other professionals involved. It is important to set our own and our families’ expectations (and schedules) for much more frequent contact and also to bill appropriately with chronic care (99487,89,90) and collaborative care CPT codes (99492,3,4 or G2214).<br/><br/></p> <h2>Behavioral Manifestations</h2> <p>During our care, the often extreme behavioral manifestations of ASD may be the most pressing issues. We need new understanding and skills to sort out and counsel on inflexible, explosive, and sensory triggered behaviors. Just as for ADHD, using the approach of Functional Behavioral Assessment and plans for home as well as school behavior can be key. More difficult in ASD is looking for physical causes, since the child may not provide clear cues because of communication and sensory differences. Conditions common in children with ASD such as constipation, dental caries, otitis, dietary intolerances, allergies, migraine, sleep deficits, menstrual cramps, or fears and changes from puberty manifesting behaviorally are often tricky to sort out. </p> <p>While the diagnosis of ASD, as for ADHD, does not require any laboratory testing, looking for possible causes is important information for the family and someday may also lead to genetic or other therapies. We need to know that recommendations include screening for Ferritin, Pb, chromosomal microarray and FMR I testing as well as checking that PKU was normal; MECP 2 is indicated in females and symptomatic males; and PTENS testing for children with head circumference greater than 2.5-3 SD. Metabolic and mitochondrial assays are indicated only when symptoms suggest. We need to develop confidence to reserve MRIs or EEGs for cases with abnormal neuro. exams, regression, or history of seizures. It is demanding to keep up with AAP recommendations in this very active area of research. <br/><br/></p> <h2>Interventions</h2> <p>The interventions for ADHD are generally school accommodations and therapies for comorbidities. In contrast, since core social communication skills are the main deficit in ASD, all children screened positive for ASD should be referred for early intervention while awaiting, as well as after, diagnosis. While all states have no or low-cost early intervention, quality and quantity (of hours offered) varies. We should also recommend and try to determine if evidence-based intervention is being provided, such as pivotal response training, UCLA discrete trial therapy, Carbone’s verbal behavior, applied behavior analysis (ABA), Early Start Denver Model, and sometimes music and social skills trainings (effect size 0.42-0.76). Such professional interventions have best evidence with more than 25 hours/week but 15 hours has benefit for higher functioning children. CBT can help anxiety even in younger children. One way for families to provide more hours and more generalizable intervention is coaching by the PLAY Project or DIRFloortime, parent mediated interventions with evidence, some with training both in person or online. Alternative communication training and other condition specific assistance are often needed (e.g. Picture Exchange Communication System for nonverbal children).</p> <p>While we should already be familiar with writing 504 plan and IEP requests to schools, which also apply to children with ASD, in addition we need to be ready to advise about other legal rights including autism waivers, wraparound services, guardianship, and trust accounts. We can share quality educational materials available online (e.g. from Autism Speaks, SPARK, and Autism Navigator). Social media groups may be supportive, but also may contain disinformation we need to dispel.<br/><br/>Unfortunately, templates, questionnaires, and lack of interdisciplinary referral and communication functions of EHRs don’t support the complexities of care for ASD. While the AAP has guidelines for diagnosis and management and an online toolkit, consider adding a system with an autism-specific module like CHADIS and joining the Autism Care Network or ECHO Autism sessions to get both information and support to take on the evolving critical role of autism care. <br/><br/></p> <p> <em>Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of <span class="Hyperlink"><a href="http://www.CHADIS.com">CHADIS</a></span>. She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at <span class="Hyperlink"><a href="mailto:pdnews%40mdedge.com?subject=">pdnews@mdedge.com</a></span>.</em> </p> </itemContent> </newsItem> <newsItem> <itemMeta> <itemRole>teaser</itemRole> <itemClass>text</itemClass> <title/> <deck/> </itemMeta> <itemContent> </itemContent> </newsItem> </itemSet></root>
The Management of Anxiety in Primary Care
This transcript has been edited for clarity.
Matthew F. Watto, MD: Welcome back to The Curbsiders. I’m Dr. Matthew Frank Watto, here with my great friend and America’s primary care physician, Dr. Paul Nelson Williams. Paul, are you ready to talk about anxiety?
Paul N. Williams, MD: Always. It’s one of my favorite topics.
Dr. Watto: We had a great guest for this podcast on anxiety — Dr. Jessi Gold, who gave us a lot of practical tips. The way she talks to her patients about anxiety is really useful. When patients say “my anxiety” or “I feel anxious,” she considers that a symptom. Anxiety can be a diagnosis or a symptom. You need to clarify what they mean when they refer to their anxiety and dig into how it affects their life.
We asked her about the Generalized Anxiety Disorder (GAD)-7 score. Like most of the experts we’ve talked to, she’s internalized that, so she doesn’t need to rely on a questionnaire. But I still rely on a questionnaire when I’m taking a history for anxiety.
We also asked her how she explains anxiety to patients. I don’t know about you, Paul, but I’ve never really thought about explaining to patients why they have anxiety.
Dr. Williams: I’ve done my best to try to normalize it, but I haven’t actually talked to patients about the evolutionary advantage of anxiety.
Dr. Watto: She frames it to patients this way: As we were evolving, it was somewhat of an advantage to be hypervigilant, to have some anxiety and a healthy amount of fear so that you weren’t killed or eaten. But now, in the modern world, anxiety isn’t playing to our advantage. Anxiety is not making them safer; it’s making their lives worse. She explains to patients that she’s trying to help them overcome that.
In terms of pharmacotherapy for anxiety, I always think about SSRIs as one of the first steps. Why not use an SNRI as first-line treatment?
Dr. Williams: I was glad we had this conversation because I feel, for whatever reason, a bit more comfortable treating depression than anxiety. In any case, Dr. Gold reaches for the SSRI first, in part because getting off an SNRI (for example, to switch to something else) can be absolutely miserable. The discontinuation effects can be severe enough to have to bridge some patients with a benzodiazepine to get them fully off the SNRI. So, an SNRI is not the first drug you should necessarily reach for.
She thinks about using an SNRI if she has tried a couple of SSRIs that have been ineffective, or if the patient has a comorbid condition that might also benefit from the SNRI in the same way that you might use a tricyclic antidepressant in the patient with both migraines and anxiety. An SNRI might be a good medication to consider in the patient with neuropathic pain and anxiety but rarely as a first-line treatment, because if it doesn’t work out, getting the patient off that medication can be a challenge.
Dr. Watto: She mentioned venlafaxine as being especially difficult to get people off of. I’ve heard that bupropion should never be used in anxiety, and if you give it, you are a terrible doctor. What did we learn about that?
Dr. Williams: It’s a drug I’ve hesitated to prescribe to patients with anxiety or even comorbid anxiety. I’m a little bit nervous for someone who has depression and anxiety to prescribe bupropion because it can be activating and make things worse. But Dr. Gold says that she has seen bupropion work for some patients so she will consider it, especially for patients who don’t want to gain weight, or for whom sexual side effects would be bothersome. So, it’s not always the wrong answer. In her expert opinion, you can try it and see how the patient responds, using shared decision-making and letting the patient know that they may not tolerate it as well as other medications.
Dr. Watto: She sees a lot of younger people — students, working professionals — who do not want to gain weight, and that’s understandable. She will tell patients, “We can try bupropion, but if you get more anxious, we might not be able to continue it. We might have to use one of the first-line agents instead.”
Dr. Williams: We talked about mirtazapine as well. She tells patients they are going to gain weight with it. You have to have that conversation with the patient to see whether that is something they are willing to tolerate. If so, mirtazapine might be worth a try, but you have to be upfront about the potential side effects and know what the medications you’re prescribing will do to patients.
Dr. Watto: We asked her about benzodiazepines. For as-needed medication for people who are experiencing panic or anxiety attacks, she prescribes propranolol 10-20 mg twice a day as needed, which is a low dose. In primary care, we use higher doses for migraine prophylaxis.
She uses propranolol because for some patients, it’s the physical symptoms of anxiety that are bothering them. She can calm down the physical symptoms with that and get by without needing to use a benzodiazepine.
But what about thoughts that make people anxious? Can we change people’s thoughts with medication?
Dr. Williams: Dr. Gold made the point that we can medicate away insomnia, for the most part. We can medicate away the physical symptoms of anxiety, which can be really bothersome. But we can’t medicate away thoughts and thought patterns. You can make patients feel better with medications, but you may not be able to get rid of the persistent bothersome thoughts. That’s where cognitive-behavioral therapy can be especially helpful. Most of these patients would benefit from therapy.
Dr. Watto: I completely agree with that. We talked about so many great things with Dr. Gold, but we can’t recap all of it here. Please click on this link to hear the full podcast episode.
Dr. Watto is Clinical Assistant Professor, Department of Medicine, Perelman School of Medicine at University of Pennsylvania; Internist, Department of Medicine, Hospital Medicine Section, Pennsylvania Hospital, Philadelphia, Pennsylvania. He has disclosed no relevant financial relationships. Dr. Williams is Associate Professor of Clinical Medicine, Department of General Internal Medicine, Lewis Katz School of Medicine; Staff Physician, Department of General Internal Medicine, Temple Internal Medicine Associates, Philadelphia, Pennsylvania. He disclosed receiving income from The Curbsiders. The Curbsiders is an internal medicine podcast, in which three board-certified internists interview experts on clinically important topics. In a collaboration with Medscape, the Curbsiders share clinical pearls and practice-changing knowledge from selected podcasts.
A version of this article appeared on Medscape.com.
This transcript has been edited for clarity.
Matthew F. Watto, MD: Welcome back to The Curbsiders. I’m Dr. Matthew Frank Watto, here with my great friend and America’s primary care physician, Dr. Paul Nelson Williams. Paul, are you ready to talk about anxiety?
Paul N. Williams, MD: Always. It’s one of my favorite topics.
Dr. Watto: We had a great guest for this podcast on anxiety — Dr. Jessi Gold, who gave us a lot of practical tips. The way she talks to her patients about anxiety is really useful. When patients say “my anxiety” or “I feel anxious,” she considers that a symptom. Anxiety can be a diagnosis or a symptom. You need to clarify what they mean when they refer to their anxiety and dig into how it affects their life.
We asked her about the Generalized Anxiety Disorder (GAD)-7 score. Like most of the experts we’ve talked to, she’s internalized that, so she doesn’t need to rely on a questionnaire. But I still rely on a questionnaire when I’m taking a history for anxiety.
We also asked her how she explains anxiety to patients. I don’t know about you, Paul, but I’ve never really thought about explaining to patients why they have anxiety.
Dr. Williams: I’ve done my best to try to normalize it, but I haven’t actually talked to patients about the evolutionary advantage of anxiety.
Dr. Watto: She frames it to patients this way: As we were evolving, it was somewhat of an advantage to be hypervigilant, to have some anxiety and a healthy amount of fear so that you weren’t killed or eaten. But now, in the modern world, anxiety isn’t playing to our advantage. Anxiety is not making them safer; it’s making their lives worse. She explains to patients that she’s trying to help them overcome that.
In terms of pharmacotherapy for anxiety, I always think about SSRIs as one of the first steps. Why not use an SNRI as first-line treatment?
Dr. Williams: I was glad we had this conversation because I feel, for whatever reason, a bit more comfortable treating depression than anxiety. In any case, Dr. Gold reaches for the SSRI first, in part because getting off an SNRI (for example, to switch to something else) can be absolutely miserable. The discontinuation effects can be severe enough to have to bridge some patients with a benzodiazepine to get them fully off the SNRI. So, an SNRI is not the first drug you should necessarily reach for.
She thinks about using an SNRI if she has tried a couple of SSRIs that have been ineffective, or if the patient has a comorbid condition that might also benefit from the SNRI in the same way that you might use a tricyclic antidepressant in the patient with both migraines and anxiety. An SNRI might be a good medication to consider in the patient with neuropathic pain and anxiety but rarely as a first-line treatment, because if it doesn’t work out, getting the patient off that medication can be a challenge.
Dr. Watto: She mentioned venlafaxine as being especially difficult to get people off of. I’ve heard that bupropion should never be used in anxiety, and if you give it, you are a terrible doctor. What did we learn about that?
Dr. Williams: It’s a drug I’ve hesitated to prescribe to patients with anxiety or even comorbid anxiety. I’m a little bit nervous for someone who has depression and anxiety to prescribe bupropion because it can be activating and make things worse. But Dr. Gold says that she has seen bupropion work for some patients so she will consider it, especially for patients who don’t want to gain weight, or for whom sexual side effects would be bothersome. So, it’s not always the wrong answer. In her expert opinion, you can try it and see how the patient responds, using shared decision-making and letting the patient know that they may not tolerate it as well as other medications.
Dr. Watto: She sees a lot of younger people — students, working professionals — who do not want to gain weight, and that’s understandable. She will tell patients, “We can try bupropion, but if you get more anxious, we might not be able to continue it. We might have to use one of the first-line agents instead.”
Dr. Williams: We talked about mirtazapine as well. She tells patients they are going to gain weight with it. You have to have that conversation with the patient to see whether that is something they are willing to tolerate. If so, mirtazapine might be worth a try, but you have to be upfront about the potential side effects and know what the medications you’re prescribing will do to patients.
Dr. Watto: We asked her about benzodiazepines. For as-needed medication for people who are experiencing panic or anxiety attacks, she prescribes propranolol 10-20 mg twice a day as needed, which is a low dose. In primary care, we use higher doses for migraine prophylaxis.
She uses propranolol because for some patients, it’s the physical symptoms of anxiety that are bothering them. She can calm down the physical symptoms with that and get by without needing to use a benzodiazepine.
But what about thoughts that make people anxious? Can we change people’s thoughts with medication?
Dr. Williams: Dr. Gold made the point that we can medicate away insomnia, for the most part. We can medicate away the physical symptoms of anxiety, which can be really bothersome. But we can’t medicate away thoughts and thought patterns. You can make patients feel better with medications, but you may not be able to get rid of the persistent bothersome thoughts. That’s where cognitive-behavioral therapy can be especially helpful. Most of these patients would benefit from therapy.
Dr. Watto: I completely agree with that. We talked about so many great things with Dr. Gold, but we can’t recap all of it here. Please click on this link to hear the full podcast episode.
Dr. Watto is Clinical Assistant Professor, Department of Medicine, Perelman School of Medicine at University of Pennsylvania; Internist, Department of Medicine, Hospital Medicine Section, Pennsylvania Hospital, Philadelphia, Pennsylvania. He has disclosed no relevant financial relationships. Dr. Williams is Associate Professor of Clinical Medicine, Department of General Internal Medicine, Lewis Katz School of Medicine; Staff Physician, Department of General Internal Medicine, Temple Internal Medicine Associates, Philadelphia, Pennsylvania. He disclosed receiving income from The Curbsiders. The Curbsiders is an internal medicine podcast, in which three board-certified internists interview experts on clinically important topics. In a collaboration with Medscape, the Curbsiders share clinical pearls and practice-changing knowledge from selected podcasts.
A version of this article appeared on Medscape.com.
This transcript has been edited for clarity.
Matthew F. Watto, MD: Welcome back to The Curbsiders. I’m Dr. Matthew Frank Watto, here with my great friend and America’s primary care physician, Dr. Paul Nelson Williams. Paul, are you ready to talk about anxiety?
Paul N. Williams, MD: Always. It’s one of my favorite topics.
Dr. Watto: We had a great guest for this podcast on anxiety — Dr. Jessi Gold, who gave us a lot of practical tips. The way she talks to her patients about anxiety is really useful. When patients say “my anxiety” or “I feel anxious,” she considers that a symptom. Anxiety can be a diagnosis or a symptom. You need to clarify what they mean when they refer to their anxiety and dig into how it affects their life.
We asked her about the Generalized Anxiety Disorder (GAD)-7 score. Like most of the experts we’ve talked to, she’s internalized that, so she doesn’t need to rely on a questionnaire. But I still rely on a questionnaire when I’m taking a history for anxiety.
We also asked her how she explains anxiety to patients. I don’t know about you, Paul, but I’ve never really thought about explaining to patients why they have anxiety.
Dr. Williams: I’ve done my best to try to normalize it, but I haven’t actually talked to patients about the evolutionary advantage of anxiety.
Dr. Watto: She frames it to patients this way: As we were evolving, it was somewhat of an advantage to be hypervigilant, to have some anxiety and a healthy amount of fear so that you weren’t killed or eaten. But now, in the modern world, anxiety isn’t playing to our advantage. Anxiety is not making them safer; it’s making their lives worse. She explains to patients that she’s trying to help them overcome that.
In terms of pharmacotherapy for anxiety, I always think about SSRIs as one of the first steps. Why not use an SNRI as first-line treatment?
Dr. Williams: I was glad we had this conversation because I feel, for whatever reason, a bit more comfortable treating depression than anxiety. In any case, Dr. Gold reaches for the SSRI first, in part because getting off an SNRI (for example, to switch to something else) can be absolutely miserable. The discontinuation effects can be severe enough to have to bridge some patients with a benzodiazepine to get them fully off the SNRI. So, an SNRI is not the first drug you should necessarily reach for.
She thinks about using an SNRI if she has tried a couple of SSRIs that have been ineffective, or if the patient has a comorbid condition that might also benefit from the SNRI in the same way that you might use a tricyclic antidepressant in the patient with both migraines and anxiety. An SNRI might be a good medication to consider in the patient with neuropathic pain and anxiety but rarely as a first-line treatment, because if it doesn’t work out, getting the patient off that medication can be a challenge.
Dr. Watto: She mentioned venlafaxine as being especially difficult to get people off of. I’ve heard that bupropion should never be used in anxiety, and if you give it, you are a terrible doctor. What did we learn about that?
Dr. Williams: It’s a drug I’ve hesitated to prescribe to patients with anxiety or even comorbid anxiety. I’m a little bit nervous for someone who has depression and anxiety to prescribe bupropion because it can be activating and make things worse. But Dr. Gold says that she has seen bupropion work for some patients so she will consider it, especially for patients who don’t want to gain weight, or for whom sexual side effects would be bothersome. So, it’s not always the wrong answer. In her expert opinion, you can try it and see how the patient responds, using shared decision-making and letting the patient know that they may not tolerate it as well as other medications.
Dr. Watto: She sees a lot of younger people — students, working professionals — who do not want to gain weight, and that’s understandable. She will tell patients, “We can try bupropion, but if you get more anxious, we might not be able to continue it. We might have to use one of the first-line agents instead.”
Dr. Williams: We talked about mirtazapine as well. She tells patients they are going to gain weight with it. You have to have that conversation with the patient to see whether that is something they are willing to tolerate. If so, mirtazapine might be worth a try, but you have to be upfront about the potential side effects and know what the medications you’re prescribing will do to patients.
Dr. Watto: We asked her about benzodiazepines. For as-needed medication for people who are experiencing panic or anxiety attacks, she prescribes propranolol 10-20 mg twice a day as needed, which is a low dose. In primary care, we use higher doses for migraine prophylaxis.
She uses propranolol because for some patients, it’s the physical symptoms of anxiety that are bothering them. She can calm down the physical symptoms with that and get by without needing to use a benzodiazepine.
But what about thoughts that make people anxious? Can we change people’s thoughts with medication?
Dr. Williams: Dr. Gold made the point that we can medicate away insomnia, for the most part. We can medicate away the physical symptoms of anxiety, which can be really bothersome. But we can’t medicate away thoughts and thought patterns. You can make patients feel better with medications, but you may not be able to get rid of the persistent bothersome thoughts. That’s where cognitive-behavioral therapy can be especially helpful. Most of these patients would benefit from therapy.
Dr. Watto: I completely agree with that. We talked about so many great things with Dr. Gold, but we can’t recap all of it here. Please click on this link to hear the full podcast episode.
Dr. Watto is Clinical Assistant Professor, Department of Medicine, Perelman School of Medicine at University of Pennsylvania; Internist, Department of Medicine, Hospital Medicine Section, Pennsylvania Hospital, Philadelphia, Pennsylvania. He has disclosed no relevant financial relationships. Dr. Williams is Associate Professor of Clinical Medicine, Department of General Internal Medicine, Lewis Katz School of Medicine; Staff Physician, Department of General Internal Medicine, Temple Internal Medicine Associates, Philadelphia, Pennsylvania. He disclosed receiving income from The Curbsiders. The Curbsiders is an internal medicine podcast, in which three board-certified internists interview experts on clinically important topics. In a collaboration with Medscape, the Curbsiders share clinical pearls and practice-changing knowledge from selected podcasts.
A version of this article appeared on Medscape.com.
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WILLIAMS, MD</bylineFull> <bylineTitleText/> <USOrGlobal/> <wireDocType/> <newsDocType/> <journalDocType/> <linkLabel/> <pageRange/> <citation/> <quizID/> <indexIssueDate/> <itemClass qcode="ninat:text"/> <provider qcode="provider:imng"> <name>IMNG Medical Media</name> <rightsInfo> <copyrightHolder> <name>Frontline Medical News</name> </copyrightHolder> <copyrightNotice>Copyright (c) 2015 Frontline Medical News, a Frontline Medical Communications Inc. company. All rights reserved. This material may not be published, broadcast, copied, or otherwise reproduced or distributed without the prior written permission of Frontline Medical Communications Inc.</copyrightNotice> </rightsInfo> </provider> <abstract/> <metaDescription>This transcript has been edited for clarity. Matthew F. Watto, MD: Welcome back to The Curbsiders. I’m Dr. Matthew Frank Watto, here with my great friend and Am</metaDescription> <articlePDF/> <teaserImage/> <teaser>SSRIs are good to reach for first but most patients with anxiety would benefit from cognitive-behavioral therapy.</teaser> <title>The Management of Anxiety in Primary Care</title> <deck/> <disclaimer/> <AuthorList/> <articleURL/> <doi/> <pubMedID/> <publishXMLStatus/> <publishXMLVersion>1</publishXMLVersion> <useEISSN>0</useEISSN> <urgency/> <pubPubdateYear/> <pubPubdateMonth/> <pubPubdateDay/> <pubVolume/> <pubNumber/> <wireChannels/> <primaryCMSID/> <CMSIDs/> <keywords/> <seeAlsos/> <publications_g> <publicationData> <publicationCode>fp</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> </publicationData> <publicationData> <publicationCode>im</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> </publicationData> <publicationData> <publicationCode>pn</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> </publicationData> </publications_g> <publications> <term>15</term> <term canonical="true">21</term> <term>25</term> </publications> <sections> <term canonical="true">52</term> </sections> <topics> <term canonical="true">248</term> </topics> <links/> </header> <itemSet> <newsItem> <itemMeta> <itemRole>Main</itemRole> <itemClass>text</itemClass> <title>The Management of Anxiety in Primary Care</title> <deck/> </itemMeta> <itemContent> <p><br/><br/><em>This transcript has been edited for clarity</em>. <br/><br/><strong>Matthew F. Watto, MD:</strong> Welcome back to The Curbsiders. I’m Dr. Matthew Frank Watto, here with my great friend and America’s primary care physician, Dr. Paul Nelson Williams. Paul, are you ready to talk about anxiety?<br/><br/><strong>Paul N. Williams, MD:</strong> Always. It’s one of my favorite topics. <br/><br/><strong>Dr. Watto:</strong> We had a great guest for this <span class="Hyperlink"><a href="https://thecurbsiders.com/curbsiders-podcast/429-anxiety-2-0-with-dr-jessi-gold">podcast on anxiety — Dr. Jessi Gold</a></span>, who gave us a lot of practical tips. The way she talks to her patients about anxiety is really useful. When patients say “my anxiety” or “I feel anxious,” she considers that a symptom. Anxiety can be a diagnosis or a symptom. You need to clarify what they mean when they refer to their anxiety and dig into how it affects their life. <br/><br/>We asked her about the <span class="Hyperlink"><a href="https://www.mdcalc.com/calc/1727/gad7-general-anxiety-disorder7">Generalized Anxiety Disorder (GAD)-7 score</a></span>. Like most of the experts we’ve talked to, she’s internalized that, so she doesn’t need to rely on a questionnaire. But I still rely on a questionnaire when I’m taking a history for anxiety. <br/><br/>We also asked her how she explains anxiety to patients. I don’t know about you, Paul, but I’ve never really thought about explaining to patients why they have anxiety. <br/><br/><strong>Dr. Williams:</strong> I’ve done my best to try to normalize it, but I haven’t actually talked to patients about the evolutionary advantage of anxiety. <br/><br/><strong>Dr. Watto:</strong> She frames it to patients this way: As we were evolving, it was somewhat of an advantage to be hypervigilant, to have some anxiety and a healthy amount of fear so that you weren’t killed or eaten. But now, in the modern world, anxiety isn’t playing to our advantage. Anxiety is not making them safer; it’s making their lives worse. She explains to patients that she’s trying to help them overcome that. <br/><br/>In terms of pharmacotherapy for anxiety, I always think about SSRIs as one of the first steps. Why not use an SNRI as first-line treatment?<br/><br/><strong>Dr. Williams:</strong> I was glad we had this conversation because I feel, for whatever reason, a bit more comfortable treating depression than anxiety. In any case, Dr. Gold reaches for the SSRI first, in part because getting off an SNRI (for example, to switch to something else) can be absolutely miserable. The discontinuation effects can be severe enough to have to bridge some patients with a benzodiazepine to get them fully off the SNRI. So, an SNRI is not the first drug you should necessarily reach for. <br/><br/>She thinks about using an SNRI if she has tried a couple of SSRIs that have been ineffective, or if the patient has a comorbid condition that might also benefit from the SNRI in the same way that you might use a tricyclic antidepressant in the patient with both migraines and anxiety. An SNRI might be a good medication to consider in the patient with neuropathic pain and anxiety but rarely as a first-line treatment, because if it doesn’t work out, getting the patient off that medication can be a challenge.<br/><br/><strong>Dr. Watto:</strong> She mentioned venlafaxine as being especially difficult to get people off of. I’ve heard that bupropion should never be used in anxiety, and if you give it, you are a terrible doctor. What did we learn about that? <br/><br/><strong>Dr. Williams:</strong> It’s a drug I’ve hesitated to prescribe to patients with anxiety or even comorbid anxiety. I’m a little bit nervous for someone who has depression and anxiety to prescribe bupropion because it can be activating and make things worse. But Dr. Gold says that she has seen bupropion work for some patients so she will consider it, especially for patients who don’t want to gain weight, or for whom sexual side effects would be bothersome. So, it’s not always the wrong answer. In her expert opinion, you can try it and see how the patient responds, using shared decision-making and letting the patient know that they may not tolerate it as well as other medications. <br/><br/><strong>Dr. Watto:</strong> She sees a lot of younger people — students, working professionals — who do not want to gain weight, and that’s understandable. She will tell patients, “We can try bupropion, but if you get more anxious, we might not be able to continue it. We might have to use one of the first-line agents instead.” <br/><br/><strong>Dr. Williams:</strong> We talked about mirtazapine as well. She tells patients they are going to gain weight with it. You have to have that conversation with the patient to see whether that is something they are willing to tolerate. If so, mirtazapine might be worth a try, but you have to be upfront about the potential side effects and know what the medications you’re prescribing will do to patients. <br/><br/><strong>Dr. Watto:</strong> We asked her about benzodiazepines. For as-needed medication for people who are experiencing panic or anxiety attacks, she prescribes propranolol 10-20 mg twice a day as needed, which is a low dose. In primary care, we use higher doses for migraine prophylaxis. <br/><br/>She uses propranolol because for some patients, it’s the physical symptoms of anxiety that are bothering them. She can calm down the physical symptoms with that and get by without needing to use a benzodiazepine. <br/><br/>But what about thoughts that make people anxious? Can we change people’s thoughts with medication? <br/><br/><strong>Dr. Williams:</strong> Dr. Gold made the point that we can medicate away insomnia, for the most part. We can medicate away the physical symptoms of anxiety, which can be really bothersome. But we can’t medicate away thoughts and thought patterns. You can make patients feel better with medications, but you may not be able to get rid of the persistent bothersome thoughts. That’s where cognitive-behavioral therapy can be especially helpful. Most of these patients would benefit from therapy.<br/><br/><strong>Dr. Watto:</strong> I completely agree with that. We talked about so many great things with Dr. Gold, but we can’t recap all of it here. Please click on this <span class="Hyperlink"><a href="https://thecurbsiders.com/curbsiders-podcast/429-anxiety-2-0-with-dr-jessi-gold">link</a></span> to hear the full podcast episode. <br/><br/></p> <p> <em>Dr. Watto is Clinical Assistant Professor, Department of Medicine, Perelman School of Medicine at University of Pennsylvania; Internist, Department of Medicine, Hospital Medicine Section, Pennsylvania Hospital, Philadelphia, Pennsylvania. He has disclosed no relevant financial relationships. Dr. Williams is Associate Professor of Clinical Medicine, Department of General Internal Medicine, Lewis Katz School of Medicine; Staff Physician, Department of General Internal Medicine, Temple Internal Medicine Associates, Philadelphia, Pennsylvania. He disclosed receiving income from The Curbsiders. The Curbsiders is an internal medicine podcast, in which three board-certified internists interview experts on clinically important topics. In a collaboration with Medscape, the Curbsiders share clinical pearls and practice-changing knowledge from selected podcasts.</em> </p> <p> <em>A version of this article appeared on <span class="Hyperlink"><a href="https://www.medscape.com/viewarticle/management-anxiety-primary-care-2024a1000ayf">Medscape.com</a></span>.</em> </p> </itemContent> </newsItem> <newsItem> <itemMeta> <itemRole>teaser</itemRole> <itemClass>text</itemClass> <title/> <deck/> </itemMeta> <itemContent> </itemContent> </newsItem> </itemSet></root>
Better Sleep Tied to Less Loneliness
HOUSTON — Sleep may have a role in driving down rates of loneliness, especially among younger adults.
A study of nearly 2300 participants showed that better sleep health is associated with significantly lower levels of loneliness across ages and that the association is particularly strong in younger individuals.
The US Surgeon General has identified loneliness as “a major public health concern, linked to high rates of negative physical and mental health outcomes,” lead researcher Joseph Dzierzewski, PhD, vice president for research and scientific affairs at the National Sleep Foundation, told this news organization.
“Loneliness is an urgent public health crisis, and there is a pressing need for providers to better understand and treat it,” Dr. Dzierzewski said in a statement.
“Better sleep health might be connected to lower feelings of loneliness by empowering people to engage in social activities, reducing feelings of negative emotions and increasing the likelihood that people interpret interactions in a positive way,” he added.
The findings were presented at SLEEP 2024: 38th Annual Meeting of the Associated Professional Sleep Societies and recently published in an online supplement of the journal Sleep.
Rested, Connected
An American Psychiatric Association poll conducted earlier this year showed 30% of US adults reported feelings of loneliness at least once a week over the past year, and 10% reported feeling lonely every day.
Younger people are more likely to report feeling lonely, with 30% of Americans, aged 18-34 years, feeling lonely every day or several times a week.
While there is growing research identifying a relationship between loneliness and poor sleep in different age groups, few studies have explored ties between social and emotional loneliness and sleep health across the adult lifespan.
In the current study led by Dr. Dzierzewski, 2297 adults (mean age, 44 years; 51% male) completed a validated sleep health questionnaire and loneliness scale.
Linear regression analyses were used to examine the direct associations between sleep health, age, and loneliness. Moderation analyses tested whether the link between sleep health and loneliness differed by age.
On average, the total sleep score was 7.7 (range, 0-12), with higher scores indicating better multidimensional sleep health, and total loneliness scale score was 8.9 (out of 11), indicating moderate levels of loneliness.
Better sleep health and younger age were associated with significantly lower loneliness total scores and social and emotional loneliness subscale scores (all P < .001).
Age significantly moderated the association between sleep health and total (P < .001) and emotional loneliness scores (P < .001) but did not moderate the association between sleep health and social loneliness (P = .034). Better sleep health was associated with lower loneliness across ages, and this association was stronger at younger ages.
“Why younger adults might experience more sleep-related benefits to loneliness than older adults is unknown and intriguing — certainly worth further investigation,” Dr. Dzierzewski said in a conference statement.
Untapped Avenue
Promoting sleep health may be an “untapped avenue” to support efforts and programs that aim to reduce loneliness and increase engagement in all age groups but especially in younger ages, the researchers noted.
Future research should consider monitoring sleep health in programs or interventions that address loneliness, they added.
“Healthcare providers should be aware of the important link between sleep health and loneliness as both sleep and social connections are essential to health and well-being. When sitting across from patients, asking about both sleep health and loneliness might yield important insights into avenues for health promotion,” said Dr. Dzierzewski.
Michael Breus, PhD, clinical psychologist and founder of SleepDoctor.com, who wasn’t involved in the study, is not surprised by the results.
It makes sense that better sleep would lead to less feelings of loneliness, he told this news organization.
Research has shown that when someone is not sleeping well, they “give others a sense of unhappiness, which socially deflects new encounters or even encounters with friends. So social awareness and social initiation would appear to both be affected by sleep quality, therefore potentially leading, at least in part, to loneliness,” he said.
Support for the study was provided by the National Institute on Aging. Dr. Dzierzewski and Dr. Breus had no relevant disclosures.
A version of this article first appeared on Medscape.com.
HOUSTON — Sleep may have a role in driving down rates of loneliness, especially among younger adults.
A study of nearly 2300 participants showed that better sleep health is associated with significantly lower levels of loneliness across ages and that the association is particularly strong in younger individuals.
The US Surgeon General has identified loneliness as “a major public health concern, linked to high rates of negative physical and mental health outcomes,” lead researcher Joseph Dzierzewski, PhD, vice president for research and scientific affairs at the National Sleep Foundation, told this news organization.
“Loneliness is an urgent public health crisis, and there is a pressing need for providers to better understand and treat it,” Dr. Dzierzewski said in a statement.
“Better sleep health might be connected to lower feelings of loneliness by empowering people to engage in social activities, reducing feelings of negative emotions and increasing the likelihood that people interpret interactions in a positive way,” he added.
The findings were presented at SLEEP 2024: 38th Annual Meeting of the Associated Professional Sleep Societies and recently published in an online supplement of the journal Sleep.
Rested, Connected
An American Psychiatric Association poll conducted earlier this year showed 30% of US adults reported feelings of loneliness at least once a week over the past year, and 10% reported feeling lonely every day.
Younger people are more likely to report feeling lonely, with 30% of Americans, aged 18-34 years, feeling lonely every day or several times a week.
While there is growing research identifying a relationship between loneliness and poor sleep in different age groups, few studies have explored ties between social and emotional loneliness and sleep health across the adult lifespan.
In the current study led by Dr. Dzierzewski, 2297 adults (mean age, 44 years; 51% male) completed a validated sleep health questionnaire and loneliness scale.
Linear regression analyses were used to examine the direct associations between sleep health, age, and loneliness. Moderation analyses tested whether the link between sleep health and loneliness differed by age.
On average, the total sleep score was 7.7 (range, 0-12), with higher scores indicating better multidimensional sleep health, and total loneliness scale score was 8.9 (out of 11), indicating moderate levels of loneliness.
Better sleep health and younger age were associated with significantly lower loneliness total scores and social and emotional loneliness subscale scores (all P < .001).
Age significantly moderated the association between sleep health and total (P < .001) and emotional loneliness scores (P < .001) but did not moderate the association between sleep health and social loneliness (P = .034). Better sleep health was associated with lower loneliness across ages, and this association was stronger at younger ages.
“Why younger adults might experience more sleep-related benefits to loneliness than older adults is unknown and intriguing — certainly worth further investigation,” Dr. Dzierzewski said in a conference statement.
Untapped Avenue
Promoting sleep health may be an “untapped avenue” to support efforts and programs that aim to reduce loneliness and increase engagement in all age groups but especially in younger ages, the researchers noted.
Future research should consider monitoring sleep health in programs or interventions that address loneliness, they added.
“Healthcare providers should be aware of the important link between sleep health and loneliness as both sleep and social connections are essential to health and well-being. When sitting across from patients, asking about both sleep health and loneliness might yield important insights into avenues for health promotion,” said Dr. Dzierzewski.
Michael Breus, PhD, clinical psychologist and founder of SleepDoctor.com, who wasn’t involved in the study, is not surprised by the results.
It makes sense that better sleep would lead to less feelings of loneliness, he told this news organization.
Research has shown that when someone is not sleeping well, they “give others a sense of unhappiness, which socially deflects new encounters or even encounters with friends. So social awareness and social initiation would appear to both be affected by sleep quality, therefore potentially leading, at least in part, to loneliness,” he said.
Support for the study was provided by the National Institute on Aging. Dr. Dzierzewski and Dr. Breus had no relevant disclosures.
A version of this article first appeared on Medscape.com.
HOUSTON — Sleep may have a role in driving down rates of loneliness, especially among younger adults.
A study of nearly 2300 participants showed that better sleep health is associated with significantly lower levels of loneliness across ages and that the association is particularly strong in younger individuals.
The US Surgeon General has identified loneliness as “a major public health concern, linked to high rates of negative physical and mental health outcomes,” lead researcher Joseph Dzierzewski, PhD, vice president for research and scientific affairs at the National Sleep Foundation, told this news organization.
“Loneliness is an urgent public health crisis, and there is a pressing need for providers to better understand and treat it,” Dr. Dzierzewski said in a statement.
“Better sleep health might be connected to lower feelings of loneliness by empowering people to engage in social activities, reducing feelings of negative emotions and increasing the likelihood that people interpret interactions in a positive way,” he added.
The findings were presented at SLEEP 2024: 38th Annual Meeting of the Associated Professional Sleep Societies and recently published in an online supplement of the journal Sleep.
Rested, Connected
An American Psychiatric Association poll conducted earlier this year showed 30% of US adults reported feelings of loneliness at least once a week over the past year, and 10% reported feeling lonely every day.
Younger people are more likely to report feeling lonely, with 30% of Americans, aged 18-34 years, feeling lonely every day or several times a week.
While there is growing research identifying a relationship between loneliness and poor sleep in different age groups, few studies have explored ties between social and emotional loneliness and sleep health across the adult lifespan.
In the current study led by Dr. Dzierzewski, 2297 adults (mean age, 44 years; 51% male) completed a validated sleep health questionnaire and loneliness scale.
Linear regression analyses were used to examine the direct associations between sleep health, age, and loneliness. Moderation analyses tested whether the link between sleep health and loneliness differed by age.
On average, the total sleep score was 7.7 (range, 0-12), with higher scores indicating better multidimensional sleep health, and total loneliness scale score was 8.9 (out of 11), indicating moderate levels of loneliness.
Better sleep health and younger age were associated with significantly lower loneliness total scores and social and emotional loneliness subscale scores (all P < .001).
Age significantly moderated the association between sleep health and total (P < .001) and emotional loneliness scores (P < .001) but did not moderate the association between sleep health and social loneliness (P = .034). Better sleep health was associated with lower loneliness across ages, and this association was stronger at younger ages.
“Why younger adults might experience more sleep-related benefits to loneliness than older adults is unknown and intriguing — certainly worth further investigation,” Dr. Dzierzewski said in a conference statement.
Untapped Avenue
Promoting sleep health may be an “untapped avenue” to support efforts and programs that aim to reduce loneliness and increase engagement in all age groups but especially in younger ages, the researchers noted.
Future research should consider monitoring sleep health in programs or interventions that address loneliness, they added.
“Healthcare providers should be aware of the important link between sleep health and loneliness as both sleep and social connections are essential to health and well-being. When sitting across from patients, asking about both sleep health and loneliness might yield important insights into avenues for health promotion,” said Dr. Dzierzewski.
Michael Breus, PhD, clinical psychologist and founder of SleepDoctor.com, who wasn’t involved in the study, is not surprised by the results.
It makes sense that better sleep would lead to less feelings of loneliness, he told this news organization.
Research has shown that when someone is not sleeping well, they “give others a sense of unhappiness, which socially deflects new encounters or even encounters with friends. So social awareness and social initiation would appear to both be affected by sleep quality, therefore potentially leading, at least in part, to loneliness,” he said.
Support for the study was provided by the National Institute on Aging. Dr. Dzierzewski and Dr. Breus had no relevant disclosures.
A version of this article first appeared on Medscape.com.
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All rights reserved. This material may not be published, broadcast, copied, or otherwise reproduced or distributed without the prior written permission of Frontline Medical Communications Inc.</copyrightNotice> </rightsInfo> </provider> <abstract/> <metaDescription>HOUSTON — Sleep may have a role in driving down rates of loneliness, especially among younger adults.</metaDescription> <articlePDF/> <teaserImage/> <teaser>“Social awareness and social initiation would appear to be affected by sleep quality, therefore potentially leading, at least in part, to loneliness.” </teaser> <title>Better Sleep Tied to Less Loneliness</title> <deck/> <disclaimer/> <AuthorList/> <articleURL/> <doi/> <pubMedID/> <publishXMLStatus/> <publishXMLVersion>1</publishXMLVersion> <useEISSN>0</useEISSN> <urgency/> <pubPubdateYear/> <pubPubdateMonth/> <pubPubdateDay/> <pubVolume/> <pubNumber/> <wireChannels/> <primaryCMSID/> <CMSIDs/> <keywords/> <seeAlsos/> <publications_g> <publicationData> <publicationCode>chph</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> </publicationData> <publicationData> <publicationCode>cpn</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> </publicationData> <publicationData> <publicationCode>fp</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> </publicationData> <publicationData> <publicationCode>im</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> </publicationData> </publications_g> <publications> <term>6</term> <term canonical="true">9</term> <term>15</term> <term>21</term> </publications> <sections> <term>27970</term> <term canonical="true">39313</term> </sections> <topics> <term canonical="true">296</term> <term>202</term> <term>248</term> </topics> <links/> </header> <itemSet> <newsItem> <itemMeta> <itemRole>Main</itemRole> <itemClass>text</itemClass> <title>Better Sleep Tied to Less Loneliness</title> <deck/> </itemMeta> <itemContent> <p>HOUSTON — Sleep may have a role in driving down rates of loneliness, especially among younger adults.</p> <p>A study of nearly 2300 participants showed that better sleep health is associated with significantly lower levels of loneliness across ages and that the association is particularly strong in younger individuals.<br/><br/>The US Surgeon General has identified loneliness as “a major public health concern, linked to high rates of negative physical and mental health outcomes,” lead researcher Joseph Dzierzewski, PhD, vice president for research and scientific affairs at the National Sleep Foundation, told this news organization.<br/><br/>“Loneliness is an urgent public health crisis, and there is a pressing need for providers to better understand and treat it,” Dr. Dzierzewski said in a statement.<br/><br/>“Better sleep health might be connected to lower feelings of loneliness by empowering people to engage in social activities, reducing feelings of negative emotions and increasing the likelihood that people interpret interactions in a positive way,” he added.<br/><br/>The findings were presented at <a href="https://www.medscape.com/viewcollection/37551">SLEEP 2024: 38th Annual Meeting of the Associated Professional Sleep Societies</a> and <a href="https://www.sleepmeeting.org/abstract-supplements/">recently published in an online supplement</a> of the journal <em>Sleep</em>.<br/><br/></p> <h2>Rested, Connected</h2> <p>An <a href="https://bit.ly/3KCjcAQ">American Psychiatric Association poll</a> conducted earlier this year showed 30% of US adults reported feelings of loneliness at least once a week over the past year, and 10% reported feeling lonely every day.</p> <p>Younger people are more likely to report feeling lonely, with 30% of Americans, aged 18-34 years, feeling lonely every day or several times a week.<br/><br/>While there is growing research identifying a relationship between loneliness and poor sleep in different age groups, few studies have explored ties between social and emotional loneliness and sleep health across the adult lifespan.<br/><br/>In the current study led by Dr. Dzierzewski, 2297 adults (mean age, 44 years; 51% male) completed a validated sleep health questionnaire and loneliness scale.<br/><br/>Linear regression analyses were used to examine the direct associations between sleep health, age, and loneliness. Moderation analyses tested whether the link between sleep health and loneliness differed by age.<br/><br/>On average, the total sleep score was 7.7 (range, 0-12), with higher scores indicating better multidimensional sleep health, and total loneliness scale score was 8.9 (out of 11), indicating moderate levels of loneliness.<br/><br/>Better sleep health and younger age were associated with significantly lower loneliness total scores and social and emotional loneliness subscale scores (all <em>P</em> < .001).<br/><br/>Age significantly moderated the association between sleep health and total (<em>P</em> < .001) and emotional loneliness scores (<em>P</em> < .001) but did not moderate the association between sleep health and social loneliness (<em>P</em> = .034). Better sleep health was associated with lower loneliness across ages, and this association was stronger at younger ages.<br/><br/>“Why younger adults might experience more sleep-related benefits to loneliness than older adults is unknown and intriguing — certainly worth further investigation,” Dr. Dzierzewski said in a conference statement.<br/><br/></p> <h2>Untapped Avenue</h2> <p>Promoting sleep health may be an “untapped avenue” to support efforts and programs that aim to reduce loneliness and increase engagement in all age groups but especially in younger ages, the researchers noted.</p> <p>Future research should consider monitoring sleep health in programs or interventions that address loneliness, they added.<br/><br/>“Healthcare providers should be aware of the important link between sleep health and loneliness as both sleep and social connections are essential to health and well-being. When sitting across from patients, asking about both sleep health and loneliness might yield important insights into avenues for health promotion,” said Dr. Dzierzewski.<br/><br/>Michael Breus, PhD, clinical psychologist and founder of <a href="https://thesleepdoctor.com/">SleepDoctor.com</a>, who wasn’t involved in the study, is not surprised by the results.<br/><br/>It makes sense that better sleep would lead to less feelings of loneliness, he told this news organization.<br/><br/>Research has shown that when someone is not sleeping well, they “give others a sense of unhappiness, which socially deflects new encounters or even encounters with friends. So social awareness and social initiation would appear to both be affected by sleep quality, therefore potentially leading, at least in part, to loneliness,” he said.<br/><br/>Support for the study was provided by the National Institute on Aging. Dr. Dzierzewski and Dr. Breus had no relevant disclosures.<span class="end"/></p> <p> <em>A version of this article first appeared on <span class="Hyperlink"><a href="https://www.medscape.com/viewarticle/better-sleep-tied-less-loneliness-2024a1000b42">Medscape.com</a></span>.</em> </p> </itemContent> </newsItem> <newsItem> <itemMeta> <itemRole>teaser</itemRole> <itemClass>text</itemClass> <title/> <deck/> </itemMeta> <itemContent> </itemContent> </newsItem> </itemSet></root>
FROM SLEEP 2024
Emergency Department Visits for Suicide Attempts Rise Across the United States
TOPLINE:
Emergency department (ED) visits in the United States for suicide attempts and intentional self-harm show an increasing trend from 2011 to 2020, with visits being most common among adolescents and the largest increase in visits being seen in adults aged 65 years or older.
METHODOLOGY:
- This study used data from the National Hospital Ambulatory Medical Care Survey, an annual nationwide cross-sectional survey, to track trends in ED visits for suicide attempts and intentional self-harm in the United States from 2011 to 2020.
- Researchers identified visits for suicide attempts and intentional self-harm, along with diagnoses of any co-occurring mental health conditions, using discharge diagnosis codes or reason-for-visit codes.
- The focus was to identify the percentages of ED visits for suicide attempts and intentional self-harm, with analyses done per 100,000 persons and for changes possibly linked to the COVID-19 pandemic in 2019-2020.
TAKEAWAY:
- The number of ED visits owing to suicide attempts and intentional self-harm increased from 1.43 million in 2011-2012 to 5.37 million in 2019-2020 (average annual percent change, 19.5%; 95% confidence interval, 16.9-22.2).
- The rate of ED visits for suicide attempts and intentional self-harm was higher among adolescents and young adults, particularly women, and lower among children.
- Despite a surge in ED visits for self-harm, less than 16% included a mental health evaluation, with visits among patients with mood disorders decreasing by 5.5% annually and those among patients with drug-related disorders increasing by 6.8% annually.
- In 2019-2020, those aged 15-20 years had the highest rate of ED visits (1552 visits per 100,000 persons), with a significant increase seen across all age groups; the largest increase was among those aged 65 years or older.
IN PRACTICE:
“Given that suicide attempts are the single greatest risk factor for suicide, evidence-based management of individuals presenting to emergency departments with suicide attempts and intentional self-harm is a critical component of comprehensive suicide prevention strategies,” the authors wrote.
SOURCE:
The investigation, led by Tanner J. Bommersbach, MD, MPH, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, was published online in The American Journal of Psychiatry.
LIMITATIONS:
Visits for suicide attempts and intentional self-harm were identified based on discharge diagnostic and reason-for-visit codes, which may have led to an underestimation of visits for suicide attempts. ED visits for suicidal vs nonsuicidal self-injury could not be distinguished due to reliance on discharge diagnostic codes. Visits for suicidal ideation, which was not the focus of the study, may have been miscoded as suicide attempts and intentional self-harm.
DISCLOSURES:
No funding source was reported for the study. Some authors received funding grants from various institutions, and one author disclosed receiving honoraria for service as a review committee member and serving as a stakeholder/consultant and as an advisory committee member for some institutes and agencies.
A version of this article appeared on Medscape.com.
TOPLINE:
Emergency department (ED) visits in the United States for suicide attempts and intentional self-harm show an increasing trend from 2011 to 2020, with visits being most common among adolescents and the largest increase in visits being seen in adults aged 65 years or older.
METHODOLOGY:
- This study used data from the National Hospital Ambulatory Medical Care Survey, an annual nationwide cross-sectional survey, to track trends in ED visits for suicide attempts and intentional self-harm in the United States from 2011 to 2020.
- Researchers identified visits for suicide attempts and intentional self-harm, along with diagnoses of any co-occurring mental health conditions, using discharge diagnosis codes or reason-for-visit codes.
- The focus was to identify the percentages of ED visits for suicide attempts and intentional self-harm, with analyses done per 100,000 persons and for changes possibly linked to the COVID-19 pandemic in 2019-2020.
TAKEAWAY:
- The number of ED visits owing to suicide attempts and intentional self-harm increased from 1.43 million in 2011-2012 to 5.37 million in 2019-2020 (average annual percent change, 19.5%; 95% confidence interval, 16.9-22.2).
- The rate of ED visits for suicide attempts and intentional self-harm was higher among adolescents and young adults, particularly women, and lower among children.
- Despite a surge in ED visits for self-harm, less than 16% included a mental health evaluation, with visits among patients with mood disorders decreasing by 5.5% annually and those among patients with drug-related disorders increasing by 6.8% annually.
- In 2019-2020, those aged 15-20 years had the highest rate of ED visits (1552 visits per 100,000 persons), with a significant increase seen across all age groups; the largest increase was among those aged 65 years or older.
IN PRACTICE:
“Given that suicide attempts are the single greatest risk factor for suicide, evidence-based management of individuals presenting to emergency departments with suicide attempts and intentional self-harm is a critical component of comprehensive suicide prevention strategies,” the authors wrote.
SOURCE:
The investigation, led by Tanner J. Bommersbach, MD, MPH, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, was published online in The American Journal of Psychiatry.
LIMITATIONS:
Visits for suicide attempts and intentional self-harm were identified based on discharge diagnostic and reason-for-visit codes, which may have led to an underestimation of visits for suicide attempts. ED visits for suicidal vs nonsuicidal self-injury could not be distinguished due to reliance on discharge diagnostic codes. Visits for suicidal ideation, which was not the focus of the study, may have been miscoded as suicide attempts and intentional self-harm.
DISCLOSURES:
No funding source was reported for the study. Some authors received funding grants from various institutions, and one author disclosed receiving honoraria for service as a review committee member and serving as a stakeholder/consultant and as an advisory committee member for some institutes and agencies.
A version of this article appeared on Medscape.com.
TOPLINE:
Emergency department (ED) visits in the United States for suicide attempts and intentional self-harm show an increasing trend from 2011 to 2020, with visits being most common among adolescents and the largest increase in visits being seen in adults aged 65 years or older.
METHODOLOGY:
- This study used data from the National Hospital Ambulatory Medical Care Survey, an annual nationwide cross-sectional survey, to track trends in ED visits for suicide attempts and intentional self-harm in the United States from 2011 to 2020.
- Researchers identified visits for suicide attempts and intentional self-harm, along with diagnoses of any co-occurring mental health conditions, using discharge diagnosis codes or reason-for-visit codes.
- The focus was to identify the percentages of ED visits for suicide attempts and intentional self-harm, with analyses done per 100,000 persons and for changes possibly linked to the COVID-19 pandemic in 2019-2020.
TAKEAWAY:
- The number of ED visits owing to suicide attempts and intentional self-harm increased from 1.43 million in 2011-2012 to 5.37 million in 2019-2020 (average annual percent change, 19.5%; 95% confidence interval, 16.9-22.2).
- The rate of ED visits for suicide attempts and intentional self-harm was higher among adolescents and young adults, particularly women, and lower among children.
- Despite a surge in ED visits for self-harm, less than 16% included a mental health evaluation, with visits among patients with mood disorders decreasing by 5.5% annually and those among patients with drug-related disorders increasing by 6.8% annually.
- In 2019-2020, those aged 15-20 years had the highest rate of ED visits (1552 visits per 100,000 persons), with a significant increase seen across all age groups; the largest increase was among those aged 65 years or older.
IN PRACTICE:
“Given that suicide attempts are the single greatest risk factor for suicide, evidence-based management of individuals presenting to emergency departments with suicide attempts and intentional self-harm is a critical component of comprehensive suicide prevention strategies,” the authors wrote.
SOURCE:
The investigation, led by Tanner J. Bommersbach, MD, MPH, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, was published online in The American Journal of Psychiatry.
LIMITATIONS:
Visits for suicide attempts and intentional self-harm were identified based on discharge diagnostic and reason-for-visit codes, which may have led to an underestimation of visits for suicide attempts. ED visits for suicidal vs nonsuicidal self-injury could not be distinguished due to reliance on discharge diagnostic codes. Visits for suicidal ideation, which was not the focus of the study, may have been miscoded as suicide attempts and intentional self-harm.
DISCLOSURES:
No funding source was reported for the study. Some authors received funding grants from various institutions, and one author disclosed receiving honoraria for service as a review committee member and serving as a stakeholder/consultant and as an advisory committee member for some institutes and agencies.
A version of this article appeared on Medscape.com.
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All rights reserved. This material may not be published, broadcast, copied, or otherwise reproduced or distributed without the prior written permission of Frontline Medical Communications Inc.</copyrightNotice> </rightsInfo> </provider> <abstract/> <metaDescription>Emergency department (ED) visits in the United States for suicide attempts and intentional self-harm show an increasing trend from 2011 to 2020, with visits bei</metaDescription> <articlePDF/> <teaserImage/> <teaser>The number of ED visits owing to suicide attempts and intentional self-harm increased from 1.43 million in 2011-2012 to 5.37 million in 2019-2020.</teaser> <title>Emergency Department Visits for Suicide Attempts Rise Across the United States</title> <deck/> <disclaimer/> <AuthorList/> <articleURL/> <doi/> <pubMedID/> <publishXMLStatus/> <publishXMLVersion>1</publishXMLVersion> <useEISSN>0</useEISSN> <urgency/> <pubPubdateYear/> <pubPubdateMonth/> <pubPubdateDay/> <pubVolume/> <pubNumber/> <wireChannels/> <primaryCMSID/> <CMSIDs/> <keywords/> <seeAlsos/> <publications_g> <publicationData> <publicationCode>cpn</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> </publicationData> <publicationData> <publicationCode>fp</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> </publicationData> <publicationData> <publicationCode>im</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> </publicationData> <publicationData> <publicationCode>mdemed</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> <journalTitle/> <journalFullTitle/> <copyrightStatement/> </publicationData> <publicationData> <publicationCode>pn</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> </publicationData> </publications_g> <publications> <term canonical="true">9</term> <term>15</term> <term>21</term> <term>58877</term> <term>25</term> </publications> <sections> <term>27970</term> <term canonical="true">39313</term> </sections> <topics> <term canonical="true">61423</term> <term>248</term> </topics> <links/> </header> <itemSet> <newsItem> <itemMeta> <itemRole>Main</itemRole> <itemClass>text</itemClass> <title>Emergency Department Visits for Suicide Attempts Rise Across the United States</title> <deck/> </itemMeta> <itemContent> <h2>TOPLINE:</h2> <p>Emergency department (ED) visits in the United States for suicide attempts and intentional self-harm show an increasing trend from 2011 to 2020, with visits being most common among adolescents and the largest increase in visits being seen in adults aged 65 years or older.</p> <h2>METHODOLOGY:</h2> <ul class="body"> <li>This study used data from the National Hospital Ambulatory Medical Care Survey, an annual nationwide cross-sectional survey, to track trends in ED visits for suicide attempts and intentional self-harm in the United States from 2011 to 2020.</li> <li>Researchers identified visits for suicide attempts and intentional self-harm, along with diagnoses of any co-occurring mental health conditions, using discharge diagnosis codes or reason-for-visit codes.</li> <li>The focus was to identify the percentages of ED visits for suicide attempts and intentional self-harm, with analyses done per 100,000 persons and for changes possibly linked to the COVID-19 pandemic in 2019-2020.</li> </ul> <h2>TAKEAWAY:</h2> <ul class="body"> <li>The number of ED visits owing to suicide attempts and intentional self-harm increased from 1.43 million in 2011-2012 to 5.37 million in 2019-2020 (average annual percent change, 19.5%; 95% confidence interval, 16.9-22.2).</li> <li>The rate of ED visits for suicide attempts and intentional self-harm was higher among adolescents and young adults, particularly women, and lower among children.</li> <li>Despite a surge in ED visits for self-harm, less than 16% included a mental health evaluation, with visits among patients with mood disorders decreasing by 5.5% annually and those among patients with drug-related disorders increasing by 6.8% annually.</li> <li>In 2019-2020, those aged 15-20 years had the highest rate of ED visits (1552 visits per 100,000 persons), with a significant increase seen across all age groups; the largest increase was among those aged 65 years or older.</li> </ul> <h2>IN PRACTICE:</h2> <p>“Given that suicide attempts are the single greatest risk factor for suicide, evidence-based management of individuals presenting to emergency departments with suicide attempts and intentional self-harm is a critical component of comprehensive suicide prevention strategies,” the authors wrote.</p> <h2>SOURCE:</h2> <p>The investigation, led by Tanner J. Bommersbach, MD, MPH, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, was <a href="https://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.20230397">published online</a> in <em>The American Journal of Psychiatry</em>.</p> <h2>LIMITATIONS:</h2> <p>Visits for suicide attempts and intentional self-harm were identified based on discharge diagnostic and reason-for-visit codes, which may have led to an underestimation of visits for suicide attempts. ED visits for suicidal vs nonsuicidal self-injury could not be distinguished due to reliance on discharge diagnostic codes. Visits for suicidal ideation, which was not the focus of the study, may have been miscoded as suicide attempts and intentional self-harm.</p> <h2>DISCLOSURES:</h2> <p>No funding source was reported for the study. Some authors received funding grants from various institutions, and one author disclosed receiving honoraria for service as a review committee member and serving as a stakeholder/consultant and as an advisory committee member for some institutes and agencies.<span class="end"/></p> <p> <em>A version of this article appeared on <span class="Hyperlink"><a href="https://www.medscape.com/viewarticle/emergency-department-visits-suicide-attempts-rise-across-2024a1000b26">Medscape.com</a></span>.</em> </p> </itemContent> </newsItem> <newsItem> <itemMeta> <itemRole>teaser</itemRole> <itemClass>text</itemClass> <title/> <deck/> </itemMeta> <itemContent> </itemContent> </newsItem> </itemSet></root>
Sharp Rise in US Pediatric ADHD Diagnoses
TOPLINE:
METHODOLOGY:
- Researchers used 2022 data from the National Survey of Children’s Health to estimate the prevalence of ever-diagnosed and current ADHD among US children between the ages of 3 and 18 years.
- They also estimated, among children with current ADHD, the severity of the condition and the presence of current co-occurring disorders and the receipt of medication and behavioral treatments.
- The researchers calculated overall weighted estimates as well as estimates for specific demographic and clinical subgroups (n = 45,169).
TAKEAWAY:
- The number of children who had ever received an ADHD diagnosis increased from 6.1 million in 2016 to 7.1 million in 2022, and the number with current ADHD increased from 5.4 million to 6.5 million.
- Of those with current ADHD in 2022, 58.1% had moderate or severe ADHD, and 77.9% had at least one co-occurring disorder.
- A total of 53.6% had received ADHD medication, 44.4% had received behavioral treatment in the past year, and 30.1% had received no ADHD-specific treatment.
- A similar percentage of children with ADHD were receiving behavioral treatment in 2022 as in 2016 (44.4% vs 46.7%, respectively), but treatment with ADHD medication was lower in 2022 than in 2016 (53.6% vs 62.0%, respectively).
IN PRACTICE:
The estimates “can be used by clinicians to understand current ADHD diagnosis and treatment utilization patterns to inform clinical practice, such as accounting for the frequency and management of co-occurring conditions and considering the notable percentage of children with ADHD not currently receiving ADHD treatment,” and can be used by policymakers, practitioners, and others “to plan for the needs of children with ADHD, such as by ensuring access to care and services for ADHD,” investigators wrote.
SOURCE:
Melissa L. Danielson, of the National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, led the study, which was published online in the Journal of Clinical Child & Adolescent Psychology.
LIMITATIONS:
Indicators reported in the analysis were on the basis of the parent report, which may be limited by recall and reporting decisions and were not validated against medical records or clinical judgment. Moreover, details about the types of treatment were not included.
DISCLOSURES:
The work was authorized as part of the contributor’s official duties as an employee of the US Government, and therefore is a work of the US Government. The authors declared no relevant financial relationships.
A version of this article appeared on Medscape.com.
TOPLINE:
METHODOLOGY:
- Researchers used 2022 data from the National Survey of Children’s Health to estimate the prevalence of ever-diagnosed and current ADHD among US children between the ages of 3 and 18 years.
- They also estimated, among children with current ADHD, the severity of the condition and the presence of current co-occurring disorders and the receipt of medication and behavioral treatments.
- The researchers calculated overall weighted estimates as well as estimates for specific demographic and clinical subgroups (n = 45,169).
TAKEAWAY:
- The number of children who had ever received an ADHD diagnosis increased from 6.1 million in 2016 to 7.1 million in 2022, and the number with current ADHD increased from 5.4 million to 6.5 million.
- Of those with current ADHD in 2022, 58.1% had moderate or severe ADHD, and 77.9% had at least one co-occurring disorder.
- A total of 53.6% had received ADHD medication, 44.4% had received behavioral treatment in the past year, and 30.1% had received no ADHD-specific treatment.
- A similar percentage of children with ADHD were receiving behavioral treatment in 2022 as in 2016 (44.4% vs 46.7%, respectively), but treatment with ADHD medication was lower in 2022 than in 2016 (53.6% vs 62.0%, respectively).
IN PRACTICE:
The estimates “can be used by clinicians to understand current ADHD diagnosis and treatment utilization patterns to inform clinical practice, such as accounting for the frequency and management of co-occurring conditions and considering the notable percentage of children with ADHD not currently receiving ADHD treatment,” and can be used by policymakers, practitioners, and others “to plan for the needs of children with ADHD, such as by ensuring access to care and services for ADHD,” investigators wrote.
SOURCE:
Melissa L. Danielson, of the National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, led the study, which was published online in the Journal of Clinical Child & Adolescent Psychology.
LIMITATIONS:
Indicators reported in the analysis were on the basis of the parent report, which may be limited by recall and reporting decisions and were not validated against medical records or clinical judgment. Moreover, details about the types of treatment were not included.
DISCLOSURES:
The work was authorized as part of the contributor’s official duties as an employee of the US Government, and therefore is a work of the US Government. The authors declared no relevant financial relationships.
A version of this article appeared on Medscape.com.
TOPLINE:
METHODOLOGY:
- Researchers used 2022 data from the National Survey of Children’s Health to estimate the prevalence of ever-diagnosed and current ADHD among US children between the ages of 3 and 18 years.
- They also estimated, among children with current ADHD, the severity of the condition and the presence of current co-occurring disorders and the receipt of medication and behavioral treatments.
- The researchers calculated overall weighted estimates as well as estimates for specific demographic and clinical subgroups (n = 45,169).
TAKEAWAY:
- The number of children who had ever received an ADHD diagnosis increased from 6.1 million in 2016 to 7.1 million in 2022, and the number with current ADHD increased from 5.4 million to 6.5 million.
- Of those with current ADHD in 2022, 58.1% had moderate or severe ADHD, and 77.9% had at least one co-occurring disorder.
- A total of 53.6% had received ADHD medication, 44.4% had received behavioral treatment in the past year, and 30.1% had received no ADHD-specific treatment.
- A similar percentage of children with ADHD were receiving behavioral treatment in 2022 as in 2016 (44.4% vs 46.7%, respectively), but treatment with ADHD medication was lower in 2022 than in 2016 (53.6% vs 62.0%, respectively).
IN PRACTICE:
The estimates “can be used by clinicians to understand current ADHD diagnosis and treatment utilization patterns to inform clinical practice, such as accounting for the frequency and management of co-occurring conditions and considering the notable percentage of children with ADHD not currently receiving ADHD treatment,” and can be used by policymakers, practitioners, and others “to plan for the needs of children with ADHD, such as by ensuring access to care and services for ADHD,” investigators wrote.
SOURCE:
Melissa L. Danielson, of the National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, led the study, which was published online in the Journal of Clinical Child & Adolescent Psychology.
LIMITATIONS:
Indicators reported in the analysis were on the basis of the parent report, which may be limited by recall and reporting decisions and were not validated against medical records or clinical judgment. Moreover, details about the types of treatment were not included.
DISCLOSURES:
The work was authorized as part of the contributor’s official duties as an employee of the US Government, and therefore is a work of the US Government. The authors declared no relevant financial relationships.
A version of this article appeared on Medscape.com.
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All rights reserved. This material may not be published, broadcast, copied, or otherwise reproduced or distributed without the prior written permission of Frontline Medical Communications Inc.</copyrightNotice> </rightsInfo> </provider> <abstract/> <metaDescription>A new analysis of a national dataset of children in the United States shows that there were roughly one million more children with attention-deficit/hyperactivi</metaDescription> <articlePDF/> <teaserImage/> <teaser>The prevalence estimates can be used by clinicians, policymakers, and others “to plan for the needs of children with ADHD, such as by ensuring access to care and services for ADHD.”</teaser> <title>Sharp Rise in US Pediatric ADHD Diagnoses</title> <deck/> <disclaimer/> <AuthorList/> <articleURL/> <doi/> <pubMedID/> <publishXMLStatus/> <publishXMLVersion>1</publishXMLVersion> <useEISSN>0</useEISSN> <urgency/> <pubPubdateYear>2024</pubPubdateYear> <pubPubdateMonth/> <pubPubdateDay/> <pubVolume/> <pubNumber/> <wireChannels/> <primaryCMSID/> <CMSIDs/> <keywords/> <seeAlsos/> <publications_g> <publicationData> <publicationCode>CPN</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> <journalTitle/> <journalFullTitle/> <copyrightStatement/> </publicationData> <publicationData> <publicationCode>FP</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> <journalTitle/> <journalFullTitle/> <copyrightStatement>Copyright 2017 Frontline Medical News</copyrightStatement> </publicationData> <publicationData> <publicationCode>PN</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> <journalTitle/> <journalFullTitle/> <copyrightStatement/> </publicationData> </publications_g> <publications> <term>9</term> <term>15</term> <term canonical="true">25</term> </publications> <sections> <term>39313</term> <term canonical="true">27970</term> </sections> <topics> <term>248</term> <term>271</term> <term canonical="true">175</term> </topics> <links/> </header> <itemSet> <newsItem> <itemMeta> <itemRole>Main</itemRole> <itemClass>text</itemClass> <title>Sharp Rise in US Pediatric ADHD Diagnoses</title> <deck/> </itemMeta> <itemContent> <h2>TOPLINE:</h2> <p> <span class="tag metaDescription">A new analysis of a national dataset of children in the United States shows that there were roughly one million more children with attention-deficit/hyperactivity disorder (ADHD) in 2022 than in 2016.</span> </p> <h2>METHODOLOGY:</h2> <ul class="body"> <li>Researchers used 2022 data from the National Survey of Children’s Health to estimate the prevalence of ever-diagnosed and current ADHD among US children between the ages of 3 and 18 years.</li> <li>They also estimated, among children with current ADHD, the severity of the condition and the presence of current co-occurring disorders and the receipt of medication and behavioral treatments.</li> <li>The researchers calculated overall weighted estimates as well as estimates for specific demographic and clinical subgroups (n = 45,169).</li> </ul> <h2>TAKEAWAY:</h2> <ul class="body"> <li>The number of children who had ever received an ADHD diagnosis increased from 6.1 million in 2016 to 7.1 million in 2022, and the number with current ADHD increased from 5.4 million to 6.5 million.</li> <li>Of those with current ADHD in 2022, 58.1% had moderate or severe ADHD, and 77.9% had at least one co-occurring disorder.</li> <li>A total of 53.6% had received ADHD medication, 44.4% had received behavioral treatment in the past year, and 30.1% had received no ADHD-specific treatment.</li> <li>A similar percentage of children with ADHD were receiving behavioral treatment in 2022 as in 2016 (44.4% vs 46.7%, respectively), but treatment with ADHD medication was lower in 2022 than in 2016 (53.6% vs 62.0%, respectively).</li> </ul> <h2>IN PRACTICE:</h2> <p>The estimates “can be used by clinicians to understand current ADHD diagnosis and treatment utilization patterns to inform clinical practice, such as accounting for the frequency and management of co-occurring conditions and considering the notable percentage of children with ADHD not currently receiving ADHD treatment,” and can be used by policymakers, practitioners, and others “to plan for the needs of children with ADHD, such as by ensuring access to care and services for ADHD,” investigators wrote.</p> <h2>SOURCE:</h2> <p>Melissa L. Danielson, of the National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, led the study, which was <a href="https://www.tandfonline.com/doi/full/10.1080/15374416.2024.2335625">published online</a> in the <em>Journal of Clinical Child & Adolescent Psychology</em>.</p> <h2>LIMITATIONS:</h2> <p>Indicators reported in the analysis were on the basis of the parent report, which may be limited by recall and reporting decisions and were not validated against medical records or clinical judgment. Moreover, details about the types of treatment were not included.</p> <h2>DISCLOSURES:</h2> <p>The work was authorized as part of the contributor’s official duties as an employee of the US Government, and therefore is a work of the US Government. The authors declared no relevant financial relationships.</p> <p> <em>A version of this article appeared on <span class="Hyperlink"><a href="https://www.medscape.com/viewarticle/sharp-rise-us-pediatric-adhd-diagnoses-2024a1000b1o">Medscape.com</a></span>.</em> </p> </itemContent> </newsItem> <newsItem> <itemMeta> <itemRole>teaser</itemRole> <itemClass>text</itemClass> <title/> <deck/> </itemMeta> <itemContent> </itemContent> </newsItem> </itemSet></root>
The Effects of Immigration on the Parent-Child Relationship
In their native country, they learned throughout their life cultural norms and systems that defined their environment. When these parents immigrate to a new country, their different set of knowledge may not be applicable in many ways to their new environment.
The Disruption of Social Roles
Culturally, language is one of the most important types of knowledge parents pass to their children. Nearly half of adult immigrants in the United States have limited English proficiency. 1
Their children often learn the language faster, often placing these children in the position of interpreters for their parents. These parents can become dependent on their children to negotiate social structures instead of vice versa, potentially undermining the social hierarchy and role of parenting. 2 Both Mr. Contreras and Dr. Nguyen recall that as children of immigrant parents — from Mexico and Vietnam, respectively — they commanded English better than their parents, which often made them take on more “adult roles.” For example, Dr. Nguyen recalls that his mother would solicit his help in grocery shopping because she could neither navigate the aisles effectively nor ask for help. Mr. Contreras commonly found himself acting as an impromptu medical translator for his mother on several occasions. This dependence of immigrant parents on their children for guidance in their host country can be pervasive in other social structures such as legal and academic.
Impact on School
Potentially, an immigrant parent’s lack of knowledge of the language and systems of their host country can make them ineffective advocates for their children at school. Mr. Contreras’s intervention for his patient as a medical student demonstrates this in the arena of school.
Mr. Contreras was rotating at a hospital burn unit in 2023 when R, a young middle school student, and his mother arrived in the emergency department. An incident had occurred at his school. R had been the victim of aggravated battery and assault, sustaining a 3x2 cm burn on his forearm from students placing hot glue onto a piece of cardboard then immediately onto his skin and silencing him by covering his mouth. For months the older students had been bullying R. R’s mother made multiple attempts with both the school’s front desk and counselors to address the issue, but to no avail. R himself, though encouraged to speak up, did not out of fear. As Mr. Contreras realized the situation and the impasse, he used his fluency in Spanish and English to facilitate a joint call with the school district. Within 10 minutes, they were able to connect with a student safety specialist and launch a full investigation. A language barrier and the lack of knowledge of their rights and school system had prevented R’s mother from effectively advocating for her child’s safety.
In Dr. Nguyen’s experience as a teacher, even in classrooms dominated by minority students, the advocacy for students struggling in classes was disproportionate. It favored White parents, but also generally more educated families. This is further supported by a study of 225 schools across six states of kindergarten children showing similar trends, that African American, Latino, and less-educated parents were less involved in their children’s education as reported by teachers.3 It is important to note that in this study teachers were 80% White, 9% Latino, 7% African American, 3% multiracial, and 1% Asian American, suggesting that cultural discrepancy between teachers and parents could be an important factor affecting parent-teacher communication. Dr. Nguyen also recalled trying to discipline several students who were disruptive in his class by telling them he would speak to their parents. Several times, these students would counter defiantly, “Well, good luck, they can’t speak English.” The parents’ dependency on their children to communicate with teachers undermined the abilities of both adults to manage their behaviors and promote learning.
The Mental Health of Immigrant Parents
Migrants often have greater incidence of mental health problems, including depression, PTSD, and anxiety, from a combination of peri-migrational experiences. 4 Immigrant mothers are known to have higher rates of post-natal depression, which cause problems later with child development. 5 Though she warns larger studies are needed, Dr. Fazel’s review of Croatian refugees suggests that displacement from one’s native country is a risk factor for poorer mental health, namely due to difficulty in psychosocial adaptation. 6 The likely mechanism is that lack of access to one’s language and culture, or a language and culture that one can navigate effectively, exacerbates, even engenders mental health sequelae. Because of this, first-generation immigrant children often face harsher and more violent parenting. 7,8 Immigrant parents also may have less access to mental health resources since they often resort to their own cultural practices. Both Mr. Contreras’s and Dr. Nguyen’s following narratives of their mothers’ struggle with mental health illustrate the causes and consequences.
Mr. Contreras, who grew up in a Mexican immigrant household in Los Angeles, saw firsthand how his mother, who faced language barriers and a distrust of Western medicine, turned to traditional healers and herbal remedies for her health needs. Accompanying her to doctor appointments as her translator, he often felt the disconnect between her cultural background and the Western medical system. For her, seeking help from traditional healers was not just about addressing physical ailments but also about finding comfort and familiarity in practices rooted in her cultural beliefs. This preference for cultural or religious methods for mental health support is not uncommon among Mexican immigrant families.
Dr. Nguyen, whose mother was a refugee from Vietnam, recalls her constant depressed mood and suicidal thoughts in the immediate years after she resettled in San Diego. This was caused mostly by the missing of her social supports in Vietnam, her difficulty adjusting to American culture and language, and her difficulty finding work. Often her depression and stress took a darker turn in terms of more violent parenting. Of course, the cause of her poor mental health is hard to parse from the traumas and violence she had faced as a refugee, but in subsequent years, her many brothers and sisters who immigrated through a more orderly process also displayed similar mental health vulnerabilities.
The Mental Health of Children of Immigrant Parents
The relationship between an immigrant parent’s poor mental health and their children is difficult to parse from what we know about native parents and their children. But the primary differences appear to be a great disruption of social roles, the effects of migration itself, and the oftentimes more strict and disciplinarian parenting style as discussed above. Given this, one would expect immigrant children to suffer greater mental health difficulties. However, a recent study of almost 500,000 children in Canada revealed decreased prevalence of conduct disorder, ADHD, and mood and anxiety disorders in immigrant youth, both first- and second-generation, as compared to non-immigrants. 9 This perhaps surprising result highlights how much more we need to understand about the effects of culture on the mental health diagnosis of immigrant youth. It suggests differences in mental health access and use from the cultural factors we mentioned above, to problems with using Western-based mental criteria and symptomatology for diagnosing non-Western children. It can even suggest the underestimation of the protective effects of native culture such as strong ethnic identity and cultural support systems, thereby challenging a purely deficit mental health model of the immigrant experience.
Summary
Dr. Duy Nguyen and Mr. Andrew Contreras are both children of immigrant parents from Vietnam and Mexico, respectively. Dr. Nguyen spent 15 years as an English teacher at San Leandro High School, whose student body was roughly 50% Hispanic and 25% Asian, making immigrant parents a huge swath of his educational partners. Mr. Contreras founded a high school outreach program where he interacted with K-12 children of immigrant youth. In addition, he partners with Fresno’s Economic Opportunity Commission to educate immigrant Hispanic parents and their teens on having difficult conversations with their teenage children on topics such as mental and reproductive health. Dr. Duy Nguyen and Mr. Andrew Contreras will explore the differences in immigrant parent-child relationships, compared with native ones, as they relate to mental health ramifications for the child and parent. They reveal immigrant mental health disruptions regarding culture and language, familial hierarchies, parenting styles, as well as parental mental health sequelae brought about by immigration using research and their own personal experiences.
Dr. Nguyen is a second-year resident at the University of California, San Francisco, Fresno Psychiatry Residency. He was a public high school English teacher for 15 years previously. Mr. Contreras is currently a 4th-year medical student at University of California, San Francisco, and applying to Psychiatry for the 2025 match.
References
1. Rao A et al. Five Key Facts About Immigrants With Limited English Proficiency. KFF. 2024 March 14. https://www.kff.org/racial-equity-and-health-policy/issue-brief-five-key-facts-about-immigrants-with-limited-english-proficiency .
2. Raffaetà R. Migration and Parenting: Reviewing the Debate and Calling for Future Research. International Journal of Migration, Health and Social Care. 2016;12(1):38-50. doi: 10.1108/IJMHSC-12-2014-0052/full/html .
3. Nzinga‐Johnson S et al. Teacher‐Parent Relationships and School Involvement Among Racially and Educationally Diverse Parents of Kindergartners. Elementary School Journal. 2009 Sept. doi: 10.1086/598844 .
4. Close C et al. The Mental Health and Wellbeing of First Generation Migrants: A Systematic-Narrative Review of Reviews. Global Health. 2016 Aug 25;12(1):47. doi: 10.1186/s12992-016-0187-3.
5. Collins CH et al. Refugee, Asylum Seeker, Immigrant Women and Postnatal Depression: Rates and Risk Factors. Arch Womens Ment Health. 2011 Feb;14(1):3-11. doi: 10.1007/s00737-010-0198-7 .
6. Fazel M, Betancourt TS. Preventive Mental Health Interventions for Refugee Children and Adolescents in High-Income Settings. Lancet Child Adolesc Health. 2018 Feb;2(2):121-132. doi: 10.1016/S2352-4642(17)30147-5 .
7. Pottie K et al. Do First Generation Immigrant Adolescents Face Higher Rates of Bullying, Violence and Suicidal Behaviours Than Do Third Generation and Native Born? J Immigr Minor Health. 2015 Oct;17(5):1557-1566. doi: 10.1007/s10903-014-0108-6.
8. Smokowski PR, Bacallao ML. Acculturation and Aggression in Latino Adolescents: A Structural Model Focusing on Cultural Risk Factors and Assets. J Abnorm Child Psychol. 2006 Oct;34(5):659-673. doi: 10.1007/s10802-006-9049-4 .
9. Gadermann AM et al. Prevalence of Mental Health Disorders Among Immigrant, Refugee, and Nonimmigrant Children and Youth in British Columbia, Canada. JAMA Netw Open. 2022;5(2):e2144934. doi: 10.1001/jamanetworkopen.2021.44934 .
In their native country, they learned throughout their life cultural norms and systems that defined their environment. When these parents immigrate to a new country, their different set of knowledge may not be applicable in many ways to their new environment.
The Disruption of Social Roles
Culturally, language is one of the most important types of knowledge parents pass to their children. Nearly half of adult immigrants in the United States have limited English proficiency. 1
Their children often learn the language faster, often placing these children in the position of interpreters for their parents. These parents can become dependent on their children to negotiate social structures instead of vice versa, potentially undermining the social hierarchy and role of parenting. 2 Both Mr. Contreras and Dr. Nguyen recall that as children of immigrant parents — from Mexico and Vietnam, respectively — they commanded English better than their parents, which often made them take on more “adult roles.” For example, Dr. Nguyen recalls that his mother would solicit his help in grocery shopping because she could neither navigate the aisles effectively nor ask for help. Mr. Contreras commonly found himself acting as an impromptu medical translator for his mother on several occasions. This dependence of immigrant parents on their children for guidance in their host country can be pervasive in other social structures such as legal and academic.
Impact on School
Potentially, an immigrant parent’s lack of knowledge of the language and systems of their host country can make them ineffective advocates for their children at school. Mr. Contreras’s intervention for his patient as a medical student demonstrates this in the arena of school.
Mr. Contreras was rotating at a hospital burn unit in 2023 when R, a young middle school student, and his mother arrived in the emergency department. An incident had occurred at his school. R had been the victim of aggravated battery and assault, sustaining a 3x2 cm burn on his forearm from students placing hot glue onto a piece of cardboard then immediately onto his skin and silencing him by covering his mouth. For months the older students had been bullying R. R’s mother made multiple attempts with both the school’s front desk and counselors to address the issue, but to no avail. R himself, though encouraged to speak up, did not out of fear. As Mr. Contreras realized the situation and the impasse, he used his fluency in Spanish and English to facilitate a joint call with the school district. Within 10 minutes, they were able to connect with a student safety specialist and launch a full investigation. A language barrier and the lack of knowledge of their rights and school system had prevented R’s mother from effectively advocating for her child’s safety.
In Dr. Nguyen’s experience as a teacher, even in classrooms dominated by minority students, the advocacy for students struggling in classes was disproportionate. It favored White parents, but also generally more educated families. This is further supported by a study of 225 schools across six states of kindergarten children showing similar trends, that African American, Latino, and less-educated parents were less involved in their children’s education as reported by teachers.3 It is important to note that in this study teachers were 80% White, 9% Latino, 7% African American, 3% multiracial, and 1% Asian American, suggesting that cultural discrepancy between teachers and parents could be an important factor affecting parent-teacher communication. Dr. Nguyen also recalled trying to discipline several students who were disruptive in his class by telling them he would speak to their parents. Several times, these students would counter defiantly, “Well, good luck, they can’t speak English.” The parents’ dependency on their children to communicate with teachers undermined the abilities of both adults to manage their behaviors and promote learning.
The Mental Health of Immigrant Parents
Migrants often have greater incidence of mental health problems, including depression, PTSD, and anxiety, from a combination of peri-migrational experiences. 4 Immigrant mothers are known to have higher rates of post-natal depression, which cause problems later with child development. 5 Though she warns larger studies are needed, Dr. Fazel’s review of Croatian refugees suggests that displacement from one’s native country is a risk factor for poorer mental health, namely due to difficulty in psychosocial adaptation. 6 The likely mechanism is that lack of access to one’s language and culture, or a language and culture that one can navigate effectively, exacerbates, even engenders mental health sequelae. Because of this, first-generation immigrant children often face harsher and more violent parenting. 7,8 Immigrant parents also may have less access to mental health resources since they often resort to their own cultural practices. Both Mr. Contreras’s and Dr. Nguyen’s following narratives of their mothers’ struggle with mental health illustrate the causes and consequences.
Mr. Contreras, who grew up in a Mexican immigrant household in Los Angeles, saw firsthand how his mother, who faced language barriers and a distrust of Western medicine, turned to traditional healers and herbal remedies for her health needs. Accompanying her to doctor appointments as her translator, he often felt the disconnect between her cultural background and the Western medical system. For her, seeking help from traditional healers was not just about addressing physical ailments but also about finding comfort and familiarity in practices rooted in her cultural beliefs. This preference for cultural or religious methods for mental health support is not uncommon among Mexican immigrant families.
Dr. Nguyen, whose mother was a refugee from Vietnam, recalls her constant depressed mood and suicidal thoughts in the immediate years after she resettled in San Diego. This was caused mostly by the missing of her social supports in Vietnam, her difficulty adjusting to American culture and language, and her difficulty finding work. Often her depression and stress took a darker turn in terms of more violent parenting. Of course, the cause of her poor mental health is hard to parse from the traumas and violence she had faced as a refugee, but in subsequent years, her many brothers and sisters who immigrated through a more orderly process also displayed similar mental health vulnerabilities.
The Mental Health of Children of Immigrant Parents
The relationship between an immigrant parent’s poor mental health and their children is difficult to parse from what we know about native parents and their children. But the primary differences appear to be a great disruption of social roles, the effects of migration itself, and the oftentimes more strict and disciplinarian parenting style as discussed above. Given this, one would expect immigrant children to suffer greater mental health difficulties. However, a recent study of almost 500,000 children in Canada revealed decreased prevalence of conduct disorder, ADHD, and mood and anxiety disorders in immigrant youth, both first- and second-generation, as compared to non-immigrants. 9 This perhaps surprising result highlights how much more we need to understand about the effects of culture on the mental health diagnosis of immigrant youth. It suggests differences in mental health access and use from the cultural factors we mentioned above, to problems with using Western-based mental criteria and symptomatology for diagnosing non-Western children. It can even suggest the underestimation of the protective effects of native culture such as strong ethnic identity and cultural support systems, thereby challenging a purely deficit mental health model of the immigrant experience.
Summary
Dr. Duy Nguyen and Mr. Andrew Contreras are both children of immigrant parents from Vietnam and Mexico, respectively. Dr. Nguyen spent 15 years as an English teacher at San Leandro High School, whose student body was roughly 50% Hispanic and 25% Asian, making immigrant parents a huge swath of his educational partners. Mr. Contreras founded a high school outreach program where he interacted with K-12 children of immigrant youth. In addition, he partners with Fresno’s Economic Opportunity Commission to educate immigrant Hispanic parents and their teens on having difficult conversations with their teenage children on topics such as mental and reproductive health. Dr. Duy Nguyen and Mr. Andrew Contreras will explore the differences in immigrant parent-child relationships, compared with native ones, as they relate to mental health ramifications for the child and parent. They reveal immigrant mental health disruptions regarding culture and language, familial hierarchies, parenting styles, as well as parental mental health sequelae brought about by immigration using research and their own personal experiences.
Dr. Nguyen is a second-year resident at the University of California, San Francisco, Fresno Psychiatry Residency. He was a public high school English teacher for 15 years previously. Mr. Contreras is currently a 4th-year medical student at University of California, San Francisco, and applying to Psychiatry for the 2025 match.
References
1. Rao A et al. Five Key Facts About Immigrants With Limited English Proficiency. KFF. 2024 March 14. https://www.kff.org/racial-equity-and-health-policy/issue-brief-five-key-facts-about-immigrants-with-limited-english-proficiency .
2. Raffaetà R. Migration and Parenting: Reviewing the Debate and Calling for Future Research. International Journal of Migration, Health and Social Care. 2016;12(1):38-50. doi: 10.1108/IJMHSC-12-2014-0052/full/html .
3. Nzinga‐Johnson S et al. Teacher‐Parent Relationships and School Involvement Among Racially and Educationally Diverse Parents of Kindergartners. Elementary School Journal. 2009 Sept. doi: 10.1086/598844 .
4. Close C et al. The Mental Health and Wellbeing of First Generation Migrants: A Systematic-Narrative Review of Reviews. Global Health. 2016 Aug 25;12(1):47. doi: 10.1186/s12992-016-0187-3.
5. Collins CH et al. Refugee, Asylum Seeker, Immigrant Women and Postnatal Depression: Rates and Risk Factors. Arch Womens Ment Health. 2011 Feb;14(1):3-11. doi: 10.1007/s00737-010-0198-7 .
6. Fazel M, Betancourt TS. Preventive Mental Health Interventions for Refugee Children and Adolescents in High-Income Settings. Lancet Child Adolesc Health. 2018 Feb;2(2):121-132. doi: 10.1016/S2352-4642(17)30147-5 .
7. Pottie K et al. Do First Generation Immigrant Adolescents Face Higher Rates of Bullying, Violence and Suicidal Behaviours Than Do Third Generation and Native Born? J Immigr Minor Health. 2015 Oct;17(5):1557-1566. doi: 10.1007/s10903-014-0108-6.
8. Smokowski PR, Bacallao ML. Acculturation and Aggression in Latino Adolescents: A Structural Model Focusing on Cultural Risk Factors and Assets. J Abnorm Child Psychol. 2006 Oct;34(5):659-673. doi: 10.1007/s10802-006-9049-4 .
9. Gadermann AM et al. Prevalence of Mental Health Disorders Among Immigrant, Refugee, and Nonimmigrant Children and Youth in British Columbia, Canada. JAMA Netw Open. 2022;5(2):e2144934. doi: 10.1001/jamanetworkopen.2021.44934 .
In their native country, they learned throughout their life cultural norms and systems that defined their environment. When these parents immigrate to a new country, their different set of knowledge may not be applicable in many ways to their new environment.
The Disruption of Social Roles
Culturally, language is one of the most important types of knowledge parents pass to their children. Nearly half of adult immigrants in the United States have limited English proficiency. 1
Their children often learn the language faster, often placing these children in the position of interpreters for their parents. These parents can become dependent on their children to negotiate social structures instead of vice versa, potentially undermining the social hierarchy and role of parenting. 2 Both Mr. Contreras and Dr. Nguyen recall that as children of immigrant parents — from Mexico and Vietnam, respectively — they commanded English better than their parents, which often made them take on more “adult roles.” For example, Dr. Nguyen recalls that his mother would solicit his help in grocery shopping because she could neither navigate the aisles effectively nor ask for help. Mr. Contreras commonly found himself acting as an impromptu medical translator for his mother on several occasions. This dependence of immigrant parents on their children for guidance in their host country can be pervasive in other social structures such as legal and academic.
Impact on School
Potentially, an immigrant parent’s lack of knowledge of the language and systems of their host country can make them ineffective advocates for their children at school. Mr. Contreras’s intervention for his patient as a medical student demonstrates this in the arena of school.
Mr. Contreras was rotating at a hospital burn unit in 2023 when R, a young middle school student, and his mother arrived in the emergency department. An incident had occurred at his school. R had been the victim of aggravated battery and assault, sustaining a 3x2 cm burn on his forearm from students placing hot glue onto a piece of cardboard then immediately onto his skin and silencing him by covering his mouth. For months the older students had been bullying R. R’s mother made multiple attempts with both the school’s front desk and counselors to address the issue, but to no avail. R himself, though encouraged to speak up, did not out of fear. As Mr. Contreras realized the situation and the impasse, he used his fluency in Spanish and English to facilitate a joint call with the school district. Within 10 minutes, they were able to connect with a student safety specialist and launch a full investigation. A language barrier and the lack of knowledge of their rights and school system had prevented R’s mother from effectively advocating for her child’s safety.
In Dr. Nguyen’s experience as a teacher, even in classrooms dominated by minority students, the advocacy for students struggling in classes was disproportionate. It favored White parents, but also generally more educated families. This is further supported by a study of 225 schools across six states of kindergarten children showing similar trends, that African American, Latino, and less-educated parents were less involved in their children’s education as reported by teachers.3 It is important to note that in this study teachers were 80% White, 9% Latino, 7% African American, 3% multiracial, and 1% Asian American, suggesting that cultural discrepancy between teachers and parents could be an important factor affecting parent-teacher communication. Dr. Nguyen also recalled trying to discipline several students who were disruptive in his class by telling them he would speak to their parents. Several times, these students would counter defiantly, “Well, good luck, they can’t speak English.” The parents’ dependency on their children to communicate with teachers undermined the abilities of both adults to manage their behaviors and promote learning.
The Mental Health of Immigrant Parents
Migrants often have greater incidence of mental health problems, including depression, PTSD, and anxiety, from a combination of peri-migrational experiences. 4 Immigrant mothers are known to have higher rates of post-natal depression, which cause problems later with child development. 5 Though she warns larger studies are needed, Dr. Fazel’s review of Croatian refugees suggests that displacement from one’s native country is a risk factor for poorer mental health, namely due to difficulty in psychosocial adaptation. 6 The likely mechanism is that lack of access to one’s language and culture, or a language and culture that one can navigate effectively, exacerbates, even engenders mental health sequelae. Because of this, first-generation immigrant children often face harsher and more violent parenting. 7,8 Immigrant parents also may have less access to mental health resources since they often resort to their own cultural practices. Both Mr. Contreras’s and Dr. Nguyen’s following narratives of their mothers’ struggle with mental health illustrate the causes and consequences.
Mr. Contreras, who grew up in a Mexican immigrant household in Los Angeles, saw firsthand how his mother, who faced language barriers and a distrust of Western medicine, turned to traditional healers and herbal remedies for her health needs. Accompanying her to doctor appointments as her translator, he often felt the disconnect between her cultural background and the Western medical system. For her, seeking help from traditional healers was not just about addressing physical ailments but also about finding comfort and familiarity in practices rooted in her cultural beliefs. This preference for cultural or religious methods for mental health support is not uncommon among Mexican immigrant families.
Dr. Nguyen, whose mother was a refugee from Vietnam, recalls her constant depressed mood and suicidal thoughts in the immediate years after she resettled in San Diego. This was caused mostly by the missing of her social supports in Vietnam, her difficulty adjusting to American culture and language, and her difficulty finding work. Often her depression and stress took a darker turn in terms of more violent parenting. Of course, the cause of her poor mental health is hard to parse from the traumas and violence she had faced as a refugee, but in subsequent years, her many brothers and sisters who immigrated through a more orderly process also displayed similar mental health vulnerabilities.
The Mental Health of Children of Immigrant Parents
The relationship between an immigrant parent’s poor mental health and their children is difficult to parse from what we know about native parents and their children. But the primary differences appear to be a great disruption of social roles, the effects of migration itself, and the oftentimes more strict and disciplinarian parenting style as discussed above. Given this, one would expect immigrant children to suffer greater mental health difficulties. However, a recent study of almost 500,000 children in Canada revealed decreased prevalence of conduct disorder, ADHD, and mood and anxiety disorders in immigrant youth, both first- and second-generation, as compared to non-immigrants. 9 This perhaps surprising result highlights how much more we need to understand about the effects of culture on the mental health diagnosis of immigrant youth. It suggests differences in mental health access and use from the cultural factors we mentioned above, to problems with using Western-based mental criteria and symptomatology for diagnosing non-Western children. It can even suggest the underestimation of the protective effects of native culture such as strong ethnic identity and cultural support systems, thereby challenging a purely deficit mental health model of the immigrant experience.
Summary
Dr. Duy Nguyen and Mr. Andrew Contreras are both children of immigrant parents from Vietnam and Mexico, respectively. Dr. Nguyen spent 15 years as an English teacher at San Leandro High School, whose student body was roughly 50% Hispanic and 25% Asian, making immigrant parents a huge swath of his educational partners. Mr. Contreras founded a high school outreach program where he interacted with K-12 children of immigrant youth. In addition, he partners with Fresno’s Economic Opportunity Commission to educate immigrant Hispanic parents and their teens on having difficult conversations with their teenage children on topics such as mental and reproductive health. Dr. Duy Nguyen and Mr. Andrew Contreras will explore the differences in immigrant parent-child relationships, compared with native ones, as they relate to mental health ramifications for the child and parent. They reveal immigrant mental health disruptions regarding culture and language, familial hierarchies, parenting styles, as well as parental mental health sequelae brought about by immigration using research and their own personal experiences.
Dr. Nguyen is a second-year resident at the University of California, San Francisco, Fresno Psychiatry Residency. He was a public high school English teacher for 15 years previously. Mr. Contreras is currently a 4th-year medical student at University of California, San Francisco, and applying to Psychiatry for the 2025 match.
References
1. Rao A et al. Five Key Facts About Immigrants With Limited English Proficiency. KFF. 2024 March 14. https://www.kff.org/racial-equity-and-health-policy/issue-brief-five-key-facts-about-immigrants-with-limited-english-proficiency .
2. Raffaetà R. Migration and Parenting: Reviewing the Debate and Calling for Future Research. International Journal of Migration, Health and Social Care. 2016;12(1):38-50. doi: 10.1108/IJMHSC-12-2014-0052/full/html .
3. Nzinga‐Johnson S et al. Teacher‐Parent Relationships and School Involvement Among Racially and Educationally Diverse Parents of Kindergartners. Elementary School Journal. 2009 Sept. doi: 10.1086/598844 .
4. Close C et al. The Mental Health and Wellbeing of First Generation Migrants: A Systematic-Narrative Review of Reviews. Global Health. 2016 Aug 25;12(1):47. doi: 10.1186/s12992-016-0187-3.
5. Collins CH et al. Refugee, Asylum Seeker, Immigrant Women and Postnatal Depression: Rates and Risk Factors. Arch Womens Ment Health. 2011 Feb;14(1):3-11. doi: 10.1007/s00737-010-0198-7 .
6. Fazel M, Betancourt TS. Preventive Mental Health Interventions for Refugee Children and Adolescents in High-Income Settings. Lancet Child Adolesc Health. 2018 Feb;2(2):121-132. doi: 10.1016/S2352-4642(17)30147-5 .
7. Pottie K et al. Do First Generation Immigrant Adolescents Face Higher Rates of Bullying, Violence and Suicidal Behaviours Than Do Third Generation and Native Born? J Immigr Minor Health. 2015 Oct;17(5):1557-1566. doi: 10.1007/s10903-014-0108-6.
8. Smokowski PR, Bacallao ML. Acculturation and Aggression in Latino Adolescents: A Structural Model Focusing on Cultural Risk Factors and Assets. J Abnorm Child Psychol. 2006 Oct;34(5):659-673. doi: 10.1007/s10802-006-9049-4 .
9. Gadermann AM et al. Prevalence of Mental Health Disorders Among Immigrant, Refugee, and Nonimmigrant Children and Youth in British Columbia, Canada. JAMA Netw Open. 2022;5(2):e2144934. doi: 10.1001/jamanetworkopen.2021.44934 .
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All rights reserved. This material may not be published, broadcast, copied, or otherwise reproduced or distributed without the prior written permission of Frontline Medical Communications Inc.</copyrightNotice> </rightsInfo> </provider> <abstract/> <metaDescription>Fundamentally, an immigrant parent’s traditional role as teacher of culture and social systems to their children is undermined by immigration.</metaDescription> <articlePDF/> <teaserImage>289439</teaserImage> <teaser> <span class="normaltextrun">Immigrant parents can become dependent on their children to negotiate social structures instead of vice versa, potentially undermining the social hierarchy and role of parenting.</span> </teaser> <title>The Effects of Immigration on the Parent-Child Relationship </title> <deck/> <disclaimer/> <AuthorList/> <articleURL/> <doi/> <pubMedID/> <publishXMLStatus/> <publishXMLVersion>1</publishXMLVersion> <useEISSN>0</useEISSN> <urgency/> <pubPubdateYear>2024</pubPubdateYear> <pubPubdateMonth/> <pubPubdateDay/> <pubVolume/> <pubNumber/> <wireChannels/> <primaryCMSID/> <CMSIDs/> <keywords/> <seeAlsos/> <publications_g> <publicationData> <publicationCode>PN</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> <journalTitle/> <journalFullTitle/> <copyrightStatement/> </publicationData> <publicationData> <publicationCode>FP</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> <journalTitle/> <journalFullTitle/> <copyrightStatement>Copyright 2017 Frontline Medical News</copyrightStatement> </publicationData> </publications_g> <publications> <term canonical="true">25</term> <term>15</term> </publications> <sections> <term>39313</term> <term canonical="true">27729</term> <term>41022</term> </sections> <topics> <term canonical="true">248</term> </topics> <links> <link> <itemClass qcode="ninat:picture"/> <altRep contenttype="image/jpeg">images/2401126b.jpg</altRep> <description role="drol:caption">Dr. Duy Nguyen</description> <description role="drol:credit"/> </link> </links> </header> <itemSet> <newsItem> <itemMeta> <itemRole>Main</itemRole> <itemClass>text</itemClass> <title>The Effects of Immigration on the Parent-Child Relationship </title> <deck/> </itemMeta> <itemContent> <p> <span class="normaltextrun"><span class="tag metaDescription">Fundamentally, an immigrant parent’s traditional role as teacher of culture and social systems to their children is undermined by immigration.</span> In their native country, they learned throughout their life cultural norms and systems that defined their environment. When these parents immigrate to a new country, their different set of knowledge may not be applicable in many ways to their new environment.</span> <span class="eop"> </span> </p> <h2> <span class="normaltextrun">The Disruption of Social Roles</span> <span class="eop"> </span> </h2> <p> <span class="normaltextrun">Culturally, language is one of the most important types of knowledge parents pass to their children. Nearly half of adult immigrants in the United States have limited English proficiency.</span> <sup>1</sup> <span class="normaltextrun"> </span> </p> <p> <span class="normaltextrun">Their children often learn the language faster, often placing these children in the position of interpreters for their parents. These parents can become dependent on their children to negotiate social structures instead of vice versa, potentially undermining the social hierarchy and role of parenting.</span> <sup>2</sup> <span class="normaltextrun"> Both Mr. Contreras and Dr. Nguyen recall that as children of immigrant parents — from Mexico and Vietnam, respectively — they commanded English better than their parents, which often made them take on more “adult roles.” For example, Dr. Nguyen recalls that his mother would solicit his help in grocery shopping because she could neither navigate the aisles effectively nor ask for help. Mr. Contreras commonly found himself acting as an impromptu medical translator for his mother on several occasions. This dependence of immigrant parents on their children for guidance in their host country can be pervasive in other social structures such as legal and academic.[[{"fid":"289439","view_mode":"medstat_image_flush_left","fields":{"format":"medstat_image_flush_left","field_file_image_alt_text[und][0][value]":"Dr. Duy Nguyen, University of California, San Francisco, Fresno","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][value]":"Dr. Duy Nguyen"},"type":"media","attributes":{"class":"media-element file-medstat_image_flush_left"}}]] <br/><br/></span> </p> <h2> <span class="normaltextrun">Impact on School</span> <span class="eop"> </span> </h2> <p> <span class="normaltextrun">Potentially, an immigrant parent’s lack of knowledge of the language and systems of their host country can make them ineffective advocates for their children at school. Mr. Contreras’s intervention for his patient as a medical student demonstrates this in the arena of school. </span> </p> <p><span class="normaltextrun">Mr. Contreras was rotating at a hospital burn unit in 2023 when R, a young middle school student, and his mother arrived in the emergency department. An incident had occurred at his school. R had been the victim of aggravated battery and assault, sustaining a 3x2 cm burn on his forearm from students placing hot glue onto a piece of cardboard then immediately onto his skin and silencing him by covering his mouth. For months the older students had been bullying R. R’s mother made multiple attempts with both the school’s front desk and counselors to address the issue, but to no avail. R himself, though encouraged to speak up, did not out of fear. As Mr. Contreras realized the situation and the impasse, he used his fluency in Spanish and English to facilitate a joint call with the school district. Within 10 minutes, they were able to connect with a student safety specialist and launch a full investigation. A language barrier and the lack of knowledge of their rights and school system had prevented R’s mother from effectively advocating for her child’s safety. <br/><br/>In Dr. Nguyen’s experience as a teacher, even in classrooms dominated by minority students, the advocacy for students struggling in classes was disproportionate. It favored White parents, but also generally more educated families. This is further supported by a study of 225 schools across six states of kindergarten children showing similar trends, that African American, Latino, and less-educated parents were less involved in their children’s education as reported by </span>teachers.<sup>3</sup><span class="normaltextrun"> It is important to note that in this study teachers were 80% White, 9% Latino, 7% African American, 3% multiracial, and 1% Asian American, suggesting that cultural discrepancy between teachers and parents could be an important factor affecting parent-teacher communication. Dr. Nguyen also recalled trying to discipline several students who were disruptive in his class by telling them he would speak to their parents. Several times, these students would counter defiantly, “Well, good luck, they can’t speak English.” The parents’ dependency on their children to communicate with teachers undermined the abilities of both adults to manage their behaviors and promote learning. <br/><br/></span></p> <h2> <span class="normaltextrun">The Mental Health of Immigrant Parents</span> <span class="eop"> </span> </h2> <p> <span class="normaltextrun">Migrants often have greater incidence of mental health problems, including depression, PTSD, and anxiety, from a combination of peri-migrational experiences.</span> <sup>4</sup> <span class="normaltextrun"> Immigrant mothers are known to have higher rates of post-natal depression, which cause problems later with child development.</span> <sup>5</sup> <span class="normaltextrun"> Though she warns larger studies are needed, Dr. Fazel’s review of Croatian refugees suggests that displacement from one’s native country is a risk factor for poorer mental health, namely due to difficulty in psychosocial adaptation.</span> <sup>6</sup> <span class="normaltextrun"> The likely mechanism is that lack of access to one’s language and culture, or a language and culture that one can navigate effectively, exacerbates, even engenders mental health sequelae. Because of this, first-generation immigrant children often face harsher and more violent parenting.</span> <sup>7,8</sup> <span class="normaltextrun"> Immigrant parents also may have less access to mental health resources since they often resort to their own cultural practices. Both Mr. Contreras’s and Dr. Nguyen’s following narratives of their mothers’ struggle with mental health illustrate the causes and consequences. </span> </p> <p> <span class="normaltextrun">Mr. Contreras, who grew up in a Mexican immigrant household in Los Angeles, saw firsthand how his mother, who faced language barriers and a distrust of Western medicine, turned to traditional healers and herbal remedies for her health needs. Accompanying her to doctor appointments as her translator, he often felt the disconnect between her cultural background and the Western medical system. For her, seeking help from traditional healers was not just about addressing physical ailments but also about finding comfort and familiarity in practices rooted in her cultural beliefs. This preference for cultural or religious methods for mental health support is not uncommon among Mexican immigrant families. <br/><br/>Dr. Nguyen, whose mother was a refugee from Vietnam, recalls her constant depressed mood and suicidal thoughts in the immediate years after she resettled in San Diego. This was caused mostly by the missing of her social supports in Vietnam, her difficulty adjusting to American culture and language, and her difficulty finding work. Often her depression and stress took a darker turn in terms of more violent parenting. Of course, the cause of her poor mental health is hard to parse from the traumas and violence she had faced as a refugee, but in subsequent years, her many brothers and sisters who immigrated through a more orderly process also displayed similar mental health vulnerabilities. <br/><br/> </span> <span class="eop"> </span> </p> <h2> <span class="normaltextrun">The Mental Health of Children of Immigrant Parents</span> <span class="eop"> </span> </h2> <p> <span class="normaltextrun">The relationship between an immigrant parent’s poor mental health and their children is difficult to parse from what we know about native parents and their children. But the primary differences appear to be a great disruption of social roles, the effects of migration itself, and the oftentimes more strict and disciplinarian parenting style as discussed above. Given this, one would expect immigrant children to suffer greater mental health difficulties. However, a recent study of almost 500,000 children in Canada revealed decreased prevalence of conduct disorder, ADHD, and mood and anxiety disorders in immigrant youth, both first- and second-generation, as compared to non-immigrants.</span> <sup>9</sup> <span class="normaltextrun"> This perhaps surprising result highlights how much more we need to understand about the effects of culture on the mental health diagnosis of immigrant youth. It suggests differences in mental health access and use from the cultural factors we mentioned above, to problems with using Western-based mental criteria and symptomatology for diagnosing non-Western children. It can even suggest the underestimation of the protective effects of native culture such as strong ethnic identity and cultural support systems, thereby challenging a purely deficit mental health model of the immigrant experience. </span> </p> <p> <span class="eop"> </span> </p> <h2> <span class="normaltextrun">Summary</span> </h2> <p> <span class="normaltextrun">Dr. Duy Nguyen and Mr. Andrew Contreras are both children of immigrant parents from Vietnam and Mexico, respectively. Dr. Nguyen spent 15 years as an English teacher at San Leandro High School, whose student body was roughly 50% Hispanic and 25% Asian, making immigrant parents a huge swath of his educational partners. Mr. Contreras founded a high school outreach program where he interacted with K-12 children of immigrant youth. In addition, he partners with Fresno’s Economic Opportunity Commission to educate immigrant Hispanic parents and their teens on having difficult conversations with their teenage children on topics such as mental and reproductive health. Dr. Duy Nguyen and Mr. Andrew Contreras will explore the differences in immigrant parent-child relationships, compared with native ones, as they relate to mental health ramifications for the child and parent. They reveal immigrant mental health disruptions regarding culture and language, familial hierarchies, parenting styles, as well as parental mental health sequelae brought about by immigration using research and their own personal experiences.</span> <span class="end"> </span> <span class="normaltextrun"> </span> </p> <p> <span class="eop"> </span> </p> <p> <em> <span class="eop">Dr. Nguyen is a second-year resident at the </span> <span class="normaltextrun">University of California, San Francisco,</span> <span class="eop"> Fresno Psychiatry Residency. He was a public high school English teacher for 15 years previously. Mr. </span> <span class="normaltextrun">Contreras is currently a 4th-year medical student at University of California, San Francisco, and applying to Psychiatry for the 2025 match.</span> </em> </p> <h2> <span class="normaltextrun">References</span> <span class="eop"> </span> </h2> <p> <span class="normaltextrun">1. Rao A et al. Five Key Facts About Immigrants With Limited English Proficiency. KFF. 2024 March 14. </span> <span class="Hyperlink"> <a href="https://www.kff.org/racial-equity-and-health-policy/issue-brief/five-key-facts-about-immigrants-with-limited-english-proficiency">https://www.kff.org/racial-equity-and-health-policy/issue-brief-five-key-facts-about-immigrants-with-limited-english-proficiency</a> </span> <span class="normaltextrun">.<br/><br/>2. Raffaetà R. Migration and Parenting: Reviewing the Debate and Calling for Future Research. International Journal of Migration, Health and Social Care. 2016;12(1):38-50. </span> <span class="Hyperlink"> <a href="https://www.emerald.com/insight/content/doi/10.1108/IJMHSC-12-2014-0052/full/html">doi: 10.1108/IJMHSC-12-2014-0052/full/html</a> </span> <span class="normaltextrun">.<br/><br/>3. Nzinga‐Johnson S et al. Teacher‐Parent Relationships and School Involvement Among Racially and Educationally Diverse Parents of Kindergartners. Elementary School Journal. 2009 Sept. </span> <span class="Hyperlink"> <a href="https://www.journals.uchicago.edu/doi/abs/10.1086/598844?journalCode=esj">doi: 10.1086/598844</a> </span> <span class="normaltextrun">.<br/><br/>4. Close C et al. The Mental Health and Wellbeing of First Generation Migrants: A Systematic-Narrative Review of Reviews. Global Health. 2016 Aug 25;12(1):47. </span> <span class="Hyperlink"><a href="https://globalizationandhealth.biomedcentral.com/articles/10.1186/s12992-016-0187-3">doi: 10.1186/s12992-016-0187-3</a>.</span> <span class="normaltextrun"><br/><br/>5. Collins CH et al. Refugee, Asylum Seeker, Immigrant Women and Postnatal Depression: Rates and Risk Factors. Arch Womens Ment Health. 2011 Feb;14(1):3-11. </span> <span class="Hyperlink"> <a href="https://link.springer.com/article/10.1007/s00737-010-0198-7">doi: 10.1007/s00737-010-0198-7</a> </span> <span class="normaltextrun">.<br/><br/>6. Fazel M, Betancourt TS. Preventive Mental Health Interventions for Refugee Children and Adolescents in High-Income Settings. Lancet Child Adolesc Health. 2018 Feb;2(2):121-132. </span> <span class="Hyperlink"> <a href="https://www.thelancet.com/journals/lanchi/article/PIIS2352-4642(17)30147-5/fulltext">doi: 10.1016/S2352-4642(17)30147-5</a> </span> <span class="normaltextrun">.<br/><br/>7. Pottie K et al. Do First Generation Immigrant Adolescents Face Higher Rates of Bullying, Violence and Suicidal Behaviours Than Do Third Generation and Native Born? J Immigr Minor Health. 2015 Oct;17(5):1557-1566. </span> <span class="Hyperlink"><a href="https://link.springer.com/article/10.1007/s10903-014-0108-6">doi: 10.1007/s10903-014-0108-6</a>.</span> <span class="normaltextrun"><br/><br/>8. Smokowski PR, Bacallao ML. Acculturation and Aggression in Latino Adolescents: A Structural Model Focusing on Cultural Risk Factors and Assets. J Abnorm Child Psychol. 2006 Oct;34(5):659-673. </span> <span class="Hyperlink"> <a href="https://link.springer.com/article/10.1007/s10802-006-9049-4">doi: 10.1007/s10802-006-9049-4</a> </span> <span class="normaltextrun">.<br/><br/>9. Gadermann AM et al. Prevalence of Mental Health Disorders Among Immigrant, Refugee, and Nonimmigrant Children and Youth in British Columbia, Canada. JAMA Netw Open. 2022;5(2):e2144934. </span> <span class="Hyperlink"> <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2789061">doi: 10.1001/jamanetworkopen.2021.44934</a> </span> <span class="normaltextrun">.</span> </p> </itemContent> </newsItem> <newsItem> <itemMeta> <itemRole>teaser</itemRole> <itemClass>text</itemClass> <title/> <deck/> </itemMeta> <itemContent> </itemContent> </newsItem> </itemSet></root>
The Smartphone Problem
I am going to guess that if we asked 500,000 adults in this country if they felt that children and adolescents were spending too much time on their smartphones, we would elicit almost uniform agreement that, yes indeed, smartphone use is gobbling up too much time from our young people. And, the adults would volunteer a long laundry list of all the bad consequences this overuse was generating. If you ask this same sample of adults if they too were spending too much time on their smartphones they would answer yes and, again, give you a list of the problems they feel are the result of this overuse.
We might begin to find a scattering of responses if we ask the adults when a child is too young to have his/her own cell phone. But, they would all agree that “young children” weren’t ready to be trusted with a cell phone. The “when” they were ready would be up for discussion. However, I suspect we might see a clustering around age 10 years. The reality is that despite what the majority may believe, a 2022 survey found that 42% of children have a cell phone by age 10, 71% by age 12, and 91% by age 14.
So, it would appear that, while we believe there can be significant downsides to having a cell phone, we are having great difficulty in policing ourselves and creating limits for our children. Does cell phone use qualify as an addiction, or is it just another example of how adults have lost the ability to say “no” to themselves and to their children?
When it comes to cell phones in school, the situation gets increasingly murky. The teachers I speak with are very clear that cell phones are creating problems for both the academic and the social experiences of their students. One teacher referred me to an article from the Norwegian Institute of Public Health, which found that banning cell phones in school decreased the incidence of psychological symptoms and diseases in girls. Bullying decreased in both genders and the girls’ GPA scores improved. In schools with cell phone bans, girls were more likely to choose and attend academic track programs, an effect which was more pronounced in young women with lower socioeconomic backgrounds. But, the if, when, and how to institute smartphone bans in school is complicated.
On one front, the movement toward cell phone bans in school has been given a major boost with the publication and publicity of a new book titled The Anxious Generation by social psychologist Jonathan Haidt, PhD. The New York University professor sees the GenZ’ers as experiencing a tsunami of mental health challenges including anxiety, self-harm, and suicide. And, he lays much of the blame for this situation on cell phone use.
He is optimistic about turning the tide because he claims that everywhere he speaks about the problem he says “I feel that I’m pushing on open doors.” Comparing the phenomenon to the collapse of the Berlin Wall, Dr. Haidt says “When you have a system that everyone hates, and then you have a way to escape it, it can change in a year.”
I wish I could share in his optimism, although I did just encounter a news story in the Portland paper describing a national program called “Wait Until 8th,” which is being considered by a parents’ group here in Maine.
The usual suspects have their own predictable take on the issue. The House and Senate have proposed a study on the use of cell phones in elementary and secondary schools and a pilot program awarding grants to some schools to create mobile device–free environments. Sounds like a momentum killer to me.
Not surprisingly, the issue of cell phone bans in school has taken on a bit of a political odor. The National Parents Union reports in a very small and inadequately described sample that 56% of parents are against total school bans. In the accompanying press release, the organizations offers an extensive list of concerns parents have reported — many cite the need to remain in contact with their children throughout the day. One has to wonder how often these concerns are a reflection of unresolved separation anxiety.
The American Academy of Pediatrics has rolled out a “5 Cs” framework that pediatricians can use to discuss media use with families. As usual, the thought is that talking about a problem is going to somehow convince parents to do what they already know is the correct action. And, of course, pediatricians have plenty of time to initiate this discussion of the obvious.
A recent study from the Department of Pediatrics at University of California, San Francisco, has found that parental monitoring, limit setting, and modeling good screen use behavior (my bolding) are the most effective strategies for reducing adolescent screen time. Using screen time allowances as a reward or punishment does not seem to be effective.
So there you have it. It looks like However, despite Dr. Haidt’s optimism about a seismic turnaround, I suspect it will more likely be guerrilla warfare — one family, one school, or one school district at a time.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.
I am going to guess that if we asked 500,000 adults in this country if they felt that children and adolescents were spending too much time on their smartphones, we would elicit almost uniform agreement that, yes indeed, smartphone use is gobbling up too much time from our young people. And, the adults would volunteer a long laundry list of all the bad consequences this overuse was generating. If you ask this same sample of adults if they too were spending too much time on their smartphones they would answer yes and, again, give you a list of the problems they feel are the result of this overuse.
We might begin to find a scattering of responses if we ask the adults when a child is too young to have his/her own cell phone. But, they would all agree that “young children” weren’t ready to be trusted with a cell phone. The “when” they were ready would be up for discussion. However, I suspect we might see a clustering around age 10 years. The reality is that despite what the majority may believe, a 2022 survey found that 42% of children have a cell phone by age 10, 71% by age 12, and 91% by age 14.
So, it would appear that, while we believe there can be significant downsides to having a cell phone, we are having great difficulty in policing ourselves and creating limits for our children. Does cell phone use qualify as an addiction, or is it just another example of how adults have lost the ability to say “no” to themselves and to their children?
When it comes to cell phones in school, the situation gets increasingly murky. The teachers I speak with are very clear that cell phones are creating problems for both the academic and the social experiences of their students. One teacher referred me to an article from the Norwegian Institute of Public Health, which found that banning cell phones in school decreased the incidence of psychological symptoms and diseases in girls. Bullying decreased in both genders and the girls’ GPA scores improved. In schools with cell phone bans, girls were more likely to choose and attend academic track programs, an effect which was more pronounced in young women with lower socioeconomic backgrounds. But, the if, when, and how to institute smartphone bans in school is complicated.
On one front, the movement toward cell phone bans in school has been given a major boost with the publication and publicity of a new book titled The Anxious Generation by social psychologist Jonathan Haidt, PhD. The New York University professor sees the GenZ’ers as experiencing a tsunami of mental health challenges including anxiety, self-harm, and suicide. And, he lays much of the blame for this situation on cell phone use.
He is optimistic about turning the tide because he claims that everywhere he speaks about the problem he says “I feel that I’m pushing on open doors.” Comparing the phenomenon to the collapse of the Berlin Wall, Dr. Haidt says “When you have a system that everyone hates, and then you have a way to escape it, it can change in a year.”
I wish I could share in his optimism, although I did just encounter a news story in the Portland paper describing a national program called “Wait Until 8th,” which is being considered by a parents’ group here in Maine.
The usual suspects have their own predictable take on the issue. The House and Senate have proposed a study on the use of cell phones in elementary and secondary schools and a pilot program awarding grants to some schools to create mobile device–free environments. Sounds like a momentum killer to me.
Not surprisingly, the issue of cell phone bans in school has taken on a bit of a political odor. The National Parents Union reports in a very small and inadequately described sample that 56% of parents are against total school bans. In the accompanying press release, the organizations offers an extensive list of concerns parents have reported — many cite the need to remain in contact with their children throughout the day. One has to wonder how often these concerns are a reflection of unresolved separation anxiety.
The American Academy of Pediatrics has rolled out a “5 Cs” framework that pediatricians can use to discuss media use with families. As usual, the thought is that talking about a problem is going to somehow convince parents to do what they already know is the correct action. And, of course, pediatricians have plenty of time to initiate this discussion of the obvious.
A recent study from the Department of Pediatrics at University of California, San Francisco, has found that parental monitoring, limit setting, and modeling good screen use behavior (my bolding) are the most effective strategies for reducing adolescent screen time. Using screen time allowances as a reward or punishment does not seem to be effective.
So there you have it. It looks like However, despite Dr. Haidt’s optimism about a seismic turnaround, I suspect it will more likely be guerrilla warfare — one family, one school, or one school district at a time.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.
I am going to guess that if we asked 500,000 adults in this country if they felt that children and adolescents were spending too much time on their smartphones, we would elicit almost uniform agreement that, yes indeed, smartphone use is gobbling up too much time from our young people. And, the adults would volunteer a long laundry list of all the bad consequences this overuse was generating. If you ask this same sample of adults if they too were spending too much time on their smartphones they would answer yes and, again, give you a list of the problems they feel are the result of this overuse.
We might begin to find a scattering of responses if we ask the adults when a child is too young to have his/her own cell phone. But, they would all agree that “young children” weren’t ready to be trusted with a cell phone. The “when” they were ready would be up for discussion. However, I suspect we might see a clustering around age 10 years. The reality is that despite what the majority may believe, a 2022 survey found that 42% of children have a cell phone by age 10, 71% by age 12, and 91% by age 14.
So, it would appear that, while we believe there can be significant downsides to having a cell phone, we are having great difficulty in policing ourselves and creating limits for our children. Does cell phone use qualify as an addiction, or is it just another example of how adults have lost the ability to say “no” to themselves and to their children?
When it comes to cell phones in school, the situation gets increasingly murky. The teachers I speak with are very clear that cell phones are creating problems for both the academic and the social experiences of their students. One teacher referred me to an article from the Norwegian Institute of Public Health, which found that banning cell phones in school decreased the incidence of psychological symptoms and diseases in girls. Bullying decreased in both genders and the girls’ GPA scores improved. In schools with cell phone bans, girls were more likely to choose and attend academic track programs, an effect which was more pronounced in young women with lower socioeconomic backgrounds. But, the if, when, and how to institute smartphone bans in school is complicated.
On one front, the movement toward cell phone bans in school has been given a major boost with the publication and publicity of a new book titled The Anxious Generation by social psychologist Jonathan Haidt, PhD. The New York University professor sees the GenZ’ers as experiencing a tsunami of mental health challenges including anxiety, self-harm, and suicide. And, he lays much of the blame for this situation on cell phone use.
He is optimistic about turning the tide because he claims that everywhere he speaks about the problem he says “I feel that I’m pushing on open doors.” Comparing the phenomenon to the collapse of the Berlin Wall, Dr. Haidt says “When you have a system that everyone hates, and then you have a way to escape it, it can change in a year.”
I wish I could share in his optimism, although I did just encounter a news story in the Portland paper describing a national program called “Wait Until 8th,” which is being considered by a parents’ group here in Maine.
The usual suspects have their own predictable take on the issue. The House and Senate have proposed a study on the use of cell phones in elementary and secondary schools and a pilot program awarding grants to some schools to create mobile device–free environments. Sounds like a momentum killer to me.
Not surprisingly, the issue of cell phone bans in school has taken on a bit of a political odor. The National Parents Union reports in a very small and inadequately described sample that 56% of parents are against total school bans. In the accompanying press release, the organizations offers an extensive list of concerns parents have reported — many cite the need to remain in contact with their children throughout the day. One has to wonder how often these concerns are a reflection of unresolved separation anxiety.
The American Academy of Pediatrics has rolled out a “5 Cs” framework that pediatricians can use to discuss media use with families. As usual, the thought is that talking about a problem is going to somehow convince parents to do what they already know is the correct action. And, of course, pediatricians have plenty of time to initiate this discussion of the obvious.
A recent study from the Department of Pediatrics at University of California, San Francisco, has found that parental monitoring, limit setting, and modeling good screen use behavior (my bolding) are the most effective strategies for reducing adolescent screen time. Using screen time allowances as a reward or punishment does not seem to be effective.
So there you have it. It looks like However, despite Dr. Haidt’s optimism about a seismic turnaround, I suspect it will more likely be guerrilla warfare — one family, one school, or one school district at a time.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.
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WILKOFF, MD</bylineFull> <bylineTitleText/> <USOrGlobal/> <wireDocType/> <newsDocType>Column</newsDocType> <journalDocType/> <linkLabel/> <pageRange/> <citation/> <quizID/> <indexIssueDate/> <itemClass qcode="ninat:text"/> <provider qcode="provider:imng"> <name>IMNG Medical Media</name> <rightsInfo> <copyrightHolder> <name>Frontline Medical News</name> </copyrightHolder> <copyrightNotice>Copyright (c) 2015 Frontline Medical News, a Frontline Medical Communications Inc. company. All rights reserved. This material may not be published, broadcast, copied, or otherwise reproduced or distributed without the prior written permission of Frontline Medical Communications Inc.</copyrightNotice> </rightsInfo> </provider> <abstract/> <metaDescription>cell phone overuse, particularly in school, is something most of us see as a problem deserving an immediate solution.</metaDescription> <articlePDF/> <teaserImage>170586</teaserImage> <teaser>Cell phone overuse, particularly in school, is something most of us see as a problem deserving an immediate solution. That solution, however, is up for debate. </teaser> <title>The Smartphone Problem</title> <deck/> <disclaimer/> <AuthorList/> <articleURL/> <doi/> <pubMedID/> <publishXMLStatus/> <publishXMLVersion>1</publishXMLVersion> <useEISSN>0</useEISSN> <urgency/> <pubPubdateYear>2024</pubPubdateYear> <pubPubdateMonth/> <pubPubdateDay/> <pubVolume/> <pubNumber/> <wireChannels/> <primaryCMSID/> <CMSIDs/> <keywords/> <seeAlsos/> <publications_g> <publicationData> <publicationCode>FP</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> <journalTitle/> <journalFullTitle/> <copyrightStatement>Copyright 2017 Frontline Medical News</copyrightStatement> </publicationData> <publicationData> <publicationCode>PN</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> <journalTitle/> <journalFullTitle/> <copyrightStatement/> </publicationData> </publications_g> <publications> <term>15</term> <term canonical="true">25</term> </publications> <sections> <term>39313</term> <term canonical="true">84</term> </sections> <topics> <term>248</term> <term canonical="true">271</term> </topics> <links> <link> <itemClass qcode="ninat:picture"/> <altRep contenttype="image/jpeg">images/24006016.jpg</altRep> <description role="drol:caption">Dr. William G. Wilkoff</description> <description role="drol:credit"/> </link> </links> </header> <itemSet> <newsItem> <itemMeta> <itemRole>Main</itemRole> <itemClass>text</itemClass> <title>The Smartphone Problem</title> <deck/> </itemMeta> <itemContent> <p>I am going to guess that if we asked 500,000 adults in this country if they felt that children and adolescents were spending too much time on their smartphones, we would elicit almost uniform agreement that, yes indeed, smartphone use is gobbling up too much time from our young people. And, the adults would volunteer a long laundry list of all the bad consequences this overuse was generating. If you ask this same sample of adults if they too were spending too much time on their smartphones they would answer yes and, again, give you a list of the problems they feel are the result of this overuse.</p> <p>We might begin to find a scattering of responses if we ask the adults when a child is too young to have his/her own cell phone. But, they would all agree that “young children” weren’t ready to be trusted with a cell phone. The “when” they were ready would be up for discussion. However, I suspect we might see a clustering around age 10 years. The reality is that despite what the majority may believe, a 2022 survey found that 42% of children have a cell phone by age 10, 71% by age 12, and 91% by age 14.<br/><br/>[[{"fid":"170586","view_mode":"medstat_image_flush_left","fields":{"format":"medstat_image_flush_left","field_file_image_alt_text[und][0][value]":"Dr. William G. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years.","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][value]":"Dr. William G. Wilkoff"},"type":"media","attributes":{"class":"media-element file-medstat_image_flush_left"}}]]So, it would appear that, while we believe there can be significant downsides to having a cell phone, we are having great difficulty in policing ourselves and creating limits for our children. Does cell phone use qualify as an addiction, or is it just another example of how adults have lost the ability to say “no” to themselves and to their children?<br/><br/>When it comes to cell phones in school, the situation gets increasingly murky. The teachers I speak with are very clear that cell phones are creating problems for both the academic and the social experiences of their students. One teacher referred me to <span class="Hyperlink"><a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=4735240">an article</a></span> from the Norwegian Institute of Public Health, which found that banning cell phones in school decreased the incidence of psychological symptoms and diseases in girls. Bullying decreased in both genders and the girls’ GPA scores improved. In schools with cell phone bans, girls were more likely to choose and attend academic track programs, an effect which was more pronounced in young women with lower socioeconomic backgrounds. But, the if, when, and how to institute smartphone bans in school is complicated.<br/><br/>On one front, the movement toward cell phone bans in school has been given a major boost with the publication and publicity of a new book titled <em><a href="https://www.anxiousgeneration.com/book">The Anxious Generation</a></em> by social psychologist Jonathan Haidt, PhD. The New York University professor sees the GenZ’ers as experiencing a tsunami of mental health challenges including anxiety, self-harm, and suicide. And, he lays much of the blame for this situation on cell phone use. <br/><br/>He is optimistic about turning the tide because he claims that everywhere he speaks about the problem he says “I feel that I’m pushing on open doors.” Comparing the phenomenon to the collapse of the Berlin Wall, Dr. Haidt says “When you have a system that everyone hates, and then you have a way to escape it, it can change in a year.”<br/><br/>I wish I could share in his optimism, although I did just encounter a news story in the Portland paper describing a national program called <span class="Hyperlink"><a href="https://www.pressherald.com/2024/05/15/wait-until-8th-parents-group-strikes-a-chord-in-scarborough-over-smartphone-concerns/">“Wait Until 8th,”</a></span> which is being considered by a parents’ group here in Maine.<br/><br/>The usual suspects have their own predictable take on the issue. The House and Senate have proposed a study on the use of cell phones in elementary and secondary schools and a pilot program awarding grants to some schools to create mobile device–free environments. Sounds like a momentum killer to me.<br/><br/>Not surprisingly, the issue of cell phone bans in school has taken on a bit of a political odor. The National Parents Union reports in a very small and inadequately described sample that <span class="Hyperlink"><a href="https://nationalparentsunion.org/2024/03/13/new-poll-shows-parents-are-against-cell-phone-ban-in-schools-raise-alarm-over-negative-effects-of-social-media-on-children/">56% of parents are against total school bans</a></span>. In the accompanying press release, the organizations offers an extensive list of concerns parents have reported — many cite the need to remain in contact with their children throughout the day. One has to wonder how often these concerns are a reflection of unresolved separation anxiety. <br/><br/>The American Academy of Pediatrics has rolled out a <span class="Hyperlink"><a href="https://www.aap.org/en/patient-care/media-and-children/center-of-excellence-on-social-media-and-youth-mental-health/5cs-of-media-use/">“5 Cs”</a></span> framework that pediatricians can use to discuss media use with families. As usual, the thought is that talking about a problem is going to somehow convince parents to do what they already know is the correct action. And, of course, pediatricians have plenty of time to initiate this discussion of the obvious.<br/><br/>A <span class="Hyperlink"><a href="https://www.nature.com/articles/s41390-024-03243-y">recent study</a></span> from the Department of Pediatrics at University of California, San Francisco, has found that parental monitoring, limit setting, and <strong>modeling good screen use behavior</strong> (my bolding) are the most effective strategies for reducing adolescent screen time. Using screen time allowances as a reward or punishment does not seem to be effective. <br/><br/>So there you have it. It looks like <span class="tag metaDescription">cell phone overuse, particularly in school, is something most of us see as a problem deserving an immediate solution.</span> However, despite Dr. Haidt’s optimism about a seismic turnaround, I suspect it will more likely be guerrilla warfare — one family, one school, or one school district at a time. <br/><br/></p> <p> <em>Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at <span class="Hyperlink"><a href="mailto:pdnews%40mdedge.com?subject=">pdnews@mdedge.com</a></span>.<span class="end"/></em> </p> </itemContent> </newsItem> <newsItem> <itemMeta> <itemRole>teaser</itemRole> <itemClass>text</itemClass> <title/> <deck/> </itemMeta> <itemContent> </itemContent> </newsItem> </itemSet></root>
Chronotherapy: Why Timing Drugs to Our Body Clocks May Work
Do drugs work better if taken by the clock?
A new analysis published in The Lancet journal’s eClinicalMedicine suggests: Yes, they do — if you consider the patient’s individual body clock. The study is the first to find that timing blood pressure drugs to a person’s personal “chronotype” — that is, whether they are a night owl or an early bird — may reduce the risk for a heart attack.
The findings represent a significant advance in the field of circadian medicine or “chronotherapy” — timing drug administration to circadian rhythms. A growing stack of research suggests this approach could reduce side effects and improve the effectiveness of a wide range of therapies, including vaccines, cancer treatments, and drugs for depression, glaucoma, pain, seizures, and other conditions. Still, despite decades of research, time of day is rarely considered in writing prescriptions.
“We are really just at the beginning of an exciting new way of looking at patient care,” said Kenneth A. Dyar, PhD, whose lab at Helmholtz Zentrum München’s Institute for Diabetes and Cancer focuses on metabolic physiology. Dr. Dyar is co-lead author of the new blood pressure analysis.
“Chronotherapy is a rapidly growing field,” he said, “and I suspect we are soon going to see more and more studies focused on ‘personalized chronotherapy,’ not only in hypertension but also potentially in other clinical areas.”
The ‘Missing Piece’ in Chronotherapy Research
Blood pressure drugs have long been chronotherapy’s battleground. After all, blood pressure follows a circadian rhythm, peaking in the morning and dropping at night.
That healthy overnight dip can disappear in people with diabetes, kidney disease, and obstructive sleep apnea. Some physicians have suggested a bed-time dose to restore that dip. But studies have had mixed results, so “take at bedtime” has become a less common recommendation in recent years.
But the debate continued. After a large 2019 Spanish study found that bedtime doses had benefits so big that the results drew questions, an even larger, 2022 randomized, controlled trial from the University of Dundee in Dundee, Scotland — called the TIME study — aimed to settle the question.
Researchers assigned over 21,000 people to take morning or night hypertension drugs for several years and found no difference in cardiovascular outcomes.
“We did this study thinking nocturnal blood pressure tablets might be better,” said Thomas MacDonald, MD, professor emeritus of clinical pharmacology and pharmacoepidemiology at the University of Dundee and principal investigator for the TIME study and the recent chronotype analysis. “But there was no difference for heart attacks, strokes, or vascular death.”
So, the researchers then looked at participants’ chronotypes, sorting outcomes based on whether the participants were late-to-bed, late-to-rise “night owls” or early-to-bed, early-to-rise “morning larks.”
Their analysis of these 5358 TIME participants found the following results: Risk for hospitalization for a heart attack was at least 34% lower for “owls” who took their drugs at bedtime. By contrast, owls’ heart attack risk was at least 62% higher with morning doses. For “larks,” the opposite was true. Morning doses were associated with an 11% lower heart attack risk and night doses with an 11% higher risk, according to supplemental data.
The personalized approach could explain why some previous chronotherapy studies have failed to show a benefit. Those studies did not individualize drug timing as this one did. But personalization could be key to circadian medicine’s success.
“Our ‘internal personal time’ appears to be an important variable to consider when dosing antihypertensives,” said co-lead author Filippo Pigazzani, MD, PhD, clinical senior lecturer and honorary consultant cardiologist at the University of Dundee School of Medicine. “Chronotherapy research has been going on for decades. We knew there was something important with time of day. But researchers haven’t considered the internal time of individual people. I think that is the missing piece.”
The analysis has several important limitations, the researchers said. A total of 95% of participants were White. And it was an observational study, not a true randomized comparison. “We started it late in the original TIME study,” Dr. MacDonald said. “You could argue we were reporting on those who survived long enough to get into the analysis.” More research is needed, they concluded.
Looking Beyond Blood Pressure
What about the rest of the body? “Almost all the cells of our body contain ‘circadian clocks’ that are synchronized by daily environmental cues, including light-dark, activity-rest, and feeding-fasting cycles,” said Dr. Dyar.
An estimated 50% of prescription drugs hit targets in the body that have circadian patterns. So, experts suspect that syncing a drug with a person’s body clock might increase effectiveness of many drugs.
A handful of US Food and Drug Administration–approved drugs already have time-of-day recommendations on the label for effectiveness or to limit side effects, including bedtime or evening for the insomnia drug Ambien, the HIV antiviral Atripla, and cholesterol-lowering Zocor. Others are intended to be taken with or after your last meal of the day, such as the long-acting insulin Levemir and the cardiovascular drug Xarelto. A morning recommendation comes with the proton pump inhibitor Nexium and the attention-deficit/hyperactivity disorder drug Ritalin.
Interest is expanding. About one third of the papers published about chronotherapy in the past 25 years have come out in the past 5 years. The May 2024 meeting of the Society for Research on Biological Rhythms featured a day-long session aimed at bringing clinicians up to speed. An organization called the International Association of Circadian Health Clinics is trying to bring circadian medicine findings to clinicians and their patients and to support research.
Moreover, while recent research suggests minding the clock could have benefits for a wide range of treatments, ignoring it could cause problems.
In a Massachusetts Institute of Technology study published in April in Science Advances, researchers looked at engineered livers made from human donor cells and found more than 300 genes that operate on a circadian schedule, many with roles in drug metabolism. They also found that circadian patterns affected the toxicity of acetaminophen and atorvastatin. Identifying the time of day to take these drugs could maximize effectiveness and minimize adverse effects, the researchers said.
Timing and the Immune System
Circadian rhythms are also seen in immune processes. In a 2023 study in The Journal of Clinical Investigation of vaccine data from 1.5 million people in Israel, researchers found that children and older adults who got their second dose of the Pfizer mRNA COVID vaccine earlier in the day were about 36% less likely to be hospitalized with SARS-CoV-2 infection than those who got an evening shot.
“The sweet spot in our data was somewhere around late morning to late afternoon,” said lead researcher Jeffrey Haspel, MD, PhD, associate professor of medicine in the division of pulmonary and critical care medicine at Washington University School of Medicine in St. Louis.
In a multicenter, 2024 analysis of 13 studies of immunotherapy for advanced cancers in 1663 people, researchers found treatment earlier in the day was associated with longer survival time and longer survival without cancer progression.
“Patients with selected metastatic cancers seemed to largely benefit from early [time of day] infusions, which is consistent with circadian mechanisms in immune-cell functions and trafficking,” the researchers noted. But “retrospective randomized trials are needed to establish recommendations for optimal circadian timing.”
Other research suggests or is investigating possible chronotherapy benefits for depression, glaucoma, respiratory diseases, stroke treatment, epilepsy, and sedatives used in surgery. So why aren’t healthcare providers adding time of day to more prescriptions? “What’s missing is more reliable data,” Dr. Dyar said.
Should You Use Chronotherapy Now?
Experts emphasize that more research is needed before doctors use chronotherapy and before medical organizations include it in treatment recommendations. But for some patients, circadian dosing may be worth a try:
Night owls whose blood pressure isn’t well controlled. Dr. Dyar and Dr. Pigazzani said night-time blood pressure drugs may be helpful for people with a “late chronotype.” Of course, patients shouldn’t change their medication schedule on their own, they said. And doctors may want to consider other concerns, like more overnight bathroom visits with evening diuretics.
In their study, the researchers determined participants’ chronotype with a few questions from the Munich Chronotype Questionnaire about what time they fell asleep and woke up on workdays and days off and whether they considered themselves “morning types” or “evening types.” (The questions can be found in supplementary data for the study.)
If a physician thinks matching the timing of a dose with chronotype would help, they can consider it, Dr. Pigazzani said. “However, I must add that this was an observational study, so I would advise healthcare practitioners to wait for our data to be confirmed in new RCTs of personalized chronotherapy of hypertension.”
Children and older adults getting vaccines. Timing COVID shots and possibly other vaccines from late morning to mid-afternoon could have a small benefit for individuals and a bigger public-health benefit, Dr. Haspel said. But the most important thing is getting vaccinated. “If you can only get one in the evening, it’s still worthwhile. Timing may add oomph at a public-health level for more vulnerable groups.”
A version of this article appeared on Medscape.com.
Do drugs work better if taken by the clock?
A new analysis published in The Lancet journal’s eClinicalMedicine suggests: Yes, they do — if you consider the patient’s individual body clock. The study is the first to find that timing blood pressure drugs to a person’s personal “chronotype” — that is, whether they are a night owl or an early bird — may reduce the risk for a heart attack.
The findings represent a significant advance in the field of circadian medicine or “chronotherapy” — timing drug administration to circadian rhythms. A growing stack of research suggests this approach could reduce side effects and improve the effectiveness of a wide range of therapies, including vaccines, cancer treatments, and drugs for depression, glaucoma, pain, seizures, and other conditions. Still, despite decades of research, time of day is rarely considered in writing prescriptions.
“We are really just at the beginning of an exciting new way of looking at patient care,” said Kenneth A. Dyar, PhD, whose lab at Helmholtz Zentrum München’s Institute for Diabetes and Cancer focuses on metabolic physiology. Dr. Dyar is co-lead author of the new blood pressure analysis.
“Chronotherapy is a rapidly growing field,” he said, “and I suspect we are soon going to see more and more studies focused on ‘personalized chronotherapy,’ not only in hypertension but also potentially in other clinical areas.”
The ‘Missing Piece’ in Chronotherapy Research
Blood pressure drugs have long been chronotherapy’s battleground. After all, blood pressure follows a circadian rhythm, peaking in the morning and dropping at night.
That healthy overnight dip can disappear in people with diabetes, kidney disease, and obstructive sleep apnea. Some physicians have suggested a bed-time dose to restore that dip. But studies have had mixed results, so “take at bedtime” has become a less common recommendation in recent years.
But the debate continued. After a large 2019 Spanish study found that bedtime doses had benefits so big that the results drew questions, an even larger, 2022 randomized, controlled trial from the University of Dundee in Dundee, Scotland — called the TIME study — aimed to settle the question.
Researchers assigned over 21,000 people to take morning or night hypertension drugs for several years and found no difference in cardiovascular outcomes.
“We did this study thinking nocturnal blood pressure tablets might be better,” said Thomas MacDonald, MD, professor emeritus of clinical pharmacology and pharmacoepidemiology at the University of Dundee and principal investigator for the TIME study and the recent chronotype analysis. “But there was no difference for heart attacks, strokes, or vascular death.”
So, the researchers then looked at participants’ chronotypes, sorting outcomes based on whether the participants were late-to-bed, late-to-rise “night owls” or early-to-bed, early-to-rise “morning larks.”
Their analysis of these 5358 TIME participants found the following results: Risk for hospitalization for a heart attack was at least 34% lower for “owls” who took their drugs at bedtime. By contrast, owls’ heart attack risk was at least 62% higher with morning doses. For “larks,” the opposite was true. Morning doses were associated with an 11% lower heart attack risk and night doses with an 11% higher risk, according to supplemental data.
The personalized approach could explain why some previous chronotherapy studies have failed to show a benefit. Those studies did not individualize drug timing as this one did. But personalization could be key to circadian medicine’s success.
“Our ‘internal personal time’ appears to be an important variable to consider when dosing antihypertensives,” said co-lead author Filippo Pigazzani, MD, PhD, clinical senior lecturer and honorary consultant cardiologist at the University of Dundee School of Medicine. “Chronotherapy research has been going on for decades. We knew there was something important with time of day. But researchers haven’t considered the internal time of individual people. I think that is the missing piece.”
The analysis has several important limitations, the researchers said. A total of 95% of participants were White. And it was an observational study, not a true randomized comparison. “We started it late in the original TIME study,” Dr. MacDonald said. “You could argue we were reporting on those who survived long enough to get into the analysis.” More research is needed, they concluded.
Looking Beyond Blood Pressure
What about the rest of the body? “Almost all the cells of our body contain ‘circadian clocks’ that are synchronized by daily environmental cues, including light-dark, activity-rest, and feeding-fasting cycles,” said Dr. Dyar.
An estimated 50% of prescription drugs hit targets in the body that have circadian patterns. So, experts suspect that syncing a drug with a person’s body clock might increase effectiveness of many drugs.
A handful of US Food and Drug Administration–approved drugs already have time-of-day recommendations on the label for effectiveness or to limit side effects, including bedtime or evening for the insomnia drug Ambien, the HIV antiviral Atripla, and cholesterol-lowering Zocor. Others are intended to be taken with or after your last meal of the day, such as the long-acting insulin Levemir and the cardiovascular drug Xarelto. A morning recommendation comes with the proton pump inhibitor Nexium and the attention-deficit/hyperactivity disorder drug Ritalin.
Interest is expanding. About one third of the papers published about chronotherapy in the past 25 years have come out in the past 5 years. The May 2024 meeting of the Society for Research on Biological Rhythms featured a day-long session aimed at bringing clinicians up to speed. An organization called the International Association of Circadian Health Clinics is trying to bring circadian medicine findings to clinicians and their patients and to support research.
Moreover, while recent research suggests minding the clock could have benefits for a wide range of treatments, ignoring it could cause problems.
In a Massachusetts Institute of Technology study published in April in Science Advances, researchers looked at engineered livers made from human donor cells and found more than 300 genes that operate on a circadian schedule, many with roles in drug metabolism. They also found that circadian patterns affected the toxicity of acetaminophen and atorvastatin. Identifying the time of day to take these drugs could maximize effectiveness and minimize adverse effects, the researchers said.
Timing and the Immune System
Circadian rhythms are also seen in immune processes. In a 2023 study in The Journal of Clinical Investigation of vaccine data from 1.5 million people in Israel, researchers found that children and older adults who got their second dose of the Pfizer mRNA COVID vaccine earlier in the day were about 36% less likely to be hospitalized with SARS-CoV-2 infection than those who got an evening shot.
“The sweet spot in our data was somewhere around late morning to late afternoon,” said lead researcher Jeffrey Haspel, MD, PhD, associate professor of medicine in the division of pulmonary and critical care medicine at Washington University School of Medicine in St. Louis.
In a multicenter, 2024 analysis of 13 studies of immunotherapy for advanced cancers in 1663 people, researchers found treatment earlier in the day was associated with longer survival time and longer survival without cancer progression.
“Patients with selected metastatic cancers seemed to largely benefit from early [time of day] infusions, which is consistent with circadian mechanisms in immune-cell functions and trafficking,” the researchers noted. But “retrospective randomized trials are needed to establish recommendations for optimal circadian timing.”
Other research suggests or is investigating possible chronotherapy benefits for depression, glaucoma, respiratory diseases, stroke treatment, epilepsy, and sedatives used in surgery. So why aren’t healthcare providers adding time of day to more prescriptions? “What’s missing is more reliable data,” Dr. Dyar said.
Should You Use Chronotherapy Now?
Experts emphasize that more research is needed before doctors use chronotherapy and before medical organizations include it in treatment recommendations. But for some patients, circadian dosing may be worth a try:
Night owls whose blood pressure isn’t well controlled. Dr. Dyar and Dr. Pigazzani said night-time blood pressure drugs may be helpful for people with a “late chronotype.” Of course, patients shouldn’t change their medication schedule on their own, they said. And doctors may want to consider other concerns, like more overnight bathroom visits with evening diuretics.
In their study, the researchers determined participants’ chronotype with a few questions from the Munich Chronotype Questionnaire about what time they fell asleep and woke up on workdays and days off and whether they considered themselves “morning types” or “evening types.” (The questions can be found in supplementary data for the study.)
If a physician thinks matching the timing of a dose with chronotype would help, they can consider it, Dr. Pigazzani said. “However, I must add that this was an observational study, so I would advise healthcare practitioners to wait for our data to be confirmed in new RCTs of personalized chronotherapy of hypertension.”
Children and older adults getting vaccines. Timing COVID shots and possibly other vaccines from late morning to mid-afternoon could have a small benefit for individuals and a bigger public-health benefit, Dr. Haspel said. But the most important thing is getting vaccinated. “If you can only get one in the evening, it’s still worthwhile. Timing may add oomph at a public-health level for more vulnerable groups.”
A version of this article appeared on Medscape.com.
Do drugs work better if taken by the clock?
A new analysis published in The Lancet journal’s eClinicalMedicine suggests: Yes, they do — if you consider the patient’s individual body clock. The study is the first to find that timing blood pressure drugs to a person’s personal “chronotype” — that is, whether they are a night owl or an early bird — may reduce the risk for a heart attack.
The findings represent a significant advance in the field of circadian medicine or “chronotherapy” — timing drug administration to circadian rhythms. A growing stack of research suggests this approach could reduce side effects and improve the effectiveness of a wide range of therapies, including vaccines, cancer treatments, and drugs for depression, glaucoma, pain, seizures, and other conditions. Still, despite decades of research, time of day is rarely considered in writing prescriptions.
“We are really just at the beginning of an exciting new way of looking at patient care,” said Kenneth A. Dyar, PhD, whose lab at Helmholtz Zentrum München’s Institute for Diabetes and Cancer focuses on metabolic physiology. Dr. Dyar is co-lead author of the new blood pressure analysis.
“Chronotherapy is a rapidly growing field,” he said, “and I suspect we are soon going to see more and more studies focused on ‘personalized chronotherapy,’ not only in hypertension but also potentially in other clinical areas.”
The ‘Missing Piece’ in Chronotherapy Research
Blood pressure drugs have long been chronotherapy’s battleground. After all, blood pressure follows a circadian rhythm, peaking in the morning and dropping at night.
That healthy overnight dip can disappear in people with diabetes, kidney disease, and obstructive sleep apnea. Some physicians have suggested a bed-time dose to restore that dip. But studies have had mixed results, so “take at bedtime” has become a less common recommendation in recent years.
But the debate continued. After a large 2019 Spanish study found that bedtime doses had benefits so big that the results drew questions, an even larger, 2022 randomized, controlled trial from the University of Dundee in Dundee, Scotland — called the TIME study — aimed to settle the question.
Researchers assigned over 21,000 people to take morning or night hypertension drugs for several years and found no difference in cardiovascular outcomes.
“We did this study thinking nocturnal blood pressure tablets might be better,” said Thomas MacDonald, MD, professor emeritus of clinical pharmacology and pharmacoepidemiology at the University of Dundee and principal investigator for the TIME study and the recent chronotype analysis. “But there was no difference for heart attacks, strokes, or vascular death.”
So, the researchers then looked at participants’ chronotypes, sorting outcomes based on whether the participants were late-to-bed, late-to-rise “night owls” or early-to-bed, early-to-rise “morning larks.”
Their analysis of these 5358 TIME participants found the following results: Risk for hospitalization for a heart attack was at least 34% lower for “owls” who took their drugs at bedtime. By contrast, owls’ heart attack risk was at least 62% higher with morning doses. For “larks,” the opposite was true. Morning doses were associated with an 11% lower heart attack risk and night doses with an 11% higher risk, according to supplemental data.
The personalized approach could explain why some previous chronotherapy studies have failed to show a benefit. Those studies did not individualize drug timing as this one did. But personalization could be key to circadian medicine’s success.
“Our ‘internal personal time’ appears to be an important variable to consider when dosing antihypertensives,” said co-lead author Filippo Pigazzani, MD, PhD, clinical senior lecturer and honorary consultant cardiologist at the University of Dundee School of Medicine. “Chronotherapy research has been going on for decades. We knew there was something important with time of day. But researchers haven’t considered the internal time of individual people. I think that is the missing piece.”
The analysis has several important limitations, the researchers said. A total of 95% of participants were White. And it was an observational study, not a true randomized comparison. “We started it late in the original TIME study,” Dr. MacDonald said. “You could argue we were reporting on those who survived long enough to get into the analysis.” More research is needed, they concluded.
Looking Beyond Blood Pressure
What about the rest of the body? “Almost all the cells of our body contain ‘circadian clocks’ that are synchronized by daily environmental cues, including light-dark, activity-rest, and feeding-fasting cycles,” said Dr. Dyar.
An estimated 50% of prescription drugs hit targets in the body that have circadian patterns. So, experts suspect that syncing a drug with a person’s body clock might increase effectiveness of many drugs.
A handful of US Food and Drug Administration–approved drugs already have time-of-day recommendations on the label for effectiveness or to limit side effects, including bedtime or evening for the insomnia drug Ambien, the HIV antiviral Atripla, and cholesterol-lowering Zocor. Others are intended to be taken with or after your last meal of the day, such as the long-acting insulin Levemir and the cardiovascular drug Xarelto. A morning recommendation comes with the proton pump inhibitor Nexium and the attention-deficit/hyperactivity disorder drug Ritalin.
Interest is expanding. About one third of the papers published about chronotherapy in the past 25 years have come out in the past 5 years. The May 2024 meeting of the Society for Research on Biological Rhythms featured a day-long session aimed at bringing clinicians up to speed. An organization called the International Association of Circadian Health Clinics is trying to bring circadian medicine findings to clinicians and their patients and to support research.
Moreover, while recent research suggests minding the clock could have benefits for a wide range of treatments, ignoring it could cause problems.
In a Massachusetts Institute of Technology study published in April in Science Advances, researchers looked at engineered livers made from human donor cells and found more than 300 genes that operate on a circadian schedule, many with roles in drug metabolism. They also found that circadian patterns affected the toxicity of acetaminophen and atorvastatin. Identifying the time of day to take these drugs could maximize effectiveness and minimize adverse effects, the researchers said.
Timing and the Immune System
Circadian rhythms are also seen in immune processes. In a 2023 study in The Journal of Clinical Investigation of vaccine data from 1.5 million people in Israel, researchers found that children and older adults who got their second dose of the Pfizer mRNA COVID vaccine earlier in the day were about 36% less likely to be hospitalized with SARS-CoV-2 infection than those who got an evening shot.
“The sweet spot in our data was somewhere around late morning to late afternoon,” said lead researcher Jeffrey Haspel, MD, PhD, associate professor of medicine in the division of pulmonary and critical care medicine at Washington University School of Medicine in St. Louis.
In a multicenter, 2024 analysis of 13 studies of immunotherapy for advanced cancers in 1663 people, researchers found treatment earlier in the day was associated with longer survival time and longer survival without cancer progression.
“Patients with selected metastatic cancers seemed to largely benefit from early [time of day] infusions, which is consistent with circadian mechanisms in immune-cell functions and trafficking,” the researchers noted. But “retrospective randomized trials are needed to establish recommendations for optimal circadian timing.”
Other research suggests or is investigating possible chronotherapy benefits for depression, glaucoma, respiratory diseases, stroke treatment, epilepsy, and sedatives used in surgery. So why aren’t healthcare providers adding time of day to more prescriptions? “What’s missing is more reliable data,” Dr. Dyar said.
Should You Use Chronotherapy Now?
Experts emphasize that more research is needed before doctors use chronotherapy and before medical organizations include it in treatment recommendations. But for some patients, circadian dosing may be worth a try:
Night owls whose blood pressure isn’t well controlled. Dr. Dyar and Dr. Pigazzani said night-time blood pressure drugs may be helpful for people with a “late chronotype.” Of course, patients shouldn’t change their medication schedule on their own, they said. And doctors may want to consider other concerns, like more overnight bathroom visits with evening diuretics.
In their study, the researchers determined participants’ chronotype with a few questions from the Munich Chronotype Questionnaire about what time they fell asleep and woke up on workdays and days off and whether they considered themselves “morning types” or “evening types.” (The questions can be found in supplementary data for the study.)
If a physician thinks matching the timing of a dose with chronotype would help, they can consider it, Dr. Pigazzani said. “However, I must add that this was an observational study, so I would advise healthcare practitioners to wait for our data to be confirmed in new RCTs of personalized chronotherapy of hypertension.”
Children and older adults getting vaccines. Timing COVID shots and possibly other vaccines from late morning to mid-afternoon could have a small benefit for individuals and a bigger public-health benefit, Dr. Haspel said. But the most important thing is getting vaccinated. “If you can only get one in the evening, it’s still worthwhile. Timing may add oomph at a public-health level for more vulnerable groups.”
A version of this article appeared on Medscape.com.
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All rights reserved. This material may not be published, broadcast, copied, or otherwise reproduced or distributed without the prior written permission of Frontline Medical Communications Inc.</copyrightNotice> </rightsInfo> </provider> <abstract/> <metaDescription>Do drugs work better if taken by the clock?</metaDescription> <articlePDF/> <teaserImage/> <teaser>More research showed circadian medicine — timing drug-taking to one’s body clock — could reduce side effects and improve the effectiveness of a wide range of therapies.</teaser> <title>Chronotherapy: Why Timing Drugs to Our Body Clocks May Work</title> <deck/> <disclaimer/> <AuthorList/> <articleURL/> <doi/> <pubMedID/> <publishXMLStatus/> <publishXMLVersion>1</publishXMLVersion> <useEISSN>0</useEISSN> <urgency/> <pubPubdateYear/> <pubPubdateMonth/> <pubPubdateDay/> <pubVolume/> <pubNumber/> <wireChannels/> <primaryCMSID/> <CMSIDs/> <keywords/> <seeAlsos/> <publications_g> <publicationData> <publicationCode>im</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> </publicationData> <publicationData> <publicationCode>card</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> </publicationData> <publicationData> <publicationCode>chph</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> </publicationData> <publicationData> <publicationCode>cpn</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> </publicationData> <publicationData> <publicationCode>fp</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> </publicationData> <publicationData> <publicationCode>mdid</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> </publicationData> <publicationData> <publicationCode>nr</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> <journalTitle>Neurology Reviews</journalTitle> <journalFullTitle>Neurology Reviews</journalFullTitle> <copyrightStatement>2018 Frontline Medical Communications Inc.,</copyrightStatement> </publicationData> <publicationData> <publicationCode>rn</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> </publicationData> <publicationData> <publicationCode>pn</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> </publicationData> <publicationData> <publicationCode>oncr</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> </publicationData> <publicationData> <publicationCode>endo</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> </publicationData> <publicationData> <publicationCode>GIHOLD</publicationCode> <pubIssueName>January 2014</pubIssueName> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> <journalTitle/> <journalFullTitle/> <copyrightStatement/> </publicationData> </publications_g> <publications> <term>21</term> <term canonical="true">5</term> <term>6</term> <term>9</term> <term>15</term> <term>51892</term> <term>22</term> <term>26</term> <term>25</term> <term>31</term> <term>34</term> </publications> <sections> <term canonical="true">27980</term> <term>39313</term> </sections> <topics> <term>194</term> <term>296</term> <term>258</term> <term>255</term> <term>263</term> <term>268</term> <term>248</term> <term>311</term> <term>284</term> <term canonical="true">229</term> <term>175</term> <term>202</term> <term>211</term> <term>232</term> <term>205</term> </topics> <links/> </header> <itemSet> <newsItem> <itemMeta> <itemRole>Main</itemRole> <itemClass>text</itemClass> <title>Chronotherapy: Why Timing Drugs to Our Body Clocks May Work</title> <deck/> </itemMeta> <itemContent> <p>Do drugs work better if taken by the clock?</p> <p>A new <span class="Hyperlink"><a href="https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(24)00212-8/fulltext">analysis</a> </span>published in <em>The Lancet</em> journal’s <em>eClinicalMedicine</em> suggests: Yes, they do — if you consider the patient’s individual body clock. The study is the first to find that timing blood pressure drugs to a person’s personal “chronotype” — that is, whether they are a night owl or an early bird — may reduce the risk for a heart attack.<br/><br/>The findings represent a significant advance in the field of circadian medicine or “chronotherapy” — timing drug administration to circadian rhythms. A growing stack of research suggests this approach could reduce side effects and improve the effectiveness of a wide range of therapies, including vaccines, cancer treatments, and drugs for depression, glaucoma, pain, seizures, and other conditions. Still, despite decades of research, time of day is <span class="Hyperlink"><a href="https://www.science.org/doi/abs/10.1126/science.aax7621">rarely considered</a></span> in writing prescriptions.<br/><br/>“We are really just at the beginning of an exciting new way of looking at patient care,” said <span class="Hyperlink"><a href="https://www.helmholtz-munich.de/en/idc/pi/kenneth-dyar">Kenneth A. Dyar</a></span>, PhD, whose lab at Helmholtz Zentrum München’s Institute for Diabetes and Cancer focuses on metabolic physiology. Dr. Dyar is co-lead author of the new blood pressure analysis.<br/><br/>“Chronotherapy is a rapidly growing field,” he said, “and I suspect we are soon going to see more and more studies focused on ‘personalized chronotherapy,’ not only in hypertension but also potentially in other clinical areas.”<br/><br/></p> <h2>The ‘Missing Piece’ in Chronotherapy Research</h2> <p>Blood pressure drugs have long been chronotherapy’s battleground. After all, blood pressure follows a circadian rhythm, peaking in the morning and dropping at night.</p> <p>That healthy overnight dip can disappear in people with <span class="Hyperlink"><a href="https://www.tandfonline.com/doi/full/10.1080/08037051.2019.1615369">diabetes</a></span>, <span class="Hyperlink"><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6231441/">kidney disease</a></span>, and <span class="Hyperlink"><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6780266/">obstructive sleep apnea</a></span>. Some physicians have suggested a bed-time dose to restore that dip. But studies have had <span class="Hyperlink"><a href="https://pubmed.ncbi.nlm.nih.gov/35983870/">mixed results</a></span>, so “take at bedtime” has become a <span class="Hyperlink"><a href="https://pubmed.ncbi.nlm.nih.gov/36448463/">less common</a></span> recommendation in recent years.<br/><br/>But the debate continued. After a large 2019 Spanish <span class="Hyperlink"><a href="https://pubmed.ncbi.nlm.nih.gov/31641769/">study</a></span> found that bedtime doses had benefits so big that the results <span class="Hyperlink"><a href="https://www.ahajournals.org/doi/10.1161/HYPERTENSIONAHA.121.16501">drew questions</a></span>, an even larger, 2022 randomized, controlled <span class="Hyperlink"><a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)01786-X/fulltext">trial</a></span> from the University of Dundee in Dundee, Scotland — called the TIME study — aimed to settle the question.<br/><br/>Researchers assigned over 21,000 people to take morning or night hypertension drugs for several years and found no difference in cardiovascular outcomes.<br/><br/>“We did this study thinking nocturnal blood pressure tablets might be better,” said <span class="Hyperlink"><a href="https://discovery.dundee.ac.uk/en/persons/thomas-macdonald">Thomas MacDonald</a></span>, MD, professor emeritus of clinical pharmacology and pharmacoepidemiology at the University of Dundee and principal investigator for the TIME study and the recent chronotype analysis. “But there was no difference for heart attacks, strokes, or vascular death.”<br/><br/>So, the researchers then looked at participants’ chronotypes, sorting outcomes based on whether the participants were late-to-bed, late-to-rise “night owls” or early-to-bed, early-to-rise “morning larks.”<br/><br/>Their analysis of these 5358 TIME participants found the following results: Risk for hospitalization for a heart attack was at least 34% lower for “owls” who took their drugs at bedtime. By contrast, owls’ heart attack risk was at least 62% higher with morning doses. For “larks,” the opposite was true. Morning doses were associated with an 11% lower heart attack risk and night doses with an 11% higher risk, according to supplemental data.<br/><br/>The personalized approach could explain why some previous chronotherapy studies have failed to show a benefit. Those studies did not individualize drug timing as this one did. But personalization could be key to circadian medicine’s success.<br/><br/>“Our ‘internal personal time’ appears to be an important variable to consider when dosing antihypertensives,” said co-lead author <span class="Hyperlink"><a href="https://discovery.dundee.ac.uk/en/persons/filippo-pigazzani">Filippo Pigazzani</a></span>, MD, PhD, clinical senior lecturer and honorary consultant cardiologist at the University of Dundee School of Medicine. “Chronotherapy research has been going on for decades. We knew there was something important with time of day. But researchers haven’t considered the internal time of individual people. I think that is the missing piece.”<br/><br/>The analysis has several important limitations, the researchers said. A total of 95% of participants were White. And it was an observational study, not a true randomized comparison. “We started it late in the original TIME study,” Dr. MacDonald said. “You could argue we were reporting on those who survived long enough to get into the analysis.” More research is needed, they concluded.<br/><br/></p> <h2>Looking Beyond Blood Pressure</h2> <p>What about the rest of the body? “Almost all the cells of our body contain ‘circadian clocks’ that are synchronized by daily environmental cues, including light-dark, activity-rest, and feeding-fasting cycles,” said Dr. Dyar.</p> <p>An estimated <span class="Hyperlink"><a href="https://journals.plos.org/ploscompbiol/article?id=10.1371/journal.pcbi.1011779">50</a></span>% of prescription drugs hit targets in the body that have circadian patterns. So, experts suspect that syncing a drug with a person’s body clock might increase effectiveness of many drugs.<br/><br/>A <span class="Hyperlink"><a href="https://journals.sagepub.com/doi/full/10.1177/0748730419892099">handful of US Food and Drug Administration–approved drugs</a></span> already have time-of-day recommendations on the label for effectiveness or to limit side effects, including bedtime or evening for the insomnia drug Ambien, the HIV antiviral Atripla, and cholesterol-lowering Zocor. Others are intended to be taken with or after your last meal of the day, such as the long-acting insulin Levemir and the cardiovascular drug Xarelto. A morning recommendation comes with the proton pump inhibitor Nexium and the attention-deficit/hyperactivity disorder drug Ritalin.<br/><br/>Interest is expanding. About one third of the papers published about chronotherapy in the past 25 years have come out in the past 5 years. The May 2024 meeting of the <span class="Hyperlink"><a href="https://srbr.org/2024-biennial-meeting/">Society for Research on Biological Rhythms</a></span> featured a day-long session aimed at bringing clinicians up to speed. An organization called the <span class="Hyperlink"><a href="https://circadianhealthclinics.com/">International Association of Circadian Health Clinics</a></span> is trying to bring circadian medicine findings to clinicians and their patients and to support research.<br/><br/>Moreover, while recent research suggests minding the clock could have benefits for a wide range of treatments, ignoring it could cause problems.<br/><br/>In a Massachusetts Institute of Technology <span class="Hyperlink"><a href="https://www.science.org/doi/10.1126/sciadv.adm9281">study</a></span> published in April in Science Advances, researchers looked at engineered livers made from human donor cells and found more than 300 genes that operate on a circadian schedule, many with roles in drug metabolism. They also found that circadian patterns affected the toxicity of acetaminophen and atorvastatin. Identifying the time of day to take these drugs could maximize effectiveness and minimize adverse effects, the researchers <span class="Hyperlink">said</span>.<br/><br/></p> <h2>Timing and the Immune System</h2> <p>Circadian rhythms are also seen in immune processes. In a <span class="Hyperlink"><a href="https://www.jci.org/articles/view/167339">2023 study</a></span> in <em>The Journal of Clinical Investigation</em> of vaccine data from 1.5 million people in Israel, researchers found that children and older adults who got their second dose of the Pfizer mRNA COVID vaccine earlier in the day were about 36% less likely to be hospitalized with SARS-CoV-2 infection than those who got an evening shot.</p> <p>“The sweet spot in our data was somewhere around late morning to late afternoon,” said lead researcher <span class="Hyperlink"><a href="https://pulmonary.wustl.edu/people/jeff-haspel-md-phd/">Jeffrey Haspel</a></span>, MD, PhD, associate professor of medicine in the division of pulmonary and critical care medicine at Washington University School of Medicine in St. Louis.<br/><br/>In a multicenter, 2024 <span class="Hyperlink"><a href="https://www.esmoopen.com/article/S2059-7029(23)01461-8/fulltext">analysis</a></span> of 13 studies of immunotherapy for advanced cancers in 1663 people, researchers found treatment earlier in the day was associated with longer survival time and longer survival without cancer progression.<br/><br/>“Patients with selected metastatic cancers seemed to largely benefit from early [time of day] infusions, which is consistent with circadian mechanisms in immune-cell functions and trafficking,” the researchers noted. But “retrospective randomized trials are needed to establish recommendations for optimal circadian timing.”<br/><br/>Other research suggests or is investigating possible chronotherapy benefits for <span class="Hyperlink"><a href="https://pubmed.ncbi.nlm.nih.gov/38171633/">depression</a></span>, <span class="Hyperlink"><a href="https://pubmed.ncbi.nlm.nih.gov/38431563/">glaucoma</a></span>, <span class="Hyperlink"><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8704788/">respiratory diseases</a></span>, <span class="Hyperlink"><a href="https://pubmed.ncbi.nlm.nih.gov/38484031/">stroke treatment</a></span>, <span class="Hyperlink"><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9197224/">epilepsy</a></span>, and <span class="Hyperlink"><a href="https://www.frontiersin.org/articles/10.3389/fcvm.2022.982209/full">sedatives used in surgery</a></span>. So why aren’t healthcare providers adding time of day to more prescriptions? “What’s missing is more reliable data,” Dr. Dyar said.<br/><br/></p> <h2>Should You Use Chronotherapy Now?</h2> <p>Experts emphasize that more research is needed before doctors use chronotherapy and before medical organizations include it in treatment recommendations. But for some patients, circadian dosing may be worth a try:</p> <p><strong>Night owls whose blood pressure isn’t well controlled.</strong> Dr. Dyar and Dr. Pigazzani said night-time blood pressure drugs may be helpful for people with a “late chronotype.” Of course, patients shouldn’t change their medication schedule on their own, they said. And doctors may want to consider other concerns, like more overnight bathroom visits with evening diuretics.<br/><br/>In their study, the researchers determined participants’ chronotype with a few questions from the <span class="Hyperlink"><a href="https://journals.sagepub.com/doi/10.1177/0748730419886986">Munich Chronotype Questionnaire</a></span> about what time they fell asleep and woke up on workdays and days off and whether they considered themselves “morning types” or “evening types.” (The questions can be found in supplementary data for the study.)<br/><br/>If a physician thinks matching the timing of a dose with chronotype would help, they can consider it, Dr. Pigazzani said. “However, I must add that this was an observational study, so I would advise healthcare practitioners to wait for our data to be confirmed in new RCTs of personalized chronotherapy of hypertension.”<br/><br/><strong>Children and older adults getting vaccines.</strong> Timing COVID shots and possibly other vaccines from late morning to mid-afternoon could have a small benefit for individuals and a bigger public-health benefit, Dr. Haspel said. But the most important thing is getting vaccinated. “If you can only get one in the evening, it’s still worthwhile. Timing may add oomph at a public-health level for more vulnerable groups.”<br/><br/></p> <p> <em>A version of this article appeared on <span class="Hyperlink"><a href="https://www.medscape.com/viewarticle/chronotherapy-why-timing-drugs-our-body-clocks-may-work-2024a1000at3">Medscape.com</a></span>.</em> </p> </itemContent> </newsItem> <newsItem> <itemMeta> <itemRole>teaser</itemRole> <itemClass>text</itemClass> <title/> <deck/> </itemMeta> <itemContent> </itemContent> </newsItem> </itemSet></root>
Antidepressants and Dementia Risk: New Data
TOPLINE:
Taking antidepressants in midlife was not associated with an increased risk of subsequent Alzheimer’s disease (AD) or AD-related dementias (ADRD), data from a large prospective study of US veterans show.
METHODOLOGY:
- Investigators analyzed data from 35,200 US veterans aged ≥ 55 years diagnosed with major depressive disorder from January 1, 2000, to June 1, 2022, and followed them for ≤ 20 years to track subsequent AD/ADRD diagnoses.
- Health information was pulled from electronic health records of the Veterans Health Administration (VHA) Corporate Data Warehouse, and veterans had to be at the VHA for ≥ 1 year before diagnosis.
- Participants were considered to be exposed to an antidepressant when a prescription lasted ≥ 3 months.
TAKEAWAY:
- A total of 32,500 individuals were diagnosed with MDD. The mean age was 65 years, and 91% were men. 17,000 patients received antidepressants for a median duration of 4 years. Median follow-up time was 3.2 years.
- There was no significant association between antidepressant exposure and the risk for AD/ADRD (events = 1056; hazard ratio, 0.93; 95% CI, 0.80-1.08) vs no exposure.
- In a subgroup analysis, investigators found no significant link between different classes of antidepressants and dementia risk. These included selective serotonin reuptake inhibitors, norepinephrine and dopamine reuptake inhibitors, and serotonin-norepinephrine reuptake inhibitors.
- Investigators emphasized the need for further research, particularly in populations with a larger representation of female patients.
IN PRACTICE:
“A possibility for the conflicting results in retrospective studies is that the heightened risk identified in participants on antidepressants may be attributed to depression itself, rather than the result of a potential pharmacological action. So, this and other clinical confounding factors need to be taken into account,” the investigators noted.
SOURCE:
The study was led by Jaime Ramos-Cejudo, PhD, VA Boston Healthcare System, Boston. It was published online May 8 in Alzheimer’s & Dementia.
LIMITATIONS:
The cohort’s relatively young age limited the number of dementia cases captured. Data from supplemental insurance, including Medicare, were not included, potentially limiting outcome capture.
DISCLOSURES:
The study was supported by the National Institutes of Health and the National Alzheimer’s Coordinating Center. The authors declared no conflicts of interest.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.
A version of this article appeared on Medscape.com.
TOPLINE:
Taking antidepressants in midlife was not associated with an increased risk of subsequent Alzheimer’s disease (AD) or AD-related dementias (ADRD), data from a large prospective study of US veterans show.
METHODOLOGY:
- Investigators analyzed data from 35,200 US veterans aged ≥ 55 years diagnosed with major depressive disorder from January 1, 2000, to June 1, 2022, and followed them for ≤ 20 years to track subsequent AD/ADRD diagnoses.
- Health information was pulled from electronic health records of the Veterans Health Administration (VHA) Corporate Data Warehouse, and veterans had to be at the VHA for ≥ 1 year before diagnosis.
- Participants were considered to be exposed to an antidepressant when a prescription lasted ≥ 3 months.
TAKEAWAY:
- A total of 32,500 individuals were diagnosed with MDD. The mean age was 65 years, and 91% were men. 17,000 patients received antidepressants for a median duration of 4 years. Median follow-up time was 3.2 years.
- There was no significant association between antidepressant exposure and the risk for AD/ADRD (events = 1056; hazard ratio, 0.93; 95% CI, 0.80-1.08) vs no exposure.
- In a subgroup analysis, investigators found no significant link between different classes of antidepressants and dementia risk. These included selective serotonin reuptake inhibitors, norepinephrine and dopamine reuptake inhibitors, and serotonin-norepinephrine reuptake inhibitors.
- Investigators emphasized the need for further research, particularly in populations with a larger representation of female patients.
IN PRACTICE:
“A possibility for the conflicting results in retrospective studies is that the heightened risk identified in participants on antidepressants may be attributed to depression itself, rather than the result of a potential pharmacological action. So, this and other clinical confounding factors need to be taken into account,” the investigators noted.
SOURCE:
The study was led by Jaime Ramos-Cejudo, PhD, VA Boston Healthcare System, Boston. It was published online May 8 in Alzheimer’s & Dementia.
LIMITATIONS:
The cohort’s relatively young age limited the number of dementia cases captured. Data from supplemental insurance, including Medicare, were not included, potentially limiting outcome capture.
DISCLOSURES:
The study was supported by the National Institutes of Health and the National Alzheimer’s Coordinating Center. The authors declared no conflicts of interest.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.
A version of this article appeared on Medscape.com.
TOPLINE:
Taking antidepressants in midlife was not associated with an increased risk of subsequent Alzheimer’s disease (AD) or AD-related dementias (ADRD), data from a large prospective study of US veterans show.
METHODOLOGY:
- Investigators analyzed data from 35,200 US veterans aged ≥ 55 years diagnosed with major depressive disorder from January 1, 2000, to June 1, 2022, and followed them for ≤ 20 years to track subsequent AD/ADRD diagnoses.
- Health information was pulled from electronic health records of the Veterans Health Administration (VHA) Corporate Data Warehouse, and veterans had to be at the VHA for ≥ 1 year before diagnosis.
- Participants were considered to be exposed to an antidepressant when a prescription lasted ≥ 3 months.
TAKEAWAY:
- A total of 32,500 individuals were diagnosed with MDD. The mean age was 65 years, and 91% were men. 17,000 patients received antidepressants for a median duration of 4 years. Median follow-up time was 3.2 years.
- There was no significant association between antidepressant exposure and the risk for AD/ADRD (events = 1056; hazard ratio, 0.93; 95% CI, 0.80-1.08) vs no exposure.
- In a subgroup analysis, investigators found no significant link between different classes of antidepressants and dementia risk. These included selective serotonin reuptake inhibitors, norepinephrine and dopamine reuptake inhibitors, and serotonin-norepinephrine reuptake inhibitors.
- Investigators emphasized the need for further research, particularly in populations with a larger representation of female patients.
IN PRACTICE:
“A possibility for the conflicting results in retrospective studies is that the heightened risk identified in participants on antidepressants may be attributed to depression itself, rather than the result of a potential pharmacological action. So, this and other clinical confounding factors need to be taken into account,” the investigators noted.
SOURCE:
The study was led by Jaime Ramos-Cejudo, PhD, VA Boston Healthcare System, Boston. It was published online May 8 in Alzheimer’s & Dementia.
LIMITATIONS:
The cohort’s relatively young age limited the number of dementia cases captured. Data from supplemental insurance, including Medicare, were not included, potentially limiting outcome capture.
DISCLOSURES:
The study was supported by the National Institutes of Health and the National Alzheimer’s Coordinating Center. The authors declared no conflicts of interest.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.
A version of this article appeared on Medscape.com.
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<root generator="drupal.xsl" gversion="1.7"> <header> <fileName>168355</fileName> <TBEID>0C050797.SIG</TBEID> <TBUniqueIdentifier>MD_0C050797</TBUniqueIdentifier> <newsOrJournal>News</newsOrJournal> <publisherName>Frontline Medical Communications</publisherName> <storyname/> <articleType>2</articleType> <TBLocation>QC Done-All Pubs</TBLocation> <QCDate>20240610T150537</QCDate> <firstPublished>20240610T154831</firstPublished> <LastPublished>20240610T154831</LastPublished> <pubStatus qcode="stat:"/> <embargoDate/> <killDate/> <CMSDate>20240610T154831</CMSDate> <articleSource/> <facebookInfo/> <meetingNumber/> <byline>Eve Bender</byline> <bylineText>EDITED EVE BENDER</bylineText> <bylineFull>EDITED EVE BENDER</bylineFull> <bylineTitleText/> <USOrGlobal/> <wireDocType/> <newsDocType/> <journalDocType/> <linkLabel/> <pageRange/> <citation/> <quizID/> <indexIssueDate/> <itemClass qcode="ninat:text"/> <provider qcode="provider:imng"> <name>IMNG Medical Media</name> <rightsInfo> <copyrightHolder> <name>Frontline Medical News</name> </copyrightHolder> <copyrightNotice>Copyright (c) 2015 Frontline Medical News, a Frontline Medical Communications Inc. company. All rights reserved. This material may not be published, broadcast, copied, or otherwise reproduced or distributed without the prior written permission of Frontline Medical Communications Inc.</copyrightNotice> </rightsInfo> </provider> <abstract/> <metaDescription>Taking antidepressants in midlife was not associated with an increased risk of subsequent Alzheimer’s disease (AD) or AD-related dementias (ADRD), data from a l</metaDescription> <articlePDF/> <teaserImage/> <teaser>Taking antidepressants in midlife was not associated with an increased risk of subsequent Alzheimer’s disease or dementia.</teaser> <title>Antidepressants and Dementia Risk: New Data</title> <deck/> <disclaimer/> <AuthorList/> <articleURL/> <doi/> <pubMedID/> <publishXMLStatus/> <publishXMLVersion>1</publishXMLVersion> <useEISSN>0</useEISSN> <urgency/> <pubPubdateYear/> <pubPubdateMonth/> <pubPubdateDay/> <pubVolume/> <pubNumber/> <wireChannels/> <primaryCMSID/> <CMSIDs/> <keywords/> <seeAlsos/> <publications_g> <publicationData> <publicationCode>cpn</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> </publicationData> <publicationData> <publicationCode>fp</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> </publicationData> <publicationData> <publicationCode>im</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> </publicationData> <publicationData> <publicationCode>mdneuro</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> <journalTitle/> <journalFullTitle/> <copyrightStatement>2018 Frontline Medical Communications Inc.,</copyrightStatement> </publicationData> </publications_g> <publications> <term>9</term> <term>15</term> <term>21</term> <term canonical="true">51946</term> </publications> <sections> <term>27970</term> <term canonical="true">39313</term> </sections> <topics> <term canonical="true">180</term> <term>64517</term> <term>202</term> <term>248</term> </topics> <links/> </header> <itemSet> <newsItem> <itemMeta> <itemRole>Main</itemRole> <itemClass>text</itemClass> <title>Antidepressants and Dementia Risk: New Data</title> <deck/> </itemMeta> <itemContent> <h2>TOPLINE:</h2> <p>Taking antidepressants in midlife was not associated with an increased risk of subsequent Alzheimer’s disease (AD) or AD-related dementias (ADRD), data from a large prospective study of US veterans show.</p> <h2>METHODOLOGY:</h2> <ul class="body"> <li>Investigators analyzed data from 35,200 US veterans aged ≥ 55 years diagnosed with major depressive disorder from January 1, 2000, to June 1, 2022, and followed them for ≤ 20 years to track subsequent AD/ADRD diagnoses.</li> <li>Health information was pulled from electronic health records of the Veterans Health Administration (VHA) Corporate Data Warehouse, and veterans had to be at the VHA for ≥ 1 year before diagnosis.</li> <li>Participants were considered to be exposed to an antidepressant when a prescription lasted ≥ 3 months.</li> </ul> <h2>TAKEAWAY:</h2> <ul class="body"> <li>A total of 32,500 individuals were diagnosed with MDD. The mean age was 65 years, and 91% were men. 17,000 patients received antidepressants for a median duration of 4 years. Median follow-up time was 3.2 years.</li> <li>There was no significant association between antidepressant exposure and the risk for AD/ADRD (events = 1056; hazard ratio, 0.93; 95% CI, 0.80-1.08) vs no exposure.</li> <li>In a subgroup analysis, investigators found no significant link between different classes of antidepressants and dementia risk. These included selective serotonin reuptake inhibitors, norepinephrine and dopamine reuptake inhibitors, and serotonin-norepinephrine reuptake inhibitors.</li> <li>Investigators emphasized the need for further research, particularly in populations with a larger representation of female patients.</li> </ul> <h2>IN PRACTICE:</h2> <p>“A possibility for the conflicting results in retrospective studies is that the heightened risk identified in participants on antidepressants may be attributed to depression itself, rather than the result of a potential pharmacological action. So, this and other clinical confounding factors need to be taken into account,” the investigators noted.</p> <h2>SOURCE:</h2> <p>The study was led by Jaime Ramos-Cejudo, PhD, VA Boston Healthcare System, Boston. It was <a href="https://alz-journals.onlinelibrary.wiley.com/doi/full/10.1002/alz.13853">published online</a> May 8 in <em>Alzheimer’s & Dementia</em>.</p> <h2>LIMITATIONS:</h2> <p>The cohort’s relatively young age limited the number of dementia cases captured. Data from supplemental insurance, including Medicare, were not included, potentially limiting outcome capture.</p> <h2>DISCLOSURES:</h2> <p>The study was supported by the National Institutes of Health and the National Alzheimer’s Coordinating Center. The authors declared no conflicts of interest.<span class="end"/></p> <p> <em>This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.</em> </p> <p> <em>A version of this article appeared on <span class="Hyperlink"><a href="https://www.medscape.com/viewarticle/antidepressants-and-dementia-risk-new-data-2024a1000asu?src=">Medscape.com</a></span>.</em> </p> </itemContent> </newsItem> <newsItem> <itemMeta> <itemRole>teaser</itemRole> <itemClass>text</itemClass> <title/> <deck/> </itemMeta> <itemContent> </itemContent> </newsItem> </itemSet></root>
PTSD Rates Soar Among College Students
TOPLINE:
Posttraumatic stress disorder (PTSD) rates among college students more than doubled between 2017 and 2022, new data showed. Rates of acute stress disorder (ASD) also increased during that time.
METHODOLOGY:
- Researchers conducted five waves of cross-sectional study from 2017 to 2022, involving 392,377 participants across 332 colleges and universities.
- The study utilized the Healthy Minds Study data, ensuring representativeness by applying sample weights based on institutional demographics.
- Outcome variables were diagnoses of PTSD and ASD, confirmed by healthcare practitioners, with statistical analysis assessing change in odds of estimated prevalence during 2017-2022.
TAKEAWAY:
- The prevalence of PTSD among US college students increased from 3.4% in 2017-2018 to 7.5% in 2021-2022.
- ASD diagnoses also rose from 0.2% in 2017-2018 to 0.7% in 2021-2022, with both increases remaining statistically significant after adjusting for demographic differences.
- Investigators noted that these findings underscore the need for targeted, trauma-informed intervention strategies in college settings.
IN PRACTICE:
“These trends highlight the escalating mental health challenges among college students, which is consistent with recent research reporting a surge in psychiatric diagnoses,” the authors wrote. “Factors contributing to this rise may include pandemic-related stressors (eg, loss of loved ones) and the effect of traumatic events (eg, campus shootings and racial trauma),” they added.
SOURCE:
The study was led by Yusen Zhai, PhD, University of Alabama at Birmingham. It was published online on May 30, 2024, in JAMA Network Open.
LIMITATIONS:
The study’s reliance on self-reported data and single questions for diagnosed PTSD and ASD may have limited the accuracy of the findings. The retrospective design and the absence of longitudinal follow-up may have restricted the ability to infer causality from the observed trends.
DISCLOSURES:
No disclosures were reported. No funding information was available.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.
A version of this article appeared on Medscape.com.
TOPLINE:
Posttraumatic stress disorder (PTSD) rates among college students more than doubled between 2017 and 2022, new data showed. Rates of acute stress disorder (ASD) also increased during that time.
METHODOLOGY:
- Researchers conducted five waves of cross-sectional study from 2017 to 2022, involving 392,377 participants across 332 colleges and universities.
- The study utilized the Healthy Minds Study data, ensuring representativeness by applying sample weights based on institutional demographics.
- Outcome variables were diagnoses of PTSD and ASD, confirmed by healthcare practitioners, with statistical analysis assessing change in odds of estimated prevalence during 2017-2022.
TAKEAWAY:
- The prevalence of PTSD among US college students increased from 3.4% in 2017-2018 to 7.5% in 2021-2022.
- ASD diagnoses also rose from 0.2% in 2017-2018 to 0.7% in 2021-2022, with both increases remaining statistically significant after adjusting for demographic differences.
- Investigators noted that these findings underscore the need for targeted, trauma-informed intervention strategies in college settings.
IN PRACTICE:
“These trends highlight the escalating mental health challenges among college students, which is consistent with recent research reporting a surge in psychiatric diagnoses,” the authors wrote. “Factors contributing to this rise may include pandemic-related stressors (eg, loss of loved ones) and the effect of traumatic events (eg, campus shootings and racial trauma),” they added.
SOURCE:
The study was led by Yusen Zhai, PhD, University of Alabama at Birmingham. It was published online on May 30, 2024, in JAMA Network Open.
LIMITATIONS:
The study’s reliance on self-reported data and single questions for diagnosed PTSD and ASD may have limited the accuracy of the findings. The retrospective design and the absence of longitudinal follow-up may have restricted the ability to infer causality from the observed trends.
DISCLOSURES:
No disclosures were reported. No funding information was available.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.
A version of this article appeared on Medscape.com.
TOPLINE:
Posttraumatic stress disorder (PTSD) rates among college students more than doubled between 2017 and 2022, new data showed. Rates of acute stress disorder (ASD) also increased during that time.
METHODOLOGY:
- Researchers conducted five waves of cross-sectional study from 2017 to 2022, involving 392,377 participants across 332 colleges and universities.
- The study utilized the Healthy Minds Study data, ensuring representativeness by applying sample weights based on institutional demographics.
- Outcome variables were diagnoses of PTSD and ASD, confirmed by healthcare practitioners, with statistical analysis assessing change in odds of estimated prevalence during 2017-2022.
TAKEAWAY:
- The prevalence of PTSD among US college students increased from 3.4% in 2017-2018 to 7.5% in 2021-2022.
- ASD diagnoses also rose from 0.2% in 2017-2018 to 0.7% in 2021-2022, with both increases remaining statistically significant after adjusting for demographic differences.
- Investigators noted that these findings underscore the need for targeted, trauma-informed intervention strategies in college settings.
IN PRACTICE:
“These trends highlight the escalating mental health challenges among college students, which is consistent with recent research reporting a surge in psychiatric diagnoses,” the authors wrote. “Factors contributing to this rise may include pandemic-related stressors (eg, loss of loved ones) and the effect of traumatic events (eg, campus shootings and racial trauma),” they added.
SOURCE:
The study was led by Yusen Zhai, PhD, University of Alabama at Birmingham. It was published online on May 30, 2024, in JAMA Network Open.
LIMITATIONS:
The study’s reliance on self-reported data and single questions for diagnosed PTSD and ASD may have limited the accuracy of the findings. The retrospective design and the absence of longitudinal follow-up may have restricted the ability to infer causality from the observed trends.
DISCLOSURES:
No disclosures were reported. No funding information was available.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.
A version of this article appeared on Medscape.com.
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All rights reserved. This material may not be published, broadcast, copied, or otherwise reproduced or distributed without the prior written permission of Frontline Medical Communications Inc.</copyrightNotice> </rightsInfo> </provider> <abstract/> <metaDescription>Posttraumatic stress disorder (PTSD) rates among college students more than doubled between 2017 and 2022, new data showed. Rates of acute stress disorder (ASD)</metaDescription> <articlePDF/> <teaserImage/> <title>PTSD Rates Soar Among College Students</title> <deck/> <disclaimer/> <AuthorList/> <articleURL/> <doi/> <pubMedID/> <publishXMLStatus/> <publishXMLVersion>1</publishXMLVersion> <useEISSN>0</useEISSN> <urgency/> <pubPubdateYear/> <pubPubdateMonth/> <pubPubdateDay/> <pubVolume/> <pubNumber/> <wireChannels/> <primaryCMSID/> <CMSIDs/> <keywords/> <seeAlsos/> <publications_g> <publicationData> <publicationCode>cpn</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> </publicationData> <publicationData> <publicationCode>fp</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> </publicationData> <publicationData> <publicationCode>im</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> </publicationData> </publications_g> <publications> <term canonical="true">9</term> <term>15</term> <term>21</term> </publications> <sections> <term canonical="true">39313</term> </sections> <topics> <term canonical="true">283</term> <term>248</term> <term>176</term> </topics> <links/> </header> <itemSet> <newsItem> <itemMeta> <itemRole>Main</itemRole> <itemClass>text</itemClass> <title>PTSD Rates Soar Among College Students</title> <deck/> </itemMeta> <itemContent> <h2>TOPLINE:</h2> <p>Posttraumatic stress disorder (PTSD) rates among college students more than doubled between 2017 and 2022, new data showed. Rates of acute stress disorder (ASD) also increased during that time.</p> <h2>METHODOLOGY:</h2> <ul class="body"> <li>Researchers conducted five waves of cross-sectional study from 2017 to 2022, involving 392,377 participants across 332 colleges and universities.</li> <li>The study utilized the Healthy Minds Study data, ensuring representativeness by applying sample weights based on institutional demographics.</li> <li>Outcome variables were diagnoses of PTSD and ASD, confirmed by healthcare practitioners, with statistical analysis assessing change in odds of estimated prevalence during 2017-2022.</li> </ul> <h2>TAKEAWAY:</h2> <ul class="body"> <li>The prevalence of PTSD among US college students increased from 3.4% in 2017-2018 to 7.5% in 2021-2022.</li> <li>ASD diagnoses also rose from 0.2% in 2017-2018 to 0.7% in 2021-2022, with both increases remaining statistically significant after adjusting for demographic differences.</li> <li>Investigators noted that these findings underscore the need for targeted, trauma-informed intervention strategies in college settings.</li> </ul> <h2>IN PRACTICE:</h2> <p>“These trends highlight the escalating mental health challenges among college students, which is consistent with recent research reporting a surge in psychiatric diagnoses,” the authors wrote. “Factors contributing to this rise may include pandemic-related stressors (eg, loss of loved ones) and the effect of traumatic events (eg, campus shootings and racial trauma),” they added.</p> <h2>SOURCE:</h2> <p>The study was led by Yusen Zhai, PhD, University of Alabama at Birmingham. It was <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2819206">published online</a> on May 30, 2024, in <em>JAMA Network Open</em>.</p> <h2>LIMITATIONS:</h2> <p>The study’s reliance on self-reported data and single questions for diagnosed PTSD and ASD may have limited the accuracy of the findings. The retrospective design and the absence of longitudinal follow-up may have restricted the ability to infer causality from the observed trends.</p> <h2>DISCLOSURES:</h2> <p>No disclosures were reported. No funding information was available.</p> <p>This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.</p> <p> <em>A version of this article appeared on <span class="Hyperlink"><a href="https://www.medscape.com/viewarticle/ptsd-rates-soar-among-college-students-2024a1000asl?src=">Medscape.com</a></span>.</em> </p> </itemContent> </newsItem> <newsItem> <itemMeta> <itemRole>teaser</itemRole> <itemClass>text</itemClass> <title/> <deck/> </itemMeta> <itemContent> <p>Posttraumatic stress disorder rates among college students more than doubled between 2017 and 2022.</p> </itemContent> </newsItem> </itemSet></root>