PTSD

Recent natural disasters, civil disorder, and the COVID-19 pandemic response created an unprecedented demand for the US National Guard and Reserve components as well as active-duty personnel to serve on homefront missions critical to our nation. At times, those serving in these capacities are front and center to the most tragic events confronting our nation, and they frequently encounter tremendous suffering.

Recognizing the potential for these missions to create psychological sequela for those who serve on them, the authority for the Veterans Health Administration (VHA) vet centers to provide readjustment counseling services was broadened on December 30, 2021. Vet centers are community-based counseling centers that have traditionally served combat veterans, and broadening services reflects a major change in mission. Revised VHA Directive 1500(2) specifies that those who “served on active duty in response to a national emergency or major disaster declared by the President” or “served on active duty in the National Guard of a State under orders of the chief executive of that State in response to a disaster or civil disorder in such State” may now receive therapy at vet centers.^1,2

As a result of this recent policy change, National Guard and active-duty Reserve service members now have parity with combat veterans to obtain therapy for symptoms arising as a result of their activation for service on homefront missions. As they seek care, we need to be ready so that these service members can obtain the best therapy services possible. Soldiers who served on homefront missions comprise a new cohort of service members now eligible for vet center therapy. Soldiers who served on homefront missions may present with issues that differ from those of combat veterans and veterans who have experienced military sexual trauma (MST), the populations treated by vet centers and other VHA mental health care clinics prior to this broadened authority. This article highlights some suggestions for service delivery to best meet the needs of this population.

Discussion 

Available evidence-based therapies to treat posttraumatic stress disorder (PTSD) are effective regardless of whether the trauma occurred in combat, on the homefront, or in a civilian setting. The vet centers and VHA mental health services already have staff trained to deliver these therapy modalities and, in this sense, are ready to provide trauma-focused therapy treatment to soldiers with PTSD who served on homefront missions.

The broadened authority for the vet centers to provide readjustment services is necessary, as it corrects for a critical gap in services, but the importance of ensuring adequate staffing to meet the expected increased demand for services cannot be underscored. According to clinical practice guidelines for the treatment of PTSD, developed by the US Department of Veterans Affairs (VA) and the US Department of Defense (DoD), the therapies with the strongest evidence-based backing are prolonged exposure-based therapy (PE), cognitive processing therapy (CPT), and eye movement and desensitization reprocessing (EMDR).³ These therapy modalities, based on findings from clinical trials, are predicated on seeing a client for a sufficient number of sessions. Attendance at these sessions is recommended at least weekly to ensure adequate intensity of service delivery.^4-7 According to the National Center for PTSD, PE typically involves 8 to 15 weekly or twice weekly sessions; CPT requires 8 to 14 or more weekly sessions, and EMDR is usually 4 to 12 weekly sessions.^4-7

Ensuring adequate staffing is critical to offer these therapies at least weekly as the efficacies of these therapies are otherwise not proven if return session visits are stretched out over multiple weeks or months. The most recent clinical research has demonstrated that PTSD recovery can be expedited and there are lower patient dropout rates when sessions are massed or compressed so that multiple sessions are administered over 1 week.^8-12 Providing these therapies in a massed format has shown to be as effective as when these therapies are provided weekly.

As the authority to treat soldiers serving on homefront missions is new, epidemiologic data do not yet exist to estimate the proportion of this population who will need treatment or present with PTSD, depression, anxiety, a substance use disorder, and/or comorbid conditions. Those with PTSD can benefit from PTSD evidence-based therapies already available for treatment. Others may benefit from treatments that are proven effective for their mental health diagnoses.

Conclusions

Now that National Guard and Reserve component soldiers who have responded to national and local emergencies are eligible for therapy, we need to be prepared to provide these services. In addition to addressing systemic staffing concerns, therapists need to be aware of the unique challenges faced by those who have served on homefront missions. These homefront missions have the potential to hit home for therapists.

Recent natural disasters, civil disorder, and the COVID-19 pandemic response created an unprecedented demand for the US National Guard and Reserve components as well as active-duty personnel to serve on homefront missions critical to our nation. At times, those serving in these capacities are front and center to the most tragic events confronting our nation, and they frequently encounter tremendous suffering.

Recognizing the potential for these missions to create psychological sequela for those who serve on them, the authority for the Veterans Health Administration (VHA) vet centers to provide readjustment counseling services was broadened on December 30, 2021. Vet centers are community-based counseling centers that have traditionally served combat veterans, and broadening services reflects a major change in mission. Revised VHA Directive 1500(2) specifies that those who “served on active duty in response to a national emergency or major disaster declared by the President” or “served on active duty in the National Guard of a State under orders of the chief executive of that State in response to a disaster or civil disorder in such State” may now receive therapy at vet centers.^1,2

As a result of this recent policy change, National Guard and active-duty Reserve service members now have parity with combat veterans to obtain therapy for symptoms arising as a result of their activation for service on homefront missions. As they seek care, we need to be ready so that these service members can obtain the best therapy services possible. Soldiers who served on homefront missions comprise a new cohort of service members now eligible for vet center therapy. Soldiers who served on homefront missions may present with issues that differ from those of combat veterans and veterans who have experienced military sexual trauma (MST), the populations treated by vet centers and other VHA mental health care clinics prior to this broadened authority. This article highlights some suggestions for service delivery to best meet the needs of this population.

Discussion 

Available evidence-based therapies to treat posttraumatic stress disorder (PTSD) are effective regardless of whether the trauma occurred in combat, on the homefront, or in a civilian setting. The vet centers and VHA mental health services already have staff trained to deliver these therapy modalities and, in this sense, are ready to provide trauma-focused therapy treatment to soldiers with PTSD who served on homefront missions.

The broadened authority for the vet centers to provide readjustment services is necessary, as it corrects for a critical gap in services, but the importance of ensuring adequate staffing to meet the expected increased demand for services cannot be underscored. According to clinical practice guidelines for the treatment of PTSD, developed by the US Department of Veterans Affairs (VA) and the US Department of Defense (DoD), the therapies with the strongest evidence-based backing are prolonged exposure-based therapy (PE), cognitive processing therapy (CPT), and eye movement and desensitization reprocessing (EMDR).³ These therapy modalities, based on findings from clinical trials, are predicated on seeing a client for a sufficient number of sessions. Attendance at these sessions is recommended at least weekly to ensure adequate intensity of service delivery.^4-7 According to the National Center for PTSD, PE typically involves 8 to 15 weekly or twice weekly sessions; CPT requires 8 to 14 or more weekly sessions, and EMDR is usually 4 to 12 weekly sessions.^4-7

Ensuring adequate staffing is critical to offer these therapies at least weekly as the efficacies of these therapies are otherwise not proven if return session visits are stretched out over multiple weeks or months. The most recent clinical research has demonstrated that PTSD recovery can be expedited and there are lower patient dropout rates when sessions are massed or compressed so that multiple sessions are administered over 1 week.^8-12 Providing these therapies in a massed format has shown to be as effective as when these therapies are provided weekly.

As the authority to treat soldiers serving on homefront missions is new, epidemiologic data do not yet exist to estimate the proportion of this population who will need treatment or present with PTSD, depression, anxiety, a substance use disorder, and/or comorbid conditions. Those with PTSD can benefit from PTSD evidence-based therapies already available for treatment. Others may benefit from treatments that are proven effective for their mental health diagnoses.

Conclusions

Now that National Guard and Reserve component soldiers who have responded to national and local emergencies are eligible for therapy, we need to be prepared to provide these services. In addition to addressing systemic staffing concerns, therapists need to be aware of the unique challenges faced by those who have served on homefront missions. These homefront missions have the potential to hit home for therapists.

Recent natural disasters, civil disorder, and the COVID-19 pandemic response created an unprecedented demand for the US National Guard and Reserve components as well as active-duty personnel to serve on homefront missions critical to our nation. At times, those serving in these capacities are front and center to the most tragic events confronting our nation, and they frequently encounter tremendous suffering.

Recognizing the potential for these missions to create psychological sequela for those who serve on them, the authority for the Veterans Health Administration (VHA) vet centers to provide readjustment counseling services was broadened on December 30, 2021. Vet centers are community-based counseling centers that have traditionally served combat veterans, and broadening services reflects a major change in mission. Revised VHA Directive 1500(2) specifies that those who “served on active duty in response to a national emergency or major disaster declared by the President” or “served on active duty in the National Guard of a State under orders of the chief executive of that State in response to a disaster or civil disorder in such State” may now receive therapy at vet centers.^1,2

As a result of this recent policy change, National Guard and active-duty Reserve service members now have parity with combat veterans to obtain therapy for symptoms arising as a result of their activation for service on homefront missions. As they seek care, we need to be ready so that these service members can obtain the best therapy services possible. Soldiers who served on homefront missions comprise a new cohort of service members now eligible for vet center therapy. Soldiers who served on homefront missions may present with issues that differ from those of combat veterans and veterans who have experienced military sexual trauma (MST), the populations treated by vet centers and other VHA mental health care clinics prior to this broadened authority. This article highlights some suggestions for service delivery to best meet the needs of this population.

Discussion 

Available evidence-based therapies to treat posttraumatic stress disorder (PTSD) are effective regardless of whether the trauma occurred in combat, on the homefront, or in a civilian setting. The vet centers and VHA mental health services already have staff trained to deliver these therapy modalities and, in this sense, are ready to provide trauma-focused therapy treatment to soldiers with PTSD who served on homefront missions.

The broadened authority for the vet centers to provide readjustment services is necessary, as it corrects for a critical gap in services, but the importance of ensuring adequate staffing to meet the expected increased demand for services cannot be underscored. According to clinical practice guidelines for the treatment of PTSD, developed by the US Department of Veterans Affairs (VA) and the US Department of Defense (DoD), the therapies with the strongest evidence-based backing are prolonged exposure-based therapy (PE), cognitive processing therapy (CPT), and eye movement and desensitization reprocessing (EMDR).³ These therapy modalities, based on findings from clinical trials, are predicated on seeing a client for a sufficient number of sessions. Attendance at these sessions is recommended at least weekly to ensure adequate intensity of service delivery.^4-7 According to the National Center for PTSD, PE typically involves 8 to 15 weekly or twice weekly sessions; CPT requires 8 to 14 or more weekly sessions, and EMDR is usually 4 to 12 weekly sessions.^4-7

Ensuring adequate staffing is critical to offer these therapies at least weekly as the efficacies of these therapies are otherwise not proven if return session visits are stretched out over multiple weeks or months. The most recent clinical research has demonstrated that PTSD recovery can be expedited and there are lower patient dropout rates when sessions are massed or compressed so that multiple sessions are administered over 1 week.^8-12 Providing these therapies in a massed format has shown to be as effective as when these therapies are provided weekly.

As the authority to treat soldiers serving on homefront missions is new, epidemiologic data do not yet exist to estimate the proportion of this population who will need treatment or present with PTSD, depression, anxiety, a substance use disorder, and/or comorbid conditions. Those with PTSD can benefit from PTSD evidence-based therapies already available for treatment. Others may benefit from treatments that are proven effective for their mental health diagnoses.

Conclusions

Now that National Guard and Reserve component soldiers who have responded to national and local emergencies are eligible for therapy, we need to be prepared to provide these services. In addition to addressing systemic staffing concerns, therapists need to be aware of the unique challenges faced by those who have served on homefront missions. These homefront missions have the potential to hit home for therapists.

Older age is associated with many health conditions that could potentially benefit from psychedelic-assisted therapy, yet very few older adults have been included in clinical trials of psychedelics, new research shows.

“Geriatric psychiatrists and others caring for older adults are interested in how much is known about psychedelic use in older adults,” study investigator C. Bree Johnston, MD, MPH, University of Arizona, Tucson, told this news organization.

University of Arizona

“A major concern is how safe psychedelic-assisted therapy is for patients with heart disease, hypertension, neurological disorders, and multimorbidity,” Dr. Johnston said.

The study is published online in the American Journal of Geriatric Psychiatry.
 

‘Groundswell’ of research

The past few years have brought a “groundswell” of interest and promising research into the potential therapeutic benefit of psychedelic-assisted therapy for a variety of conditions affecting adults, the researchers noted.

They include psilocybin-assisted therapy for the distress associated with a terminal diagnosis, depression, and addiction, and MDMA-assisted therapy for PTSD.

However, in most studies, psychedelic therapy has been tested in relatively young healthy adults, raising the question of how generalizable the study results are for the patients that most geropsychiatrists will be treating, the investigators noted.

They reviewed “the most important” research studies on psilocybin- and MDMA-assisted therapies published over the past 2 decades that are likely to be relevant for geriatric psychiatrists and other professionals caring for older adults.

The researchers point out that psychedelics and related compounds have shown efficacy for the treatment of a number of conditions that are common among older adults, including mood disorders, distress associated with a serious medical illness, PTSD, substance use problems, and prolonged grief.

Psychedelics also have properties that may provide for cognitive impairment and dementia and promote personal growth among healthy older adults.

Research has shown that psychedelics can be safely administered to healthy adults in controlled conditions.

However, both psilocybin and MDMA can increase blood pressure and heart rate, which could be a concern if used in older adults with cardiovascular disease, the investigators noted.

“Healthy older adults are likely to face similar risks when undergoing psychedelic-assisted therapy as healthy younger adults,” said Dr. Johnston.

“In carefully selected adults, those risks appear to be minor when psychedelics are administered in controlled conditions under the guidance of a skilled therapist,” she added.

Given the potential of psychedelic compounds to benefit older adults, the authors call for more research to establish the safety and efficacy among older adults, particularly those with multiple comorbidities.
 

Pressing knowledge gaps

The exclusion of older adults from clinical trials of novel treatments is “one of contemporary psychiatry’s more pressing problems – one that extends beyond psychedelics,” Ipsit V. Vahia, MD, associate chief of the division of geriatric psychiatry, McLean Hospital, Belmont, Mass., who wasn’t involved in the review, told this news organization.

courtesy McLean Hospital

“Currently, there is little evidence that clinicians can lean on while considering the use of psychedelics in older adults,” Dr. Vahia said.

This paper highlights “the most pressing gaps in the evidence that bear addressing in order to develop more substantial best practices around the use of these drugs,” he added.

For example, little is known about appropriate dosing, pharmacokinetics, and pharmacodynamics of psychedelics in older adults, Dr. Vahia said.

“Their risks, particularly cardiovascular risks, are barely studied, and almost nothing is known about how these drugs may impact those in their 80s or older, or those with serious medical comorbidities who use multiple medications,” Dr. Vahia said. “The majority of the existing literature has excluded older adults, and the extremely limited evidence that does exist has been collected in relatively healthy, and relatively young (aged below 75) persons.”

Dr. Vahia noted that, before psychedelics as a class can be considered viable treatment options for a broader group of older adults, “more research is needed, particularly to establish safety.”

This research had no specific funding. Dr. Johnston and Dr. Vahia have no relevant conflicts of interest.

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

Older age is associated with many health conditions that could potentially benefit from psychedelic-assisted therapy, yet very few older adults have been included in clinical trials of psychedelics, new research shows.

“Geriatric psychiatrists and others caring for older adults are interested in how much is known about psychedelic use in older adults,” study investigator C. Bree Johnston, MD, MPH, University of Arizona, Tucson, told this news organization.

University of Arizona

“A major concern is how safe psychedelic-assisted therapy is for patients with heart disease, hypertension, neurological disorders, and multimorbidity,” Dr. Johnston said.

The study is published online in the American Journal of Geriatric Psychiatry.
 

‘Groundswell’ of research

The past few years have brought a “groundswell” of interest and promising research into the potential therapeutic benefit of psychedelic-assisted therapy for a variety of conditions affecting adults, the researchers noted.

They include psilocybin-assisted therapy for the distress associated with a terminal diagnosis, depression, and addiction, and MDMA-assisted therapy for PTSD.

However, in most studies, psychedelic therapy has been tested in relatively young healthy adults, raising the question of how generalizable the study results are for the patients that most geropsychiatrists will be treating, the investigators noted.

They reviewed “the most important” research studies on psilocybin- and MDMA-assisted therapies published over the past 2 decades that are likely to be relevant for geriatric psychiatrists and other professionals caring for older adults.

The researchers point out that psychedelics and related compounds have shown efficacy for the treatment of a number of conditions that are common among older adults, including mood disorders, distress associated with a serious medical illness, PTSD, substance use problems, and prolonged grief.

Psychedelics also have properties that may provide for cognitive impairment and dementia and promote personal growth among healthy older adults.

Research has shown that psychedelics can be safely administered to healthy adults in controlled conditions.

However, both psilocybin and MDMA can increase blood pressure and heart rate, which could be a concern if used in older adults with cardiovascular disease, the investigators noted.

“Healthy older adults are likely to face similar risks when undergoing psychedelic-assisted therapy as healthy younger adults,” said Dr. Johnston.

“In carefully selected adults, those risks appear to be minor when psychedelics are administered in controlled conditions under the guidance of a skilled therapist,” she added.

Given the potential of psychedelic compounds to benefit older adults, the authors call for more research to establish the safety and efficacy among older adults, particularly those with multiple comorbidities.
 

Pressing knowledge gaps

The exclusion of older adults from clinical trials of novel treatments is “one of contemporary psychiatry’s more pressing problems – one that extends beyond psychedelics,” Ipsit V. Vahia, MD, associate chief of the division of geriatric psychiatry, McLean Hospital, Belmont, Mass., who wasn’t involved in the review, told this news organization.

courtesy McLean Hospital

“Currently, there is little evidence that clinicians can lean on while considering the use of psychedelics in older adults,” Dr. Vahia said.

This paper highlights “the most pressing gaps in the evidence that bear addressing in order to develop more substantial best practices around the use of these drugs,” he added.

For example, little is known about appropriate dosing, pharmacokinetics, and pharmacodynamics of psychedelics in older adults, Dr. Vahia said.

“Their risks, particularly cardiovascular risks, are barely studied, and almost nothing is known about how these drugs may impact those in their 80s or older, or those with serious medical comorbidities who use multiple medications,” Dr. Vahia said. “The majority of the existing literature has excluded older adults, and the extremely limited evidence that does exist has been collected in relatively healthy, and relatively young (aged below 75) persons.”

Dr. Vahia noted that, before psychedelics as a class can be considered viable treatment options for a broader group of older adults, “more research is needed, particularly to establish safety.”

This research had no specific funding. Dr. Johnston and Dr. Vahia have no relevant conflicts of interest.

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

Older age is associated with many health conditions that could potentially benefit from psychedelic-assisted therapy, yet very few older adults have been included in clinical trials of psychedelics, new research shows.

“Geriatric psychiatrists and others caring for older adults are interested in how much is known about psychedelic use in older adults,” study investigator C. Bree Johnston, MD, MPH, University of Arizona, Tucson, told this news organization.

University of Arizona

“A major concern is how safe psychedelic-assisted therapy is for patients with heart disease, hypertension, neurological disorders, and multimorbidity,” Dr. Johnston said.

The study is published online in the American Journal of Geriatric Psychiatry.
 

‘Groundswell’ of research

The past few years have brought a “groundswell” of interest and promising research into the potential therapeutic benefit of psychedelic-assisted therapy for a variety of conditions affecting adults, the researchers noted.

They include psilocybin-assisted therapy for the distress associated with a terminal diagnosis, depression, and addiction, and MDMA-assisted therapy for PTSD.

However, in most studies, psychedelic therapy has been tested in relatively young healthy adults, raising the question of how generalizable the study results are for the patients that most geropsychiatrists will be treating, the investigators noted.

They reviewed “the most important” research studies on psilocybin- and MDMA-assisted therapies published over the past 2 decades that are likely to be relevant for geriatric psychiatrists and other professionals caring for older adults.

The researchers point out that psychedelics and related compounds have shown efficacy for the treatment of a number of conditions that are common among older adults, including mood disorders, distress associated with a serious medical illness, PTSD, substance use problems, and prolonged grief.

Psychedelics also have properties that may provide for cognitive impairment and dementia and promote personal growth among healthy older adults.

Research has shown that psychedelics can be safely administered to healthy adults in controlled conditions.

However, both psilocybin and MDMA can increase blood pressure and heart rate, which could be a concern if used in older adults with cardiovascular disease, the investigators noted.

“Healthy older adults are likely to face similar risks when undergoing psychedelic-assisted therapy as healthy younger adults,” said Dr. Johnston.

“In carefully selected adults, those risks appear to be minor when psychedelics are administered in controlled conditions under the guidance of a skilled therapist,” she added.

Given the potential of psychedelic compounds to benefit older adults, the authors call for more research to establish the safety and efficacy among older adults, particularly those with multiple comorbidities.
 

Pressing knowledge gaps

The exclusion of older adults from clinical trials of novel treatments is “one of contemporary psychiatry’s more pressing problems – one that extends beyond psychedelics,” Ipsit V. Vahia, MD, associate chief of the division of geriatric psychiatry, McLean Hospital, Belmont, Mass., who wasn’t involved in the review, told this news organization.

courtesy McLean Hospital

“Currently, there is little evidence that clinicians can lean on while considering the use of psychedelics in older adults,” Dr. Vahia said.

This paper highlights “the most pressing gaps in the evidence that bear addressing in order to develop more substantial best practices around the use of these drugs,” he added.

For example, little is known about appropriate dosing, pharmacokinetics, and pharmacodynamics of psychedelics in older adults, Dr. Vahia said.

“Their risks, particularly cardiovascular risks, are barely studied, and almost nothing is known about how these drugs may impact those in their 80s or older, or those with serious medical comorbidities who use multiple medications,” Dr. Vahia said. “The majority of the existing literature has excluded older adults, and the extremely limited evidence that does exist has been collected in relatively healthy, and relatively young (aged below 75) persons.”

Dr. Vahia noted that, before psychedelics as a class can be considered viable treatment options for a broader group of older adults, “more research is needed, particularly to establish safety.”

This research had no specific funding. Dr. Johnston and Dr. Vahia have no relevant conflicts of interest.

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

Feelings of detachment following a traumatic event are a marker of more severe psychiatric outcomes, including depression and anxiety, new research suggests.

The results highlight the importance of screening for dissociation in patients who have experienced trauma, study investigator Lauren A.M. Lebois, PhD, director of the dissociative disorders and trauma research program at McLean Hospital in Belmont, Mass., told this news organization.

“Clinicians could identify individuals potentially at risk of a chronic, more severe psychiatric course before these people go down that road, and they have the opportunity to connect folks with a phased trauma treatment approach to speed their recovery,” said Dr. Lebois, who is also an assistant professor of psychiatry at Harvard Medical School, Boston.

The study was published in the American Journal of Psychiatry.
 

Underdiagnosed

Feelings of detachment or derealization are a type of dissociation. Patients with the syndrome report feeling foggy or as if they are in a dream. Dissociative diagnoses are not rare and, in fact, are more prevalent than schizophrenia.

Research supports a powerful relationship between dissociation and traumatic experiences. However, dissociation is among the most stigmatized of psychiatric conditions. Even among clinicians and researchers, beliefs about dissociation are often not based on the scientific literature, said Dr. Lebois.

“For instance, skepticism, misunderstanding, and lack of professional education about dissociation all contribute to striking rates of underdiagnosis and misdiagnoses,” she said.

Dr. Lebois and colleagues used data from the larger Advancing Understanding of Recovery After Trauma (AURORA) study and included 1,464 adults, mean age 35 years, appearing at 22 U.S. emergency departments. Patients experienced a traumatic event such as a motor vehicle crash or physical or sexual assault.

About 2 weeks after the trauma, participants reported symptoms of derealization as measured by a two-item version of the Brief Dissociative Experiences Scale.
 

Brain imaging data

A subset of 145 patients underwent functional MRI (fMRI), during which they completed an emotion reactivity task (viewing fearful-looking human faces) and a resting-state scan.

In addition to measuring history of childhood maltreatment, researchers assessed posttraumatic stress symptom severity at 2 weeks and again at 3 months using the posttraumatic stress disorder checklist. Also at 3 months, they measured depression and anxiety symptoms, pain, and functional impairment.

About 55% of self-report participants and 50% of MRI participants endorsed some level of persistent derealization at 2 weeks.

After controlling for potential confounders, including sex, age, childhood maltreatment, and current posttraumatic stress symptoms, researchers found persistent derealization was associated with increased ventromedial prefrontal cortex (vmPFC) activity while viewing fearful faces.

The vmPFC helps to regulate emotional and physical reactions. “This region puts the ‘brakes’ on your emotional and physical reactivity – helping you to calm down” after a threatening or stressful experience has passed, said Dr. Lebois.

Researchers also found an association between higher self-reported derealization and decreased resting-state connectivity between the vmPFC and the orbitofrontal cortex and right lobule VIIIa – a region of the cerebellum involved in sensorimotor function.

“This may contribute to perceptual and affective distortions experienced during derealization – for example, feelings that surroundings are fading away, unreal, or strange,” said Dr. Lebois.
 

More pain, depression, anxiety

Higher levels of self-reported derealization at 2 weeks post trauma predicted higher levels of PTSD, anxiety, and depression as well as more bodily pain and impairment in work, family, and social life at 3 months.

“When we accounted for baseline levels of posttraumatic stress symptoms and trauma history, higher levels of self-reported derealization still predicted higher posttraumatic stress disorder and depression symptoms at 3 months,” said Dr. Lebois.

Additional adjusted analyses showed increased vmPFC activity during the fearful face task predicted 3-month self-reported PTSD symptoms.

Dr. Lebois “highly recommends” clinicians screen for dissociative symptoms, including derealization, in patients with trauma. Self-report screening tools are freely available online.

She noted patients with significant dissociative symptoms often do better with a “phase-oriented” approach to trauma treatment.

“In phase one, they learn emotional regulation skills to help them take more control over when they dissociate. Then they can successfully move on to trauma processing in phase two, which can involve exposure to trauma details.”

Although the field is not yet ready to use brain scans to diagnose dissociative symptoms, the new results “take us one step closer to being able to use objective neuroimaging biomarkers of derealization to augment subjective self-report measures,” said Dr. Lebois.

A limitation of the study was it could not determine a causal relationship, as some derealization may have been present before the traumatic event. The findings may not generalize to other types of dissociation, and the derealization assessment was measured only through a self-report 2 weeks after the trauma.

Another limitation was exclusion of patients with self-inflicted injuries or who were involved in domestic violence. The researchers noted the prevalence of derealization might have been even higher if such individuals were included.
 

An important investigation

In an accompanying editorial, Lisa M. Shin, PhD, department of psychology, Tufts University, and department of psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, notes having both clinical and neuroimaging variables as well as a large sample size makes the study “an important investigation” into predictors of psychiatric symptoms post-trauma.

Investigating a specific subtype of dissociation – persistent derealization – adds to the “novelty” of the study, she said.

The new findings “are certainly exciting for their potential clinical relevance and contributions to neurocircuitry models of PTSD,” she writes.

Some may argue administering a short, self-report measure of derealization “is far more efficient, cost-effective, and inclusive than conducting a specialized and expensive fMRI scan that is unlikely to be available to everyone,” notes Dr. Shin.

However, she added, a potential benefit of such a scan is identification of specific brain regions as potential targets for intervention. “For example, the results of this and other studies suggest that the vmPFC is a reasonable target for transcranial magnetic stimulation or its variants.”

The new results need to be replicated in a large, independent sample, said Dr. Shin. She added it would be helpful to know if other types of dissociation, and activation in other subregions of the vmPFC, also predict psychiatric outcomes after a trauma.

The study was supported by National Institute of Mental Health grants, the U.S. Army Medical Research and Material Command, One Mind, and the Mayday Fund. Dr. Lebois has received grant support from NIMH, and her spouse receives payments from Vanderbilt University for technology licensed to Acadia Pharmaceuticals. Dr. Shin receives textbook-related royalties from Pearson.

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

Feelings of detachment following a traumatic event are a marker of more severe psychiatric outcomes, including depression and anxiety, new research suggests.

The results highlight the importance of screening for dissociation in patients who have experienced trauma, study investigator Lauren A.M. Lebois, PhD, director of the dissociative disorders and trauma research program at McLean Hospital in Belmont, Mass., told this news organization.

“Clinicians could identify individuals potentially at risk of a chronic, more severe psychiatric course before these people go down that road, and they have the opportunity to connect folks with a phased trauma treatment approach to speed their recovery,” said Dr. Lebois, who is also an assistant professor of psychiatry at Harvard Medical School, Boston.

The study was published in the American Journal of Psychiatry.
 

Underdiagnosed

Feelings of detachment or derealization are a type of dissociation. Patients with the syndrome report feeling foggy or as if they are in a dream. Dissociative diagnoses are not rare and, in fact, are more prevalent than schizophrenia.

Research supports a powerful relationship between dissociation and traumatic experiences. However, dissociation is among the most stigmatized of psychiatric conditions. Even among clinicians and researchers, beliefs about dissociation are often not based on the scientific literature, said Dr. Lebois.

“For instance, skepticism, misunderstanding, and lack of professional education about dissociation all contribute to striking rates of underdiagnosis and misdiagnoses,” she said.

Dr. Lebois and colleagues used data from the larger Advancing Understanding of Recovery After Trauma (AURORA) study and included 1,464 adults, mean age 35 years, appearing at 22 U.S. emergency departments. Patients experienced a traumatic event such as a motor vehicle crash or physical or sexual assault.

About 2 weeks after the trauma, participants reported symptoms of derealization as measured by a two-item version of the Brief Dissociative Experiences Scale.
 

Brain imaging data

A subset of 145 patients underwent functional MRI (fMRI), during which they completed an emotion reactivity task (viewing fearful-looking human faces) and a resting-state scan.

In addition to measuring history of childhood maltreatment, researchers assessed posttraumatic stress symptom severity at 2 weeks and again at 3 months using the posttraumatic stress disorder checklist. Also at 3 months, they measured depression and anxiety symptoms, pain, and functional impairment.

About 55% of self-report participants and 50% of MRI participants endorsed some level of persistent derealization at 2 weeks.

After controlling for potential confounders, including sex, age, childhood maltreatment, and current posttraumatic stress symptoms, researchers found persistent derealization was associated with increased ventromedial prefrontal cortex (vmPFC) activity while viewing fearful faces.

The vmPFC helps to regulate emotional and physical reactions. “This region puts the ‘brakes’ on your emotional and physical reactivity – helping you to calm down” after a threatening or stressful experience has passed, said Dr. Lebois.

Researchers also found an association between higher self-reported derealization and decreased resting-state connectivity between the vmPFC and the orbitofrontal cortex and right lobule VIIIa – a region of the cerebellum involved in sensorimotor function.

“This may contribute to perceptual and affective distortions experienced during derealization – for example, feelings that surroundings are fading away, unreal, or strange,” said Dr. Lebois.
 

More pain, depression, anxiety

Higher levels of self-reported derealization at 2 weeks post trauma predicted higher levels of PTSD, anxiety, and depression as well as more bodily pain and impairment in work, family, and social life at 3 months.

“When we accounted for baseline levels of posttraumatic stress symptoms and trauma history, higher levels of self-reported derealization still predicted higher posttraumatic stress disorder and depression symptoms at 3 months,” said Dr. Lebois.

Additional adjusted analyses showed increased vmPFC activity during the fearful face task predicted 3-month self-reported PTSD symptoms.

Dr. Lebois “highly recommends” clinicians screen for dissociative symptoms, including derealization, in patients with trauma. Self-report screening tools are freely available online.

She noted patients with significant dissociative symptoms often do better with a “phase-oriented” approach to trauma treatment.

“In phase one, they learn emotional regulation skills to help them take more control over when they dissociate. Then they can successfully move on to trauma processing in phase two, which can involve exposure to trauma details.”

Although the field is not yet ready to use brain scans to diagnose dissociative symptoms, the new results “take us one step closer to being able to use objective neuroimaging biomarkers of derealization to augment subjective self-report measures,” said Dr. Lebois.

A limitation of the study was it could not determine a causal relationship, as some derealization may have been present before the traumatic event. The findings may not generalize to other types of dissociation, and the derealization assessment was measured only through a self-report 2 weeks after the trauma.

Another limitation was exclusion of patients with self-inflicted injuries or who were involved in domestic violence. The researchers noted the prevalence of derealization might have been even higher if such individuals were included.
 

An important investigation

In an accompanying editorial, Lisa M. Shin, PhD, department of psychology, Tufts University, and department of psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, notes having both clinical and neuroimaging variables as well as a large sample size makes the study “an important investigation” into predictors of psychiatric symptoms post-trauma.

Investigating a specific subtype of dissociation – persistent derealization – adds to the “novelty” of the study, she said.

The new findings “are certainly exciting for their potential clinical relevance and contributions to neurocircuitry models of PTSD,” she writes.

Some may argue administering a short, self-report measure of derealization “is far more efficient, cost-effective, and inclusive than conducting a specialized and expensive fMRI scan that is unlikely to be available to everyone,” notes Dr. Shin.

However, she added, a potential benefit of such a scan is identification of specific brain regions as potential targets for intervention. “For example, the results of this and other studies suggest that the vmPFC is a reasonable target for transcranial magnetic stimulation or its variants.”

The new results need to be replicated in a large, independent sample, said Dr. Shin. She added it would be helpful to know if other types of dissociation, and activation in other subregions of the vmPFC, also predict psychiatric outcomes after a trauma.

The study was supported by National Institute of Mental Health grants, the U.S. Army Medical Research and Material Command, One Mind, and the Mayday Fund. Dr. Lebois has received grant support from NIMH, and her spouse receives payments from Vanderbilt University for technology licensed to Acadia Pharmaceuticals. Dr. Shin receives textbook-related royalties from Pearson.

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

Feelings of detachment following a traumatic event are a marker of more severe psychiatric outcomes, including depression and anxiety, new research suggests.

The results highlight the importance of screening for dissociation in patients who have experienced trauma, study investigator Lauren A.M. Lebois, PhD, director of the dissociative disorders and trauma research program at McLean Hospital in Belmont, Mass., told this news organization.

“Clinicians could identify individuals potentially at risk of a chronic, more severe psychiatric course before these people go down that road, and they have the opportunity to connect folks with a phased trauma treatment approach to speed their recovery,” said Dr. Lebois, who is also an assistant professor of psychiatry at Harvard Medical School, Boston.

The study was published in the American Journal of Psychiatry.
 

Underdiagnosed

Feelings of detachment or derealization are a type of dissociation. Patients with the syndrome report feeling foggy or as if they are in a dream. Dissociative diagnoses are not rare and, in fact, are more prevalent than schizophrenia.

Research supports a powerful relationship between dissociation and traumatic experiences. However, dissociation is among the most stigmatized of psychiatric conditions. Even among clinicians and researchers, beliefs about dissociation are often not based on the scientific literature, said Dr. Lebois.

“For instance, skepticism, misunderstanding, and lack of professional education about dissociation all contribute to striking rates of underdiagnosis and misdiagnoses,” she said.

Dr. Lebois and colleagues used data from the larger Advancing Understanding of Recovery After Trauma (AURORA) study and included 1,464 adults, mean age 35 years, appearing at 22 U.S. emergency departments. Patients experienced a traumatic event such as a motor vehicle crash or physical or sexual assault.

About 2 weeks after the trauma, participants reported symptoms of derealization as measured by a two-item version of the Brief Dissociative Experiences Scale.
 

Brain imaging data

A subset of 145 patients underwent functional MRI (fMRI), during which they completed an emotion reactivity task (viewing fearful-looking human faces) and a resting-state scan.

In addition to measuring history of childhood maltreatment, researchers assessed posttraumatic stress symptom severity at 2 weeks and again at 3 months using the posttraumatic stress disorder checklist. Also at 3 months, they measured depression and anxiety symptoms, pain, and functional impairment.

About 55% of self-report participants and 50% of MRI participants endorsed some level of persistent derealization at 2 weeks.

After controlling for potential confounders, including sex, age, childhood maltreatment, and current posttraumatic stress symptoms, researchers found persistent derealization was associated with increased ventromedial prefrontal cortex (vmPFC) activity while viewing fearful faces.

The vmPFC helps to regulate emotional and physical reactions. “This region puts the ‘brakes’ on your emotional and physical reactivity – helping you to calm down” after a threatening or stressful experience has passed, said Dr. Lebois.

Researchers also found an association between higher self-reported derealization and decreased resting-state connectivity between the vmPFC and the orbitofrontal cortex and right lobule VIIIa – a region of the cerebellum involved in sensorimotor function.

“This may contribute to perceptual and affective distortions experienced during derealization – for example, feelings that surroundings are fading away, unreal, or strange,” said Dr. Lebois.
 

More pain, depression, anxiety

Higher levels of self-reported derealization at 2 weeks post trauma predicted higher levels of PTSD, anxiety, and depression as well as more bodily pain and impairment in work, family, and social life at 3 months.

“When we accounted for baseline levels of posttraumatic stress symptoms and trauma history, higher levels of self-reported derealization still predicted higher posttraumatic stress disorder and depression symptoms at 3 months,” said Dr. Lebois.

Additional adjusted analyses showed increased vmPFC activity during the fearful face task predicted 3-month self-reported PTSD symptoms.

Dr. Lebois “highly recommends” clinicians screen for dissociative symptoms, including derealization, in patients with trauma. Self-report screening tools are freely available online.

She noted patients with significant dissociative symptoms often do better with a “phase-oriented” approach to trauma treatment.

“In phase one, they learn emotional regulation skills to help them take more control over when they dissociate. Then they can successfully move on to trauma processing in phase two, which can involve exposure to trauma details.”

Although the field is not yet ready to use brain scans to diagnose dissociative symptoms, the new results “take us one step closer to being able to use objective neuroimaging biomarkers of derealization to augment subjective self-report measures,” said Dr. Lebois.

A limitation of the study was it could not determine a causal relationship, as some derealization may have been present before the traumatic event. The findings may not generalize to other types of dissociation, and the derealization assessment was measured only through a self-report 2 weeks after the trauma.

Another limitation was exclusion of patients with self-inflicted injuries or who were involved in domestic violence. The researchers noted the prevalence of derealization might have been even higher if such individuals were included.
 

An important investigation

In an accompanying editorial, Lisa M. Shin, PhD, department of psychology, Tufts University, and department of psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, notes having both clinical and neuroimaging variables as well as a large sample size makes the study “an important investigation” into predictors of psychiatric symptoms post-trauma.

Investigating a specific subtype of dissociation – persistent derealization – adds to the “novelty” of the study, she said.

The new findings “are certainly exciting for their potential clinical relevance and contributions to neurocircuitry models of PTSD,” she writes.

Some may argue administering a short, self-report measure of derealization “is far more efficient, cost-effective, and inclusive than conducting a specialized and expensive fMRI scan that is unlikely to be available to everyone,” notes Dr. Shin.

However, she added, a potential benefit of such a scan is identification of specific brain regions as potential targets for intervention. “For example, the results of this and other studies suggest that the vmPFC is a reasonable target for transcranial magnetic stimulation or its variants.”

The new results need to be replicated in a large, independent sample, said Dr. Shin. She added it would be helpful to know if other types of dissociation, and activation in other subregions of the vmPFC, also predict psychiatric outcomes after a trauma.

The study was supported by National Institute of Mental Health grants, the U.S. Army Medical Research and Material Command, One Mind, and the Mayday Fund. Dr. Lebois has received grant support from NIMH, and her spouse receives payments from Vanderbilt University for technology licensed to Acadia Pharmaceuticals. Dr. Shin receives textbook-related royalties from Pearson.

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

The combination of the two antiviral medications glecaprevir and pibrentasvir (Mavyret) is linked to improved symptoms in posttraumatic stress disorder, new research suggests.

A national cohort study of U.S. Veterans Affairs patients included more than 250 participants with PTSD and comorbid hepatitis C virus.

Results showed the glecaprevir/pibrentasvir (GLE/PIB) combo was more strongly associated with PTSD symptom improvement than other antiviral combinations tested in the study, including ledipasvir/sofosbuvir.

“While there are great treatments available for PTSD, there’s a lot of desire in the field to find a new medication that will be helpful,” lead author Brian Shiner, MD, acting associate chief of staff for research, VA Medical Center, White River Junction, Vt., told this news organization.

“We had a great opportunity to use a novel data mining method to look in a wonderful database for a new treatment and we found something very promising,” said Dr. Shiner, who is also an associate professor of psychiatry at the Geisel School of Medicine at Dartmouth, Hanover, N.H.

The findings were published online in the American Journal of Epidemiology.
 

Common psychiatric disorder

PTSD is one of the most common psychiatric disorders, with an estimated lifetime prevalence of 6.4% in the United States. Yet only two drugs, the SSRIs sertraline (Zoloft) and paroxetine (Paxil), have been approved by the Food and Drug Administration to treat PTSD.

The VA recommends trauma-based psychotherapy, such as prolonged exposure and cognitive processing therapy, as first-line treatments for PTSD. However, not all patents respond to or have access to these approaches, said Dr. Shiner.

The investigators wanted to examine whether existing medications might reduce PTSD symptoms. Their previous exploratory study used “data mining” of national VA medical records.

Results from that study showed the three hepatitis C antivirals of GLE (an NS3/4A protease inhibitor), PIB (a NS5A protein inhibitor), and velpatasvir (another NS5A protein inhibitor) were associated with more than double the expected number of patients experiencing a clinically meaningful improvement in PTSD symptoms.

Sertraline was associated with only a slightly higher than expected improvement.

“SSRIs are effective, better than placebo, but the effects are not as good as we would hope,” Dr. Shiner said.

He noted that GLE and PIB are always prescribed together (Mavyret), whereas velpatasvir is commonly prescribed with the NS5B polymerase inhibitor sofosbuvir under the brand name Epclusa. Sofosbuvir is also commonly prescribed with the NS5A protein inhibitor ledipasvir under the brand name Harvoni.
 

Strong association

The new study included 253 VA users with a diagnosis of PTSD and hepatitis C. Of these, 54 were receiving GLE/PIB, 145 were receiving ledipasvir/sofosbuvir, and 54 were receiving sofosbuvir/velpatasvir.

Researchers compared the groups with respect to change over 8-12 weeks on the PTSD Checklist (PCL), a 20-item self-report scale.

In adjusted analyses, the largest mean improvement on the PCL was 14.9 points for the GLE/PIB group and the smallest adjusted mean improvement on the PCL was 7.5 points for the ledipasvir/sofosbuvir group (mean difference, 7.34 points; 95% confidence interval, 1.05-13.63).

The adjusted proportion of patients improving by 15 points or more on the PCL was highest for the GLE/PIB group at 43.6% and lowest for the ledipasvir/sofosbuvir group at 26.3%.

Even when accounting for patients receiving trauma-based therapy or SSRIs, “it still looks like there’s a strong association of the hepatitis C antivirals with PTSD symptom improvement,” said Dr. Shiner.

Researchers also carried out a sensitivity analysis among only patients who were cured of HCV (over 90% of the total sample), defined as having an undetectable HCV viral load up to a year after completion of therapy. The analysis showed PTSD outcomes were still superior for participants receiving GLE/PIB.

“The sensitivity analysis was not that robust because almost everyone was cured, so it included almost everybody, but it didn’t point us away from the possibility of an off-target effect,” Dr. Shiner said.

Why antivirals may improve PTSD symptoms is not clear, but they may affect the immune response in patients with hepatitis C – and there may also be an immune response in PTSD, he noted. “Some of those factors may be shared, and that could explain some of the off-target effect.”

However, he noted the GLE/PIB drug combination is costly and patients with PTSD can probably access it only through enrolling in a study.

“We are not recommending that people go out and purchase this very expensive drug to treat their PTSD at this point,” Dr. Shiner said.

He added that the research team has now received funding from the Department of Defense to conduct a randomized, placebo-controlled trial of GLE/PIB as a potential treatment for PTSD.
 

Promising potential treatment

PTSD expert Elspeth Cameron Ritchie, MD, chief of psychiatry at Medstar Washington Hospital Center, Washington, D.C., said the results suggest GLE/PIB is a promising potential treatment for PTSD.

“I definitely think this should be looked at further,” said Dr. Ritchie, who was not involved with the research.

She noted that current PTSD therapies have drawbacks. SSRIs have side effects, the most “troubling” being sexual dysfunction. And although cognitive-behavioral therapy is effective, “people have to stick with it” and studies show about two thirds of patients drop out, she said.

Potentially effective PTSD treatment approaches include “self-soothing” or “self-regulating” techniques such as exercise, meditation, yoga, and working with animals, she added.

Dr. Ritchie pointed out the numbers of participants in the study were relatively small, including two groups that had only 54 patients each.

And while the GLE/PIB combination should be explored further, cost, availability, and side effects of this medication need to be taken into consideration, she said.

Dr. Ritchie added she is not overly concerned that the mechanism of action for the combination on PTSD may not be well understood. She noted several psychiatric medications fall into that category, including electroconvulsive therapy and lithium.

“When lithium was first found to be effective against bipolar disorder, we had no clue why,” she said. “So I would not discount the antiviral based on us not knowing how it works.”

However, “we’re a long way off” from starting a patient with PTSD on an antiviral, said Dr. Ritchie, adding there are “a lot of steps to go through” to get FDA approval.

The study was funded by the National Institute of Mental Health. The cohort used for this study was developed through support from the Department of Defense. Dr. Shiner is a coinventor on a provisional patent application covering the use of glecaprevir, pibrentasvir, and velpatasvir for PTSD and other psychiatric indications. Dr. Ritchie reported no relevant financial relationships.

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

The combination of the two antiviral medications glecaprevir and pibrentasvir (Mavyret) is linked to improved symptoms in posttraumatic stress disorder, new research suggests.

A national cohort study of U.S. Veterans Affairs patients included more than 250 participants with PTSD and comorbid hepatitis C virus.

Results showed the glecaprevir/pibrentasvir (GLE/PIB) combo was more strongly associated with PTSD symptom improvement than other antiviral combinations tested in the study, including ledipasvir/sofosbuvir.

“While there are great treatments available for PTSD, there’s a lot of desire in the field to find a new medication that will be helpful,” lead author Brian Shiner, MD, acting associate chief of staff for research, VA Medical Center, White River Junction, Vt., told this news organization.

“We had a great opportunity to use a novel data mining method to look in a wonderful database for a new treatment and we found something very promising,” said Dr. Shiner, who is also an associate professor of psychiatry at the Geisel School of Medicine at Dartmouth, Hanover, N.H.

The findings were published online in the American Journal of Epidemiology.
 

Common psychiatric disorder

PTSD is one of the most common psychiatric disorders, with an estimated lifetime prevalence of 6.4% in the United States. Yet only two drugs, the SSRIs sertraline (Zoloft) and paroxetine (Paxil), have been approved by the Food and Drug Administration to treat PTSD.

The VA recommends trauma-based psychotherapy, such as prolonged exposure and cognitive processing therapy, as first-line treatments for PTSD. However, not all patents respond to or have access to these approaches, said Dr. Shiner.

The investigators wanted to examine whether existing medications might reduce PTSD symptoms. Their previous exploratory study used “data mining” of national VA medical records.

Results from that study showed the three hepatitis C antivirals of GLE (an NS3/4A protease inhibitor), PIB (a NS5A protein inhibitor), and velpatasvir (another NS5A protein inhibitor) were associated with more than double the expected number of patients experiencing a clinically meaningful improvement in PTSD symptoms.

Sertraline was associated with only a slightly higher than expected improvement.

“SSRIs are effective, better than placebo, but the effects are not as good as we would hope,” Dr. Shiner said.

He noted that GLE and PIB are always prescribed together (Mavyret), whereas velpatasvir is commonly prescribed with the NS5B polymerase inhibitor sofosbuvir under the brand name Epclusa. Sofosbuvir is also commonly prescribed with the NS5A protein inhibitor ledipasvir under the brand name Harvoni.
 

Strong association

The new study included 253 VA users with a diagnosis of PTSD and hepatitis C. Of these, 54 were receiving GLE/PIB, 145 were receiving ledipasvir/sofosbuvir, and 54 were receiving sofosbuvir/velpatasvir.

Researchers compared the groups with respect to change over 8-12 weeks on the PTSD Checklist (PCL), a 20-item self-report scale.

In adjusted analyses, the largest mean improvement on the PCL was 14.9 points for the GLE/PIB group and the smallest adjusted mean improvement on the PCL was 7.5 points for the ledipasvir/sofosbuvir group (mean difference, 7.34 points; 95% confidence interval, 1.05-13.63).

The adjusted proportion of patients improving by 15 points or more on the PCL was highest for the GLE/PIB group at 43.6% and lowest for the ledipasvir/sofosbuvir group at 26.3%.

Even when accounting for patients receiving trauma-based therapy or SSRIs, “it still looks like there’s a strong association of the hepatitis C antivirals with PTSD symptom improvement,” said Dr. Shiner.

Researchers also carried out a sensitivity analysis among only patients who were cured of HCV (over 90% of the total sample), defined as having an undetectable HCV viral load up to a year after completion of therapy. The analysis showed PTSD outcomes were still superior for participants receiving GLE/PIB.

“The sensitivity analysis was not that robust because almost everyone was cured, so it included almost everybody, but it didn’t point us away from the possibility of an off-target effect,” Dr. Shiner said.

Why antivirals may improve PTSD symptoms is not clear, but they may affect the immune response in patients with hepatitis C – and there may also be an immune response in PTSD, he noted. “Some of those factors may be shared, and that could explain some of the off-target effect.”

However, he noted the GLE/PIB drug combination is costly and patients with PTSD can probably access it only through enrolling in a study.

“We are not recommending that people go out and purchase this very expensive drug to treat their PTSD at this point,” Dr. Shiner said.

He added that the research team has now received funding from the Department of Defense to conduct a randomized, placebo-controlled trial of GLE/PIB as a potential treatment for PTSD.
 

Promising potential treatment

PTSD expert Elspeth Cameron Ritchie, MD, chief of psychiatry at Medstar Washington Hospital Center, Washington, D.C., said the results suggest GLE/PIB is a promising potential treatment for PTSD.

“I definitely think this should be looked at further,” said Dr. Ritchie, who was not involved with the research.

She noted that current PTSD therapies have drawbacks. SSRIs have side effects, the most “troubling” being sexual dysfunction. And although cognitive-behavioral therapy is effective, “people have to stick with it” and studies show about two thirds of patients drop out, she said.

Potentially effective PTSD treatment approaches include “self-soothing” or “self-regulating” techniques such as exercise, meditation, yoga, and working with animals, she added.

Dr. Ritchie pointed out the numbers of participants in the study were relatively small, including two groups that had only 54 patients each.

And while the GLE/PIB combination should be explored further, cost, availability, and side effects of this medication need to be taken into consideration, she said.

Dr. Ritchie added she is not overly concerned that the mechanism of action for the combination on PTSD may not be well understood. She noted several psychiatric medications fall into that category, including electroconvulsive therapy and lithium.

“When lithium was first found to be effective against bipolar disorder, we had no clue why,” she said. “So I would not discount the antiviral based on us not knowing how it works.”

However, “we’re a long way off” from starting a patient with PTSD on an antiviral, said Dr. Ritchie, adding there are “a lot of steps to go through” to get FDA approval.

The study was funded by the National Institute of Mental Health. The cohort used for this study was developed through support from the Department of Defense. Dr. Shiner is a coinventor on a provisional patent application covering the use of glecaprevir, pibrentasvir, and velpatasvir for PTSD and other psychiatric indications. Dr. Ritchie reported no relevant financial relationships.

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

The combination of the two antiviral medications glecaprevir and pibrentasvir (Mavyret) is linked to improved symptoms in posttraumatic stress disorder, new research suggests.

A national cohort study of U.S. Veterans Affairs patients included more than 250 participants with PTSD and comorbid hepatitis C virus.

Results showed the glecaprevir/pibrentasvir (GLE/PIB) combo was more strongly associated with PTSD symptom improvement than other antiviral combinations tested in the study, including ledipasvir/sofosbuvir.

“While there are great treatments available for PTSD, there’s a lot of desire in the field to find a new medication that will be helpful,” lead author Brian Shiner, MD, acting associate chief of staff for research, VA Medical Center, White River Junction, Vt., told this news organization.

“We had a great opportunity to use a novel data mining method to look in a wonderful database for a new treatment and we found something very promising,” said Dr. Shiner, who is also an associate professor of psychiatry at the Geisel School of Medicine at Dartmouth, Hanover, N.H.

The findings were published online in the American Journal of Epidemiology.
 

Common psychiatric disorder

PTSD is one of the most common psychiatric disorders, with an estimated lifetime prevalence of 6.4% in the United States. Yet only two drugs, the SSRIs sertraline (Zoloft) and paroxetine (Paxil), have been approved by the Food and Drug Administration to treat PTSD.

The VA recommends trauma-based psychotherapy, such as prolonged exposure and cognitive processing therapy, as first-line treatments for PTSD. However, not all patents respond to or have access to these approaches, said Dr. Shiner.

The investigators wanted to examine whether existing medications might reduce PTSD symptoms. Their previous exploratory study used “data mining” of national VA medical records.

Results from that study showed the three hepatitis C antivirals of GLE (an NS3/4A protease inhibitor), PIB (a NS5A protein inhibitor), and velpatasvir (another NS5A protein inhibitor) were associated with more than double the expected number of patients experiencing a clinically meaningful improvement in PTSD symptoms.

Sertraline was associated with only a slightly higher than expected improvement.

“SSRIs are effective, better than placebo, but the effects are not as good as we would hope,” Dr. Shiner said.

He noted that GLE and PIB are always prescribed together (Mavyret), whereas velpatasvir is commonly prescribed with the NS5B polymerase inhibitor sofosbuvir under the brand name Epclusa. Sofosbuvir is also commonly prescribed with the NS5A protein inhibitor ledipasvir under the brand name Harvoni.
 

Strong association

The new study included 253 VA users with a diagnosis of PTSD and hepatitis C. Of these, 54 were receiving GLE/PIB, 145 were receiving ledipasvir/sofosbuvir, and 54 were receiving sofosbuvir/velpatasvir.

Researchers compared the groups with respect to change over 8-12 weeks on the PTSD Checklist (PCL), a 20-item self-report scale.

In adjusted analyses, the largest mean improvement on the PCL was 14.9 points for the GLE/PIB group and the smallest adjusted mean improvement on the PCL was 7.5 points for the ledipasvir/sofosbuvir group (mean difference, 7.34 points; 95% confidence interval, 1.05-13.63).

The adjusted proportion of patients improving by 15 points or more on the PCL was highest for the GLE/PIB group at 43.6% and lowest for the ledipasvir/sofosbuvir group at 26.3%.

Even when accounting for patients receiving trauma-based therapy or SSRIs, “it still looks like there’s a strong association of the hepatitis C antivirals with PTSD symptom improvement,” said Dr. Shiner.

Researchers also carried out a sensitivity analysis among only patients who were cured of HCV (over 90% of the total sample), defined as having an undetectable HCV viral load up to a year after completion of therapy. The analysis showed PTSD outcomes were still superior for participants receiving GLE/PIB.

“The sensitivity analysis was not that robust because almost everyone was cured, so it included almost everybody, but it didn’t point us away from the possibility of an off-target effect,” Dr. Shiner said.

Why antivirals may improve PTSD symptoms is not clear, but they may affect the immune response in patients with hepatitis C – and there may also be an immune response in PTSD, he noted. “Some of those factors may be shared, and that could explain some of the off-target effect.”

However, he noted the GLE/PIB drug combination is costly and patients with PTSD can probably access it only through enrolling in a study.

“We are not recommending that people go out and purchase this very expensive drug to treat their PTSD at this point,” Dr. Shiner said.

He added that the research team has now received funding from the Department of Defense to conduct a randomized, placebo-controlled trial of GLE/PIB as a potential treatment for PTSD.
 

Promising potential treatment

PTSD expert Elspeth Cameron Ritchie, MD, chief of psychiatry at Medstar Washington Hospital Center, Washington, D.C., said the results suggest GLE/PIB is a promising potential treatment for PTSD.

“I definitely think this should be looked at further,” said Dr. Ritchie, who was not involved with the research.

She noted that current PTSD therapies have drawbacks. SSRIs have side effects, the most “troubling” being sexual dysfunction. And although cognitive-behavioral therapy is effective, “people have to stick with it” and studies show about two thirds of patients drop out, she said.

Potentially effective PTSD treatment approaches include “self-soothing” or “self-regulating” techniques such as exercise, meditation, yoga, and working with animals, she added.

Dr. Ritchie pointed out the numbers of participants in the study were relatively small, including two groups that had only 54 patients each.

And while the GLE/PIB combination should be explored further, cost, availability, and side effects of this medication need to be taken into consideration, she said.

Dr. Ritchie added she is not overly concerned that the mechanism of action for the combination on PTSD may not be well understood. She noted several psychiatric medications fall into that category, including electroconvulsive therapy and lithium.

“When lithium was first found to be effective against bipolar disorder, we had no clue why,” she said. “So I would not discount the antiviral based on us not knowing how it works.”

However, “we’re a long way off” from starting a patient with PTSD on an antiviral, said Dr. Ritchie, adding there are “a lot of steps to go through” to get FDA approval.

The study was funded by the National Institute of Mental Health. The cohort used for this study was developed through support from the Department of Defense. Dr. Shiner is a coinventor on a provisional patent application covering the use of glecaprevir, pibrentasvir, and velpatasvir for PTSD and other psychiatric indications. Dr. Ritchie reported no relevant financial relationships.

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

At the beginning of July, Brazilians across the country were appalled when they heard that an anesthesiologist was accused of sexually abusing a woman he had been treating during cesarean delivery. The incident was recorded on video by nurses and nurse technicians who, having become suspicious of the excessive amount of sedatives given to mothers-to-be by this particular anesthesiologist, decided to film him during a procedure. To do this, they made a last-minute change, switching delivery rooms to one in which they had hidden a cell phone in a cabinet.

What the footage showed was horrifying and the assailant, Giovanni Quintella Bezerra, was arrested on the spot. He’s a 32-year-old, White, successful physician, and he’s now accused of rape. The authorities are looking into whether there are more victims, others who may have been abused by the physician. The police are investigating about 40 surgeries in which Dr. Bezerra participated. That same month saw the arrest of another physician, gynecologist Ricardo Teles Martins, who was arrested after being accused of sexually harassing and abusing several women in Hidrolândia, in the northeastern state of Ceará.

In gathering information about these incidents, this news organization interviewed four Brazilian specialists to get their insights on the issues that have been brought to light by these recent cases and the factors that play a role in these kinds of criminal acts. Claudio Cohen, MD, PhD, is a psychiatrist, bioethicist, and professor at the University of São Paulo in Brazil. Daniela Pedroso, MA, is a psychologist who has 25 years’ experience working with victims of sexual violence. Gynecologist and obstetrician Jefferson Drezett, MD, PhD, is a professor in the field of population genetics and reproductive and sexual health at the Federal University of ABC, São Paulo, and in the department of health, life cycles, and society at the University of São Paulo School of Public Health. Maria Alice Scardoelli, MD, is a psychiatrist who also serves as vice-chair of the São Paulo Regional Council of Medicine (Cremesp).


 

Accusations and investigations

Not all incidents of sexual violence in health care institutions are reported, and precise numbers are difficult to obtain. The fact that there are any cases at all is troubling. In 2019, journalists from The Intercept found that over a period of 6 years (2014-2019), 1,734 such attacks were recorded in nine Brazilian states. They were able to get that information from the states’ Public Security Secretariats by using the Information Access Act, a law that regulates the right to access public information.

Efforts to determine how widespread this type of sexual violence is are further complicated by the difficulties in collating the accusations filed at each state’s regional council of medicine, police stations, and public prosecutor’s office. Which investigative steps are taken depends upon where the report was filed, and only occasionally do these entities communicate with each other. According to its data, Cremesp received 78 accusations in 2019. In 2020, that number increased to 84. In 2021, it was 83; these types of attacks were the seventh most common among the investigations opened that year. In the first 6 months of 2022, there were 36 complaints. The number includes investigations opened on the basis of press reports. In such cases, enough information must be available in the press reports make it possible to initiate an evaluation and assessment of the matter. There is no information about how many accusations became the subject of professional ethics proceedings and how many were formally adjudicated.

“Each accusation received is investigated by a technical committee made up of professionals from various specialties. There really needs to be a rigorous evaluation and assessment during the investigation. We cannot be unfair: It may turn out that there was no truth to the accusation after all, and yet someone’s career may already have been destroyed,” explained Dr. Scardoelli.

After the accusation is investigated and accepted by Cremesp, there is no deadline by which the proceedings must end. They can take up to 5 years, and sometimes longer. Since March, however, a deadline for the investigation period has been in effect, after which the proceedings can commence.

“We now have 90 days to make an evaluation and assessment in the investigation phase; that time period can be extended by 3 months, starting from the date the accusation is submitted to the council. If the case is accepted, then the proceedings are opened,” Dr. Scardoelli said.

Some incidents are not reported by victims. And there are incidents that are reported only after many years have passed. This was the case with Nina Marqueti, the actress at the center of #OndeDói — “Where It Hurts” — a campaign that was launched to raise awareness about sexual violence committed by health care professionals. When she was 16, her pediatrician sexually abused her. It wasn’t until 2019, more than a decade later, that she felt able to make this accusation known publicly.

Almost immediately, the campaign received over 4,000 posts online. Most of them were people’s accounts of acts of violence committed by physicians during appointments in their offices or during treatment in a hospital. These are available on Twitter under the hashtag #ondedoi.
 

Inadequate sex education?

News reports about physicians who abuse patients have a tremendous impact on the public. People are genuinely surprised when they hear the words “health care professional” and “sex attack” in the same sentence. “One of the most disturbing aspects is that health care professionals are committing these acts of violence against women who are in a vulnerable state, typically when they’re under anesthesia, they’ve fallen ill, or when the health care professional introduces an element of deception into the procedure so as to create the opportunity to abuse the patient in some way,” said Dr. Drezett.

As Dr. Cohen sees it, to perpetrate these acts of sexual violence, physicians – as well as lawyers, religious leaders, judges, politicians, police officers, and other persons in a position of trust – make use of their power to take advantage of a person’s vulnerability. “Physicians, lawyers, police officers, religious leaders, dads, bosses, husbands – the people who commit sexual abuse all have something in common,” he said. “In terms of the emotional aspect, all of them are taking advantage of both the power that their position holds in society and the asymmetrical power dynamics that exist between them and the other person.”

Indeed, anyone who knocks on a physician’s door seeking a diagnosis or treatment, anyone who knocks on a lawyer’s door seeking assistance, is putting themselves in a fragile situation. “The abuser considers the other person an object, not a human being who has rights,” said Dr. Cohen. People who fit the psychological and behavioral profile of a sexual assailant find in these “powerful” professions and in the circumstances and opportunities these professions provide a means to fulfill their desires. In medicine, however, there is yet another imbalance, one involving consent to touch a person’s body.

The age of the recently arrested anesthesiologist is something that caught Dr. Cohen’s attention. As noted in one of his many books, Bioética e Sexualidade nas Relações Profissionais [Bioethics and Sexuality in Professional Relationships], published in 1999 by the São Paulo Medical Association, age is a characteristic that repeatedly came up in his analysis of 150 sexual abuse proceedings handled by Cremesp.

“When I looked over the cases, I saw that most of the abusers were not right out of med school in their twenties – a time when sex is at the forefront of one’s life – nor were the abusers on the older end of the age spectrum. The abusers were, in fact, those who had already had several years of experience – as was the case with this 32-year-old anesthesiologist who, at a particular moment in time, breached all prohibitions and betrayed the expectations that society had of him as a physician: to care for people’s well-being and to alleviate their suffering. There was nothing that could hold him back from fulfilling his desire, not even the presence of nurses and other physicians in the operating room.” As for the findings of Dr. Cohen’s review, the majority of the 150 cases were dismissed because of lack of evidence.

To Ms. Pedroso, who has treated more than 12,000 victims of sexual harassment, it’s the questioning and intimidation that women feel in relationship to the male physician – a person who is viewed as holding knowledge about her body – that leaves them vulnerable and more subject to acts of violence, especially in more remote places. “We’re speaking, yet again, about rape culture. Not many people know what that term means, but, generally speaking, it has to do with the objectification of women’s bodies and the issue of boys growing up thinking they have the right to touch girls and women and that they will go unpunished for doing so.”

The lack of sex education and efforts to prevent sexual abuse are contributing factors for why the situation remains unchanged. “We are long overdue. We live in a country where there’s this completely mistaken belief that talking about sex education involves teaching children how to have sex, as opposed to teaching them how to protect themselves. We teach girls that they have to protect themselves from being raped, but we don’t teach boys not to rape.”

Another point highlighted by Ms. Pedroso is the fact that to carry out their actions, sexual assailants seek out-of-the-way places, places where they believe the rules can be bent and where they won’t be caught. This is what may have happened with Dr. Bezerra. During a recent press conference, the coordinator of the Health Section of the Rio de Janeiro Public Defender’s Office, Thaísa Guerreiro, stated that although the Women’s Hospital in São João do Meriti – one of the places where the assailant worked as an anesthesiologist – had adopted protocols to protect patients, it failed to enforce them. Another observation was that the health care professionals normalized violations of a woman’s right to have a companion present throughout labor and delivery, a right guaranteed by federal law. Ms. Guerreiro went on to say that the hospital’s chief of anesthesia and the state’s health coordination office did not question this, nor did they find it strange or surprising. According to witness statements, Dr. Bezerra would ask the patients’ husbands to leave the room in the middle of the procedure.

It should be clarified, Dr. Drezett mentioned, that although obstetric violence and sexual abuse overlap in places, they do not have the same root cause or definition. “There are two sets of situations that we term ‘obstetric violence.’ One involves any type of disrespectful treatment, whether comments or neglect, during pregnancy, delivery, or the postpartum period. The other refers to health care professionals’ attitudes in imposing inadequate and outdated medical procedures at the time of birth, such as keeping the woman fasting, having her pubic hair removed, and inducing labor or speeding up the delivery with oxytocin and [routine] episiotomy, among other things.”
 

Early education crucial

How are health care institutions dealing with this problem? “Very poorly. Sexual violence perpetrated by physicians and other health care professionals is a taboo subject that people are still afraid to talk about,” Dr. Cohen observed. “Regrettably, sexual violence happens all too often. Before, maybe we weren’t talking about it much because, from our viewpoint, health care professionals, such as physicians and nurses, weren’t likely to commit acts of violence while performing their duties,” noted Dr. Drezett.

Dr. Drezett also spoke about schools and what role they can play. “Of course, schools should discuss violence against women, especially in the field of health care. This has been done for a long time now, though it’s not in every curriculum in every medical school or nursing school, nor in every school of social work or of psychology,” said Dr. Drezett. For example, in the bioethics classes taken in the third and fourth years of the University of São Paolo’s medical degree program, Dr. Cohen asks students to reflect on the significance of being in a position where you ask a patient you’ve never met to undress so you can perform an exam, and the patient promptly and readily complies. “This is not about the physician, it’s about the power of the institution,” the professor pointed out. Sexual violence is a problem on the university campus as well. Another front in the battle has formed across various schools, where groups of students have created feminist collectives to have sexual violence and other issues related to gender-based violence added to the agenda.

Dr. Drezett said it’s very unlikely that efforts made during a degree program are going to succeed in preventing students who are prone to commit sexual violence from engaging in such behavior. “We’re talking about gender-specific lessons, where discussions about gender-based violence should be started much, much earlier – parents talking to their children, teachers talking to their pupils.” He also doesn’t believe that the molesters are dissuaded by the fact that these accusations get publicized in the media. “If they were, the Roger Abdelmassih case would have done away with the problem.”

On the other hand, Dr. Drezett suggested, publicizing these stories can help to bring very positive issues out into the open. What the Bezerra case made clear was that laws were not followed and rights were not protected. An environment was thus created in which the sexual crime could be perpetrated, with nurses coming to suspect acts of obstetric violence, such as use of sedation, which prevented the woman from having skin-to-skin contact with the newborn and from breastfeeding within the first few hours of birth – two clinical practices that are recommended the world over.

“Health care professionals who act properly, in accordance with best practices for interacting with others and performing daily duties, at all times, in public or private practice – they remove themselves from situations like those described in the Bezerra case; they don’t practice medicine in a reckless manner,” said Dr. Drezett.

Another negative aspect of all this, he said, is that the suspicion and wariness that patients feel may spread far and wide. “Among my colleagues are anesthetists and anesthesiologists with impeccable ethical and professional records. They are very upset that people are now regarding them with doubt and uncertainty. We need to make it clear that those horrifying cases are the exceptions, not the rule,” he said. There is also a need to correct the misconception that such abuse is always in some way associated with obstetrics and gynecology.

“This is not true. These incidents can happen in any doctor’s office. It all depends on the physician – whether he or she has designs on committing a criminal act,” Dr. Drezett noted. He did point out that there are few sexual molesters among health care professionals, though there are numerous cases. Yet this in no way diminishes the seriousness of the incidents. “Of course, we’re speaking again about the exceptions, but in my experience of treating victims, I’ve seen, for example, more cases where it’s been a police officer, not a physician, committing an act of sexual violence against a woman,” he stated.

The nurses and nurse technicians at São João do Meriti Hospital who reported the abuser acted very assertively. If they hadn’t gathered the evidence to back up their accusations, it’s possible that the physician wouldn’t have been caught in the act and that the case would have taken a different course – including pressure being put on them and their becoming the target of retaliation.

A version of this article first appeared on Medscape.com. This article was translated from the Medscape Portuguese edition.

At the beginning of July, Brazilians across the country were appalled when they heard that an anesthesiologist was accused of sexually abusing a woman he had been treating during cesarean delivery. The incident was recorded on video by nurses and nurse technicians who, having become suspicious of the excessive amount of sedatives given to mothers-to-be by this particular anesthesiologist, decided to film him during a procedure. To do this, they made a last-minute change, switching delivery rooms to one in which they had hidden a cell phone in a cabinet.

What the footage showed was horrifying and the assailant, Giovanni Quintella Bezerra, was arrested on the spot. He’s a 32-year-old, White, successful physician, and he’s now accused of rape. The authorities are looking into whether there are more victims, others who may have been abused by the physician. The police are investigating about 40 surgeries in which Dr. Bezerra participated. That same month saw the arrest of another physician, gynecologist Ricardo Teles Martins, who was arrested after being accused of sexually harassing and abusing several women in Hidrolândia, in the northeastern state of Ceará.

In gathering information about these incidents, this news organization interviewed four Brazilian specialists to get their insights on the issues that have been brought to light by these recent cases and the factors that play a role in these kinds of criminal acts. Claudio Cohen, MD, PhD, is a psychiatrist, bioethicist, and professor at the University of São Paulo in Brazil. Daniela Pedroso, MA, is a psychologist who has 25 years’ experience working with victims of sexual violence. Gynecologist and obstetrician Jefferson Drezett, MD, PhD, is a professor in the field of population genetics and reproductive and sexual health at the Federal University of ABC, São Paulo, and in the department of health, life cycles, and society at the University of São Paulo School of Public Health. Maria Alice Scardoelli, MD, is a psychiatrist who also serves as vice-chair of the São Paulo Regional Council of Medicine (Cremesp).


 

Accusations and investigations

Not all incidents of sexual violence in health care institutions are reported, and precise numbers are difficult to obtain. The fact that there are any cases at all is troubling. In 2019, journalists from The Intercept found that over a period of 6 years (2014-2019), 1,734 such attacks were recorded in nine Brazilian states. They were able to get that information from the states’ Public Security Secretariats by using the Information Access Act, a law that regulates the right to access public information.

Efforts to determine how widespread this type of sexual violence is are further complicated by the difficulties in collating the accusations filed at each state’s regional council of medicine, police stations, and public prosecutor’s office. Which investigative steps are taken depends upon where the report was filed, and only occasionally do these entities communicate with each other. According to its data, Cremesp received 78 accusations in 2019. In 2020, that number increased to 84. In 2021, it was 83; these types of attacks were the seventh most common among the investigations opened that year. In the first 6 months of 2022, there were 36 complaints. The number includes investigations opened on the basis of press reports. In such cases, enough information must be available in the press reports make it possible to initiate an evaluation and assessment of the matter. There is no information about how many accusations became the subject of professional ethics proceedings and how many were formally adjudicated.

“Each accusation received is investigated by a technical committee made up of professionals from various specialties. There really needs to be a rigorous evaluation and assessment during the investigation. We cannot be unfair: It may turn out that there was no truth to the accusation after all, and yet someone’s career may already have been destroyed,” explained Dr. Scardoelli.

After the accusation is investigated and accepted by Cremesp, there is no deadline by which the proceedings must end. They can take up to 5 years, and sometimes longer. Since March, however, a deadline for the investigation period has been in effect, after which the proceedings can commence.

“We now have 90 days to make an evaluation and assessment in the investigation phase; that time period can be extended by 3 months, starting from the date the accusation is submitted to the council. If the case is accepted, then the proceedings are opened,” Dr. Scardoelli said.

Some incidents are not reported by victims. And there are incidents that are reported only after many years have passed. This was the case with Nina Marqueti, the actress at the center of #OndeDói — “Where It Hurts” — a campaign that was launched to raise awareness about sexual violence committed by health care professionals. When she was 16, her pediatrician sexually abused her. It wasn’t until 2019, more than a decade later, that she felt able to make this accusation known publicly.

Almost immediately, the campaign received over 4,000 posts online. Most of them were people’s accounts of acts of violence committed by physicians during appointments in their offices or during treatment in a hospital. These are available on Twitter under the hashtag #ondedoi.
 

Inadequate sex education?

News reports about physicians who abuse patients have a tremendous impact on the public. People are genuinely surprised when they hear the words “health care professional” and “sex attack” in the same sentence. “One of the most disturbing aspects is that health care professionals are committing these acts of violence against women who are in a vulnerable state, typically when they’re under anesthesia, they’ve fallen ill, or when the health care professional introduces an element of deception into the procedure so as to create the opportunity to abuse the patient in some way,” said Dr. Drezett.

As Dr. Cohen sees it, to perpetrate these acts of sexual violence, physicians – as well as lawyers, religious leaders, judges, politicians, police officers, and other persons in a position of trust – make use of their power to take advantage of a person’s vulnerability. “Physicians, lawyers, police officers, religious leaders, dads, bosses, husbands – the people who commit sexual abuse all have something in common,” he said. “In terms of the emotional aspect, all of them are taking advantage of both the power that their position holds in society and the asymmetrical power dynamics that exist between them and the other person.”

Indeed, anyone who knocks on a physician’s door seeking a diagnosis or treatment, anyone who knocks on a lawyer’s door seeking assistance, is putting themselves in a fragile situation. “The abuser considers the other person an object, not a human being who has rights,” said Dr. Cohen. People who fit the psychological and behavioral profile of a sexual assailant find in these “powerful” professions and in the circumstances and opportunities these professions provide a means to fulfill their desires. In medicine, however, there is yet another imbalance, one involving consent to touch a person’s body.

The age of the recently arrested anesthesiologist is something that caught Dr. Cohen’s attention. As noted in one of his many books, Bioética e Sexualidade nas Relações Profissionais [Bioethics and Sexuality in Professional Relationships], published in 1999 by the São Paulo Medical Association, age is a characteristic that repeatedly came up in his analysis of 150 sexual abuse proceedings handled by Cremesp.

“When I looked over the cases, I saw that most of the abusers were not right out of med school in their twenties – a time when sex is at the forefront of one’s life – nor were the abusers on the older end of the age spectrum. The abusers were, in fact, those who had already had several years of experience – as was the case with this 32-year-old anesthesiologist who, at a particular moment in time, breached all prohibitions and betrayed the expectations that society had of him as a physician: to care for people’s well-being and to alleviate their suffering. There was nothing that could hold him back from fulfilling his desire, not even the presence of nurses and other physicians in the operating room.” As for the findings of Dr. Cohen’s review, the majority of the 150 cases were dismissed because of lack of evidence.

To Ms. Pedroso, who has treated more than 12,000 victims of sexual harassment, it’s the questioning and intimidation that women feel in relationship to the male physician – a person who is viewed as holding knowledge about her body – that leaves them vulnerable and more subject to acts of violence, especially in more remote places. “We’re speaking, yet again, about rape culture. Not many people know what that term means, but, generally speaking, it has to do with the objectification of women’s bodies and the issue of boys growing up thinking they have the right to touch girls and women and that they will go unpunished for doing so.”

The lack of sex education and efforts to prevent sexual abuse are contributing factors for why the situation remains unchanged. “We are long overdue. We live in a country where there’s this completely mistaken belief that talking about sex education involves teaching children how to have sex, as opposed to teaching them how to protect themselves. We teach girls that they have to protect themselves from being raped, but we don’t teach boys not to rape.”

Another point highlighted by Ms. Pedroso is the fact that to carry out their actions, sexual assailants seek out-of-the-way places, places where they believe the rules can be bent and where they won’t be caught. This is what may have happened with Dr. Bezerra. During a recent press conference, the coordinator of the Health Section of the Rio de Janeiro Public Defender’s Office, Thaísa Guerreiro, stated that although the Women’s Hospital in São João do Meriti – one of the places where the assailant worked as an anesthesiologist – had adopted protocols to protect patients, it failed to enforce them. Another observation was that the health care professionals normalized violations of a woman’s right to have a companion present throughout labor and delivery, a right guaranteed by federal law. Ms. Guerreiro went on to say that the hospital’s chief of anesthesia and the state’s health coordination office did not question this, nor did they find it strange or surprising. According to witness statements, Dr. Bezerra would ask the patients’ husbands to leave the room in the middle of the procedure.

It should be clarified, Dr. Drezett mentioned, that although obstetric violence and sexual abuse overlap in places, they do not have the same root cause or definition. “There are two sets of situations that we term ‘obstetric violence.’ One involves any type of disrespectful treatment, whether comments or neglect, during pregnancy, delivery, or the postpartum period. The other refers to health care professionals’ attitudes in imposing inadequate and outdated medical procedures at the time of birth, such as keeping the woman fasting, having her pubic hair removed, and inducing labor or speeding up the delivery with oxytocin and [routine] episiotomy, among other things.”
 

Early education crucial

How are health care institutions dealing with this problem? “Very poorly. Sexual violence perpetrated by physicians and other health care professionals is a taboo subject that people are still afraid to talk about,” Dr. Cohen observed. “Regrettably, sexual violence happens all too often. Before, maybe we weren’t talking about it much because, from our viewpoint, health care professionals, such as physicians and nurses, weren’t likely to commit acts of violence while performing their duties,” noted Dr. Drezett.

Dr. Drezett also spoke about schools and what role they can play. “Of course, schools should discuss violence against women, especially in the field of health care. This has been done for a long time now, though it’s not in every curriculum in every medical school or nursing school, nor in every school of social work or of psychology,” said Dr. Drezett. For example, in the bioethics classes taken in the third and fourth years of the University of São Paolo’s medical degree program, Dr. Cohen asks students to reflect on the significance of being in a position where you ask a patient you’ve never met to undress so you can perform an exam, and the patient promptly and readily complies. “This is not about the physician, it’s about the power of the institution,” the professor pointed out. Sexual violence is a problem on the university campus as well. Another front in the battle has formed across various schools, where groups of students have created feminist collectives to have sexual violence and other issues related to gender-based violence added to the agenda.

Dr. Drezett said it’s very unlikely that efforts made during a degree program are going to succeed in preventing students who are prone to commit sexual violence from engaging in such behavior. “We’re talking about gender-specific lessons, where discussions about gender-based violence should be started much, much earlier – parents talking to their children, teachers talking to their pupils.” He also doesn’t believe that the molesters are dissuaded by the fact that these accusations get publicized in the media. “If they were, the Roger Abdelmassih case would have done away with the problem.”

On the other hand, Dr. Drezett suggested, publicizing these stories can help to bring very positive issues out into the open. What the Bezerra case made clear was that laws were not followed and rights were not protected. An environment was thus created in which the sexual crime could be perpetrated, with nurses coming to suspect acts of obstetric violence, such as use of sedation, which prevented the woman from having skin-to-skin contact with the newborn and from breastfeeding within the first few hours of birth – two clinical practices that are recommended the world over.

“Health care professionals who act properly, in accordance with best practices for interacting with others and performing daily duties, at all times, in public or private practice – they remove themselves from situations like those described in the Bezerra case; they don’t practice medicine in a reckless manner,” said Dr. Drezett.

Another negative aspect of all this, he said, is that the suspicion and wariness that patients feel may spread far and wide. “Among my colleagues are anesthetists and anesthesiologists with impeccable ethical and professional records. They are very upset that people are now regarding them with doubt and uncertainty. We need to make it clear that those horrifying cases are the exceptions, not the rule,” he said. There is also a need to correct the misconception that such abuse is always in some way associated with obstetrics and gynecology.

“This is not true. These incidents can happen in any doctor’s office. It all depends on the physician – whether he or she has designs on committing a criminal act,” Dr. Drezett noted. He did point out that there are few sexual molesters among health care professionals, though there are numerous cases. Yet this in no way diminishes the seriousness of the incidents. “Of course, we’re speaking again about the exceptions, but in my experience of treating victims, I’ve seen, for example, more cases where it’s been a police officer, not a physician, committing an act of sexual violence against a woman,” he stated.

The nurses and nurse technicians at São João do Meriti Hospital who reported the abuser acted very assertively. If they hadn’t gathered the evidence to back up their accusations, it’s possible that the physician wouldn’t have been caught in the act and that the case would have taken a different course – including pressure being put on them and their becoming the target of retaliation.

A version of this article first appeared on Medscape.com. This article was translated from the Medscape Portuguese edition.

At the beginning of July, Brazilians across the country were appalled when they heard that an anesthesiologist was accused of sexually abusing a woman he had been treating during cesarean delivery. The incident was recorded on video by nurses and nurse technicians who, having become suspicious of the excessive amount of sedatives given to mothers-to-be by this particular anesthesiologist, decided to film him during a procedure. To do this, they made a last-minute change, switching delivery rooms to one in which they had hidden a cell phone in a cabinet.

What the footage showed was horrifying and the assailant, Giovanni Quintella Bezerra, was arrested on the spot. He’s a 32-year-old, White, successful physician, and he’s now accused of rape. The authorities are looking into whether there are more victims, others who may have been abused by the physician. The police are investigating about 40 surgeries in which Dr. Bezerra participated. That same month saw the arrest of another physician, gynecologist Ricardo Teles Martins, who was arrested after being accused of sexually harassing and abusing several women in Hidrolândia, in the northeastern state of Ceará.

In gathering information about these incidents, this news organization interviewed four Brazilian specialists to get their insights on the issues that have been brought to light by these recent cases and the factors that play a role in these kinds of criminal acts. Claudio Cohen, MD, PhD, is a psychiatrist, bioethicist, and professor at the University of São Paulo in Brazil. Daniela Pedroso, MA, is a psychologist who has 25 years’ experience working with victims of sexual violence. Gynecologist and obstetrician Jefferson Drezett, MD, PhD, is a professor in the field of population genetics and reproductive and sexual health at the Federal University of ABC, São Paulo, and in the department of health, life cycles, and society at the University of São Paulo School of Public Health. Maria Alice Scardoelli, MD, is a psychiatrist who also serves as vice-chair of the São Paulo Regional Council of Medicine (Cremesp).


 

Accusations and investigations

Not all incidents of sexual violence in health care institutions are reported, and precise numbers are difficult to obtain. The fact that there are any cases at all is troubling. In 2019, journalists from The Intercept found that over a period of 6 years (2014-2019), 1,734 such attacks were recorded in nine Brazilian states. They were able to get that information from the states’ Public Security Secretariats by using the Information Access Act, a law that regulates the right to access public information.

Efforts to determine how widespread this type of sexual violence is are further complicated by the difficulties in collating the accusations filed at each state’s regional council of medicine, police stations, and public prosecutor’s office. Which investigative steps are taken depends upon where the report was filed, and only occasionally do these entities communicate with each other. According to its data, Cremesp received 78 accusations in 2019. In 2020, that number increased to 84. In 2021, it was 83; these types of attacks were the seventh most common among the investigations opened that year. In the first 6 months of 2022, there were 36 complaints. The number includes investigations opened on the basis of press reports. In such cases, enough information must be available in the press reports make it possible to initiate an evaluation and assessment of the matter. There is no information about how many accusations became the subject of professional ethics proceedings and how many were formally adjudicated.

“Each accusation received is investigated by a technical committee made up of professionals from various specialties. There really needs to be a rigorous evaluation and assessment during the investigation. We cannot be unfair: It may turn out that there was no truth to the accusation after all, and yet someone’s career may already have been destroyed,” explained Dr. Scardoelli.

After the accusation is investigated and accepted by Cremesp, there is no deadline by which the proceedings must end. They can take up to 5 years, and sometimes longer. Since March, however, a deadline for the investigation period has been in effect, after which the proceedings can commence.

“We now have 90 days to make an evaluation and assessment in the investigation phase; that time period can be extended by 3 months, starting from the date the accusation is submitted to the council. If the case is accepted, then the proceedings are opened,” Dr. Scardoelli said.

Some incidents are not reported by victims. And there are incidents that are reported only after many years have passed. This was the case with Nina Marqueti, the actress at the center of #OndeDói — “Where It Hurts” — a campaign that was launched to raise awareness about sexual violence committed by health care professionals. When she was 16, her pediatrician sexually abused her. It wasn’t until 2019, more than a decade later, that she felt able to make this accusation known publicly.

Almost immediately, the campaign received over 4,000 posts online. Most of them were people’s accounts of acts of violence committed by physicians during appointments in their offices or during treatment in a hospital. These are available on Twitter under the hashtag #ondedoi.
 

Inadequate sex education?

News reports about physicians who abuse patients have a tremendous impact on the public. People are genuinely surprised when they hear the words “health care professional” and “sex attack” in the same sentence. “One of the most disturbing aspects is that health care professionals are committing these acts of violence against women who are in a vulnerable state, typically when they’re under anesthesia, they’ve fallen ill, or when the health care professional introduces an element of deception into the procedure so as to create the opportunity to abuse the patient in some way,” said Dr. Drezett.

As Dr. Cohen sees it, to perpetrate these acts of sexual violence, physicians – as well as lawyers, religious leaders, judges, politicians, police officers, and other persons in a position of trust – make use of their power to take advantage of a person’s vulnerability. “Physicians, lawyers, police officers, religious leaders, dads, bosses, husbands – the people who commit sexual abuse all have something in common,” he said. “In terms of the emotional aspect, all of them are taking advantage of both the power that their position holds in society and the asymmetrical power dynamics that exist between them and the other person.”

Indeed, anyone who knocks on a physician’s door seeking a diagnosis or treatment, anyone who knocks on a lawyer’s door seeking assistance, is putting themselves in a fragile situation. “The abuser considers the other person an object, not a human being who has rights,” said Dr. Cohen. People who fit the psychological and behavioral profile of a sexual assailant find in these “powerful” professions and in the circumstances and opportunities these professions provide a means to fulfill their desires. In medicine, however, there is yet another imbalance, one involving consent to touch a person’s body.

The age of the recently arrested anesthesiologist is something that caught Dr. Cohen’s attention. As noted in one of his many books, Bioética e Sexualidade nas Relações Profissionais [Bioethics and Sexuality in Professional Relationships], published in 1999 by the São Paulo Medical Association, age is a characteristic that repeatedly came up in his analysis of 150 sexual abuse proceedings handled by Cremesp.

“When I looked over the cases, I saw that most of the abusers were not right out of med school in their twenties – a time when sex is at the forefront of one’s life – nor were the abusers on the older end of the age spectrum. The abusers were, in fact, those who had already had several years of experience – as was the case with this 32-year-old anesthesiologist who, at a particular moment in time, breached all prohibitions and betrayed the expectations that society had of him as a physician: to care for people’s well-being and to alleviate their suffering. There was nothing that could hold him back from fulfilling his desire, not even the presence of nurses and other physicians in the operating room.” As for the findings of Dr. Cohen’s review, the majority of the 150 cases were dismissed because of lack of evidence.

To Ms. Pedroso, who has treated more than 12,000 victims of sexual harassment, it’s the questioning and intimidation that women feel in relationship to the male physician – a person who is viewed as holding knowledge about her body – that leaves them vulnerable and more subject to acts of violence, especially in more remote places. “We’re speaking, yet again, about rape culture. Not many people know what that term means, but, generally speaking, it has to do with the objectification of women’s bodies and the issue of boys growing up thinking they have the right to touch girls and women and that they will go unpunished for doing so.”

The lack of sex education and efforts to prevent sexual abuse are contributing factors for why the situation remains unchanged. “We are long overdue. We live in a country where there’s this completely mistaken belief that talking about sex education involves teaching children how to have sex, as opposed to teaching them how to protect themselves. We teach girls that they have to protect themselves from being raped, but we don’t teach boys not to rape.”

Another point highlighted by Ms. Pedroso is the fact that to carry out their actions, sexual assailants seek out-of-the-way places, places where they believe the rules can be bent and where they won’t be caught. This is what may have happened with Dr. Bezerra. During a recent press conference, the coordinator of the Health Section of the Rio de Janeiro Public Defender’s Office, Thaísa Guerreiro, stated that although the Women’s Hospital in São João do Meriti – one of the places where the assailant worked as an anesthesiologist – had adopted protocols to protect patients, it failed to enforce them. Another observation was that the health care professionals normalized violations of a woman’s right to have a companion present throughout labor and delivery, a right guaranteed by federal law. Ms. Guerreiro went on to say that the hospital’s chief of anesthesia and the state’s health coordination office did not question this, nor did they find it strange or surprising. According to witness statements, Dr. Bezerra would ask the patients’ husbands to leave the room in the middle of the procedure.

It should be clarified, Dr. Drezett mentioned, that although obstetric violence and sexual abuse overlap in places, they do not have the same root cause or definition. “There are two sets of situations that we term ‘obstetric violence.’ One involves any type of disrespectful treatment, whether comments or neglect, during pregnancy, delivery, or the postpartum period. The other refers to health care professionals’ attitudes in imposing inadequate and outdated medical procedures at the time of birth, such as keeping the woman fasting, having her pubic hair removed, and inducing labor or speeding up the delivery with oxytocin and [routine] episiotomy, among other things.”
 

Early education crucial

How are health care institutions dealing with this problem? “Very poorly. Sexual violence perpetrated by physicians and other health care professionals is a taboo subject that people are still afraid to talk about,” Dr. Cohen observed. “Regrettably, sexual violence happens all too often. Before, maybe we weren’t talking about it much because, from our viewpoint, health care professionals, such as physicians and nurses, weren’t likely to commit acts of violence while performing their duties,” noted Dr. Drezett.

Dr. Drezett also spoke about schools and what role they can play. “Of course, schools should discuss violence against women, especially in the field of health care. This has been done for a long time now, though it’s not in every curriculum in every medical school or nursing school, nor in every school of social work or of psychology,” said Dr. Drezett. For example, in the bioethics classes taken in the third and fourth years of the University of São Paolo’s medical degree program, Dr. Cohen asks students to reflect on the significance of being in a position where you ask a patient you’ve never met to undress so you can perform an exam, and the patient promptly and readily complies. “This is not about the physician, it’s about the power of the institution,” the professor pointed out. Sexual violence is a problem on the university campus as well. Another front in the battle has formed across various schools, where groups of students have created feminist collectives to have sexual violence and other issues related to gender-based violence added to the agenda.

Dr. Drezett said it’s very unlikely that efforts made during a degree program are going to succeed in preventing students who are prone to commit sexual violence from engaging in such behavior. “We’re talking about gender-specific lessons, where discussions about gender-based violence should be started much, much earlier – parents talking to their children, teachers talking to their pupils.” He also doesn’t believe that the molesters are dissuaded by the fact that these accusations get publicized in the media. “If they were, the Roger Abdelmassih case would have done away with the problem.”

On the other hand, Dr. Drezett suggested, publicizing these stories can help to bring very positive issues out into the open. What the Bezerra case made clear was that laws were not followed and rights were not protected. An environment was thus created in which the sexual crime could be perpetrated, with nurses coming to suspect acts of obstetric violence, such as use of sedation, which prevented the woman from having skin-to-skin contact with the newborn and from breastfeeding within the first few hours of birth – two clinical practices that are recommended the world over.

“Health care professionals who act properly, in accordance with best practices for interacting with others and performing daily duties, at all times, in public or private practice – they remove themselves from situations like those described in the Bezerra case; they don’t practice medicine in a reckless manner,” said Dr. Drezett.

Another negative aspect of all this, he said, is that the suspicion and wariness that patients feel may spread far and wide. “Among my colleagues are anesthetists and anesthesiologists with impeccable ethical and professional records. They are very upset that people are now regarding them with doubt and uncertainty. We need to make it clear that those horrifying cases are the exceptions, not the rule,” he said. There is also a need to correct the misconception that such abuse is always in some way associated with obstetrics and gynecology.

“This is not true. These incidents can happen in any doctor’s office. It all depends on the physician – whether he or she has designs on committing a criminal act,” Dr. Drezett noted. He did point out that there are few sexual molesters among health care professionals, though there are numerous cases. Yet this in no way diminishes the seriousness of the incidents. “Of course, we’re speaking again about the exceptions, but in my experience of treating victims, I’ve seen, for example, more cases where it’s been a police officer, not a physician, committing an act of sexual violence against a woman,” he stated.

The nurses and nurse technicians at São João do Meriti Hospital who reported the abuser acted very assertively. If they hadn’t gathered the evidence to back up their accusations, it’s possible that the physician wouldn’t have been caught in the act and that the case would have taken a different course – including pressure being put on them and their becoming the target of retaliation.

A version of this article first appeared on Medscape.com. This article was translated from the Medscape Portuguese edition.

Federal Health Care Data Trends (click to view the digital edition) is a special supplement to Federal Practitioner highlighting the latest research and study outcomes related to the health of veteran and active-duty populations. 

In this issue:

• Vaccinations
• Mental Health and Related Disorders
• LGBTQ+ Veterans
• Military Sexual Trauma
• Sleep Disorders
• Respiratory Illnesses
• HIV Care in the VA
• Rheumatologic Diseases
• The Cancer-Obesity Connection
• Skin Health for Active-Duty Personnel
• Contraception
• Chronic Kidney Disease
• Cardiovascular Diseases
• Neurologic Disorders
• Hearing, Vision, and Balance

Federal Practitioner would like to thank the following experts for their review of content and helpful guidance in developing this issue: 

Kelvin N.V. Bush, MD, FACC, CCDS; Sonya Borrero, MD, MS; Kenneth L. Cameron, PhD, MPH, ATC, FNATA; Jason DeViva, PhD; Ellen Lockard Edens, MD; Leonard E. Egede, MD, MS; Amy Justice, MD, PhD; Stephanie Knudson, MD; Willis H. Lyford, MD; Sarah O. Meadows, PhD; Tamara Schult, PhD, MPH; Eric L. Singman, MD, PhD; Art Wallace, MD, PhD; Elizabeth Waterhouse, MD, FAAN

Federal Health Care Data Trends (click to view the digital edition) is a special supplement to Federal Practitioner highlighting the latest research and study outcomes related to the health of veteran and active-duty populations. 

In this issue:

• Vaccinations
• Mental Health and Related Disorders
• LGBTQ+ Veterans
• Military Sexual Trauma
• Sleep Disorders
• Respiratory Illnesses
• HIV Care in the VA
• Rheumatologic Diseases
• The Cancer-Obesity Connection
• Skin Health for Active-Duty Personnel
• Contraception
• Chronic Kidney Disease
• Cardiovascular Diseases
• Neurologic Disorders
• Hearing, Vision, and Balance

Federal Practitioner would like to thank the following experts for their review of content and helpful guidance in developing this issue: 

Kelvin N.V. Bush, MD, FACC, CCDS; Sonya Borrero, MD, MS; Kenneth L. Cameron, PhD, MPH, ATC, FNATA; Jason DeViva, PhD; Ellen Lockard Edens, MD; Leonard E. Egede, MD, MS; Amy Justice, MD, PhD; Stephanie Knudson, MD; Willis H. Lyford, MD; Sarah O. Meadows, PhD; Tamara Schult, PhD, MPH; Eric L. Singman, MD, PhD; Art Wallace, MD, PhD; Elizabeth Waterhouse, MD, FAAN

Federal Health Care Data Trends (click to view the digital edition) is a special supplement to Federal Practitioner highlighting the latest research and study outcomes related to the health of veteran and active-duty populations. 

In this issue:

• Vaccinations
• Mental Health and Related Disorders
• LGBTQ+ Veterans
• Military Sexual Trauma
• Sleep Disorders
• Respiratory Illnesses
• HIV Care in the VA
• Rheumatologic Diseases
• The Cancer-Obesity Connection
• Skin Health for Active-Duty Personnel
• Contraception
• Chronic Kidney Disease
• Cardiovascular Diseases
• Neurologic Disorders
• Hearing, Vision, and Balance

Federal Practitioner would like to thank the following experts for their review of content and helpful guidance in developing this issue: 

Kelvin N.V. Bush, MD, FACC, CCDS; Sonya Borrero, MD, MS; Kenneth L. Cameron, PhD, MPH, ATC, FNATA; Jason DeViva, PhD; Ellen Lockard Edens, MD; Leonard E. Egede, MD, MS; Amy Justice, MD, PhD; Stephanie Knudson, MD; Willis H. Lyford, MD; Sarah O. Meadows, PhD; Tamara Schult, PhD, MPH; Eric L. Singman, MD, PhD; Art Wallace, MD, PhD; Elizabeth Waterhouse, MD, FAAN

In September 2022, the University of California, Berkeley, will start training its first class of “trip facilitators,” who will learn how to guide individuals through therapeutic psychedelic experiences aimed at addressing a variety of mental health problems.

The UC Berkeley Center for the Science of Psychedelics (BCSP) training program aims to create a cadre of facilitators who will be ready to help if, and when, substances such as psilocybin, MDMA, and LSD are approved in the United States, Tina Trujillo, PhD, an associate professor at UC Berkeley’s School of Education, told reporters at a press briefing.

Hallucinogenic drugs are on the Drug Enforcement Administration’s (DEA) Schedule I list because they are considered to have no currently accepted medical use and high abuse potential. But there has been an explosion of research into psychedelics – combined with therapy – as treatment for severe depression, posttraumatic stress disorder, substance-use disorder, and other mental health conditions. Some 100 clinical trials are underway.

“The estimates are that we’re going to need 100,000 trained psychedelic facilitators once psilocybin and MDMA are approved by the [U.S. Food and Drug Administration] FDA, which is expected to happen within the next 5 years or so,” said Michael Pollan, co-founder of the BCSP. He is author of “How to Change Your Mind,” a 2018 book about psychedelics, which has been adapted into a four-part docuseries currently streaming on Netflix.

Courtesy Alia Malley

Nine-month program

The first 24 trainees – a mix of physicians, nurses, psychotherapists, and social workers – will undergo 9 months of education and preparation in “the technical, the cultural, the mystical, and the ethical dimensions of psychedelic facilitation,” said Dr. Trujillo.

The BCSP’s Certificate Program in Psychedelic Facilitation will have “an emphasis on both western science and spiritual care traditions,” she said.

Trainees will receive 150 instructional hours and a 25-hour practicum and will take part in a final 5-day retreat. The program will initially focus only on psilocybin, in part because the BCSP is involved in several FDA-approved trials testing the drug.

In one study – which aims to enroll participants in the fall – researchers will use functional MRI to examine the neural correlates of the psychedelic experience in individuals receiving low-dose psilocybin.

Eligible trainees will have an opportunity to participate in the Berkeley psilocybin trials and “increase their first-hand knowledge,” Dr. Trujillo said.

At the conclusion of the training, students will receive a certificate, “not a license or sanction to go off and practice,” she said. She noted that eventually, when facilitation is legal, certificate holders will be able to practice in clinical research settings or in health care settings.
 

Growing acceptance in psychiatry

Mr. Pollan said there has been a radical change in acceptance of psychedelics as potential therapies.

“The shift from destroyer of young minds in the ‘60s to effective medicine in the 2020s is as sudden as it is confusing for many people,” he said. He noted that the Berkeley center hopes to provide evidence-based information for journalists, the public, and clinicians.

He said that after his book was released, he expected pushback from “mainstream psychiatry.” Instead, he was invited to give grand rounds talks. Psychiatrists are “very open to the potential of psychedelics,” Mr. Pollan said.

“The reason for that, quite frankly, is because they are desperate,” he said. “The tools of conventional psychiatry to deal with things like depression and anxiety and addiction are not very good, and some of them are failing,” he said.

Mr. Pollan cited some other indicators of acceptance. In Oregon, beginning in 2023, psilocybin will be available to anyone older than 21 years but only for use in licensed facilities with licensed facilitators, and the substance must be produced by a licensed manufacturer.

In November, Colorado will ask voters whether they want to follow the Oregon model and legalize psilocybin. If approved, another Colorado ballot initiative would decriminalize possession.

Mr. Pollan noted that Cory Booker, the Democratic Senator from New Jersey, and Rand Paul, a conservative Republican Senator from Kentucky, have found a common cause, introducing legislation to let select terminally ill patients have access to psychedelics and other Schedule I drugs.

Some 400 companies are conducting research on psychedelics. Researchers must have a license from the DEA to obtain and study the substances, Andrea Gomez, assistant professor of neurobiology at UC Berkeley, told reporters.

She said growing interest in the potential of these drugs might lead more researchers to “jump through the hoops” to get the licenses. The floodgates would truly open if the National Institutes of Health started funding studies, she said.

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

In September 2022, the University of California, Berkeley, will start training its first class of “trip facilitators,” who will learn how to guide individuals through therapeutic psychedelic experiences aimed at addressing a variety of mental health problems.

The UC Berkeley Center for the Science of Psychedelics (BCSP) training program aims to create a cadre of facilitators who will be ready to help if, and when, substances such as psilocybin, MDMA, and LSD are approved in the United States, Tina Trujillo, PhD, an associate professor at UC Berkeley’s School of Education, told reporters at a press briefing.

Hallucinogenic drugs are on the Drug Enforcement Administration’s (DEA) Schedule I list because they are considered to have no currently accepted medical use and high abuse potential. But there has been an explosion of research into psychedelics – combined with therapy – as treatment for severe depression, posttraumatic stress disorder, substance-use disorder, and other mental health conditions. Some 100 clinical trials are underway.

“The estimates are that we’re going to need 100,000 trained psychedelic facilitators once psilocybin and MDMA are approved by the [U.S. Food and Drug Administration] FDA, which is expected to happen within the next 5 years or so,” said Michael Pollan, co-founder of the BCSP. He is author of “How to Change Your Mind,” a 2018 book about psychedelics, which has been adapted into a four-part docuseries currently streaming on Netflix.

Courtesy Alia Malley

Nine-month program

The first 24 trainees – a mix of physicians, nurses, psychotherapists, and social workers – will undergo 9 months of education and preparation in “the technical, the cultural, the mystical, and the ethical dimensions of psychedelic facilitation,” said Dr. Trujillo.

The BCSP’s Certificate Program in Psychedelic Facilitation will have “an emphasis on both western science and spiritual care traditions,” she said.

Trainees will receive 150 instructional hours and a 25-hour practicum and will take part in a final 5-day retreat. The program will initially focus only on psilocybin, in part because the BCSP is involved in several FDA-approved trials testing the drug.

In one study – which aims to enroll participants in the fall – researchers will use functional MRI to examine the neural correlates of the psychedelic experience in individuals receiving low-dose psilocybin.

Eligible trainees will have an opportunity to participate in the Berkeley psilocybin trials and “increase their first-hand knowledge,” Dr. Trujillo said.

At the conclusion of the training, students will receive a certificate, “not a license or sanction to go off and practice,” she said. She noted that eventually, when facilitation is legal, certificate holders will be able to practice in clinical research settings or in health care settings.
 

Growing acceptance in psychiatry

Mr. Pollan said there has been a radical change in acceptance of psychedelics as potential therapies.

“The shift from destroyer of young minds in the ‘60s to effective medicine in the 2020s is as sudden as it is confusing for many people,” he said. He noted that the Berkeley center hopes to provide evidence-based information for journalists, the public, and clinicians.

He said that after his book was released, he expected pushback from “mainstream psychiatry.” Instead, he was invited to give grand rounds talks. Psychiatrists are “very open to the potential of psychedelics,” Mr. Pollan said.

“The reason for that, quite frankly, is because they are desperate,” he said. “The tools of conventional psychiatry to deal with things like depression and anxiety and addiction are not very good, and some of them are failing,” he said.

Mr. Pollan cited some other indicators of acceptance. In Oregon, beginning in 2023, psilocybin will be available to anyone older than 21 years but only for use in licensed facilities with licensed facilitators, and the substance must be produced by a licensed manufacturer.

In November, Colorado will ask voters whether they want to follow the Oregon model and legalize psilocybin. If approved, another Colorado ballot initiative would decriminalize possession.

Mr. Pollan noted that Cory Booker, the Democratic Senator from New Jersey, and Rand Paul, a conservative Republican Senator from Kentucky, have found a common cause, introducing legislation to let select terminally ill patients have access to psychedelics and other Schedule I drugs.

Some 400 companies are conducting research on psychedelics. Researchers must have a license from the DEA to obtain and study the substances, Andrea Gomez, assistant professor of neurobiology at UC Berkeley, told reporters.

She said growing interest in the potential of these drugs might lead more researchers to “jump through the hoops” to get the licenses. The floodgates would truly open if the National Institutes of Health started funding studies, she said.

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

In September 2022, the University of California, Berkeley, will start training its first class of “trip facilitators,” who will learn how to guide individuals through therapeutic psychedelic experiences aimed at addressing a variety of mental health problems.

The UC Berkeley Center for the Science of Psychedelics (BCSP) training program aims to create a cadre of facilitators who will be ready to help if, and when, substances such as psilocybin, MDMA, and LSD are approved in the United States, Tina Trujillo, PhD, an associate professor at UC Berkeley’s School of Education, told reporters at a press briefing.

Hallucinogenic drugs are on the Drug Enforcement Administration’s (DEA) Schedule I list because they are considered to have no currently accepted medical use and high abuse potential. But there has been an explosion of research into psychedelics – combined with therapy – as treatment for severe depression, posttraumatic stress disorder, substance-use disorder, and other mental health conditions. Some 100 clinical trials are underway.

“The estimates are that we’re going to need 100,000 trained psychedelic facilitators once psilocybin and MDMA are approved by the [U.S. Food and Drug Administration] FDA, which is expected to happen within the next 5 years or so,” said Michael Pollan, co-founder of the BCSP. He is author of “How to Change Your Mind,” a 2018 book about psychedelics, which has been adapted into a four-part docuseries currently streaming on Netflix.

Courtesy Alia Malley

Nine-month program

The first 24 trainees – a mix of physicians, nurses, psychotherapists, and social workers – will undergo 9 months of education and preparation in “the technical, the cultural, the mystical, and the ethical dimensions of psychedelic facilitation,” said Dr. Trujillo.

The BCSP’s Certificate Program in Psychedelic Facilitation will have “an emphasis on both western science and spiritual care traditions,” she said.

Trainees will receive 150 instructional hours and a 25-hour practicum and will take part in a final 5-day retreat. The program will initially focus only on psilocybin, in part because the BCSP is involved in several FDA-approved trials testing the drug.

In one study – which aims to enroll participants in the fall – researchers will use functional MRI to examine the neural correlates of the psychedelic experience in individuals receiving low-dose psilocybin.

Eligible trainees will have an opportunity to participate in the Berkeley psilocybin trials and “increase their first-hand knowledge,” Dr. Trujillo said.

At the conclusion of the training, students will receive a certificate, “not a license or sanction to go off and practice,” she said. She noted that eventually, when facilitation is legal, certificate holders will be able to practice in clinical research settings or in health care settings.
 

Growing acceptance in psychiatry

Mr. Pollan said there has been a radical change in acceptance of psychedelics as potential therapies.

“The shift from destroyer of young minds in the ‘60s to effective medicine in the 2020s is as sudden as it is confusing for many people,” he said. He noted that the Berkeley center hopes to provide evidence-based information for journalists, the public, and clinicians.

He said that after his book was released, he expected pushback from “mainstream psychiatry.” Instead, he was invited to give grand rounds talks. Psychiatrists are “very open to the potential of psychedelics,” Mr. Pollan said.

“The reason for that, quite frankly, is because they are desperate,” he said. “The tools of conventional psychiatry to deal with things like depression and anxiety and addiction are not very good, and some of them are failing,” he said.

Mr. Pollan cited some other indicators of acceptance. In Oregon, beginning in 2023, psilocybin will be available to anyone older than 21 years but only for use in licensed facilities with licensed facilitators, and the substance must be produced by a licensed manufacturer.

In November, Colorado will ask voters whether they want to follow the Oregon model and legalize psilocybin. If approved, another Colorado ballot initiative would decriminalize possession.

Mr. Pollan noted that Cory Booker, the Democratic Senator from New Jersey, and Rand Paul, a conservative Republican Senator from Kentucky, have found a common cause, introducing legislation to let select terminally ill patients have access to psychedelics and other Schedule I drugs.

Some 400 companies are conducting research on psychedelics. Researchers must have a license from the DEA to obtain and study the substances, Andrea Gomez, assistant professor of neurobiology at UC Berkeley, told reporters.

She said growing interest in the potential of these drugs might lead more researchers to “jump through the hoops” to get the licenses. The floodgates would truly open if the National Institutes of Health started funding studies, she said.

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

There’s little doubt that long COVID is real. Even as doctors and federal agencies struggle to define the syndrome, hospitals and health care systems are opening long COVID specialty treatment programs. As of July 25, there’s at least one long COVID center in almost every state – 48 out of 50, according to the patient advocacy group Survivor Corps.

Among the biggest challenges will be treating the mental health effects of long COVID. Well after people recover from acute COVID infections, they can still have a wide range of lingering symptoms, including depression, anxiety, brain fog, and PTSD.

courtesy Oregon Health & Science University

Specialized centers will be tackling these problems even as the United States struggles to deal with mental health needs.

One study of COVID patients found more than one-third of them had symptoms of depression, anxiety, or PTSD 3-6 months after their initial infection. Another analysis of 30 previous studies of long COVID patients found roughly one in eight of them had severe depression – and that the risk was similar regardless of whether people were hospitalized for COVID-19.

“Many of these symptoms can emerge months into the course of long COVID illness,” said Jordan Anderson, DO, a neuropsychiatrist who sees patients at the Long COVID-19 Program at Oregon Health & Science University, Portland. Psychological symptoms are often made worse by physical setbacks like extreme fatigue and by challenges of working, caring for children, and keeping up with daily routines, he said.

“This impact is not only severe, but also chronic for many,” he said.

Like dozens of hospitals around the country, Oregon Health & Science opened its center for long COVID as it became clear that more patients would need help for ongoing physical and mental health symptoms. Today, there’s at least one long COVID center – sometimes called post-COVID care centers or clinics – in every state but Kansas and South Dakota, Survivor Corps said.

Many long COVID care centers aim to tackle both physical and mental health symptoms, said Tracy Vannorsdall, PhD, a neuropsychologist with the Johns Hopkins Post-Acute COVID-19 Team program. One goal at Hopkins is to identify patients with psychological issues that might otherwise get overlooked.

A sizable minority of patients at the Johns Hopkins center – up to about 35% – report mental health problems that they didn’t have until after they got COVID-19, Dr. Vannorsdall says. The most common mental health issues providers see are depression, anxiety, and trauma-related distress.

“Routine assessment is key,” Dr. Vannorsdall said. “If patients are not asked about their mental health symptoms, they may not spontaneously report them to their provider due to fear of stigma or simply not appreciating that there are effective treatments available for these issues.”

Fear that doctors won’t take symptoms seriously is common, says Heather Murray MD, a senior instructor in psychiatry at the University of Colorado at Denver, Aurora.

“Many patients worry their physicians, loved ones, and society will not believe them or will minimize their symptoms and suffering,” said Dr. Murray, who treats patients at the UCHealth Post-COVID Clinic.

Diagnostic tests in long COVID patients often don’t have conclusive results, which can lead doctors and patients themselves to question whether symptoms are truly “physical versus psychosomatic,” she said. “It is important that providers believe their patients and treat their symptoms, even when diagnostic tests are unrevealing.”
 

Growing mental health crisis

Patients often find their way to academic treatment centers after surviving severe COVID-19 infections. But a growing number of long COVID patients show up at these centers after milder cases. These patients were never hospitalized for COVID-19 but still have persistent symptoms like fatigue, thinking problems, and mood disorders.

Among the major challenges is a shortage of mental health care providers to meet the surging need for care since the start of the pandemic. Around the world, anxiety and depression surged 25% during the first year of the pandemic, according to the World Health Organization.

In the United States, 40% of adults report feelings of anxiety and depression, and one in three high school students have feelings of sadness and hopelessness, according to a March 2022 statement from the White House.

Despite this surging need for care, almost half of Americans live in areas with a severe shortage of mental health care providers, according to the Health Resources and Services Administration. As of 2019, the United States had a shortage of about 6,790 mental health providers. Since then, the shortage has worsened; it’s now about 7,500 providers.

“One of the biggest challenges for hospitals and clinics in treating mental health disorders in long COVID is the limited resources and long wait times to get in for evaluations and treatment,” said Nyaz Didehbani, PhD, a neuropsychologist who treats long COVID patients at the COVID Recover program at the University of Texas Southwestern Medical Center, Dallas.

These delays can lead to worse outcomes, Dr. Didehbani said. “Additionally, patients do not feel that they are being heard, as many providers are not aware of the mental health impact and relationship with physical and cognitive symptoms.” .

Even when doctors recognize that psychological challenges are common with long COVID, they still have to think creatively to come up with treatments that meet the unique needs of these patients, said Thida Thant, MD, an assistant professor of psychiatry at the University of Colorado who treats patients at the UCHealth Post-COVID Clinic.

“There are at least two major factors that make treating psychological issues in long COVID more complex: The fact that the pandemic is still ongoing and still so divisive throughout society, and the fact that we don’t know a single best way to treat all symptoms of long COVID,” she said.

Some common treatments for anxiety and depression, like psychotherapy and medication, can be used for long COVID patients with these conditions. But another intervention that can work wonders for many people with mood disorders – exercise – doesn’t always work for long COVID patients. That’s because many of them struggle with physical challenges like chronic fatigue and what’s known as postexertional malaise, or a worsening of symptoms after even limited physical effort.

“While we normally encourage patients to be active, have a daily routine, and to engage in physical activity as part of their mental health treatment, some long COVID patients find that their symptoms worsen after increased activity,” Dr. Vannorsdall said.

Patients who are able to reach long COVID care centers are much more apt to get mental health problems diagnosed and treated, doctors at many programs around the country agree. But many patients hardest hit by the pandemic – the poor and racial and ethnic minorities – are also less likely to have ready access to hospitals that offer these programs, said Dr. Anderson.

“Affluent, predominantly White populations are showing up in these clinics, while we know that non-White populations have disproportionally high rates of acute infection, hospitalization, and death related to the virus,” he said.

Clinics are also concentrated in academic medical centers and in urban areas, limiting options for people in rural communities who may have to drive for hours to access care, Dr. Anderson said.

“Even before long COVID, we already knew that many people live in areas where there simply aren’t enough mental health services available,” said John Zulueta, MD, an assistant professor of clinical psychiatry at the University of Illinois at Chicago who provides mental health evaluations at the UI Health Post-COVID Clinic.

“As more patients develop mental health issues associated with long COVID, it’s going to put more stress on an already stressed system,” he said.

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

There’s little doubt that long COVID is real. Even as doctors and federal agencies struggle to define the syndrome, hospitals and health care systems are opening long COVID specialty treatment programs. As of July 25, there’s at least one long COVID center in almost every state – 48 out of 50, according to the patient advocacy group Survivor Corps.

Among the biggest challenges will be treating the mental health effects of long COVID. Well after people recover from acute COVID infections, they can still have a wide range of lingering symptoms, including depression, anxiety, brain fog, and PTSD.

courtesy Oregon Health & Science University

Specialized centers will be tackling these problems even as the United States struggles to deal with mental health needs.

One study of COVID patients found more than one-third of them had symptoms of depression, anxiety, or PTSD 3-6 months after their initial infection. Another analysis of 30 previous studies of long COVID patients found roughly one in eight of them had severe depression – and that the risk was similar regardless of whether people were hospitalized for COVID-19.

“Many of these symptoms can emerge months into the course of long COVID illness,” said Jordan Anderson, DO, a neuropsychiatrist who sees patients at the Long COVID-19 Program at Oregon Health & Science University, Portland. Psychological symptoms are often made worse by physical setbacks like extreme fatigue and by challenges of working, caring for children, and keeping up with daily routines, he said.

“This impact is not only severe, but also chronic for many,” he said.

Like dozens of hospitals around the country, Oregon Health & Science opened its center for long COVID as it became clear that more patients would need help for ongoing physical and mental health symptoms. Today, there’s at least one long COVID center – sometimes called post-COVID care centers or clinics – in every state but Kansas and South Dakota, Survivor Corps said.

Many long COVID care centers aim to tackle both physical and mental health symptoms, said Tracy Vannorsdall, PhD, a neuropsychologist with the Johns Hopkins Post-Acute COVID-19 Team program. One goal at Hopkins is to identify patients with psychological issues that might otherwise get overlooked.

A sizable minority of patients at the Johns Hopkins center – up to about 35% – report mental health problems that they didn’t have until after they got COVID-19, Dr. Vannorsdall says. The most common mental health issues providers see are depression, anxiety, and trauma-related distress.

“Routine assessment is key,” Dr. Vannorsdall said. “If patients are not asked about their mental health symptoms, they may not spontaneously report them to their provider due to fear of stigma or simply not appreciating that there are effective treatments available for these issues.”

Fear that doctors won’t take symptoms seriously is common, says Heather Murray MD, a senior instructor in psychiatry at the University of Colorado at Denver, Aurora.

“Many patients worry their physicians, loved ones, and society will not believe them or will minimize their symptoms and suffering,” said Dr. Murray, who treats patients at the UCHealth Post-COVID Clinic.

Diagnostic tests in long COVID patients often don’t have conclusive results, which can lead doctors and patients themselves to question whether symptoms are truly “physical versus psychosomatic,” she said. “It is important that providers believe their patients and treat their symptoms, even when diagnostic tests are unrevealing.”
 

Growing mental health crisis

Patients often find their way to academic treatment centers after surviving severe COVID-19 infections. But a growing number of long COVID patients show up at these centers after milder cases. These patients were never hospitalized for COVID-19 but still have persistent symptoms like fatigue, thinking problems, and mood disorders.

Among the major challenges is a shortage of mental health care providers to meet the surging need for care since the start of the pandemic. Around the world, anxiety and depression surged 25% during the first year of the pandemic, according to the World Health Organization.

In the United States, 40% of adults report feelings of anxiety and depression, and one in three high school students have feelings of sadness and hopelessness, according to a March 2022 statement from the White House.

Despite this surging need for care, almost half of Americans live in areas with a severe shortage of mental health care providers, according to the Health Resources and Services Administration. As of 2019, the United States had a shortage of about 6,790 mental health providers. Since then, the shortage has worsened; it’s now about 7,500 providers.

“One of the biggest challenges for hospitals and clinics in treating mental health disorders in long COVID is the limited resources and long wait times to get in for evaluations and treatment,” said Nyaz Didehbani, PhD, a neuropsychologist who treats long COVID patients at the COVID Recover program at the University of Texas Southwestern Medical Center, Dallas.

These delays can lead to worse outcomes, Dr. Didehbani said. “Additionally, patients do not feel that they are being heard, as many providers are not aware of the mental health impact and relationship with physical and cognitive symptoms.” .

Even when doctors recognize that psychological challenges are common with long COVID, they still have to think creatively to come up with treatments that meet the unique needs of these patients, said Thida Thant, MD, an assistant professor of psychiatry at the University of Colorado who treats patients at the UCHealth Post-COVID Clinic.

“There are at least two major factors that make treating psychological issues in long COVID more complex: The fact that the pandemic is still ongoing and still so divisive throughout society, and the fact that we don’t know a single best way to treat all symptoms of long COVID,” she said.

Some common treatments for anxiety and depression, like psychotherapy and medication, can be used for long COVID patients with these conditions. But another intervention that can work wonders for many people with mood disorders – exercise – doesn’t always work for long COVID patients. That’s because many of them struggle with physical challenges like chronic fatigue and what’s known as postexertional malaise, or a worsening of symptoms after even limited physical effort.

“While we normally encourage patients to be active, have a daily routine, and to engage in physical activity as part of their mental health treatment, some long COVID patients find that their symptoms worsen after increased activity,” Dr. Vannorsdall said.

Patients who are able to reach long COVID care centers are much more apt to get mental health problems diagnosed and treated, doctors at many programs around the country agree. But many patients hardest hit by the pandemic – the poor and racial and ethnic minorities – are also less likely to have ready access to hospitals that offer these programs, said Dr. Anderson.

“Affluent, predominantly White populations are showing up in these clinics, while we know that non-White populations have disproportionally high rates of acute infection, hospitalization, and death related to the virus,” he said.

Clinics are also concentrated in academic medical centers and in urban areas, limiting options for people in rural communities who may have to drive for hours to access care, Dr. Anderson said.

“Even before long COVID, we already knew that many people live in areas where there simply aren’t enough mental health services available,” said John Zulueta, MD, an assistant professor of clinical psychiatry at the University of Illinois at Chicago who provides mental health evaluations at the UI Health Post-COVID Clinic.

“As more patients develop mental health issues associated with long COVID, it’s going to put more stress on an already stressed system,” he said.

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

There’s little doubt that long COVID is real. Even as doctors and federal agencies struggle to define the syndrome, hospitals and health care systems are opening long COVID specialty treatment programs. As of July 25, there’s at least one long COVID center in almost every state – 48 out of 50, according to the patient advocacy group Survivor Corps.

Among the biggest challenges will be treating the mental health effects of long COVID. Well after people recover from acute COVID infections, they can still have a wide range of lingering symptoms, including depression, anxiety, brain fog, and PTSD.

courtesy Oregon Health & Science University

Specialized centers will be tackling these problems even as the United States struggles to deal with mental health needs.

One study of COVID patients found more than one-third of them had symptoms of depression, anxiety, or PTSD 3-6 months after their initial infection. Another analysis of 30 previous studies of long COVID patients found roughly one in eight of them had severe depression – and that the risk was similar regardless of whether people were hospitalized for COVID-19.

“Many of these symptoms can emerge months into the course of long COVID illness,” said Jordan Anderson, DO, a neuropsychiatrist who sees patients at the Long COVID-19 Program at Oregon Health & Science University, Portland. Psychological symptoms are often made worse by physical setbacks like extreme fatigue and by challenges of working, caring for children, and keeping up with daily routines, he said.

“This impact is not only severe, but also chronic for many,” he said.

Like dozens of hospitals around the country, Oregon Health & Science opened its center for long COVID as it became clear that more patients would need help for ongoing physical and mental health symptoms. Today, there’s at least one long COVID center – sometimes called post-COVID care centers or clinics – in every state but Kansas and South Dakota, Survivor Corps said.

Many long COVID care centers aim to tackle both physical and mental health symptoms, said Tracy Vannorsdall, PhD, a neuropsychologist with the Johns Hopkins Post-Acute COVID-19 Team program. One goal at Hopkins is to identify patients with psychological issues that might otherwise get overlooked.

A sizable minority of patients at the Johns Hopkins center – up to about 35% – report mental health problems that they didn’t have until after they got COVID-19, Dr. Vannorsdall says. The most common mental health issues providers see are depression, anxiety, and trauma-related distress.

“Routine assessment is key,” Dr. Vannorsdall said. “If patients are not asked about their mental health symptoms, they may not spontaneously report them to their provider due to fear of stigma or simply not appreciating that there are effective treatments available for these issues.”

Fear that doctors won’t take symptoms seriously is common, says Heather Murray MD, a senior instructor in psychiatry at the University of Colorado at Denver, Aurora.

“Many patients worry their physicians, loved ones, and society will not believe them or will minimize their symptoms and suffering,” said Dr. Murray, who treats patients at the UCHealth Post-COVID Clinic.

Diagnostic tests in long COVID patients often don’t have conclusive results, which can lead doctors and patients themselves to question whether symptoms are truly “physical versus psychosomatic,” she said. “It is important that providers believe their patients and treat their symptoms, even when diagnostic tests are unrevealing.”
 

Growing mental health crisis

Patients often find their way to academic treatment centers after surviving severe COVID-19 infections. But a growing number of long COVID patients show up at these centers after milder cases. These patients were never hospitalized for COVID-19 but still have persistent symptoms like fatigue, thinking problems, and mood disorders.

Among the major challenges is a shortage of mental health care providers to meet the surging need for care since the start of the pandemic. Around the world, anxiety and depression surged 25% during the first year of the pandemic, according to the World Health Organization.

In the United States, 40% of adults report feelings of anxiety and depression, and one in three high school students have feelings of sadness and hopelessness, according to a March 2022 statement from the White House.

Despite this surging need for care, almost half of Americans live in areas with a severe shortage of mental health care providers, according to the Health Resources and Services Administration. As of 2019, the United States had a shortage of about 6,790 mental health providers. Since then, the shortage has worsened; it’s now about 7,500 providers.

“One of the biggest challenges for hospitals and clinics in treating mental health disorders in long COVID is the limited resources and long wait times to get in for evaluations and treatment,” said Nyaz Didehbani, PhD, a neuropsychologist who treats long COVID patients at the COVID Recover program at the University of Texas Southwestern Medical Center, Dallas.

These delays can lead to worse outcomes, Dr. Didehbani said. “Additionally, patients do not feel that they are being heard, as many providers are not aware of the mental health impact and relationship with physical and cognitive symptoms.” .

Even when doctors recognize that psychological challenges are common with long COVID, they still have to think creatively to come up with treatments that meet the unique needs of these patients, said Thida Thant, MD, an assistant professor of psychiatry at the University of Colorado who treats patients at the UCHealth Post-COVID Clinic.

“There are at least two major factors that make treating psychological issues in long COVID more complex: The fact that the pandemic is still ongoing and still so divisive throughout society, and the fact that we don’t know a single best way to treat all symptoms of long COVID,” she said.

Some common treatments for anxiety and depression, like psychotherapy and medication, can be used for long COVID patients with these conditions. But another intervention that can work wonders for many people with mood disorders – exercise – doesn’t always work for long COVID patients. That’s because many of them struggle with physical challenges like chronic fatigue and what’s known as postexertional malaise, or a worsening of symptoms after even limited physical effort.

“While we normally encourage patients to be active, have a daily routine, and to engage in physical activity as part of their mental health treatment, some long COVID patients find that their symptoms worsen after increased activity,” Dr. Vannorsdall said.

Patients who are able to reach long COVID care centers are much more apt to get mental health problems diagnosed and treated, doctors at many programs around the country agree. But many patients hardest hit by the pandemic – the poor and racial and ethnic minorities – are also less likely to have ready access to hospitals that offer these programs, said Dr. Anderson.

“Affluent, predominantly White populations are showing up in these clinics, while we know that non-White populations have disproportionally high rates of acute infection, hospitalization, and death related to the virus,” he said.

Clinics are also concentrated in academic medical centers and in urban areas, limiting options for people in rural communities who may have to drive for hours to access care, Dr. Anderson said.

“Even before long COVID, we already knew that many people live in areas where there simply aren’t enough mental health services available,” said John Zulueta, MD, an assistant professor of clinical psychiatry at the University of Illinois at Chicago who provides mental health evaluations at the UI Health Post-COVID Clinic.

“As more patients develop mental health issues associated with long COVID, it’s going to put more stress on an already stressed system,” he said.

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

Medically reviewed by Jennifer Casarella, MD

Dan Miller has parked his Nissan Altima on the side of the road near a field outside Chicago and is holding a gun to his head. 

Haunted for years by the compounded trauma of tours of duty in the Middle East and his work as a police officer in Chicago, at that moment, Dr. Miller saw no reason to live. And there were troubles at home with his wife and children, who had grown fearful of his behavior.

“My whole world was falling apart,” he says of that dark night in 2014. “It left a hole I didn’t know how to fill.”

He chose not to pull the trigger after a brochure on the passenger seat of his car gave him an unexpected perspective – and launched him on a path to help others in his situation.

Had Mr. Miller taken his life that night, he would have joined thousands of other veterans who died by suicide. About 17 U.S. veterans lose their lives this way each day, on average, according to the Department of Veterans Affairs. In 2019, the last year for which records are available, 6,261 veterans took their own lives – and the suicide rate for veterans was 52% higher than for nonveterans, the agency’s records show. 

The problem has become so severe that the Veterans Health Administration now uses artificial intelligence (AI) to help identify veterans at the highest risk of suicide – and reach out to them before a crisis strikes.

But that wasn’t available when Dan Miller’s life was unraveling.

In the years leading up to his near-suicide, his wife had pushed him to get help. “She said, ‘You’re not the same person you were when you left. The kids are scared of you. The pets are scared of you,” he recalls.

He resisted, even when his wife threatened divorce. Rising through the ranks of the Marines, Mr. Miller had become more emotionally isolated. He feared losing his job and the respect of others if he let anyone know what he was going through.

Finally, he gave the VHA a chance. He went in for an initial consultation in 2010 and didn’t find it helpful. He didn’t like being told what to do. So he stopped. He turned to obsessive exercise and excessive drinking.

That day in 2014, Mr. Miller’s wife told him she was taking the kids out for a playdate. After she left, he was served with divorce papers. Less than an hour later, he was parked in his car with his gun, ready to end his life.

But if it all had happened just a few years later, things might never have gotten to that point.
 

Scanning for suicide risk

In 2017, the VHA piloted its AI program, called REACH VET, that aims to help prevent veterans from dying by suicide.

Every month, a computer scans the electronic health records of all VHA patients who’ve had a health care visit for any reason in the last 2 years. It checks more than 140 variables and weights them to estimate someone’s overall suicide risk at that moment in time.

To build the risk algorithm, a computer combed through the medical records of 6,360 veterans confirmed to have died by suicide between 2009 and 2011. (The VHA continually updates the list of variables from the health records of VHA patients, including those who have died by suicide since then and others.)

Some variables are things you’d expect:

• A past suicide attempt.
• A diagnosis of depression or other mental illness.
• A diagnosis of a terminal illness.

Others are more surprising. For example, a diagnosis of arthritis or diabetes adds weight.

REACH VET flags the riskiest cases – the top 0.1% – for a mental health or primary care provider to review. They reach out to the patient to tell them how and why their record was flagged, discuss any recommended treatment changes, and ask them to come in for a visit.

“It’s an opportunity to talk about their risk factors, which is designed to lead to a conversation about safety planning,” says clinical psychologist Matthew Miller, PhD, national director of the U.S. Department of Veterans Affairs’ Suicide Prevention Program. He’s not related to Dan Miller.

Making a suicide safety plan

A safety plan is a document that outlines how a person can help prevent their own suicide in a crisis. 

The plan may include:

• A list of personal triggers or warning signs.
• What’s helped them in the past.
• Names of people or organizations who can support them.
• Plans to remove means of suicide, such as guns, from their environment.
• Their reasons for living.

In people at risk for suicide, research shows that having a safety plan reduces suicidal thoughts and attempts, lowers rates of depression and hopelessness, and boosts veterans’ engagement with the health care system. It may also help people manage things that trigger their suicidal thoughts.
 

Getting the call

What if REACH VET had been around when Dan Miller was in crisis – and he’d gotten a call from the VHA?

“It absolutely, positively would have helped because one of the biggest things on that day when I got served was feeling completely alone and that I had no one to turn to,” Mr. Miller says. He’s now a speaker for the Wounded Warrior Project, a nonprofit that serves veterans and active-duty service people.

Vets’ reactions to the unexpected VHA phone call, psychologist Dr. Miller says, “run the gamut from ‘Thank you for contacting me. Let’s talk,’ to ‘What are you talking about? Leave me alone!’ ”

Nothing stops all suicides. But REACH VET is having an impact. In a clinical trial, vets contacted through REACH VET had more doctor visits, were more likely to have a written suicide prevention safety plan, and had fewer hospital admissions for mental health, ER visits, and suicide attempts.
 

An assist from AI

Even simple outreach can make a big difference. And there’s research to prove it.

One study included 4,730 veterans recently discharged from psychiatric care at the VHA, a group considered at high risk for suicide. 

Half of them got 13 caring emails from hospital staff in the weeks after leaving the hospital. The emails mentioned personal things the patient had shared, like a love of hiking, and wished them well. The other veterans got routine follow-up but no emails.

Two years later, those who got the caring emails were less likely to have died by suicide than the other vets. The study was published in 2014 in Contemporary Clinical Trials.

Researchers have done studies like this many times: with handwritten notes from the primary care doctor, postcards from the ER, and so forth. The results never vary: The notes reduce suicide risk.

“If we could use AI to identify people to receive notes or phone calls, it would be a very effective and inexpensive way to guide follow-up care,” says Rebecca Bernert, PhD, director and founder of the Suicide Prevention Research Laboratory at Stanford (Calif.) University.
 

AI doesn’t replace clinical judgment.

“AI can capture data that we miss due to the limits of our humanity,” psychologist Dr. Miller says. “There’s suicide prevention processes founded on big data and AI, and there are processes founded in clinical intuition and acumen.”

AI is only as good as the data it’s based on. If that data lacks diversity, it may miss things. And variables that apply to veterans may differ in civilians.
 

Stopping suicidal thoughts

Google is putting AI to work against suicide, too. Its MUM (Multitask Unified Model) technology seeks to understand the intent behind what we google.

MUM powers Google Search. It can often tell the difference between a search for information about suicide for someone writing a research paper on the topic and a search for information on how or where to carry out a suicide.

When Google Search detects that someone in the United States might be in crisis and at risk of suicide, the first search results that person gets are the number for the National Suicide Prevention Lifeline and other resources for people in crisis.

Google Home Assistant works in the same way. When a user makes a query that signals a suicide-related crisis, the gadget serves up resources that offer help.

MUM is working to understand the nuances of crisis language in 75 languages so that Google Search can provide people in crisis with hotlines or other resources in many countries.

“We want to find partners that are accessible to users in terms of hours of operation. We have a strong preference for finding partners that promise confidentiality and privacy to the extent that those are permitted [in that country],” says Anne Merritt, MD, a product manager at Google Search.

Other companies are working on apps that use AI to spot suicide risk in other ways, including voice technology that may notice subtle changes in the voice of someone who’s depressed and may be thinking of suicide. Those are still in development but show promise. Keep in mind that apps do not require government approval, so if you try one, be sure to let your health care provider know.
 

Changing the channel

Seeing a hotline number on your phone or computer screen can help, Dan Miller says. “If I happened to be online, searching maybe for a bridge to jump off of ... and suddenly that pops up on the screen, it’s like it changes the channel.”

It may not work for everyone, he says, but that search result could interrupt someone’s suicidal train of thought.

That’s crucial, psychologist Dr. Miller says, because most suicide attempts escalate from first thought to potentially fatal action in just 1 hour. That’s how fast it happened for Dan Miller in 2014.

“When you’re able to put time and space between the suicidal thought and the access to the method to act on that thought, you save lives,” Dr. Bernert says.
 

Making a different choice

An interruption in Mr. Miller’s thinking is what had saved his life.

Holding the gun to his head, Mr. Miller looked over at the passenger seat at a brochure from Wounded Warrior Project, which he had just learned about. Mr. Miller noticed a photo of a man in a wheelchair, a veteran like him, who had no legs. He thought that the man looked worse off than him but hadn’t given up.

Mr. Miller put down his gun and decided to get help.

Recovering from a near suicide attempt, he says, is a journey. It doesn’t happen overnight. Now, 8 years later, Mr. Miller is planning a brief break from the speaker circuit. He plans to spend 2 weeks in an outpatient counseling program for posttraumatic stress disorder and traumatic brain injury.

“Telling my story to strangers – part of it is healing me in a way, but I’m learning that repeating the story over and over again is also keeping me from letting it go. And I’m still healing.”

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

Medically reviewed by Jennifer Casarella, MD

Dan Miller has parked his Nissan Altima on the side of the road near a field outside Chicago and is holding a gun to his head. 

Haunted for years by the compounded trauma of tours of duty in the Middle East and his work as a police officer in Chicago, at that moment, Dr. Miller saw no reason to live. And there were troubles at home with his wife and children, who had grown fearful of his behavior.

“My whole world was falling apart,” he says of that dark night in 2014. “It left a hole I didn’t know how to fill.”

He chose not to pull the trigger after a brochure on the passenger seat of his car gave him an unexpected perspective – and launched him on a path to help others in his situation.

Had Mr. Miller taken his life that night, he would have joined thousands of other veterans who died by suicide. About 17 U.S. veterans lose their lives this way each day, on average, according to the Department of Veterans Affairs. In 2019, the last year for which records are available, 6,261 veterans took their own lives – and the suicide rate for veterans was 52% higher than for nonveterans, the agency’s records show. 

The problem has become so severe that the Veterans Health Administration now uses artificial intelligence (AI) to help identify veterans at the highest risk of suicide – and reach out to them before a crisis strikes.

But that wasn’t available when Dan Miller’s life was unraveling.

In the years leading up to his near-suicide, his wife had pushed him to get help. “She said, ‘You’re not the same person you were when you left. The kids are scared of you. The pets are scared of you,” he recalls.

He resisted, even when his wife threatened divorce. Rising through the ranks of the Marines, Mr. Miller had become more emotionally isolated. He feared losing his job and the respect of others if he let anyone know what he was going through.

Finally, he gave the VHA a chance. He went in for an initial consultation in 2010 and didn’t find it helpful. He didn’t like being told what to do. So he stopped. He turned to obsessive exercise and excessive drinking.

That day in 2014, Mr. Miller’s wife told him she was taking the kids out for a playdate. After she left, he was served with divorce papers. Less than an hour later, he was parked in his car with his gun, ready to end his life.

But if it all had happened just a few years later, things might never have gotten to that point.
 

Scanning for suicide risk

In 2017, the VHA piloted its AI program, called REACH VET, that aims to help prevent veterans from dying by suicide.

Every month, a computer scans the electronic health records of all VHA patients who’ve had a health care visit for any reason in the last 2 years. It checks more than 140 variables and weights them to estimate someone’s overall suicide risk at that moment in time.

To build the risk algorithm, a computer combed through the medical records of 6,360 veterans confirmed to have died by suicide between 2009 and 2011. (The VHA continually updates the list of variables from the health records of VHA patients, including those who have died by suicide since then and others.)

Some variables are things you’d expect:

• A past suicide attempt.
• A diagnosis of depression or other mental illness.
• A diagnosis of a terminal illness.

Others are more surprising. For example, a diagnosis of arthritis or diabetes adds weight.

REACH VET flags the riskiest cases – the top 0.1% – for a mental health or primary care provider to review. They reach out to the patient to tell them how and why their record was flagged, discuss any recommended treatment changes, and ask them to come in for a visit.

“It’s an opportunity to talk about their risk factors, which is designed to lead to a conversation about safety planning,” says clinical psychologist Matthew Miller, PhD, national director of the U.S. Department of Veterans Affairs’ Suicide Prevention Program. He’s not related to Dan Miller.

Making a suicide safety plan

A safety plan is a document that outlines how a person can help prevent their own suicide in a crisis. 

The plan may include:

• A list of personal triggers or warning signs.
• What’s helped them in the past.
• Names of people or organizations who can support them.
• Plans to remove means of suicide, such as guns, from their environment.
• Their reasons for living.

In people at risk for suicide, research shows that having a safety plan reduces suicidal thoughts and attempts, lowers rates of depression and hopelessness, and boosts veterans’ engagement with the health care system. It may also help people manage things that trigger their suicidal thoughts.
 

Getting the call

What if REACH VET had been around when Dan Miller was in crisis – and he’d gotten a call from the VHA?

“It absolutely, positively would have helped because one of the biggest things on that day when I got served was feeling completely alone and that I had no one to turn to,” Mr. Miller says. He’s now a speaker for the Wounded Warrior Project, a nonprofit that serves veterans and active-duty service people.

Vets’ reactions to the unexpected VHA phone call, psychologist Dr. Miller says, “run the gamut from ‘Thank you for contacting me. Let’s talk,’ to ‘What are you talking about? Leave me alone!’ ”

Nothing stops all suicides. But REACH VET is having an impact. In a clinical trial, vets contacted through REACH VET had more doctor visits, were more likely to have a written suicide prevention safety plan, and had fewer hospital admissions for mental health, ER visits, and suicide attempts.
 

An assist from AI

Even simple outreach can make a big difference. And there’s research to prove it.

One study included 4,730 veterans recently discharged from psychiatric care at the VHA, a group considered at high risk for suicide. 

Half of them got 13 caring emails from hospital staff in the weeks after leaving the hospital. The emails mentioned personal things the patient had shared, like a love of hiking, and wished them well. The other veterans got routine follow-up but no emails.

Two years later, those who got the caring emails were less likely to have died by suicide than the other vets. The study was published in 2014 in Contemporary Clinical Trials.

Researchers have done studies like this many times: with handwritten notes from the primary care doctor, postcards from the ER, and so forth. The results never vary: The notes reduce suicide risk.

“If we could use AI to identify people to receive notes or phone calls, it would be a very effective and inexpensive way to guide follow-up care,” says Rebecca Bernert, PhD, director and founder of the Suicide Prevention Research Laboratory at Stanford (Calif.) University.
 

AI doesn’t replace clinical judgment.

“AI can capture data that we miss due to the limits of our humanity,” psychologist Dr. Miller says. “There’s suicide prevention processes founded on big data and AI, and there are processes founded in clinical intuition and acumen.”

AI is only as good as the data it’s based on. If that data lacks diversity, it may miss things. And variables that apply to veterans may differ in civilians.
 

Stopping suicidal thoughts

Google is putting AI to work against suicide, too. Its MUM (Multitask Unified Model) technology seeks to understand the intent behind what we google.

MUM powers Google Search. It can often tell the difference between a search for information about suicide for someone writing a research paper on the topic and a search for information on how or where to carry out a suicide.

When Google Search detects that someone in the United States might be in crisis and at risk of suicide, the first search results that person gets are the number for the National Suicide Prevention Lifeline and other resources for people in crisis.

Google Home Assistant works in the same way. When a user makes a query that signals a suicide-related crisis, the gadget serves up resources that offer help.

MUM is working to understand the nuances of crisis language in 75 languages so that Google Search can provide people in crisis with hotlines or other resources in many countries.

“We want to find partners that are accessible to users in terms of hours of operation. We have a strong preference for finding partners that promise confidentiality and privacy to the extent that those are permitted [in that country],” says Anne Merritt, MD, a product manager at Google Search.

Other companies are working on apps that use AI to spot suicide risk in other ways, including voice technology that may notice subtle changes in the voice of someone who’s depressed and may be thinking of suicide. Those are still in development but show promise. Keep in mind that apps do not require government approval, so if you try one, be sure to let your health care provider know.
 

Changing the channel

Seeing a hotline number on your phone or computer screen can help, Dan Miller says. “If I happened to be online, searching maybe for a bridge to jump off of ... and suddenly that pops up on the screen, it’s like it changes the channel.”

It may not work for everyone, he says, but that search result could interrupt someone’s suicidal train of thought.

That’s crucial, psychologist Dr. Miller says, because most suicide attempts escalate from first thought to potentially fatal action in just 1 hour. That’s how fast it happened for Dan Miller in 2014.

“When you’re able to put time and space between the suicidal thought and the access to the method to act on that thought, you save lives,” Dr. Bernert says.
 

Making a different choice

An interruption in Mr. Miller’s thinking is what had saved his life.

Holding the gun to his head, Mr. Miller looked over at the passenger seat at a brochure from Wounded Warrior Project, which he had just learned about. Mr. Miller noticed a photo of a man in a wheelchair, a veteran like him, who had no legs. He thought that the man looked worse off than him but hadn’t given up.

Mr. Miller put down his gun and decided to get help.

Recovering from a near suicide attempt, he says, is a journey. It doesn’t happen overnight. Now, 8 years later, Mr. Miller is planning a brief break from the speaker circuit. He plans to spend 2 weeks in an outpatient counseling program for posttraumatic stress disorder and traumatic brain injury.

“Telling my story to strangers – part of it is healing me in a way, but I’m learning that repeating the story over and over again is also keeping me from letting it go. And I’m still healing.”

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

Medically reviewed by Jennifer Casarella, MD

Dan Miller has parked his Nissan Altima on the side of the road near a field outside Chicago and is holding a gun to his head. 

Haunted for years by the compounded trauma of tours of duty in the Middle East and his work as a police officer in Chicago, at that moment, Dr. Miller saw no reason to live. And there were troubles at home with his wife and children, who had grown fearful of his behavior.

“My whole world was falling apart,” he says of that dark night in 2014. “It left a hole I didn’t know how to fill.”

He chose not to pull the trigger after a brochure on the passenger seat of his car gave him an unexpected perspective – and launched him on a path to help others in his situation.

Had Mr. Miller taken his life that night, he would have joined thousands of other veterans who died by suicide. About 17 U.S. veterans lose their lives this way each day, on average, according to the Department of Veterans Affairs. In 2019, the last year for which records are available, 6,261 veterans took their own lives – and the suicide rate for veterans was 52% higher than for nonveterans, the agency’s records show. 

The problem has become so severe that the Veterans Health Administration now uses artificial intelligence (AI) to help identify veterans at the highest risk of suicide – and reach out to them before a crisis strikes.

But that wasn’t available when Dan Miller’s life was unraveling.

In the years leading up to his near-suicide, his wife had pushed him to get help. “She said, ‘You’re not the same person you were when you left. The kids are scared of you. The pets are scared of you,” he recalls.

He resisted, even when his wife threatened divorce. Rising through the ranks of the Marines, Mr. Miller had become more emotionally isolated. He feared losing his job and the respect of others if he let anyone know what he was going through.

Finally, he gave the VHA a chance. He went in for an initial consultation in 2010 and didn’t find it helpful. He didn’t like being told what to do. So he stopped. He turned to obsessive exercise and excessive drinking.

That day in 2014, Mr. Miller’s wife told him she was taking the kids out for a playdate. After she left, he was served with divorce papers. Less than an hour later, he was parked in his car with his gun, ready to end his life.

But if it all had happened just a few years later, things might never have gotten to that point.
 

Scanning for suicide risk

In 2017, the VHA piloted its AI program, called REACH VET, that aims to help prevent veterans from dying by suicide.

Every month, a computer scans the electronic health records of all VHA patients who’ve had a health care visit for any reason in the last 2 years. It checks more than 140 variables and weights them to estimate someone’s overall suicide risk at that moment in time.

To build the risk algorithm, a computer combed through the medical records of 6,360 veterans confirmed to have died by suicide between 2009 and 2011. (The VHA continually updates the list of variables from the health records of VHA patients, including those who have died by suicide since then and others.)

Some variables are things you’d expect:

• A past suicide attempt.
• A diagnosis of depression or other mental illness.
• A diagnosis of a terminal illness.

Others are more surprising. For example, a diagnosis of arthritis or diabetes adds weight.

REACH VET flags the riskiest cases – the top 0.1% – for a mental health or primary care provider to review. They reach out to the patient to tell them how and why their record was flagged, discuss any recommended treatment changes, and ask them to come in for a visit.

“It’s an opportunity to talk about their risk factors, which is designed to lead to a conversation about safety planning,” says clinical psychologist Matthew Miller, PhD, national director of the U.S. Department of Veterans Affairs’ Suicide Prevention Program. He’s not related to Dan Miller.

Making a suicide safety plan

A safety plan is a document that outlines how a person can help prevent their own suicide in a crisis. 

The plan may include:

• A list of personal triggers or warning signs.
• What’s helped them in the past.
• Names of people or organizations who can support them.
• Plans to remove means of suicide, such as guns, from their environment.
• Their reasons for living.

In people at risk for suicide, research shows that having a safety plan reduces suicidal thoughts and attempts, lowers rates of depression and hopelessness, and boosts veterans’ engagement with the health care system. It may also help people manage things that trigger their suicidal thoughts.
 

Getting the call

What if REACH VET had been around when Dan Miller was in crisis – and he’d gotten a call from the VHA?

“It absolutely, positively would have helped because one of the biggest things on that day when I got served was feeling completely alone and that I had no one to turn to,” Mr. Miller says. He’s now a speaker for the Wounded Warrior Project, a nonprofit that serves veterans and active-duty service people.

Vets’ reactions to the unexpected VHA phone call, psychologist Dr. Miller says, “run the gamut from ‘Thank you for contacting me. Let’s talk,’ to ‘What are you talking about? Leave me alone!’ ”

Nothing stops all suicides. But REACH VET is having an impact. In a clinical trial, vets contacted through REACH VET had more doctor visits, were more likely to have a written suicide prevention safety plan, and had fewer hospital admissions for mental health, ER visits, and suicide attempts.
 

An assist from AI

Even simple outreach can make a big difference. And there’s research to prove it.

One study included 4,730 veterans recently discharged from psychiatric care at the VHA, a group considered at high risk for suicide. 

Half of them got 13 caring emails from hospital staff in the weeks after leaving the hospital. The emails mentioned personal things the patient had shared, like a love of hiking, and wished them well. The other veterans got routine follow-up but no emails.

Two years later, those who got the caring emails were less likely to have died by suicide than the other vets. The study was published in 2014 in Contemporary Clinical Trials.

Researchers have done studies like this many times: with handwritten notes from the primary care doctor, postcards from the ER, and so forth. The results never vary: The notes reduce suicide risk.

“If we could use AI to identify people to receive notes or phone calls, it would be a very effective and inexpensive way to guide follow-up care,” says Rebecca Bernert, PhD, director and founder of the Suicide Prevention Research Laboratory at Stanford (Calif.) University.
 

AI doesn’t replace clinical judgment.

“AI can capture data that we miss due to the limits of our humanity,” psychologist Dr. Miller says. “There’s suicide prevention processes founded on big data and AI, and there are processes founded in clinical intuition and acumen.”

AI is only as good as the data it’s based on. If that data lacks diversity, it may miss things. And variables that apply to veterans may differ in civilians.
 

Stopping suicidal thoughts

Google is putting AI to work against suicide, too. Its MUM (Multitask Unified Model) technology seeks to understand the intent behind what we google.

MUM powers Google Search. It can often tell the difference between a search for information about suicide for someone writing a research paper on the topic and a search for information on how or where to carry out a suicide.

When Google Search detects that someone in the United States might be in crisis and at risk of suicide, the first search results that person gets are the number for the National Suicide Prevention Lifeline and other resources for people in crisis.

Google Home Assistant works in the same way. When a user makes a query that signals a suicide-related crisis, the gadget serves up resources that offer help.

MUM is working to understand the nuances of crisis language in 75 languages so that Google Search can provide people in crisis with hotlines or other resources in many countries.

“We want to find partners that are accessible to users in terms of hours of operation. We have a strong preference for finding partners that promise confidentiality and privacy to the extent that those are permitted [in that country],” says Anne Merritt, MD, a product manager at Google Search.

Other companies are working on apps that use AI to spot suicide risk in other ways, including voice technology that may notice subtle changes in the voice of someone who’s depressed and may be thinking of suicide. Those are still in development but show promise. Keep in mind that apps do not require government approval, so if you try one, be sure to let your health care provider know.
 

Changing the channel

Seeing a hotline number on your phone or computer screen can help, Dan Miller says. “If I happened to be online, searching maybe for a bridge to jump off of ... and suddenly that pops up on the screen, it’s like it changes the channel.”

It may not work for everyone, he says, but that search result could interrupt someone’s suicidal train of thought.

That’s crucial, psychologist Dr. Miller says, because most suicide attempts escalate from first thought to potentially fatal action in just 1 hour. That’s how fast it happened for Dan Miller in 2014.

“When you’re able to put time and space between the suicidal thought and the access to the method to act on that thought, you save lives,” Dr. Bernert says.
 

Making a different choice

An interruption in Mr. Miller’s thinking is what had saved his life.

Holding the gun to his head, Mr. Miller looked over at the passenger seat at a brochure from Wounded Warrior Project, which he had just learned about. Mr. Miller noticed a photo of a man in a wheelchair, a veteran like him, who had no legs. He thought that the man looked worse off than him but hadn’t given up.

Mr. Miller put down his gun and decided to get help.

Recovering from a near suicide attempt, he says, is a journey. It doesn’t happen overnight. Now, 8 years later, Mr. Miller is planning a brief break from the speaker circuit. He plans to spend 2 weeks in an outpatient counseling program for posttraumatic stress disorder and traumatic brain injury.

“Telling my story to strangers – part of it is healing me in a way, but I’m learning that repeating the story over and over again is also keeping me from letting it go. And I’m still healing.”

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

A few weeks ago, right after 19 children and two adults were killed by a gunman in Uvalde, Texas, Americans were really on edge. Many people I know became hypervigilant while going about activities previously thought of as routine, such as waiting for a subway or going to a grocery store.

On top of that, we are still facing the ongoing COVID-19 pandemic. Despite vaccines and therapeutics, the United States is still losing more than 300 people each day to the virus. Many people who have tested positive have continued to experience debilitating long-haul symptoms many months after testing negative, and I believe not knowing what your future life will bring from this terrible illness could lead some to posttraumatic stress disorder.

In addition to constant updates about COVID, we are getting almost daily reports about monkeypox. In New York state, medical professionals and institutions receive regular, almost weekly, information about the spread of influenza. But where are the reports and treatment approaches for PTSD, which would not only increase awareness but also lead to more care?

Some might believe that I am obsessed with PTSD, since I’ve written a great deal on the subject, particularly “underdiagnosed” PTSD. The key question I have is: How can clinicians treating patients NOT consider that we are amid an epidemic of PTSD, including a delayed-onset form of the illness?

We know the signs and symptoms of PTSD. They include flashbacks, intrusive recollections, physical distress related to stimuli related to the trauma, insomnia, social isolation, avoidance of certain situations, negative thinking, and hyperarousal – coupled with anxiety and depression. PTSD can be a great masquerader. It can be triggered by many events, large and small, and all too often will masquerade as general anxiety or existential despair and depression. Too often, PTSD is undiagnosed or unrecognized completely. PTSD is also a costly disease that is an enormous economic burden on the U.S. economy.

As clinicians, we must be aware of the more subtle events that may trigger PTSD. We must think beyond ICD codes and DSM criteria and realize that each individual processes an event or a series of events differently. For example, seriously ill people in ICUs or undergoing critical care have been known to experience PTSD well beyond their physical recovery (J Crit Care. 2017 Dec. doi: 10.1016/j.jcrc.2017.06.014). Years after the Sept. 11, 2001, World Trade Center disaster, many are still suffering from PTSD symptoms (Biol Psychiatry. 2020 May 1. doi: 10.1016/j.biopsych.2020.02.817).

Again, in some cases, not knowing what the future may bring regarding life itself can lead to PTSD. I have treated patients who have lost jobs and experienced devastating social and financial losses, which were perceived as a separation from “life as they know it.” These can be precursors to PTSD for some who are sensitive to the disorder.

Intergenerational trauma is also a real phenomenon to which we must be attuned. I have treated two adult children of Holocaust survivors, both born in America well after World War II, who developed PTSD after hearing family recollections over and over about the brutality suffered by relatives, combined with watching films about people sent to concentration camps. Both of those patients self-diagnosed their symptoms as depression. Research shows that Holocaust traumatization can affect three generations (J Anxiety Disord. 2021 Jun. doi: 10.1016/j.janxdis.2021.102401).

In light of the high incidence of traumatic events affecting millions directly, more codified treatment approaches are needed that can be used both for individuals and for those in group settings.

To date, the best treatment rests with cognitive-behavioral therapy (CBT) and guided imagery coupled with relaxation techniques and the various types of in vivo exposure therapy, which I prefer to in vitro or flooding care. In terms of medication management, the U.S. Food and Drug Administration has approved only two antidepressant medications for PTSD, sertraline (Zoloft) and paroxetine (Paxil), although other selective serotonin reuptake inhibitors have been used off- label, and prazosin, a hypertensive medication, has been used off-label for PTSD-related insomnia and nightmares (Prim Care Companion CNS Disord. 2012 Mar 22. doi: 10.4088/PCC.11r01222). Thus, the limited number of choices for medication management means more research is needed so that more medications are developed that are more precisely directed at PTSD treatment.
 

Implications for society at large

In a recent article published in the Journal of Clinical Psychiatry (2022 Apr 25. doi: 10.4088/JCP.21m14116), authors Lori L. Davis and colleagues point out that the economic burden of PTSD goes beyond health care costs and rivals the costs of other mental illnesses, including depression and anxiety. In the process, Dr. Davis and colleagues note, unemployment caused by job loss, disability, homelessness, substance use, disordered care, as well as premature mortality, all contribute to this severe burden, going beyond PTSD itself.

This study shows that the annual economic burden of PTSD is $232 billion. Most of that burden is attributed to the civilian population, which they suggest to be $189.5 billion, or 82%.

After reading that article, it became clear to me that my “obsession” with PTSD is not really an obsession at all. Rather, it is a true concern that, against the backdrop of long COVID, gun violence, political and economic turmoil, and other factors, it is important that clinicians understand how to recognize and treat PTSD. The stakes have never been higher.

Dr. London is a practicing psychiatrist and has been a newspaper columnist for 35 years, specializing in and writing about short-term therapy, including cognitive-behavioral therapy and guided imagery. He is author of “Find Freedom Fast” (New York: Kettlehole Publishing, 2019). He has no conflicts of interest.

A few weeks ago, right after 19 children and two adults were killed by a gunman in Uvalde, Texas, Americans were really on edge. Many people I know became hypervigilant while going about activities previously thought of as routine, such as waiting for a subway or going to a grocery store.

On top of that, we are still facing the ongoing COVID-19 pandemic. Despite vaccines and therapeutics, the United States is still losing more than 300 people each day to the virus. Many people who have tested positive have continued to experience debilitating long-haul symptoms many months after testing negative, and I believe not knowing what your future life will bring from this terrible illness could lead some to posttraumatic stress disorder.

In addition to constant updates about COVID, we are getting almost daily reports about monkeypox. In New York state, medical professionals and institutions receive regular, almost weekly, information about the spread of influenza. But where are the reports and treatment approaches for PTSD, which would not only increase awareness but also lead to more care?

Some might believe that I am obsessed with PTSD, since I’ve written a great deal on the subject, particularly “underdiagnosed” PTSD. The key question I have is: How can clinicians treating patients NOT consider that we are amid an epidemic of PTSD, including a delayed-onset form of the illness?

We know the signs and symptoms of PTSD. They include flashbacks, intrusive recollections, physical distress related to stimuli related to the trauma, insomnia, social isolation, avoidance of certain situations, negative thinking, and hyperarousal – coupled with anxiety and depression. PTSD can be a great masquerader. It can be triggered by many events, large and small, and all too often will masquerade as general anxiety or existential despair and depression. Too often, PTSD is undiagnosed or unrecognized completely. PTSD is also a costly disease that is an enormous economic burden on the U.S. economy.

As clinicians, we must be aware of the more subtle events that may trigger PTSD. We must think beyond ICD codes and DSM criteria and realize that each individual processes an event or a series of events differently. For example, seriously ill people in ICUs or undergoing critical care have been known to experience PTSD well beyond their physical recovery (J Crit Care. 2017 Dec. doi: 10.1016/j.jcrc.2017.06.014). Years after the Sept. 11, 2001, World Trade Center disaster, many are still suffering from PTSD symptoms (Biol Psychiatry. 2020 May 1. doi: 10.1016/j.biopsych.2020.02.817).

Again, in some cases, not knowing what the future may bring regarding life itself can lead to PTSD. I have treated patients who have lost jobs and experienced devastating social and financial losses, which were perceived as a separation from “life as they know it.” These can be precursors to PTSD for some who are sensitive to the disorder.

Intergenerational trauma is also a real phenomenon to which we must be attuned. I have treated two adult children of Holocaust survivors, both born in America well after World War II, who developed PTSD after hearing family recollections over and over about the brutality suffered by relatives, combined with watching films about people sent to concentration camps. Both of those patients self-diagnosed their symptoms as depression. Research shows that Holocaust traumatization can affect three generations (J Anxiety Disord. 2021 Jun. doi: 10.1016/j.janxdis.2021.102401).

In light of the high incidence of traumatic events affecting millions directly, more codified treatment approaches are needed that can be used both for individuals and for those in group settings.

To date, the best treatment rests with cognitive-behavioral therapy (CBT) and guided imagery coupled with relaxation techniques and the various types of in vivo exposure therapy, which I prefer to in vitro or flooding care. In terms of medication management, the U.S. Food and Drug Administration has approved only two antidepressant medications for PTSD, sertraline (Zoloft) and paroxetine (Paxil), although other selective serotonin reuptake inhibitors have been used off- label, and prazosin, a hypertensive medication, has been used off-label for PTSD-related insomnia and nightmares (Prim Care Companion CNS Disord. 2012 Mar 22. doi: 10.4088/PCC.11r01222). Thus, the limited number of choices for medication management means more research is needed so that more medications are developed that are more precisely directed at PTSD treatment.
 

Implications for society at large

In a recent article published in the Journal of Clinical Psychiatry (2022 Apr 25. doi: 10.4088/JCP.21m14116), authors Lori L. Davis and colleagues point out that the economic burden of PTSD goes beyond health care costs and rivals the costs of other mental illnesses, including depression and anxiety. In the process, Dr. Davis and colleagues note, unemployment caused by job loss, disability, homelessness, substance use, disordered care, as well as premature mortality, all contribute to this severe burden, going beyond PTSD itself.

This study shows that the annual economic burden of PTSD is $232 billion. Most of that burden is attributed to the civilian population, which they suggest to be $189.5 billion, or 82%.

After reading that article, it became clear to me that my “obsession” with PTSD is not really an obsession at all. Rather, it is a true concern that, against the backdrop of long COVID, gun violence, political and economic turmoil, and other factors, it is important that clinicians understand how to recognize and treat PTSD. The stakes have never been higher.

Dr. London is a practicing psychiatrist and has been a newspaper columnist for 35 years, specializing in and writing about short-term therapy, including cognitive-behavioral therapy and guided imagery. He is author of “Find Freedom Fast” (New York: Kettlehole Publishing, 2019). He has no conflicts of interest.

A few weeks ago, right after 19 children and two adults were killed by a gunman in Uvalde, Texas, Americans were really on edge. Many people I know became hypervigilant while going about activities previously thought of as routine, such as waiting for a subway or going to a grocery store.

On top of that, we are still facing the ongoing COVID-19 pandemic. Despite vaccines and therapeutics, the United States is still losing more than 300 people each day to the virus. Many people who have tested positive have continued to experience debilitating long-haul symptoms many months after testing negative, and I believe not knowing what your future life will bring from this terrible illness could lead some to posttraumatic stress disorder.

In addition to constant updates about COVID, we are getting almost daily reports about monkeypox. In New York state, medical professionals and institutions receive regular, almost weekly, information about the spread of influenza. But where are the reports and treatment approaches for PTSD, which would not only increase awareness but also lead to more care?

Some might believe that I am obsessed with PTSD, since I’ve written a great deal on the subject, particularly “underdiagnosed” PTSD. The key question I have is: How can clinicians treating patients NOT consider that we are amid an epidemic of PTSD, including a delayed-onset form of the illness?

We know the signs and symptoms of PTSD. They include flashbacks, intrusive recollections, physical distress related to stimuli related to the trauma, insomnia, social isolation, avoidance of certain situations, negative thinking, and hyperarousal – coupled with anxiety and depression. PTSD can be a great masquerader. It can be triggered by many events, large and small, and all too often will masquerade as general anxiety or existential despair and depression. Too often, PTSD is undiagnosed or unrecognized completely. PTSD is also a costly disease that is an enormous economic burden on the U.S. economy.

As clinicians, we must be aware of the more subtle events that may trigger PTSD. We must think beyond ICD codes and DSM criteria and realize that each individual processes an event or a series of events differently. For example, seriously ill people in ICUs or undergoing critical care have been known to experience PTSD well beyond their physical recovery (J Crit Care. 2017 Dec. doi: 10.1016/j.jcrc.2017.06.014). Years after the Sept. 11, 2001, World Trade Center disaster, many are still suffering from PTSD symptoms (Biol Psychiatry. 2020 May 1. doi: 10.1016/j.biopsych.2020.02.817).

Again, in some cases, not knowing what the future may bring regarding life itself can lead to PTSD. I have treated patients who have lost jobs and experienced devastating social and financial losses, which were perceived as a separation from “life as they know it.” These can be precursors to PTSD for some who are sensitive to the disorder.

Intergenerational trauma is also a real phenomenon to which we must be attuned. I have treated two adult children of Holocaust survivors, both born in America well after World War II, who developed PTSD after hearing family recollections over and over about the brutality suffered by relatives, combined with watching films about people sent to concentration camps. Both of those patients self-diagnosed their symptoms as depression. Research shows that Holocaust traumatization can affect three generations (J Anxiety Disord. 2021 Jun. doi: 10.1016/j.janxdis.2021.102401).

In light of the high incidence of traumatic events affecting millions directly, more codified treatment approaches are needed that can be used both for individuals and for those in group settings.

To date, the best treatment rests with cognitive-behavioral therapy (CBT) and guided imagery coupled with relaxation techniques and the various types of in vivo exposure therapy, which I prefer to in vitro or flooding care. In terms of medication management, the U.S. Food and Drug Administration has approved only two antidepressant medications for PTSD, sertraline (Zoloft) and paroxetine (Paxil), although other selective serotonin reuptake inhibitors have been used off- label, and prazosin, a hypertensive medication, has been used off-label for PTSD-related insomnia and nightmares (Prim Care Companion CNS Disord. 2012 Mar 22. doi: 10.4088/PCC.11r01222). Thus, the limited number of choices for medication management means more research is needed so that more medications are developed that are more precisely directed at PTSD treatment.
 

Implications for society at large

In a recent article published in the Journal of Clinical Psychiatry (2022 Apr 25. doi: 10.4088/JCP.21m14116), authors Lori L. Davis and colleagues point out that the economic burden of PTSD goes beyond health care costs and rivals the costs of other mental illnesses, including depression and anxiety. In the process, Dr. Davis and colleagues note, unemployment caused by job loss, disability, homelessness, substance use, disordered care, as well as premature mortality, all contribute to this severe burden, going beyond PTSD itself.

This study shows that the annual economic burden of PTSD is $232 billion. Most of that burden is attributed to the civilian population, which they suggest to be $189.5 billion, or 82%.

After reading that article, it became clear to me that my “obsession” with PTSD is not really an obsession at all. Rather, it is a true concern that, against the backdrop of long COVID, gun violence, political and economic turmoil, and other factors, it is important that clinicians understand how to recognize and treat PTSD. The stakes have never been higher.

Dr. London is a practicing psychiatrist and has been a newspaper columnist for 35 years, specializing in and writing about short-term therapy, including cognitive-behavioral therapy and guided imagery. He is author of “Find Freedom Fast” (New York: Kettlehole Publishing, 2019). He has no conflicts of interest.