Randy Dotinga

SAN DIEGO – Research suggests that as many as 23% of patients with substance use disorder (SUD) also have ADHD, adding an extra layer of complexity to a difficult-to-treat condition. What to do?

“Treating the ADHD can be useful in reducing the severity of symptoms without worsening the substance use disorder. It shouldn’t be avoided,” said psychiatrist Larissa J. Mooney, MD, of the University of California, Los Angeles, and the Veterans Affairs Greater Los Angeles Healthcare System, in a presentation at the annual Psych Congress.

When ADHD is on board, “it’s a more complicated and challenging clinical course,” Dr. Mooney said. The duo of disorders is linked to higher rates of polysubstance abuse and other psychiatric conditions, such as anxiety, bipolar disorder, posttraumatic stress, and antisocial/borderline conditions (Eur Addict Res. 2018;24[1]:43-51).

“These individuals typically have more difficulty with [drug] abstinence, more health consequences, and reduced quality of life, and social and professional consequences,” she said. “Some studies have suggested that they may not respond to lower doses of medication for attention-deficit/hyperactivity disorder and may require doses in the higher range.”

Research has hinted that several drugs that might prove helpful in these patients by improving both conditions, Dr. Mooney said. These include up to 180 mg/day of methylphenidate (Ritalin), 60- and 80-mg doses of mixed amphetamine salts/extended release, atomoxetine (Strattera), and bupropion.

In regard to bupropion, she said, “I find it to be a good choice in my substance use disorder patients for their depression and concentration problems. I have a greater number of individuals at 450 milligrams per day and the XL formulation.”

Early research has suggested that guanfacine XR (Intuniv), which is used to treat children with ADHD, also might be helpful in adults, including those with SUD. “We need more research to show if this is helpful,” she said. “It’s a reasonable choice in terms of weighing pros and cons, because it’s not [a controlled substance].”

Still, some of those medications are stimulants, Dr. Mooney said, and their use in patients with SUD is controversial. There are concerns about misuse and diversion.

“We want to have some flexibility,” she said, but it’s important to think about risks and priorities. In certain cases, ADHD may be a secondary concern.

“Some patients have a severe substance use disorder that keeps landing them in the emergency room or causing them to be hospitalized,” she said. “I’m more worried about that than the impairment function from ADHD.”

If you do consider stimulants, she said, longer-acting formulations can be less risky because there’s less potential for diversion. “Also, think about their treatment plan: Is their functioning improving? Are they or showing up for appointments? These are factors that will say: ‘Oh, I’m on the right path with this medication.’ ”

Behavioral treatment also can be helpful in these patients, she said, although “some may not be willing or motivated to put in the time that it takes to do the behavioral work.”

Dr. Mooney disclosed an advisory board relationship with Alkermes and grant/research support from the National Institute on Drug Abuse.

SAN DIEGO – Research suggests that as many as 23% of patients with substance use disorder (SUD) also have ADHD, adding an extra layer of complexity to a difficult-to-treat condition. What to do?

“Treating the ADHD can be useful in reducing the severity of symptoms without worsening the substance use disorder. It shouldn’t be avoided,” said psychiatrist Larissa J. Mooney, MD, of the University of California, Los Angeles, and the Veterans Affairs Greater Los Angeles Healthcare System, in a presentation at the annual Psych Congress.

When ADHD is on board, “it’s a more complicated and challenging clinical course,” Dr. Mooney said. The duo of disorders is linked to higher rates of polysubstance abuse and other psychiatric conditions, such as anxiety, bipolar disorder, posttraumatic stress, and antisocial/borderline conditions (Eur Addict Res. 2018;24[1]:43-51).

“These individuals typically have more difficulty with [drug] abstinence, more health consequences, and reduced quality of life, and social and professional consequences,” she said. “Some studies have suggested that they may not respond to lower doses of medication for attention-deficit/hyperactivity disorder and may require doses in the higher range.”

Research has hinted that several drugs that might prove helpful in these patients by improving both conditions, Dr. Mooney said. These include up to 180 mg/day of methylphenidate (Ritalin), 60- and 80-mg doses of mixed amphetamine salts/extended release, atomoxetine (Strattera), and bupropion.

In regard to bupropion, she said, “I find it to be a good choice in my substance use disorder patients for their depression and concentration problems. I have a greater number of individuals at 450 milligrams per day and the XL formulation.”

Early research has suggested that guanfacine XR (Intuniv), which is used to treat children with ADHD, also might be helpful in adults, including those with SUD. “We need more research to show if this is helpful,” she said. “It’s a reasonable choice in terms of weighing pros and cons, because it’s not [a controlled substance].”

Still, some of those medications are stimulants, Dr. Mooney said, and their use in patients with SUD is controversial. There are concerns about misuse and diversion.

“We want to have some flexibility,” she said, but it’s important to think about risks and priorities. In certain cases, ADHD may be a secondary concern.

“Some patients have a severe substance use disorder that keeps landing them in the emergency room or causing them to be hospitalized,” she said. “I’m more worried about that than the impairment function from ADHD.”

If you do consider stimulants, she said, longer-acting formulations can be less risky because there’s less potential for diversion. “Also, think about their treatment plan: Is their functioning improving? Are they or showing up for appointments? These are factors that will say: ‘Oh, I’m on the right path with this medication.’ ”

Behavioral treatment also can be helpful in these patients, she said, although “some may not be willing or motivated to put in the time that it takes to do the behavioral work.”

Dr. Mooney disclosed an advisory board relationship with Alkermes and grant/research support from the National Institute on Drug Abuse.

SAN DIEGO – Research suggests that as many as 23% of patients with substance use disorder (SUD) also have ADHD, adding an extra layer of complexity to a difficult-to-treat condition. What to do?

“Treating the ADHD can be useful in reducing the severity of symptoms without worsening the substance use disorder. It shouldn’t be avoided,” said psychiatrist Larissa J. Mooney, MD, of the University of California, Los Angeles, and the Veterans Affairs Greater Los Angeles Healthcare System, in a presentation at the annual Psych Congress.

When ADHD is on board, “it’s a more complicated and challenging clinical course,” Dr. Mooney said. The duo of disorders is linked to higher rates of polysubstance abuse and other psychiatric conditions, such as anxiety, bipolar disorder, posttraumatic stress, and antisocial/borderline conditions (Eur Addict Res. 2018;24[1]:43-51).

“These individuals typically have more difficulty with [drug] abstinence, more health consequences, and reduced quality of life, and social and professional consequences,” she said. “Some studies have suggested that they may not respond to lower doses of medication for attention-deficit/hyperactivity disorder and may require doses in the higher range.”

Research has hinted that several drugs that might prove helpful in these patients by improving both conditions, Dr. Mooney said. These include up to 180 mg/day of methylphenidate (Ritalin), 60- and 80-mg doses of mixed amphetamine salts/extended release, atomoxetine (Strattera), and bupropion.

In regard to bupropion, she said, “I find it to be a good choice in my substance use disorder patients for their depression and concentration problems. I have a greater number of individuals at 450 milligrams per day and the XL formulation.”

Early research has suggested that guanfacine XR (Intuniv), which is used to treat children with ADHD, also might be helpful in adults, including those with SUD. “We need more research to show if this is helpful,” she said. “It’s a reasonable choice in terms of weighing pros and cons, because it’s not [a controlled substance].”

Still, some of those medications are stimulants, Dr. Mooney said, and their use in patients with SUD is controversial. There are concerns about misuse and diversion.

“We want to have some flexibility,” she said, but it’s important to think about risks and priorities. In certain cases, ADHD may be a secondary concern.

“Some patients have a severe substance use disorder that keeps landing them in the emergency room or causing them to be hospitalized,” she said. “I’m more worried about that than the impairment function from ADHD.”

If you do consider stimulants, she said, longer-acting formulations can be less risky because there’s less potential for diversion. “Also, think about their treatment plan: Is their functioning improving? Are they or showing up for appointments? These are factors that will say: ‘Oh, I’m on the right path with this medication.’ ”

Behavioral treatment also can be helpful in these patients, she said, although “some may not be willing or motivated to put in the time that it takes to do the behavioral work.”

Dr. Mooney disclosed an advisory board relationship with Alkermes and grant/research support from the National Institute on Drug Abuse.

SAN DIEGO – Even if a P value hints at statistical significance by dipping under .05, it might not tell you anything worthwhile. Effect sizes are hugely important – as long as accompanying P values measure up. And pharmaceutical companies often keep revealing numbers under wraps unless you know what – and whom – to ask.

Those lessons come courtesy of Leslie Citrome, MD, MPH, who spoke to colleagues about study numbers at Psych Congress 2019.

Dr. Citrome, clinical professor of psychiatry and behavioral sciences at New York Medical College, Valhalla, offered several tips about interpreting medical statistics as you make clinical decisions.

Don’t get hung up on the P value.

The P value helps you understand how likely it is that a difference in a study is statistically significant. In medical research, P values under .05 are considered especially desirable. They suggest that an outcome – drug A performed better than drug B, for example – didn’t happen purely by chance.

Here’s the hitch: The P value might not matter at all. “Clinicians often assume that if the P value is less than.05, the result must be important. But even a P value of less than .05 is meaningless outside of the context of how big the treatment effect is,” Dr. Citrome said. “If a clinical trial result shows us a small effect size, then who cares?”

Understand what effect sizes tell you.

Effect size measurements evaluate clinical impact and include number needed to treat (NNT) and number needed to harm (NNH). NNT refers to the number of patients needed to treat with an intervention in order to get a positive effect in one additional patient; NNH is the reverse and examines negative effects that can range from the minor (mild dry mouth) to the devastating (death).

What’s a good size for an NNT? “I respect any NNT versus placebo of less than 10,” Dr. Citrome said. “It’s something I’ll probably consider in day-to-day practice.” Double-digit and triple-digit NNTs “are usually irrelevant unless we’re dealing with very specific outcomes that have long-term consequences.”

As for the opposite side of the picture – NNH – values higher than 10 are ideal.

He cautioned that NNT and NNH, like P values, cannot stand alone. In fact, they work together. In order to have value, NNT or NNH must be statistically significant, and P values provide this crucial insight.

Consider Dr. Citrome’s blood pressure.

As Dr. Citrome noted, research suggests that, among patients with diastolic BP from 90 to 109 mm Hg, 1 additional person will avoid death, stroke, or heart attack for every 141 people who take an antihypertensive medication, compared to those who do not, over a 5-year period. That’s a lot of people taking medication for a long time, with potential side effects, for a fairly small effect size. However, the outcomes are dire, so it is still worth it. 

Then there’s Dr. Citrome himself, who has had diastolic BP in the range of 115 to 129 mm Hg. The NNT is 3. For every 3 people who take an antihypertensive vs. not over a 5-year period, 1 additional person will avoid a potentially catastrophic cardiovascular event.

“Guess who’s pretty adherent to taking his antihypertensive medication?” he asked. “I am.”

Ask for effect sizes if you don’t see them.

It’s not unusual for pharmaceutical representatives to avoid providing information about medication effect sizes. “The sales representatives as well as speakers at [Food and Drug Administration]–regulated promotional speaking events can only speak to basically what’s on the label. NNT and NNH are not currently found on product labels. But they are very relevant, and we need to know this information.”

What to do? “There is a workaround here,” he said. “Ask the sales rep to talk to a medical science liaison, who is free to come to your office and talk about all the data that they have.”

Dr. Citrome reported multiple disclosures, including various relationships with pharmaceutical companies.

SAN DIEGO – Even if a P value hints at statistical significance by dipping under .05, it might not tell you anything worthwhile. Effect sizes are hugely important – as long as accompanying P values measure up. And pharmaceutical companies often keep revealing numbers under wraps unless you know what – and whom – to ask.

Those lessons come courtesy of Leslie Citrome, MD, MPH, who spoke to colleagues about study numbers at Psych Congress 2019.

Dr. Citrome, clinical professor of psychiatry and behavioral sciences at New York Medical College, Valhalla, offered several tips about interpreting medical statistics as you make clinical decisions.

Don’t get hung up on the P value.

The P value helps you understand how likely it is that a difference in a study is statistically significant. In medical research, P values under .05 are considered especially desirable. They suggest that an outcome – drug A performed better than drug B, for example – didn’t happen purely by chance.

Here’s the hitch: The P value might not matter at all. “Clinicians often assume that if the P value is less than.05, the result must be important. But even a P value of less than .05 is meaningless outside of the context of how big the treatment effect is,” Dr. Citrome said. “If a clinical trial result shows us a small effect size, then who cares?”

Understand what effect sizes tell you.

Effect size measurements evaluate clinical impact and include number needed to treat (NNT) and number needed to harm (NNH). NNT refers to the number of patients needed to treat with an intervention in order to get a positive effect in one additional patient; NNH is the reverse and examines negative effects that can range from the minor (mild dry mouth) to the devastating (death).

What’s a good size for an NNT? “I respect any NNT versus placebo of less than 10,” Dr. Citrome said. “It’s something I’ll probably consider in day-to-day practice.” Double-digit and triple-digit NNTs “are usually irrelevant unless we’re dealing with very specific outcomes that have long-term consequences.”

As for the opposite side of the picture – NNH – values higher than 10 are ideal.

He cautioned that NNT and NNH, like P values, cannot stand alone. In fact, they work together. In order to have value, NNT or NNH must be statistically significant, and P values provide this crucial insight.

Consider Dr. Citrome’s blood pressure.

As Dr. Citrome noted, research suggests that, among patients with diastolic BP from 90 to 109 mm Hg, 1 additional person will avoid death, stroke, or heart attack for every 141 people who take an antihypertensive medication, compared to those who do not, over a 5-year period. That’s a lot of people taking medication for a long time, with potential side effects, for a fairly small effect size. However, the outcomes are dire, so it is still worth it. 

Then there’s Dr. Citrome himself, who has had diastolic BP in the range of 115 to 129 mm Hg. The NNT is 3. For every 3 people who take an antihypertensive vs. not over a 5-year period, 1 additional person will avoid a potentially catastrophic cardiovascular event.

“Guess who’s pretty adherent to taking his antihypertensive medication?” he asked. “I am.”

Ask for effect sizes if you don’t see them.

It’s not unusual for pharmaceutical representatives to avoid providing information about medication effect sizes. “The sales representatives as well as speakers at [Food and Drug Administration]–regulated promotional speaking events can only speak to basically what’s on the label. NNT and NNH are not currently found on product labels. But they are very relevant, and we need to know this information.”

What to do? “There is a workaround here,” he said. “Ask the sales rep to talk to a medical science liaison, who is free to come to your office and talk about all the data that they have.”

Dr. Citrome reported multiple disclosures, including various relationships with pharmaceutical companies.

SAN DIEGO – Even if a P value hints at statistical significance by dipping under .05, it might not tell you anything worthwhile. Effect sizes are hugely important – as long as accompanying P values measure up. And pharmaceutical companies often keep revealing numbers under wraps unless you know what – and whom – to ask.

Those lessons come courtesy of Leslie Citrome, MD, MPH, who spoke to colleagues about study numbers at Psych Congress 2019.

Dr. Citrome, clinical professor of psychiatry and behavioral sciences at New York Medical College, Valhalla, offered several tips about interpreting medical statistics as you make clinical decisions.

Don’t get hung up on the P value.

The P value helps you understand how likely it is that a difference in a study is statistically significant. In medical research, P values under .05 are considered especially desirable. They suggest that an outcome – drug A performed better than drug B, for example – didn’t happen purely by chance.

Here’s the hitch: The P value might not matter at all. “Clinicians often assume that if the P value is less than.05, the result must be important. But even a P value of less than .05 is meaningless outside of the context of how big the treatment effect is,” Dr. Citrome said. “If a clinical trial result shows us a small effect size, then who cares?”

Understand what effect sizes tell you.

Effect size measurements evaluate clinical impact and include number needed to treat (NNT) and number needed to harm (NNH). NNT refers to the number of patients needed to treat with an intervention in order to get a positive effect in one additional patient; NNH is the reverse and examines negative effects that can range from the minor (mild dry mouth) to the devastating (death).

What’s a good size for an NNT? “I respect any NNT versus placebo of less than 10,” Dr. Citrome said. “It’s something I’ll probably consider in day-to-day practice.” Double-digit and triple-digit NNTs “are usually irrelevant unless we’re dealing with very specific outcomes that have long-term consequences.”

As for the opposite side of the picture – NNH – values higher than 10 are ideal.

He cautioned that NNT and NNH, like P values, cannot stand alone. In fact, they work together. In order to have value, NNT or NNH must be statistically significant, and P values provide this crucial insight.

Consider Dr. Citrome’s blood pressure.

As Dr. Citrome noted, research suggests that, among patients with diastolic BP from 90 to 109 mm Hg, 1 additional person will avoid death, stroke, or heart attack for every 141 people who take an antihypertensive medication, compared to those who do not, over a 5-year period. That’s a lot of people taking medication for a long time, with potential side effects, for a fairly small effect size. However, the outcomes are dire, so it is still worth it. 

Then there’s Dr. Citrome himself, who has had diastolic BP in the range of 115 to 129 mm Hg. The NNT is 3. For every 3 people who take an antihypertensive vs. not over a 5-year period, 1 additional person will avoid a potentially catastrophic cardiovascular event.

“Guess who’s pretty adherent to taking his antihypertensive medication?” he asked. “I am.”

Ask for effect sizes if you don’t see them.

It’s not unusual for pharmaceutical representatives to avoid providing information about medication effect sizes. “The sales representatives as well as speakers at [Food and Drug Administration]–regulated promotional speaking events can only speak to basically what’s on the label. NNT and NNH are not currently found on product labels. But they are very relevant, and we need to know this information.”

What to do? “There is a workaround here,” he said. “Ask the sales rep to talk to a medical science liaison, who is free to come to your office and talk about all the data that they have.”

Dr. Citrome reported multiple disclosures, including various relationships with pharmaceutical companies.

SAN DIEGO – Physician suicide is “a public health crisis because of the sheer volume of people who are dying,” and many medical authorities are contributing to stigma through “invasive” questionnaires, a prevention advocate said at the annual Psych Congress.

“Physicians fear sharing their mental health struggles with the state medical health board,” said Pamela Wible, MD, a family physician who practices in Eugene, Ore., at the meeting. They “pretend, deny, and lie,” she said, and sometimes they seek care and medication hours away in order to avoid detection.

One solution, she said, is to highlight state medical boards that do it right and state medical boards that do it wrong, including the “very worst,” which is that of Alaska.

Dr. Wible, who speaks of suffering from suicidal feelings herself as physician in 2004, is a leading advocate for suicide prevention in the medical profession.

She told colleagues at the Psych Congress that anesthesiologists face the highest risk of suicide, followed by surgeons, ob.gyns., and psychiatrists.

“They end their lives not because they want to die but because they want to stop the pain and they can’t find any other way,” she said. “They have a great work ethic until the end: They’re smiling, doing complex surgeries, and cracking jokes to the surgical team, then they shoot themselves in the closet.”

Colleagues are often shocked, she said: “ ‘Wait a minute. He was just joking with me yesterday. What do you mean he hung himself in his office?’ ‘She just had a newborn baby and she was so happy!’ If you see the smile, you don’t see the pain.”

In 2018, she wrote a Washington Post commentary titled “What I’ve learned from my tally of 757 doctor suicides” that was based on her registry of physician suicides. In the United States, she wrote, 1 million patients lose a physician to suicide each year. Factors contributing to suicides include patient deaths, malpractice suits, “academic distress,” and overwork. “Doctors who need help don’t seek it because they fear mental health care won’t remain confidential,” she wrote. “So they drive out of town, pay cash, and use fake names to hide from state medical boards, hospitals, and insurance plans out of fear that they will lose state licensure, hospital privileges, and health plan participation.”

Dr. Wible oversaw a 2019 research project that analyzed state medical board applications. The goal was to grade the state boards by how intrusively their application questions grill applicants about their mental health history. “Physicians fear sharing their mental health struggles with the state medical health board and with each other,” she said. Some lie, and others – “the really honest physicians” – are so dedicated to telling the truth that “they’ll withhold getting care because they want to correctly check the ‘no’ box.”

Seven states – Alabama, Alaska, Delaware, Florida, Mississippi, Rhode Island, and Washington –received “F” grades for “highly invasive mental health questions unlinked to current impairment that contain confusing, punitive, or adversarial language.”

Roke~commonswiki

Alaska, Dr. Wible said, asks multiple 25 yes-or-no questions about mental health. One question lists 14 conditions, almost all related to mental health – including depression, “any organic mental disorder,” and “any condition requiring chronic medical or behavioral treatment” – and asks, “Have you ever been diagnosed with, treated for, or do you currently have” any of them. This is “the most invasive mental health question we found on any application,” Dr. Wible wrote on her website.

States also hurt applicants by asking peers of applicants about their mental health, she said. “I’m not against getting peer references, but can we stop getting into everyone’s business with their psych history? What we really want to know is: ‘Are you are safe with patients today?’ ”

Dr. Wible also criticizes state medical boards for asking about mental health impairment over the last 5 years: They don’t get higher than a “C.”

The 13 states with “A” grades either don’t ask about mental health or simply ask about general impairment: Connecticut, Hawaii, Indiana, Kentucky, New Jersey, Maine, Maryland, Massachusetts, Michigan, Nevada, New York, Pennsylvania, and Wyoming.

Massachusetts, for example, asks, “Do you have a medical or physical condition that currently impairs your ability to practice medicine?”

“That is a question anyone can understand,” Dr. Wible said. “I think that’s good wording.”

Going forward, she said, “we’ve got to remove these mental health questions. If we could do this, our profession would be so much better, and we’d lose so many fewer people.”

And, she added, “what we really need to do is share our stories. It’s therapeutic for you and your colleagues, it creates collegial trust and bonding, and it destigmatizes physician mental health.”

Dr. Wible reported no relevant disclosures.

SAN DIEGO – Physician suicide is “a public health crisis because of the sheer volume of people who are dying,” and many medical authorities are contributing to stigma through “invasive” questionnaires, a prevention advocate said at the annual Psych Congress.

“Physicians fear sharing their mental health struggles with the state medical health board,” said Pamela Wible, MD, a family physician who practices in Eugene, Ore., at the meeting. They “pretend, deny, and lie,” she said, and sometimes they seek care and medication hours away in order to avoid detection.

One solution, she said, is to highlight state medical boards that do it right and state medical boards that do it wrong, including the “very worst,” which is that of Alaska.

Dr. Wible, who speaks of suffering from suicidal feelings herself as physician in 2004, is a leading advocate for suicide prevention in the medical profession.

She told colleagues at the Psych Congress that anesthesiologists face the highest risk of suicide, followed by surgeons, ob.gyns., and psychiatrists.

“They end their lives not because they want to die but because they want to stop the pain and they can’t find any other way,” she said. “They have a great work ethic until the end: They’re smiling, doing complex surgeries, and cracking jokes to the surgical team, then they shoot themselves in the closet.”

Colleagues are often shocked, she said: “ ‘Wait a minute. He was just joking with me yesterday. What do you mean he hung himself in his office?’ ‘She just had a newborn baby and she was so happy!’ If you see the smile, you don’t see the pain.”

In 2018, she wrote a Washington Post commentary titled “What I’ve learned from my tally of 757 doctor suicides” that was based on her registry of physician suicides. In the United States, she wrote, 1 million patients lose a physician to suicide each year. Factors contributing to suicides include patient deaths, malpractice suits, “academic distress,” and overwork. “Doctors who need help don’t seek it because they fear mental health care won’t remain confidential,” she wrote. “So they drive out of town, pay cash, and use fake names to hide from state medical boards, hospitals, and insurance plans out of fear that they will lose state licensure, hospital privileges, and health plan participation.”

Dr. Wible oversaw a 2019 research project that analyzed state medical board applications. The goal was to grade the state boards by how intrusively their application questions grill applicants about their mental health history. “Physicians fear sharing their mental health struggles with the state medical health board and with each other,” she said. Some lie, and others – “the really honest physicians” – are so dedicated to telling the truth that “they’ll withhold getting care because they want to correctly check the ‘no’ box.”

Seven states – Alabama, Alaska, Delaware, Florida, Mississippi, Rhode Island, and Washington –received “F” grades for “highly invasive mental health questions unlinked to current impairment that contain confusing, punitive, or adversarial language.”

Roke~commonswiki

Alaska, Dr. Wible said, asks multiple 25 yes-or-no questions about mental health. One question lists 14 conditions, almost all related to mental health – including depression, “any organic mental disorder,” and “any condition requiring chronic medical or behavioral treatment” – and asks, “Have you ever been diagnosed with, treated for, or do you currently have” any of them. This is “the most invasive mental health question we found on any application,” Dr. Wible wrote on her website.

States also hurt applicants by asking peers of applicants about their mental health, she said. “I’m not against getting peer references, but can we stop getting into everyone’s business with their psych history? What we really want to know is: ‘Are you are safe with patients today?’ ”

Dr. Wible also criticizes state medical boards for asking about mental health impairment over the last 5 years: They don’t get higher than a “C.”

The 13 states with “A” grades either don’t ask about mental health or simply ask about general impairment: Connecticut, Hawaii, Indiana, Kentucky, New Jersey, Maine, Maryland, Massachusetts, Michigan, Nevada, New York, Pennsylvania, and Wyoming.

Massachusetts, for example, asks, “Do you have a medical or physical condition that currently impairs your ability to practice medicine?”

“That is a question anyone can understand,” Dr. Wible said. “I think that’s good wording.”

Going forward, she said, “we’ve got to remove these mental health questions. If we could do this, our profession would be so much better, and we’d lose so many fewer people.”

And, she added, “what we really need to do is share our stories. It’s therapeutic for you and your colleagues, it creates collegial trust and bonding, and it destigmatizes physician mental health.”

Dr. Wible reported no relevant disclosures.

SAN DIEGO – Physician suicide is “a public health crisis because of the sheer volume of people who are dying,” and many medical authorities are contributing to stigma through “invasive” questionnaires, a prevention advocate said at the annual Psych Congress.

“Physicians fear sharing their mental health struggles with the state medical health board,” said Pamela Wible, MD, a family physician who practices in Eugene, Ore., at the meeting. They “pretend, deny, and lie,” she said, and sometimes they seek care and medication hours away in order to avoid detection.

One solution, she said, is to highlight state medical boards that do it right and state medical boards that do it wrong, including the “very worst,” which is that of Alaska.

Dr. Wible, who speaks of suffering from suicidal feelings herself as physician in 2004, is a leading advocate for suicide prevention in the medical profession.

She told colleagues at the Psych Congress that anesthesiologists face the highest risk of suicide, followed by surgeons, ob.gyns., and psychiatrists.

“They end their lives not because they want to die but because they want to stop the pain and they can’t find any other way,” she said. “They have a great work ethic until the end: They’re smiling, doing complex surgeries, and cracking jokes to the surgical team, then they shoot themselves in the closet.”

Colleagues are often shocked, she said: “ ‘Wait a minute. He was just joking with me yesterday. What do you mean he hung himself in his office?’ ‘She just had a newborn baby and she was so happy!’ If you see the smile, you don’t see the pain.”

In 2018, she wrote a Washington Post commentary titled “What I’ve learned from my tally of 757 doctor suicides” that was based on her registry of physician suicides. In the United States, she wrote, 1 million patients lose a physician to suicide each year. Factors contributing to suicides include patient deaths, malpractice suits, “academic distress,” and overwork. “Doctors who need help don’t seek it because they fear mental health care won’t remain confidential,” she wrote. “So they drive out of town, pay cash, and use fake names to hide from state medical boards, hospitals, and insurance plans out of fear that they will lose state licensure, hospital privileges, and health plan participation.”

Dr. Wible oversaw a 2019 research project that analyzed state medical board applications. The goal was to grade the state boards by how intrusively their application questions grill applicants about their mental health history. “Physicians fear sharing their mental health struggles with the state medical health board and with each other,” she said. Some lie, and others – “the really honest physicians” – are so dedicated to telling the truth that “they’ll withhold getting care because they want to correctly check the ‘no’ box.”

Seven states – Alabama, Alaska, Delaware, Florida, Mississippi, Rhode Island, and Washington –received “F” grades for “highly invasive mental health questions unlinked to current impairment that contain confusing, punitive, or adversarial language.”

Roke~commonswiki

Alaska, Dr. Wible said, asks multiple 25 yes-or-no questions about mental health. One question lists 14 conditions, almost all related to mental health – including depression, “any organic mental disorder,” and “any condition requiring chronic medical or behavioral treatment” – and asks, “Have you ever been diagnosed with, treated for, or do you currently have” any of them. This is “the most invasive mental health question we found on any application,” Dr. Wible wrote on her website.

States also hurt applicants by asking peers of applicants about their mental health, she said. “I’m not against getting peer references, but can we stop getting into everyone’s business with their psych history? What we really want to know is: ‘Are you are safe with patients today?’ ”

Dr. Wible also criticizes state medical boards for asking about mental health impairment over the last 5 years: They don’t get higher than a “C.”

The 13 states with “A” grades either don’t ask about mental health or simply ask about general impairment: Connecticut, Hawaii, Indiana, Kentucky, New Jersey, Maine, Maryland, Massachusetts, Michigan, Nevada, New York, Pennsylvania, and Wyoming.

Massachusetts, for example, asks, “Do you have a medical or physical condition that currently impairs your ability to practice medicine?”

“That is a question anyone can understand,” Dr. Wible said. “I think that’s good wording.”

Going forward, she said, “we’ve got to remove these mental health questions. If we could do this, our profession would be so much better, and we’d lose so many fewer people.”

And, she added, “what we really need to do is share our stories. It’s therapeutic for you and your colleagues, it creates collegial trust and bonding, and it destigmatizes physician mental health.”

Dr. Wible reported no relevant disclosures.

SAN DIEGO – The Food and Drug Administration has not approved a drug to treat agitation in dementia, and the absence of medication candidates is only part of the picture. As a geriatric psychiatrist explained to colleagues, the FDA has not taken the step of recognizing that the condition exists. But there are still options to treat this dangerous disorder – although none is ideal.

Research into efficacy of potential treatments for agitation is limited, variable, and “have high placebo effects,” said Marc E. Agronin, MD, of the MIND Institute and Miami Jewish Health, at the annual Psych Congress. “There is no one single magic bullet, especially since there are so many manifestations of agitation, and there are side effects of medication. This is a tough area to focus on.”

What can clinicians do? Dr. Agronin recommended starting with the steps in the DICE algorithm.

• Describe: Learn about the aspects of agitation by talking to caregivers and understanding the circumstances when symptoms develop.
• Investigate: Identify contributing factors, such as those related to illness, medication, and the environment.
• Create: Come up with a team strategy to address the contributing factors. Address the most urgent risks first, such as danger to self or others, which can require quick action – such as medication adjustment, an ED visit, or psychiatric hospitalization. Delirium is especially dangerous since it can lead to injury and subacute cognitive decline. And keep in mind, Dr. Agorin said, that it may be risky to do nothing or undertreat.
• Evaluate: Track the results of the strategy while realizing that there’s “not always a quick fix.” Research suggests that therapeutic approaches such as music, aromatherapy, exercise, group activities, hand massage, and thermal baths can be helpful, Dr. Agronin said.

As for medications, he advised starting with lower doses, perhaps 50%, because older people are less tolerant of medication. And beware of oversedation, dizziness, and lowered blood pressure, which can lead to falls. A hip fracture can “spiral down to someone’s demise very quickly,” he said.

Here’s a closer look at Dr. Agronin’s comments regarding specific medications.

• Antipsychotics: “Every antipsychotic has been used for agitation,” he said, “and they probably have the best efficacy,” compared with other drugs. But the risk of side effects is moderate to high, and atypical antipsychotics have a black-box warning about their use in dementia-related psychosis in elderly patients. Also, discontinuation of antipsychotics can trigger worsening symptoms in some patients. There has been tremendous controversy in recent years over the use of antipsychotics in older patients, but other drugs might be less effective than antipsychotics while still having similar side effect profiles, he said. And clinicians might be too cautious about doses even when they do use these drugs.
• Benzodiazepines: They can work quickly but come with a risk of sedation. Trazodone is an “excellent” alternative to reduce agitation in the short-term, he said.
• Antidepressants: These drugs can address underlying depression. Study results have been mixed.
• Mood stabilizers: Study results are mixed. “Unfortunately, in many situations [clinicians] get scared away from antipsychotics and use mood stabilizers, but there is less data for them in terms of efficacy, and there are a lot of side effects that have to be monitored,” he said.

Dr. Agronin is the author of “How We Age” (Da Capo Lifelong Books, 2012) and “The End of Old Age” (Da Capo Lifelong Books, 2018). He has no relevant disclosures.

SAN DIEGO – The Food and Drug Administration has not approved a drug to treat agitation in dementia, and the absence of medication candidates is only part of the picture. As a geriatric psychiatrist explained to colleagues, the FDA has not taken the step of recognizing that the condition exists. But there are still options to treat this dangerous disorder – although none is ideal.

Research into efficacy of potential treatments for agitation is limited, variable, and “have high placebo effects,” said Marc E. Agronin, MD, of the MIND Institute and Miami Jewish Health, at the annual Psych Congress. “There is no one single magic bullet, especially since there are so many manifestations of agitation, and there are side effects of medication. This is a tough area to focus on.”

What can clinicians do? Dr. Agronin recommended starting with the steps in the DICE algorithm.

• Describe: Learn about the aspects of agitation by talking to caregivers and understanding the circumstances when symptoms develop.
• Investigate: Identify contributing factors, such as those related to illness, medication, and the environment.
• Create: Come up with a team strategy to address the contributing factors. Address the most urgent risks first, such as danger to self or others, which can require quick action – such as medication adjustment, an ED visit, or psychiatric hospitalization. Delirium is especially dangerous since it can lead to injury and subacute cognitive decline. And keep in mind, Dr. Agorin said, that it may be risky to do nothing or undertreat.
• Evaluate: Track the results of the strategy while realizing that there’s “not always a quick fix.” Research suggests that therapeutic approaches such as music, aromatherapy, exercise, group activities, hand massage, and thermal baths can be helpful, Dr. Agronin said.

As for medications, he advised starting with lower doses, perhaps 50%, because older people are less tolerant of medication. And beware of oversedation, dizziness, and lowered blood pressure, which can lead to falls. A hip fracture can “spiral down to someone’s demise very quickly,” he said.

Here’s a closer look at Dr. Agronin’s comments regarding specific medications.

• Antipsychotics: “Every antipsychotic has been used for agitation,” he said, “and they probably have the best efficacy,” compared with other drugs. But the risk of side effects is moderate to high, and atypical antipsychotics have a black-box warning about their use in dementia-related psychosis in elderly patients. Also, discontinuation of antipsychotics can trigger worsening symptoms in some patients. There has been tremendous controversy in recent years over the use of antipsychotics in older patients, but other drugs might be less effective than antipsychotics while still having similar side effect profiles, he said. And clinicians might be too cautious about doses even when they do use these drugs.
• Benzodiazepines: They can work quickly but come with a risk of sedation. Trazodone is an “excellent” alternative to reduce agitation in the short-term, he said.
• Antidepressants: These drugs can address underlying depression. Study results have been mixed.
• Mood stabilizers: Study results are mixed. “Unfortunately, in many situations [clinicians] get scared away from antipsychotics and use mood stabilizers, but there is less data for them in terms of efficacy, and there are a lot of side effects that have to be monitored,” he said.

Dr. Agronin is the author of “How We Age” (Da Capo Lifelong Books, 2012) and “The End of Old Age” (Da Capo Lifelong Books, 2018). He has no relevant disclosures.

SAN DIEGO – The Food and Drug Administration has not approved a drug to treat agitation in dementia, and the absence of medication candidates is only part of the picture. As a geriatric psychiatrist explained to colleagues, the FDA has not taken the step of recognizing that the condition exists. But there are still options to treat this dangerous disorder – although none is ideal.

Research into efficacy of potential treatments for agitation is limited, variable, and “have high placebo effects,” said Marc E. Agronin, MD, of the MIND Institute and Miami Jewish Health, at the annual Psych Congress. “There is no one single magic bullet, especially since there are so many manifestations of agitation, and there are side effects of medication. This is a tough area to focus on.”

What can clinicians do? Dr. Agronin recommended starting with the steps in the DICE algorithm.

• Describe: Learn about the aspects of agitation by talking to caregivers and understanding the circumstances when symptoms develop.
• Investigate: Identify contributing factors, such as those related to illness, medication, and the environment.
• Create: Come up with a team strategy to address the contributing factors. Address the most urgent risks first, such as danger to self or others, which can require quick action – such as medication adjustment, an ED visit, or psychiatric hospitalization. Delirium is especially dangerous since it can lead to injury and subacute cognitive decline. And keep in mind, Dr. Agorin said, that it may be risky to do nothing or undertreat.
• Evaluate: Track the results of the strategy while realizing that there’s “not always a quick fix.” Research suggests that therapeutic approaches such as music, aromatherapy, exercise, group activities, hand massage, and thermal baths can be helpful, Dr. Agronin said.

As for medications, he advised starting with lower doses, perhaps 50%, because older people are less tolerant of medication. And beware of oversedation, dizziness, and lowered blood pressure, which can lead to falls. A hip fracture can “spiral down to someone’s demise very quickly,” he said.

Here’s a closer look at Dr. Agronin’s comments regarding specific medications.

• Antipsychotics: “Every antipsychotic has been used for agitation,” he said, “and they probably have the best efficacy,” compared with other drugs. But the risk of side effects is moderate to high, and atypical antipsychotics have a black-box warning about their use in dementia-related psychosis in elderly patients. Also, discontinuation of antipsychotics can trigger worsening symptoms in some patients. There has been tremendous controversy in recent years over the use of antipsychotics in older patients, but other drugs might be less effective than antipsychotics while still having similar side effect profiles, he said. And clinicians might be too cautious about doses even when they do use these drugs.
• Benzodiazepines: They can work quickly but come with a risk of sedation. Trazodone is an “excellent” alternative to reduce agitation in the short-term, he said.
• Antidepressants: These drugs can address underlying depression. Study results have been mixed.
• Mood stabilizers: Study results are mixed. “Unfortunately, in many situations [clinicians] get scared away from antipsychotics and use mood stabilizers, but there is less data for them in terms of efficacy, and there are a lot of side effects that have to be monitored,” he said.

Dr. Agronin is the author of “How We Age” (Da Capo Lifelong Books, 2012) and “The End of Old Age” (Da Capo Lifelong Books, 2018). He has no relevant disclosures.

SAN DIEGO – Its toll is obscured by the opioid crisis, but methamphetamine use is on the rise in the United States. There are no approved treatments for methamphetamine use, but a psychiatrist told colleagues that several off-label medications might prove helpful.

However, the evidence supporting the use of these medications for patients taking methamphetamine is not robust, “and none are even close to [Food and Drug Administration] approval,” said Larissa J. Mooney, MD, of the University of California, Los Angeles, and the VA Greater Los Angeles Healthcare System. “But if I use something that’s approved for depression or might be helpful for anxiety symptoms, maybe it would also help reduce their likelihood of relapse in conjunction with an evidence-based behavioral program or treatment with a therapist.”

Dr. Mooney, who spoke at the annual Psych Congress, highlighted a federal report estimating that 0.4% of people aged 18-25 in 2017 used the drug within the past month, compared with 0.3% of those aged 26 and higher.

There were about 758,000 current adult users of methamphetamine in 2017, the report found.

Meanwhile, concurrent use of methamphetamine among patients who use opioids chronically has almost doubled, to 34% in 2017, from 19% in 2011 (Drug Alcohol Depend. 2018 Dec 1;193:14-20). And, Dr. Mooney said, deaths from stimulants are rising, even independent of opioid deaths.

Stimulant users typically have other psychiatric conditions, such as depression, anxiety, and concentration problems, Dr. Mooney said. In those cases, she said, treating those conditions might help with the substance use, too.

For methamphetamine use disorder, she highlighted some medications that might be helpful, although, again, she cautioned that evidence is not strong:

• Bupropion (Wellbutrin). Research suggests that this drug is more effective in patients with less severe methamphetamine use disorder, Dr. Mooney said. “It’s a more stimulating antidepressant, and can be helpful with concentration and attention.”
• Mirtazapine (Remeron). “I keep it in my list of options for some [who are] really anxious and not sleeping well,” she said. “It might be beneficial.”
• Naltrexone (ReVia, Depade, Vivitrol). “There are some early signs of efficacy,” she said, and a randomized, controlled trial is in progress.
• Methylphenidate (Ritalin, Concerta) and topiramate (Topamax). There’s “low-strength” evidence that the drugs can be helpful and lower use of methamphetamine, she said. However, methylphenidate is a stimulant. There’s controversy over the use of stimulants to treat patients with substance use disorders, Dr. Mooney said, and she tends to be conservative about their use in this population.

Why not use them to treat methamphetamine users in the same way that opioids such as methadone are used to treat opioid use addiction? “We don’t have an equivalent stimulant that works in the same way,” she said. “They don’t stay in the system for 24 hours. If you take a prescription stimulant, by the end of the day it wears off. It won’t stay in the same way as agonist treatments for opioid disorder.”

Even so, she said, “it makes sense that stimulants might be helpful.”

Dr. Mooney disclosed an advisory board relationship with Alkermes and grant/research support from the National Institute on Drug Abuse.

SAN DIEGO – Its toll is obscured by the opioid crisis, but methamphetamine use is on the rise in the United States. There are no approved treatments for methamphetamine use, but a psychiatrist told colleagues that several off-label medications might prove helpful.

However, the evidence supporting the use of these medications for patients taking methamphetamine is not robust, “and none are even close to [Food and Drug Administration] approval,” said Larissa J. Mooney, MD, of the University of California, Los Angeles, and the VA Greater Los Angeles Healthcare System. “But if I use something that’s approved for depression or might be helpful for anxiety symptoms, maybe it would also help reduce their likelihood of relapse in conjunction with an evidence-based behavioral program or treatment with a therapist.”

Dr. Mooney, who spoke at the annual Psych Congress, highlighted a federal report estimating that 0.4% of people aged 18-25 in 2017 used the drug within the past month, compared with 0.3% of those aged 26 and higher.

There were about 758,000 current adult users of methamphetamine in 2017, the report found.

Meanwhile, concurrent use of methamphetamine among patients who use opioids chronically has almost doubled, to 34% in 2017, from 19% in 2011 (Drug Alcohol Depend. 2018 Dec 1;193:14-20). And, Dr. Mooney said, deaths from stimulants are rising, even independent of opioid deaths.

Stimulant users typically have other psychiatric conditions, such as depression, anxiety, and concentration problems, Dr. Mooney said. In those cases, she said, treating those conditions might help with the substance use, too.

For methamphetamine use disorder, she highlighted some medications that might be helpful, although, again, she cautioned that evidence is not strong:

• Bupropion (Wellbutrin). Research suggests that this drug is more effective in patients with less severe methamphetamine use disorder, Dr. Mooney said. “It’s a more stimulating antidepressant, and can be helpful with concentration and attention.”
• Mirtazapine (Remeron). “I keep it in my list of options for some [who are] really anxious and not sleeping well,” she said. “It might be beneficial.”
• Naltrexone (ReVia, Depade, Vivitrol). “There are some early signs of efficacy,” she said, and a randomized, controlled trial is in progress.
• Methylphenidate (Ritalin, Concerta) and topiramate (Topamax). There’s “low-strength” evidence that the drugs can be helpful and lower use of methamphetamine, she said. However, methylphenidate is a stimulant. There’s controversy over the use of stimulants to treat patients with substance use disorders, Dr. Mooney said, and she tends to be conservative about their use in this population.

Why not use them to treat methamphetamine users in the same way that opioids such as methadone are used to treat opioid use addiction? “We don’t have an equivalent stimulant that works in the same way,” she said. “They don’t stay in the system for 24 hours. If you take a prescription stimulant, by the end of the day it wears off. It won’t stay in the same way as agonist treatments for opioid disorder.”

Even so, she said, “it makes sense that stimulants might be helpful.”

Dr. Mooney disclosed an advisory board relationship with Alkermes and grant/research support from the National Institute on Drug Abuse.

SAN DIEGO – Its toll is obscured by the opioid crisis, but methamphetamine use is on the rise in the United States. There are no approved treatments for methamphetamine use, but a psychiatrist told colleagues that several off-label medications might prove helpful.

However, the evidence supporting the use of these medications for patients taking methamphetamine is not robust, “and none are even close to [Food and Drug Administration] approval,” said Larissa J. Mooney, MD, of the University of California, Los Angeles, and the VA Greater Los Angeles Healthcare System. “But if I use something that’s approved for depression or might be helpful for anxiety symptoms, maybe it would also help reduce their likelihood of relapse in conjunction with an evidence-based behavioral program or treatment with a therapist.”

Dr. Mooney, who spoke at the annual Psych Congress, highlighted a federal report estimating that 0.4% of people aged 18-25 in 2017 used the drug within the past month, compared with 0.3% of those aged 26 and higher.

There were about 758,000 current adult users of methamphetamine in 2017, the report found.

Meanwhile, concurrent use of methamphetamine among patients who use opioids chronically has almost doubled, to 34% in 2017, from 19% in 2011 (Drug Alcohol Depend. 2018 Dec 1;193:14-20). And, Dr. Mooney said, deaths from stimulants are rising, even independent of opioid deaths.

Stimulant users typically have other psychiatric conditions, such as depression, anxiety, and concentration problems, Dr. Mooney said. In those cases, she said, treating those conditions might help with the substance use, too.

For methamphetamine use disorder, she highlighted some medications that might be helpful, although, again, she cautioned that evidence is not strong:

• Bupropion (Wellbutrin). Research suggests that this drug is more effective in patients with less severe methamphetamine use disorder, Dr. Mooney said. “It’s a more stimulating antidepressant, and can be helpful with concentration and attention.”
• Mirtazapine (Remeron). “I keep it in my list of options for some [who are] really anxious and not sleeping well,” she said. “It might be beneficial.”
• Naltrexone (ReVia, Depade, Vivitrol). “There are some early signs of efficacy,” she said, and a randomized, controlled trial is in progress.
• Methylphenidate (Ritalin, Concerta) and topiramate (Topamax). There’s “low-strength” evidence that the drugs can be helpful and lower use of methamphetamine, she said. However, methylphenidate is a stimulant. There’s controversy over the use of stimulants to treat patients with substance use disorders, Dr. Mooney said, and she tends to be conservative about their use in this population.

Why not use them to treat methamphetamine users in the same way that opioids such as methadone are used to treat opioid use addiction? “We don’t have an equivalent stimulant that works in the same way,” she said. “They don’t stay in the system for 24 hours. If you take a prescription stimulant, by the end of the day it wears off. It won’t stay in the same way as agonist treatments for opioid disorder.”

Even so, she said, “it makes sense that stimulants might be helpful.”

Dr. Mooney disclosed an advisory board relationship with Alkermes and grant/research support from the National Institute on Drug Abuse.

New research presents a complex picture of self-reported suicidal behavior in U.S. teenagers over the last few decades. Rates of suicidal ideation and plans dipped overall from 1991 to 2017, but the rate of suicide attempts grew slightly in black adolescents.

White young people “have historically had higher rates of suicide attempts...compared with their black counterparts; however, this study provides some evidence to the contrary,” wrote the authors of the report, which appears in the November issue of Pediatrics.

The investigators, led by Michael A. Lindsey, PhD, executive director of the McSilver Institute for Poverty Policy and Research at New York University, New York, note that suicide is the second leading cause of death in the United States in those aged 12-17. (Accidents rank first.) According to recent research, black children younger than 12 are at higher risk for death by suicide, compared with whites.

For the new study, researchers analyzed data from the Youth Risk Behavior Survey, which is conducted every 2 years among high school students in all 50 states and the District of Columbia. They examined data from 198,540 teens (mean age=16, 51% male; 49% female).

During the study period, the weighted overall prevalences rates of suicidal ideation, planning, attempt, and injury due to attempt were 19%, 15%, 8%, and 3%, respectively. “Our findings reveal that over that span of time, almost 1 in 5 adolescents are thinking about suicide... and > 1 in 10 has a suicide plan,” the researchers wrote.

Rates of suicidal ideation and planning fell overall, and among females, the rate of suicide attempts fell significantly (odds ratio [OR]=0.98). But self-reported suicide attempts grew significantly among black teens (OR=1.02), and injuries due to suicide attempts grew among black males (OR=1.04).

The findings are “troubling because attempts are the most prominent risk factor associated with suicide death,” the study authors wrote. “Findings regarding the rising rates of suicide attempts in black youth may be related to the documented disparities in mental health treatment and common social etiologic factors disproportionately experienced by black youth.”

In an accompanying commentary, psychiatrist Benjamin N. Shain, MD, PhD, of the University of Chicago, noted a seemingly “counterintuitive” fact: Black teens still have lower rates of suicide than whites teens “despite the greater, long-standing difficulties encountered by black adolescents, including disparities in mental health treatment and disproportionately higher stressors, racial discrimination, and childhood abuse and neglect, as well as other adverse experiences, such as poverty.”

It’s not clear why the reported suicide rate is lower in black adolescents than their white counterparts, Dr. Shain wrote, but misclassification and “undercount as a result of violence with suicidal intent, for example, ‘suicide by cop’” may play a role. Additionally, protective factors may have kept suicide rates down. “External attributional orientation (eg, blaming others or ‘the system’ for difficulties) among blacks may have buffered this group from internalizing blame related to psychological stressors,” he wrote.

Among black adolescents, the growing rate of suicidal behavior is concerning and may be due to a weakening of the hypothesized protective mechanism. Perhaps, Dr. Shain wrote, they now are blaming themselves more for difficulties encountered, “thus leading to an increase in suicide risk factors, particularly depression.” He stressed that, regardless of the reasons for the increase in suicide and suicide attempts, prevention and intervention efforts remain critical.

No study funding is reported, and authors report no relevant disclosures. Dr. Shain reports no relevant disclosures.


SOURCE: Lindsey MA et al, Pediatrics. 2019;144(5): e20191187, DOI:10.1542/peds.2019-1187.

New research presents a complex picture of self-reported suicidal behavior in U.S. teenagers over the last few decades. Rates of suicidal ideation and plans dipped overall from 1991 to 2017, but the rate of suicide attempts grew slightly in black adolescents.

White young people “have historically had higher rates of suicide attempts...compared with their black counterparts; however, this study provides some evidence to the contrary,” wrote the authors of the report, which appears in the November issue of Pediatrics.

The investigators, led by Michael A. Lindsey, PhD, executive director of the McSilver Institute for Poverty Policy and Research at New York University, New York, note that suicide is the second leading cause of death in the United States in those aged 12-17. (Accidents rank first.) According to recent research, black children younger than 12 are at higher risk for death by suicide, compared with whites.

For the new study, researchers analyzed data from the Youth Risk Behavior Survey, which is conducted every 2 years among high school students in all 50 states and the District of Columbia. They examined data from 198,540 teens (mean age=16, 51% male; 49% female).

During the study period, the weighted overall prevalences rates of suicidal ideation, planning, attempt, and injury due to attempt were 19%, 15%, 8%, and 3%, respectively. “Our findings reveal that over that span of time, almost 1 in 5 adolescents are thinking about suicide... and > 1 in 10 has a suicide plan,” the researchers wrote.

Rates of suicidal ideation and planning fell overall, and among females, the rate of suicide attempts fell significantly (odds ratio [OR]=0.98). But self-reported suicide attempts grew significantly among black teens (OR=1.02), and injuries due to suicide attempts grew among black males (OR=1.04).

The findings are “troubling because attempts are the most prominent risk factor associated with suicide death,” the study authors wrote. “Findings regarding the rising rates of suicide attempts in black youth may be related to the documented disparities in mental health treatment and common social etiologic factors disproportionately experienced by black youth.”

In an accompanying commentary, psychiatrist Benjamin N. Shain, MD, PhD, of the University of Chicago, noted a seemingly “counterintuitive” fact: Black teens still have lower rates of suicide than whites teens “despite the greater, long-standing difficulties encountered by black adolescents, including disparities in mental health treatment and disproportionately higher stressors, racial discrimination, and childhood abuse and neglect, as well as other adverse experiences, such as poverty.”

It’s not clear why the reported suicide rate is lower in black adolescents than their white counterparts, Dr. Shain wrote, but misclassification and “undercount as a result of violence with suicidal intent, for example, ‘suicide by cop’” may play a role. Additionally, protective factors may have kept suicide rates down. “External attributional orientation (eg, blaming others or ‘the system’ for difficulties) among blacks may have buffered this group from internalizing blame related to psychological stressors,” he wrote.

Among black adolescents, the growing rate of suicidal behavior is concerning and may be due to a weakening of the hypothesized protective mechanism. Perhaps, Dr. Shain wrote, they now are blaming themselves more for difficulties encountered, “thus leading to an increase in suicide risk factors, particularly depression.” He stressed that, regardless of the reasons for the increase in suicide and suicide attempts, prevention and intervention efforts remain critical.

No study funding is reported, and authors report no relevant disclosures. Dr. Shain reports no relevant disclosures.


SOURCE: Lindsey MA et al, Pediatrics. 2019;144(5): e20191187, DOI:10.1542/peds.2019-1187.

New research presents a complex picture of self-reported suicidal behavior in U.S. teenagers over the last few decades. Rates of suicidal ideation and plans dipped overall from 1991 to 2017, but the rate of suicide attempts grew slightly in black adolescents.

White young people “have historically had higher rates of suicide attempts...compared with their black counterparts; however, this study provides some evidence to the contrary,” wrote the authors of the report, which appears in the November issue of Pediatrics.

The investigators, led by Michael A. Lindsey, PhD, executive director of the McSilver Institute for Poverty Policy and Research at New York University, New York, note that suicide is the second leading cause of death in the United States in those aged 12-17. (Accidents rank first.) According to recent research, black children younger than 12 are at higher risk for death by suicide, compared with whites.

For the new study, researchers analyzed data from the Youth Risk Behavior Survey, which is conducted every 2 years among high school students in all 50 states and the District of Columbia. They examined data from 198,540 teens (mean age=16, 51% male; 49% female).

During the study period, the weighted overall prevalences rates of suicidal ideation, planning, attempt, and injury due to attempt were 19%, 15%, 8%, and 3%, respectively. “Our findings reveal that over that span of time, almost 1 in 5 adolescents are thinking about suicide... and > 1 in 10 has a suicide plan,” the researchers wrote.

Rates of suicidal ideation and planning fell overall, and among females, the rate of suicide attempts fell significantly (odds ratio [OR]=0.98). But self-reported suicide attempts grew significantly among black teens (OR=1.02), and injuries due to suicide attempts grew among black males (OR=1.04).

The findings are “troubling because attempts are the most prominent risk factor associated with suicide death,” the study authors wrote. “Findings regarding the rising rates of suicide attempts in black youth may be related to the documented disparities in mental health treatment and common social etiologic factors disproportionately experienced by black youth.”

In an accompanying commentary, psychiatrist Benjamin N. Shain, MD, PhD, of the University of Chicago, noted a seemingly “counterintuitive” fact: Black teens still have lower rates of suicide than whites teens “despite the greater, long-standing difficulties encountered by black adolescents, including disparities in mental health treatment and disproportionately higher stressors, racial discrimination, and childhood abuse and neglect, as well as other adverse experiences, such as poverty.”

It’s not clear why the reported suicide rate is lower in black adolescents than their white counterparts, Dr. Shain wrote, but misclassification and “undercount as a result of violence with suicidal intent, for example, ‘suicide by cop’” may play a role. Additionally, protective factors may have kept suicide rates down. “External attributional orientation (eg, blaming others or ‘the system’ for difficulties) among blacks may have buffered this group from internalizing blame related to psychological stressors,” he wrote.

Among black adolescents, the growing rate of suicidal behavior is concerning and may be due to a weakening of the hypothesized protective mechanism. Perhaps, Dr. Shain wrote, they now are blaming themselves more for difficulties encountered, “thus leading to an increase in suicide risk factors, particularly depression.” He stressed that, regardless of the reasons for the increase in suicide and suicide attempts, prevention and intervention efforts remain critical.

No study funding is reported, and authors report no relevant disclosures. Dr. Shain reports no relevant disclosures.


SOURCE: Lindsey MA et al, Pediatrics. 2019;144(5): e20191187, DOI:10.1542/peds.2019-1187.

MINNEAPOLIS -- Medical professionals within the US Department of Veterans Affairs (VA) can’t prescribe cannabis or certify patients to be able to get it. VA pharmacists can’t dispense it. Still, “we’re asked about it plenty,” a hospice and palliative care specialist told colleagues, at the annual meeting of the Association of VA Hematology/Oncology (AVAHO).

That brings up a big question, said Michael Stellini, MD, MS, FACP, FAAHPM, of Wayne State University, Karmanos Cancer Center, and the John D. Dingell VA Medical Center, in Detroit Michigan: “Should sick people be smoking pot?”

Even the question itself isn’t a simple one to answer since smoking isn’t the only way to consume cannabis for medical purposes. And figuring out the best advice is difficult. As Dr. Stellini said, there’s plenty of uncertainty about crucial cannabis topics like safety and benefits.

Dr. Stellini offered a number of facts and tips about cannabis in medicine.

Understand ‘qualifying conditions’ in your state

In states with legal medical marijuana, he said, physicians do not prescribe marijuana. However, they may certify that patients are eligible to get the drug for medical purposes if they meet certain qualifications.

A typical list of qualifying conditions includes diseases such as cancer, glaucoma, HIV/AIDS and Crohn’s disease. Qualifying conditions also tend to include treatments for severe diseases that produce wasting syndrome, severe and chronic pain, severe nausea, seizures and severe and persistent muscle spasm.

In Michigan, where Dr. Stellini practices, a panel in 2018 approved a long list of added qualifying conditions such as chronic pain, obsessive compulsive disorder and arthritis. But the panel rejected other conditions such as anxiety, asthma, panic attacks and schizophrenia.

Vaporizers are an alternative to joints, but...

Vaporizers are commonly used as an alternative to smoking marijuana joints, Dr. Stellini said, and they don’t significantly release tars or much if any carbon monoxide. While research is limited, he said, use of vaporizers hasn’t been linked to more lung cancer or chronic obstructive pulmonary disease.

“Vaping” is another option, but it’s been linked to dozens of deaths and hundreds of cases of illness in recent weeks. Many patients have reported using products that contain THC, a component of marijuana.

Other delivery methods exist

Marijuana can be ingested in liquid and solid food. “But edibles can have a slow onset of action compared to vaporizing or smoking,” Dr. Stellini said. “You might over-indulge. When users get to their steady state, they might have some adverse effects [AEs].”

Marijuana still has risks

Cannabis use has a long list of well-known AEs linked to the THC component. The most common are drowsiness, fatigue, dizziness, dry mouth, anxiety, cognitive effects, cough, and nausea, Dr. Stellini said. More serious AEs such as psychosis have been reported.

And, of course, users of cannabis with THC get high if they use enough.

A 2017 National Academies of Sciences, Engineering and Medicine report linked cannabis use to a higher risk of motor vehicle accidents. Still, Dr. Stellini said, “it’s relatively safe with respect to mortality, especially compared to opioids.”¹

Risk of use in cancer may be low

Research suggest that patients with cancer use cannabis as much as other people and perhaps even more, Dr. Stellini said. But are they facing any extra risks? In general, he said, it doesn’t appear that way.

Cannabis seems to be safe when used with chemotherapy, he said, and drug-drug interactions in cancer appear to be rare. Some studies have suggested that cannabinoids—a component of marijuana—may be an effective treatment for chemotherapy-induced peripheral neuropathy.

However, he said, 1 study has raised a red flag about a possible interaction with cancer immunotherapy. Researchers found evidence that patients who used cannabis had lower tumor response rates to nivolomab for advanced melanoma, non-small cell lung cancer, and renal clear cell carcinoma. However, survival wasn’t affected.²

Meanwhile, he said, there’s no strong evidence that cannabis is a useful treatment for cancer, he said, although it’s worth investigating.

Cannabidiol is the hot new product

Cannabidiol, also known as CBD, has become hugely popular, Dr. Stellini said. It is derived from hemp and doesn’t cause a “buzz” like cannabis.

Due to lack of regulation, he said, buyers should beware. And, he said, CBD has multiple EAs. Standard doses can cause drowsiness, fatigue, dizziness, dry mouth, hypotension and lightheadedness.

Dr. Stellini reports no relevant disclosures.

MINNEAPOLIS -- Medical professionals within the US Department of Veterans Affairs (VA) can’t prescribe cannabis or certify patients to be able to get it. VA pharmacists can’t dispense it. Still, “we’re asked about it plenty,” a hospice and palliative care specialist told colleagues, at the annual meeting of the Association of VA Hematology/Oncology (AVAHO).

That brings up a big question, said Michael Stellini, MD, MS, FACP, FAAHPM, of Wayne State University, Karmanos Cancer Center, and the John D. Dingell VA Medical Center, in Detroit Michigan: “Should sick people be smoking pot?”

Even the question itself isn’t a simple one to answer since smoking isn’t the only way to consume cannabis for medical purposes. And figuring out the best advice is difficult. As Dr. Stellini said, there’s plenty of uncertainty about crucial cannabis topics like safety and benefits.

Dr. Stellini offered a number of facts and tips about cannabis in medicine.

Understand ‘qualifying conditions’ in your state

In states with legal medical marijuana, he said, physicians do not prescribe marijuana. However, they may certify that patients are eligible to get the drug for medical purposes if they meet certain qualifications.

A typical list of qualifying conditions includes diseases such as cancer, glaucoma, HIV/AIDS and Crohn’s disease. Qualifying conditions also tend to include treatments for severe diseases that produce wasting syndrome, severe and chronic pain, severe nausea, seizures and severe and persistent muscle spasm.

In Michigan, where Dr. Stellini practices, a panel in 2018 approved a long list of added qualifying conditions such as chronic pain, obsessive compulsive disorder and arthritis. But the panel rejected other conditions such as anxiety, asthma, panic attacks and schizophrenia.

Vaporizers are an alternative to joints, but...

Vaporizers are commonly used as an alternative to smoking marijuana joints, Dr. Stellini said, and they don’t significantly release tars or much if any carbon monoxide. While research is limited, he said, use of vaporizers hasn’t been linked to more lung cancer or chronic obstructive pulmonary disease.

“Vaping” is another option, but it’s been linked to dozens of deaths and hundreds of cases of illness in recent weeks. Many patients have reported using products that contain THC, a component of marijuana.

Other delivery methods exist

Marijuana can be ingested in liquid and solid food. “But edibles can have a slow onset of action compared to vaporizing or smoking,” Dr. Stellini said. “You might over-indulge. When users get to their steady state, they might have some adverse effects [AEs].”

Marijuana still has risks

Cannabis use has a long list of well-known AEs linked to the THC component. The most common are drowsiness, fatigue, dizziness, dry mouth, anxiety, cognitive effects, cough, and nausea, Dr. Stellini said. More serious AEs such as psychosis have been reported.

And, of course, users of cannabis with THC get high if they use enough.

A 2017 National Academies of Sciences, Engineering and Medicine report linked cannabis use to a higher risk of motor vehicle accidents. Still, Dr. Stellini said, “it’s relatively safe with respect to mortality, especially compared to opioids.”¹

Risk of use in cancer may be low

Research suggest that patients with cancer use cannabis as much as other people and perhaps even more, Dr. Stellini said. But are they facing any extra risks? In general, he said, it doesn’t appear that way.

Cannabis seems to be safe when used with chemotherapy, he said, and drug-drug interactions in cancer appear to be rare. Some studies have suggested that cannabinoids—a component of marijuana—may be an effective treatment for chemotherapy-induced peripheral neuropathy.

However, he said, 1 study has raised a red flag about a possible interaction with cancer immunotherapy. Researchers found evidence that patients who used cannabis had lower tumor response rates to nivolomab for advanced melanoma, non-small cell lung cancer, and renal clear cell carcinoma. However, survival wasn’t affected.²

Meanwhile, he said, there’s no strong evidence that cannabis is a useful treatment for cancer, he said, although it’s worth investigating.

Cannabidiol is the hot new product

Cannabidiol, also known as CBD, has become hugely popular, Dr. Stellini said. It is derived from hemp and doesn’t cause a “buzz” like cannabis.

Due to lack of regulation, he said, buyers should beware. And, he said, CBD has multiple EAs. Standard doses can cause drowsiness, fatigue, dizziness, dry mouth, hypotension and lightheadedness.

Dr. Stellini reports no relevant disclosures.

MINNEAPOLIS -- Medical professionals within the US Department of Veterans Affairs (VA) can’t prescribe cannabis or certify patients to be able to get it. VA pharmacists can’t dispense it. Still, “we’re asked about it plenty,” a hospice and palliative care specialist told colleagues, at the annual meeting of the Association of VA Hematology/Oncology (AVAHO).

That brings up a big question, said Michael Stellini, MD, MS, FACP, FAAHPM, of Wayne State University, Karmanos Cancer Center, and the John D. Dingell VA Medical Center, in Detroit Michigan: “Should sick people be smoking pot?”

Even the question itself isn’t a simple one to answer since smoking isn’t the only way to consume cannabis for medical purposes. And figuring out the best advice is difficult. As Dr. Stellini said, there’s plenty of uncertainty about crucial cannabis topics like safety and benefits.

Dr. Stellini offered a number of facts and tips about cannabis in medicine.

Understand ‘qualifying conditions’ in your state

In states with legal medical marijuana, he said, physicians do not prescribe marijuana. However, they may certify that patients are eligible to get the drug for medical purposes if they meet certain qualifications.

A typical list of qualifying conditions includes diseases such as cancer, glaucoma, HIV/AIDS and Crohn’s disease. Qualifying conditions also tend to include treatments for severe diseases that produce wasting syndrome, severe and chronic pain, severe nausea, seizures and severe and persistent muscle spasm.

In Michigan, where Dr. Stellini practices, a panel in 2018 approved a long list of added qualifying conditions such as chronic pain, obsessive compulsive disorder and arthritis. But the panel rejected other conditions such as anxiety, asthma, panic attacks and schizophrenia.

Vaporizers are an alternative to joints, but...

Vaporizers are commonly used as an alternative to smoking marijuana joints, Dr. Stellini said, and they don’t significantly release tars or much if any carbon monoxide. While research is limited, he said, use of vaporizers hasn’t been linked to more lung cancer or chronic obstructive pulmonary disease.

“Vaping” is another option, but it’s been linked to dozens of deaths and hundreds of cases of illness in recent weeks. Many patients have reported using products that contain THC, a component of marijuana.

Other delivery methods exist

Marijuana can be ingested in liquid and solid food. “But edibles can have a slow onset of action compared to vaporizing or smoking,” Dr. Stellini said. “You might over-indulge. When users get to their steady state, they might have some adverse effects [AEs].”

Marijuana still has risks

Cannabis use has a long list of well-known AEs linked to the THC component. The most common are drowsiness, fatigue, dizziness, dry mouth, anxiety, cognitive effects, cough, and nausea, Dr. Stellini said. More serious AEs such as psychosis have been reported.

And, of course, users of cannabis with THC get high if they use enough.

A 2017 National Academies of Sciences, Engineering and Medicine report linked cannabis use to a higher risk of motor vehicle accidents. Still, Dr. Stellini said, “it’s relatively safe with respect to mortality, especially compared to opioids.”¹

Risk of use in cancer may be low

Research suggest that patients with cancer use cannabis as much as other people and perhaps even more, Dr. Stellini said. But are they facing any extra risks? In general, he said, it doesn’t appear that way.

Cannabis seems to be safe when used with chemotherapy, he said, and drug-drug interactions in cancer appear to be rare. Some studies have suggested that cannabinoids—a component of marijuana—may be an effective treatment for chemotherapy-induced peripheral neuropathy.

However, he said, 1 study has raised a red flag about a possible interaction with cancer immunotherapy. Researchers found evidence that patients who used cannabis had lower tumor response rates to nivolomab for advanced melanoma, non-small cell lung cancer, and renal clear cell carcinoma. However, survival wasn’t affected.²

Meanwhile, he said, there’s no strong evidence that cannabis is a useful treatment for cancer, he said, although it’s worth investigating.

Cannabidiol is the hot new product

Cannabidiol, also known as CBD, has become hugely popular, Dr. Stellini said. It is derived from hemp and doesn’t cause a “buzz” like cannabis.

Due to lack of regulation, he said, buyers should beware. And, he said, CBD has multiple EAs. Standard doses can cause drowsiness, fatigue, dizziness, dry mouth, hypotension and lightheadedness.

Dr. Stellini reports no relevant disclosures.

MINNEAPOLIS -- Ignore the big health claims about vitamin supplements, pork, and nitrate-free food products. Meet patients “where they are,” even if that means you focus first on helping a morbidly obese patient maintain her weight instead of losing pounds. And use nutrition to empower patients and reduce the risk of cancer recurrence.

Dianne Piepenburg, MS, RDN, CSO, a certified oncology nutritionist at the Malcolm Randall VA Medical Center in Gainesville, Florida, offered these tips and more in a presentation about nutrition for cancer survivors. She spoke at the annual meeting of the Association of VA Hematology/Oncology (AVAHO).

According to the National Institutes of Health, an estimated 17 million cancer survivors live in the US, accounting for 5% of the population. Nearly two-thirds are aged ≥ 65 years.¹

Piepenburg highlighted the existence of certified specialists in oncology nutrition (CSOs). To be certified, registered dietitian nutritionists must have worked in that job for at least 2 years, have at least 2,000 hours of practice experience within the past 5 years and pass a board exam every 5 years.

Oncology nutritionists seek to empower cancer survivors to regain equilibrium in their lives, she said. “When a patient is told what scan to have next, what blood work they have to have, what treatment they need to be on, they feel they’re losing control,” she said. “Nutrition gives the power back to them, and they feel like there’s something they can do that’s in their control.”

Piepenburg urged colleagues to “meet patients where they are.” She gave the example of a patient with breast cancer whose body mass index is in the 50s, making her morbidly obese. “Our discussion wasn’t, ‘Let’s start [losing weight] today.’ Instead, I said, ‘Can we at least prevent you from gaining any more weight?’ She thought she could at least do that, try to recuperate a bit, and then start looking at a healthy weight loss. We’ll start there and circle back in a few months and see where we’re at.”

Piepenburg urged colleagues to bring exercise into the discussion. “We need people to be physically active no matter what phase of their survivorship journey they are in,” she said.

What about people who say, “I’ve never exercised a day in my life”? Her response: “I tell folks that we need them to move more. Maybe they’re walking to the mailbox or 3 laps around the house that day.”

Oncology patients should also watch sugar, meat, and processed foods. Refined sugar, fast food and processed food should be limited, Piepenburg said, along with red meats, such as beef, pork and lamb.

“Pork is not the ‘other white meat.’ How many of you grew up seeing and hearing that in the 1970s and 1980s? It’s a red meat, and it’s metabolized like a red meat.”

Advise patients to limit bacon, sausage, and lunch meat, she said, “even if they say, ‘I bought the nitrate-free and it’s really healthy for me.’”

It’s okay to eat some red meat, she said, “but there’s a tipping point. Tell them they can have some red meat but have it as a treat and please focus more on plant-based proteins—nuts, beans, legumes. But it’s tough for a lot of our veterans who grew up on meat and potatoes, and the only vegetable they eat is corn.”

It’s tough to limit grilling in a place like Minnesota, Piepenburg said, where the prime grilling season is short, and locals go a bit nuts when it’s nice enough outside. “I tell them to at least marinate the meat and put it on indirect heat.”

Finally, she encouraged oncology care providers to not fall for vitamin hype. Don’t rely on supplements for cancer prevention, she said. With some exceptions, she said, research has suggested they don’t work, and a 1990s study of beta-carotene and retinyl palmitate (vitamin A) in lung cancer was halted because patients actually fared worse on the regimen, although the effects didn’t seem to persist.²

MINNEAPOLIS -- Ignore the big health claims about vitamin supplements, pork, and nitrate-free food products. Meet patients “where they are,” even if that means you focus first on helping a morbidly obese patient maintain her weight instead of losing pounds. And use nutrition to empower patients and reduce the risk of cancer recurrence.

Dianne Piepenburg, MS, RDN, CSO, a certified oncology nutritionist at the Malcolm Randall VA Medical Center in Gainesville, Florida, offered these tips and more in a presentation about nutrition for cancer survivors. She spoke at the annual meeting of the Association of VA Hematology/Oncology (AVAHO).

According to the National Institutes of Health, an estimated 17 million cancer survivors live in the US, accounting for 5% of the population. Nearly two-thirds are aged ≥ 65 years.¹

Piepenburg highlighted the existence of certified specialists in oncology nutrition (CSOs). To be certified, registered dietitian nutritionists must have worked in that job for at least 2 years, have at least 2,000 hours of practice experience within the past 5 years and pass a board exam every 5 years.

Oncology nutritionists seek to empower cancer survivors to regain equilibrium in their lives, she said. “When a patient is told what scan to have next, what blood work they have to have, what treatment they need to be on, they feel they’re losing control,” she said. “Nutrition gives the power back to them, and they feel like there’s something they can do that’s in their control.”

Piepenburg urged colleagues to “meet patients where they are.” She gave the example of a patient with breast cancer whose body mass index is in the 50s, making her morbidly obese. “Our discussion wasn’t, ‘Let’s start [losing weight] today.’ Instead, I said, ‘Can we at least prevent you from gaining any more weight?’ She thought she could at least do that, try to recuperate a bit, and then start looking at a healthy weight loss. We’ll start there and circle back in a few months and see where we’re at.”

Piepenburg urged colleagues to bring exercise into the discussion. “We need people to be physically active no matter what phase of their survivorship journey they are in,” she said.

What about people who say, “I’ve never exercised a day in my life”? Her response: “I tell folks that we need them to move more. Maybe they’re walking to the mailbox or 3 laps around the house that day.”

Oncology patients should also watch sugar, meat, and processed foods. Refined sugar, fast food and processed food should be limited, Piepenburg said, along with red meats, such as beef, pork and lamb.

“Pork is not the ‘other white meat.’ How many of you grew up seeing and hearing that in the 1970s and 1980s? It’s a red meat, and it’s metabolized like a red meat.”

Advise patients to limit bacon, sausage, and lunch meat, she said, “even if they say, ‘I bought the nitrate-free and it’s really healthy for me.’”

It’s okay to eat some red meat, she said, “but there’s a tipping point. Tell them they can have some red meat but have it as a treat and please focus more on plant-based proteins—nuts, beans, legumes. But it’s tough for a lot of our veterans who grew up on meat and potatoes, and the only vegetable they eat is corn.”

It’s tough to limit grilling in a place like Minnesota, Piepenburg said, where the prime grilling season is short, and locals go a bit nuts when it’s nice enough outside. “I tell them to at least marinate the meat and put it on indirect heat.”

Finally, she encouraged oncology care providers to not fall for vitamin hype. Don’t rely on supplements for cancer prevention, she said. With some exceptions, she said, research has suggested they don’t work, and a 1990s study of beta-carotene and retinyl palmitate (vitamin A) in lung cancer was halted because patients actually fared worse on the regimen, although the effects didn’t seem to persist.²

MINNEAPOLIS -- Ignore the big health claims about vitamin supplements, pork, and nitrate-free food products. Meet patients “where they are,” even if that means you focus first on helping a morbidly obese patient maintain her weight instead of losing pounds. And use nutrition to empower patients and reduce the risk of cancer recurrence.

Dianne Piepenburg, MS, RDN, CSO, a certified oncology nutritionist at the Malcolm Randall VA Medical Center in Gainesville, Florida, offered these tips and more in a presentation about nutrition for cancer survivors. She spoke at the annual meeting of the Association of VA Hematology/Oncology (AVAHO).

According to the National Institutes of Health, an estimated 17 million cancer survivors live in the US, accounting for 5% of the population. Nearly two-thirds are aged ≥ 65 years.¹

Piepenburg highlighted the existence of certified specialists in oncology nutrition (CSOs). To be certified, registered dietitian nutritionists must have worked in that job for at least 2 years, have at least 2,000 hours of practice experience within the past 5 years and pass a board exam every 5 years.

Oncology nutritionists seek to empower cancer survivors to regain equilibrium in their lives, she said. “When a patient is told what scan to have next, what blood work they have to have, what treatment they need to be on, they feel they’re losing control,” she said. “Nutrition gives the power back to them, and they feel like there’s something they can do that’s in their control.”

Piepenburg urged colleagues to “meet patients where they are.” She gave the example of a patient with breast cancer whose body mass index is in the 50s, making her morbidly obese. “Our discussion wasn’t, ‘Let’s start [losing weight] today.’ Instead, I said, ‘Can we at least prevent you from gaining any more weight?’ She thought she could at least do that, try to recuperate a bit, and then start looking at a healthy weight loss. We’ll start there and circle back in a few months and see where we’re at.”

Piepenburg urged colleagues to bring exercise into the discussion. “We need people to be physically active no matter what phase of their survivorship journey they are in,” she said.

What about people who say, “I’ve never exercised a day in my life”? Her response: “I tell folks that we need them to move more. Maybe they’re walking to the mailbox or 3 laps around the house that day.”

Oncology patients should also watch sugar, meat, and processed foods. Refined sugar, fast food and processed food should be limited, Piepenburg said, along with red meats, such as beef, pork and lamb.

“Pork is not the ‘other white meat.’ How many of you grew up seeing and hearing that in the 1970s and 1980s? It’s a red meat, and it’s metabolized like a red meat.”

Advise patients to limit bacon, sausage, and lunch meat, she said, “even if they say, ‘I bought the nitrate-free and it’s really healthy for me.’”

It’s okay to eat some red meat, she said, “but there’s a tipping point. Tell them they can have some red meat but have it as a treat and please focus more on plant-based proteins—nuts, beans, legumes. But it’s tough for a lot of our veterans who grew up on meat and potatoes, and the only vegetable they eat is corn.”

It’s tough to limit grilling in a place like Minnesota, Piepenburg said, where the prime grilling season is short, and locals go a bit nuts when it’s nice enough outside. “I tell them to at least marinate the meat and put it on indirect heat.”

Finally, she encouraged oncology care providers to not fall for vitamin hype. Don’t rely on supplements for cancer prevention, she said. With some exceptions, she said, research has suggested they don’t work, and a 1990s study of beta-carotene and retinyl palmitate (vitamin A) in lung cancer was halted because patients actually fared worse on the regimen, although the effects didn’t seem to persist.²

SAN DIEGO – Mental health professionals can lower the risk of legal exposure from patients filing malpractice suits through proper assessment and proper documentation, a psychiatrist said at the annual Psych Congress.

“You don’t have to have a perfect performance, but you do have to gather relevant data. And you’ll be judged on whether you took reasonable precautions once you identified the risk,” said Phillip J. Resnick, MD, professor of psychiatry at Case Western Reserve University, Cleveland.

Research suggests that 35% of malpractice claims involve incorrect treatment and 19% involve medication problems. More than half of all U.S. physicians reportedly have been sued, and psychiatrists are named in lawsuits less often than other medical specialists.

What’s “reasonable” in terms of assessment and precautions? In the past, courts may have held to a community standard: Did you provide the usual care that others in your region would provide? This approach allowed physicians to avoid responsibility if “you could prove that the majority of [local] doctors do what you did,” Dr. Resnick said, even if they’re “sloppy and bad.”

A newer, “reasonably prudent practitioner” standard expects medical professionals to do the right thing no matter where they live. “You have to do what a prudent practitioner would do whether others in your community are doing it or not,” said Dr. Resnick, who has consulted on numerous well-known cases, including that of Jeffrey Dahmer, Susan Smith, Timothy McVey, and Theodore Kaczynski.

Psychiatrists can be vulnerable legally if they refuse to respond to concerns from family members, Dr. Resnick said. The best approach is to listen. “You don’t need permission to listen – only to release information. You can always listen.”

Dr. Resnick is a former president of the American Academy of Psychiatry and the Law. He has no disclosures.

SAN DIEGO – Mental health professionals can lower the risk of legal exposure from patients filing malpractice suits through proper assessment and proper documentation, a psychiatrist said at the annual Psych Congress.

“You don’t have to have a perfect performance, but you do have to gather relevant data. And you’ll be judged on whether you took reasonable precautions once you identified the risk,” said Phillip J. Resnick, MD, professor of psychiatry at Case Western Reserve University, Cleveland.

Research suggests that 35% of malpractice claims involve incorrect treatment and 19% involve medication problems. More than half of all U.S. physicians reportedly have been sued, and psychiatrists are named in lawsuits less often than other medical specialists.

What’s “reasonable” in terms of assessment and precautions? In the past, courts may have held to a community standard: Did you provide the usual care that others in your region would provide? This approach allowed physicians to avoid responsibility if “you could prove that the majority of [local] doctors do what you did,” Dr. Resnick said, even if they’re “sloppy and bad.”

A newer, “reasonably prudent practitioner” standard expects medical professionals to do the right thing no matter where they live. “You have to do what a prudent practitioner would do whether others in your community are doing it or not,” said Dr. Resnick, who has consulted on numerous well-known cases, including that of Jeffrey Dahmer, Susan Smith, Timothy McVey, and Theodore Kaczynski.

Psychiatrists can be vulnerable legally if they refuse to respond to concerns from family members, Dr. Resnick said. The best approach is to listen. “You don’t need permission to listen – only to release information. You can always listen.”

Dr. Resnick is a former president of the American Academy of Psychiatry and the Law. He has no disclosures.

SAN DIEGO – Mental health professionals can lower the risk of legal exposure from patients filing malpractice suits through proper assessment and proper documentation, a psychiatrist said at the annual Psych Congress.

“You don’t have to have a perfect performance, but you do have to gather relevant data. And you’ll be judged on whether you took reasonable precautions once you identified the risk,” said Phillip J. Resnick, MD, professor of psychiatry at Case Western Reserve University, Cleveland.

Research suggests that 35% of malpractice claims involve incorrect treatment and 19% involve medication problems. More than half of all U.S. physicians reportedly have been sued, and psychiatrists are named in lawsuits less often than other medical specialists.

What’s “reasonable” in terms of assessment and precautions? In the past, courts may have held to a community standard: Did you provide the usual care that others in your region would provide? This approach allowed physicians to avoid responsibility if “you could prove that the majority of [local] doctors do what you did,” Dr. Resnick said, even if they’re “sloppy and bad.”

A newer, “reasonably prudent practitioner” standard expects medical professionals to do the right thing no matter where they live. “You have to do what a prudent practitioner would do whether others in your community are doing it or not,” said Dr. Resnick, who has consulted on numerous well-known cases, including that of Jeffrey Dahmer, Susan Smith, Timothy McVey, and Theodore Kaczynski.

Psychiatrists can be vulnerable legally if they refuse to respond to concerns from family members, Dr. Resnick said. The best approach is to listen. “You don’t need permission to listen – only to release information. You can always listen.”

Dr. Resnick is a former president of the American Academy of Psychiatry and the Law. He has no disclosures.

SAN DIEGO – Substance use disorders rarely ride alone, a psychiatrist told colleagues, and it’s crucial to treat the accompanying mental illness that is almost always present.

“If you’re really depressed and you’re smoking marijuana, the smoking could have made it worse, but you were probably depressed before,” said Timothy E. Wilens, MD, of Harvard Medical School and Massachusetts General Hospital, both in Boston. Dr. Wilens spoke at the annual Psych Congress.

He pointed to numbers supporting the link between substance use and mental illness. He also offered several tips about treating substance use disorder (SUD).

In ADHD, consider the big picture. If a person has both ADHD and SUD, treat both if the level of substance abuse is lower. But focus on the SUD in more severe cases, he said, and realize that “most likely your treatment for ADHD isn’t going to work as well.”

Be prepared to give high doses. “When you’re using stimulants in people with use disorders, you have to use high doses. You have to be brave,” he said. The same goes for the anxiolytic buspirone (Buspar) in patients with depression and SUD.

Consider N-acetyl cysteine in cannabis use disorder. N-acetyl cysteine, a nutraceutical used as an asthma medication, has shown promise in trials as a treatment for cannabis use disorder, Dr. Wilens said. It helps patients avoid the temptation to smoke. “They won’t say they’ve lost all their cravings, but you’ll hear, ‘I just didn’t need to do it; I’m not smoking as much.’ If you hear that from your patients, you know it’s working. It’s a subtle effect, but it can help.”

Scamming’ drugs shouldn’t be your main worry. Substance use research suggests that users of pharmaceutical drugs for nonmedical uses rarely get them directly from practitioners (7%), but instead mainly get them through friends, Dr. Wilens said. “If you work with this population and treat ADHD or anxiety, you’re paranoid that everyone coming in wants to scam medicines. Be more concerned about oversupplying them with immediate-release medications and not [taking] them to task about keeping the medication safely stored.”

Interventions such as Alcoholics Anonymous are as “effective as any other treatment for substance abuse, and it’s not costly,” Dr. Wilens said. He added that the Rational Recovery program, an alternative to Alcoholics Anonymous, also seems to work well. The approaches to ending substance use differ in that Alcoholics Anonymous’s orientation is spiritual and Rational Recovery’s is cognitive.

Dr. Wilens reported various disclosures, including consulting relationships with Ironshore Pharmaceuticals, KemPharm, and Neurovance/Otsuka.

SAN DIEGO – Substance use disorders rarely ride alone, a psychiatrist told colleagues, and it’s crucial to treat the accompanying mental illness that is almost always present.

“If you’re really depressed and you’re smoking marijuana, the smoking could have made it worse, but you were probably depressed before,” said Timothy E. Wilens, MD, of Harvard Medical School and Massachusetts General Hospital, both in Boston. Dr. Wilens spoke at the annual Psych Congress.

He pointed to numbers supporting the link between substance use and mental illness. He also offered several tips about treating substance use disorder (SUD).

In ADHD, consider the big picture. If a person has both ADHD and SUD, treat both if the level of substance abuse is lower. But focus on the SUD in more severe cases, he said, and realize that “most likely your treatment for ADHD isn’t going to work as well.”

Be prepared to give high doses. “When you’re using stimulants in people with use disorders, you have to use high doses. You have to be brave,” he said. The same goes for the anxiolytic buspirone (Buspar) in patients with depression and SUD.

Consider N-acetyl cysteine in cannabis use disorder. N-acetyl cysteine, a nutraceutical used as an asthma medication, has shown promise in trials as a treatment for cannabis use disorder, Dr. Wilens said. It helps patients avoid the temptation to smoke. “They won’t say they’ve lost all their cravings, but you’ll hear, ‘I just didn’t need to do it; I’m not smoking as much.’ If you hear that from your patients, you know it’s working. It’s a subtle effect, but it can help.”

Scamming’ drugs shouldn’t be your main worry. Substance use research suggests that users of pharmaceutical drugs for nonmedical uses rarely get them directly from practitioners (7%), but instead mainly get them through friends, Dr. Wilens said. “If you work with this population and treat ADHD or anxiety, you’re paranoid that everyone coming in wants to scam medicines. Be more concerned about oversupplying them with immediate-release medications and not [taking] them to task about keeping the medication safely stored.”

Interventions such as Alcoholics Anonymous are as “effective as any other treatment for substance abuse, and it’s not costly,” Dr. Wilens said. He added that the Rational Recovery program, an alternative to Alcoholics Anonymous, also seems to work well. The approaches to ending substance use differ in that Alcoholics Anonymous’s orientation is spiritual and Rational Recovery’s is cognitive.

Dr. Wilens reported various disclosures, including consulting relationships with Ironshore Pharmaceuticals, KemPharm, and Neurovance/Otsuka.

SAN DIEGO – Substance use disorders rarely ride alone, a psychiatrist told colleagues, and it’s crucial to treat the accompanying mental illness that is almost always present.

“If you’re really depressed and you’re smoking marijuana, the smoking could have made it worse, but you were probably depressed before,” said Timothy E. Wilens, MD, of Harvard Medical School and Massachusetts General Hospital, both in Boston. Dr. Wilens spoke at the annual Psych Congress.

He pointed to numbers supporting the link between substance use and mental illness. He also offered several tips about treating substance use disorder (SUD).

In ADHD, consider the big picture. If a person has both ADHD and SUD, treat both if the level of substance abuse is lower. But focus on the SUD in more severe cases, he said, and realize that “most likely your treatment for ADHD isn’t going to work as well.”

Be prepared to give high doses. “When you’re using stimulants in people with use disorders, you have to use high doses. You have to be brave,” he said. The same goes for the anxiolytic buspirone (Buspar) in patients with depression and SUD.

Consider N-acetyl cysteine in cannabis use disorder. N-acetyl cysteine, a nutraceutical used as an asthma medication, has shown promise in trials as a treatment for cannabis use disorder, Dr. Wilens said. It helps patients avoid the temptation to smoke. “They won’t say they’ve lost all their cravings, but you’ll hear, ‘I just didn’t need to do it; I’m not smoking as much.’ If you hear that from your patients, you know it’s working. It’s a subtle effect, but it can help.”

Scamming’ drugs shouldn’t be your main worry. Substance use research suggests that users of pharmaceutical drugs for nonmedical uses rarely get them directly from practitioners (7%), but instead mainly get them through friends, Dr. Wilens said. “If you work with this population and treat ADHD or anxiety, you’re paranoid that everyone coming in wants to scam medicines. Be more concerned about oversupplying them with immediate-release medications and not [taking] them to task about keeping the medication safely stored.”

Interventions such as Alcoholics Anonymous are as “effective as any other treatment for substance abuse, and it’s not costly,” Dr. Wilens said. He added that the Rational Recovery program, an alternative to Alcoholics Anonymous, also seems to work well. The approaches to ending substance use differ in that Alcoholics Anonymous’s orientation is spiritual and Rational Recovery’s is cognitive.

Dr. Wilens reported various disclosures, including consulting relationships with Ironshore Pharmaceuticals, KemPharm, and Neurovance/Otsuka.