When trust disappears, mental health plummets

The Flint water crisis is well-known and infamous. After the city chose to switch water sources in 2014, residents complained of dirty, smelly water coming through their taps and making them sick. City officials denied anything was wrong until Dr. Mona Hanna-Attisha — also the winner of the 2021 Bernard Lown Award for Social Responsibility in Healthcare — collected data and found that the blood lead levels of her pediatric patients had doubled. Her team blew the whistle at a public press conference and forced the city to start working on solutions. The recovery has been bumpy, and as of March 2022 the Environmental Protection Agency (EPA) was still recommending Flint residents only consume filtered water.

The water crisis began quickly and has lasted a long time, so it’s no surprise that the residents would feel the mental toll it takes to navigate their situation day-in and day-out. In this most recent longitudinal study, researchers successfully recruited 1,951 Flint residents to complete their survey five years after the onset of the water crisis. They found that 1 in 5 residents met criteria for depression, 1 in 4 for presumptive PTSD, and 1 in 10 for comorbid depression and PTSD. Sociodemographic factors were significantly associated with meeting these criteria, suggesting that the water crisis exacerbated an already-brewing mental health crisis. Unsurprisingly, researchers also connected a lack of confidence in public health information and officials to higher risk for depression, PTSD, and comorbidity.

Inequities played their role in the Flint water crisis. Like climate disasters, when infrastructure collapses in majority Black, working-class areas, recovery is slow. In 2017, a government-appointed civil rights commission affirmed what many Flint residents already knew – that systemic racism combined with implicit bias had contributed to the city’s crisis.

Flint – not even the first, definitely not the last

As this study was being conducted and released, we’ve had plenty more water crises. Right now, Jackson, Mississippi is gaining a ton of press for their contaminated water crisis caused by historic flooding back in August. In California, both schoolchildren and incarcerated individuals may be exposed to contaminated water. In June, the EPA issued guidance to all of the 2.7 million residents of Chicago to avoid their drinking water. This past Wednesday, The Guardian reported 1 in 20 tap water tests in Chicago found lead. Before Flint even happened, there was a 2004 water crisis in Washington, DC. 

Some of these were due to cost-savings schemes or hard-to-update infrastructure, others were due to natural disasters. What’s clear is that we do not have as secure a hold on clean, drinkable water as we need to have. The EPA has been pushing for water infrastructure improvements as well as for voluntary, regular lead testing, but these efforts take years of concentrated efforts. While no area is immune, these crises tend to pop up and persist in communities with less resources and display our significant equity issues in terms of infrastructure and support. Unless we address these inequities, unless we pour our resources into preserving the life-supporting systems like our water pipes and infrastructure, we’re going to continue to see these crises pop up in the coming years. And as this most recent study shows, the impact of failing to do so can last for years.

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Apps that connect people to mental health providers have been seen as a way to improve needed access to these services. However, a recent Bloomberg investigation of the popular mental health app Cerebral finds evidence of harmful overtreatment. Cerebral connects users to a therapist and a psychiatric nurse practitioner for a monthly fee.

Former Cerebral employees interviewed for the article said the company prioritized quantity over quality, pushing more patient visits, shorter appointments, and more prescriptions. In one case, a Cerebral user was prescribed three antidepressants, an anticonvulsant, and an antipsychotic over the course of three months. One of these medications was prescribed after just an 18-minute video visit. She began having concerning side effects from the medications. After she reported having auditory hallucinations, her Cerebral nurse practitioner determined she needed in-person services and terminated her cerebral treatment.

Cerebral makes it especially easy to access ADHD medication, and advertises on social media as a platform to help those with undiagnosed ADHD to get treatment. However, former nurses for Cerebral told Bloomberg they “feared that they were fueling a new addiction crisis” by making Adderall and other amphetamines so easy to get.

Watchdog group Media Matters recently warned that advertisements for Cerebral and other mental health apps are “capitalizing on the TikTok phenomenon of ADHD self-diagnosis.” For example, one of these ads encourages female users who are “spacey, forgetful, or chatty” to consider they may have ADHD and seek a diagnosis.

Cerebral is not the first app to circumvent the traditional health care system to seemingly “improve access.” Companies like Hims, Kick, and Roman promise an easier way to access prescription drugs for conditions such as hair loss, erectile dysfunction, and anxiety by connecting directly with doctors online, who prescribe medications that are mailed directly to the customer. Experts have raised concerns with these apps about off-label prescribing, too-short patient visits, and lack of regulation in the industry.

In the case of Cerebral, overmedication may also be an unintended consequence of telehealth rules adopted during the pandemic. Previously, federal rules required that patients meet with a provider in person before receiving a prescription for amphetamines or benzodiazepines.

The medical app world is currently a “wild west” with little regulation. It appears that Cerebral and other mental health apps are capitalizing on the demand for services and the popularity of social media, but without any guardrails there is a high risk of overdiagnosis and overmedication. We clearly need more regulation, but it’s worth noting that these apps would not be so popular if in-person therapy and other mental health services were more easily accessible.

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Preventing deaths of despair

But even though we have saved lives by locking down, we still have to address the health effects of this decision, including the impact on our country’s mental health. In a report published last month, leaders of the Well Being Trust warned that severe unemployment and social isolation due to the lockdown could lead to as many as 150,000 additional deaths from drugs, alcohol, and suicide.

We can reduce deaths of despair without putting more people’s health at risk from Covid-19.

Does this mean that “the solution is more harmful than the cure”? Not according to the report authors. They clarify that “this report is not a call to suddenly reopen the country,” and without taking the proper precautions, reopening prematurely will lead to even more needless death and suffering.

There are many actions we can take to reduce deaths of despair without putting more people’s health at risk from Covid-19:

• Get as many people back to work as possible — but not necessarily in the same job they were in before. Create a Civilian Health Corps, reminiscent of the New Deal Era Civilian Conservation Corps, that puts millions of unemployed people to work as contact tracers or crisis counselors.

• Provide better social connections by securing reliable internet everywhere in the country and funding community groups that are putting on virtual events to allow people to socialize remotely.

• Bring mental health care to where people are, doing more telehealth visits and counseling via video. This is especially important for black Americans, who are weathering a double pandemic of Covid-19 and police violence.

• Empower Americans to protect themselves and their families by providing reliable information with a message of unity, rather than the current mishmash of tweets and misinformation.

Avoiding overprescribing

At the same time, we have to be careful to avoid treating every case of pandemic-induced anxiety with prescriptions. According to an analysis from pharmacy benefit manager Express Scripts, the number of weekly prescriptions for antidepressants, anti-anxiety medications, and sleep aids rose by about 19%, 15%, and 34%, respectively, between February 15 and March 15.

Doctors are worried about the long-term effects of increased prescribing, such as physical dependence, overdose, and withdrawal symptoms.

While prescribing for anxiety may seem like a “quick fix,” doctors are worried about the long-term effects of increased prescribing, including physical dependence, overdose, and withdrawal symptoms. Additionally, these medications can be dangerous for older Americans, who can suffer adverse events such as falls, dizziness, and cognitive decline.

One can imagine a situation in which bringing attention to the mental health crisis driven by Covid-19 and the lockdown leads to a dangerous increase in prescriptions of these medications. We cannot rely on medications alone to mitigate this crisis; we have to tackle the sources of anxiety such as unemployment and loneliness.

The post Paying attention to the mental health effects of lockdown appeared first on Lown Institute.

We spoke with Steve, who experienced a “prescribing cascade” firsthand, in which one prescription of a psychiatric drug led to side effects, which prompted another prescription, and another, and another. Steve wanted to share his story to shed light on the harm that can happen from an overload of psychiatric medications.

Steve’s story of overprescribing began when he experienced symptoms of depression as an undergraduate and sought psychological help. He was prescribed an SSRI (Zoloft), which led to feelings of apathy and numbness. He also began to experience sexual dysfunction, which is often common in patients who are prescribed antidepressants. In order to treat erectile dysfunction, Steve was prescribed Wellbutrin, another antidepressant. Within a month or two he began to lose motor control of different parts of his body, often causing him to bang his head uncontrollably against the wall. When he confronted his psychiatric nurse practitioner over this traumatic and abnormal side effect, she attributed it to bipolar disorder. “She saw the problem as ‘existing in me’ and not an effect of the drugs,” said Steve.

Additional antipsychotics were prescribed to tame the behavior, but the combinations of, and cross titration between, medications left him feeling more depressed then when he first sought out help. When he would try to stop, he often was left feeling non-functional, in what he described as a vegetative state. The worst to discontinue, in Steve’s experience, were the antidepressants.

For ten years, Steve saw different mental health providers who added medications and changed dosages. At its peak, Steve was taking five different psychiatric medications. When he would tell clinicians about his concerns with the psychiatric medications he was taking, he heard over and over, “The medications are safe and the doctors mean well.” Not one recommended he stop. It wasn’t until Steve was admitted to the hospital for multi-organ failure that a gastroenterologist set him on the path to deprescribe his psychiatric medications.

Steve had been initially diagnosed with mild depression, and then after starting antidepressants a more complex mood disorder, but was skeptical of the later diagnosis and hired a forensic psychiatrist to give her opinion. It was eventually determined that he may have been misdiagnosed, as the psychiatrist observed that Steve was not showing symptoms of mania or bipolar disorder as she understood it, but that he had almost certainly been traumatized by side effects of medications that were supposed to help him.

Steve’s experiences have left him disillusioned with the reliance on medications to treat mental health issues, given that the risks and benefits of these drugs are not always certain.

Steve believes that psychiatrists, instead of just prescribing medications to relieve symptoms, should support patients by being kind and providing concrete advice and more structured and interactive activities. Medications can be an important tool to treat mental health conditions, but when the only tool you choose to pick up is a hammer, everything tends to like a nail. “Psychiatrists should feel like they can talk with patients, go on walks with them, and help coach them,” said Steve. He is hoping that by sharing his story he can help young people who have experienced the harsh side effects of antidepressants and other psychiatric medications feel less alone.

The post The psychiatric “prescribing cascade”: A patient story appeared first on Lown Institute.

Is our health care system adequately prepared to treat more behavioral health problems in younger people? So far, the answer is no. Amid the growing need for mental health treatment, mental health care remains inaccessible for many people who need it, particularly low-income people.

Take Massachusetts, for example. Although Massachusetts has more mental health care providers per capita than any other state, only about half accept Medicaid or even private insurance, making it extremely difficult to find affordable care. According to a survey of Massachusetts residents by the Blue Cross Blue Shield of Massachusetts Foundation, more than half of respondents who sought mental health or addiction treatment had difficulty getting care, and 39 percent went without treatment.

“Mental health care has become, in large measure, a private-pay business that operates outside the insurance system,” wrote journalist Liz Kowalzyk in The Boston Globe.

Psychiatrists in particular are less likely to accept insurance, compared to physicians in other specialties, according to a 2014 study in JAMA Psychiatry. Only about 55 percent of psychiatrists accepted private insurance, compared to 89 percent of other doctors, and just 43 percent of psychiatrists accepted Medicaid, compared to 73 percent of other physicians.

However, even when mental health care providers accept insurance, insurers are finding ways not to cover needed services. According to an investigation in Bloomberg News, insurers are skirting around the Mental Health Parity law by “padding their directories” with clinicians who are no longer in network, requesting “piles of paperwork” before approving treatment, and giving smaller reimbursements to mental health clinicians than to other clinicians for the same services. Insurers have been able to get away with this in part because the law is ambiguous in setting parity rules, and because enforcement efforts by government agencies are meager and disjointed.

To put it simply, when it comes to mental health, “we have a lousy system of care,” said Dr. Wun Jung Kim, a child psychiatrist and professor at Rutgers University, in USA Today.

The post Is our health care system prepared for a pediatric mental health crisis? appeared first on Lown Institute.

However, other researchers are concerned that this panel recommendation represents a further lowering of the bar for clinical evidence, and that the drug is not as safe and effective as the company claims. 

Lower standard of evidence

FDA experts gave an overall strong recommendation for approving esketamine, with 14 voting yes, two voting no, and one abstaining. However, a few reviewers, as well as some other researchers, questioned the low standard of evidence provided by Johnson & Johnson on the drug’s effectiveness and safety.

The agency’s “gold standard” for formal approval is two positive, well-controlled studies. However, J&J presented just one positive short-term trial and a positive randomized withdrawal trial. What’s the difference? As Dr. Erick Turner, researcher at Oregon Health & Science University and former FDA reviewer pointed out on Twitter, withdrawal trials are more likely to be positive because the patients being tested have already reacted well to the drug in an earlier trial. The other two studies presented were negative, although again Turner points out that J&J tried to spin the studies as positive during the panel review. 

“What precedent is set when 2 of 3 shorter efficacy studies didn’t meet the primary endpoint?” asked panel member Dr. Steven Meisel, system director of medication safety at Fairview Health Services, Endpoints News reports. “That’s something the agency has to wrestle with. Do we set a precedent that may be hard to step back from?”

Safety issues

As for safety, some panelists were concerned about potential side effects, such as disassociation (feeling “spacey” or confused), sedation, and increased blood pressure. Ultimately, 15 panelists voted that the outline of the drug’s safety profile was sufficient for initial review, despite the fact that J&J only presented information from dog and rat studies showing that esketamine did not cause neurotoxicity (see the last page of J&J’s presentation).

Another safety issue is the potential for abuse of esketamine, which is why the FDA panel recommended that the drug only be given in the health care setting under supervision. However, it is unclear how this process would work in practice, and there is a chance that people could obtain and use ketamine illegally as has happened with opioids and benzodiazepines. 

“The thing I’m most concerned about really is diversion and misuse and things like that,” said one panelist, but she believed that “ultimately, the benefits outweigh the risks.”

Marketing before approval

A few doctors on social media noted that J&J has not waited for FDA approval before marketing esketamine. Though drug marketing before FDA approval is illegal, many companies get around this regulation through a loophole — by doing presentations or educational sessions about a condition without mentioning the drug. 

One doctor wrote on Twitter about attending a talk about “the future of antidepressant treatment” that turned out to be “all about glutamate and ketamine.” They also showed attendees a cartoon music video about how ketamine works to reduce depression.

Another doctor mentioned that J&J has already been offering lunch presentations on treatment-resistant depression and “the role of glutamate in depression” but did not mention esketamine specifically.

These pre-approval marketing tactics are worrisome. Hiding drug marketing behind informational lectures means that doctors are primed to think of this treatment as positive. Despite the best of intentions from the FDA panel to restrict esketamine use to the indication it is meant for, in the settings it is meant for, we’ve seen time and time again that marketing can lead to non-indicated and harmful uses of powerful drugs. 

The post Esketamine nears FDA approval, prompting both excitement and concern appeared first on Lown Institute.

Fortunately, a new study from Harvard Medical School researchers Dr. Sumit Agarwal and Dr. Bruce Landon (former Lown Conference speaker) answers these questions. Agarwal and Landon looked at a nationally representative sample of 386,457 outpatient visits from 2003 – 2015 to identify benzodiazepine prescribing patterns.

What they found was unsettling. Overall, outpatient visits in which a benzodiazepine was prescribed doubled from 3.8% of visits in 2003 to 7.4% in 2015. While most of the prescriptions were for FDA-approved indications, such as anxiety and depression, the largest increases in prescribing were for non-FDA-approved indications, such as back pain and chronic pain. Additionally, while benzo prescriptions by psychiatrists remained stable, the proportion of primary care visits in which benzos were prescribed more than doubled. 

What does this tell us about the use of benzodiazepines in the U.S.? It seems as though benzos are being increasingly prescribed for conditions for which opioids used to be prescribed, like chronic pain. It’s possible primary care doctors have the perception that opioids are risky but benzos are “safe.” However, there are real risks to prescribing benzos long term, including physical dependence and debilitating withdrawal symptoms. Also, the use of benzos along with opioids can lead to overdose and death, as demonstrated by the skyrocketing rate of overdoses involving benzos over the past decade.

This also shows that primary care doctors are increasingly tasked with treating patients with chronic pain and mental health issues, and are turning to benzos as one answer. Primary care physicians usually do not have the time, resources, or training to handle a large number of chronic pain patients, noted Dr. Anna Lembke, associate professor of psychiatry at Stanford University School of Medicine, in an NPR interview.

As we implement policies to reduce opioid overprescribing, we have to also increase awareness of the potential harms of benzodiazepines, especially for long-term use, as well as give primary care physicians more non-pharmacological treatment options for chronic pain.

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