Many Patients Hide Life-Threatening Issues From Their Doctors

A new study finds that many patients who have faced domestic violence, sexual assault, depression or thoughts of suicide are likely to hide this information from their healthcare providers.

The findings, published online in JAMA Network Open, show that up to 47.5 percent of patients who have experienced one or more of these four threats do not disclose this critical information to care providers out of embarrassment, fear of judgment or the possible long-term implications of sharing such information.

Understanding how to make patients feel more comfortable with clinicians is key to helping patients address such life-threatening risks, says the study’s senior author Angela Fagerlin, PhD, chair of the department of Population Health Sciences at the University of Utah Health.

“For primary care providers to help patients achieve their best health, they need to know what the patient is struggling with,” says Fagerlin. For example, patients who withhold they have been sexually assaulted are potentially at risk for post-traumatic stress disorder and sexually-transmitted diseases, she explains.

“There are numerous ways providers can help patients, such as getting resources, therapy and treatment.”

The study involved more than 4,500 people in two national online surveys from 2015. Participants in one survey averaged 36 years old, while participants from the second had a median age of 61.

The respondents reviewed a list of medically relevant information and were asked to indicate whether they had ever withheld this information from a clinician. They were also asked the reasons why they withheld the information.

The surveys show that 40 to 47.5 percent of participants chose not to tell their provider that they had experienced at least one of the four threats. Over 70 percent said the reason why was embarrassment or fear of being judged or lectured.

If the patient was female or younger, the odds were higher they would keep this information to themselves. What compounds this issue is that several recent studies have shown how health care providers downplay or fail to take seriously women’s medical complaints.

One limitation noted by the study’s first author, Andrea Gurmankin Levy, PhD, MBe, a professor in social sciences at Middlesex Community College in Middletown, Connecticut, is that study participants may have not shared in their survey responses all the information they withheld, meaning that this phenomenon may be even more prevalent than the study reveals.

Levy says the survey reinforces that there is discomfort and a lack of trust between patients and providers. If patients filled out a questionnaire about sensitive information when they arrive at the provider’s office, might that improve the information flow? For example, is it easier to tell a piece of paper something sensitive than to look into your clinician’s eyes and say it?

This is the team’s second article based on the 2015 surveys. The first, published in November 2018, revealed that 60 to 80 percent of those surveyed did not share pertinent information with their provider regarding daily issues like diet and exercise. One third did not speak up when they disagreed with their provider’s recommendations.

Both surveys raise concerns about communication and trust between patients and their caregivers. Improving this relationship falls both on providers’ and patients’ shoulders, the authors say.

Providers need to establish an atmosphere where the patient feels neither judged nor rushed, but rather are able to share concerns fundamental to their well-being. In addition, patients will benefit by sharing sensitive information with their providers.

Researchers from University of Utah Health, Middlesex Community College, University of Michigan and University of Iowa collaborated on the study.

Source: University of Utah Health

Working With Animals Can Increase Risk of Depression, Anxiety and Suicide

“Talking about veterinarian suicide certainly gets people to pay attention, but it does not tell the whole, nuanced story about what may be contributing to poor well-being in this population,” said Katherine Goldberg, DVM, LMSW, community consultation and intervention specialist at Cornell Health and founder of Whole Animal Veterinary Geriatrics and Palliative Care Services, who also presented at the meeting. “More research is under way to help better understand why veterinarians might be at an increased risk, but a combination of personality traits, professional demands and the veterinary learning environment all likely contribute.”

Economic challenges could be a contributing factor, according to Goldberg, who noted that the average veterinary school graduate reported having more than $143,000 of school loan debt while earning a starting salary of around $73,000 in 2016.

“Personal finance concerns are stressful for many veterinarians, especially recent graduates, and at the same time, many clients regularly question the cost of care for their animals and may be suspicious that their vet is trying to ‘push’ services that their pet doesn’t need,” she said.

Goldberg also described a multi-center study that looked at rates of adverse childhood experiences — a term used to describe all types of abuse, neglect and other traumatic experiences — in veterinary students, in an effort to understand what may be causing their poor mental health.

However, veterinarians just starting their practice were not more predisposed to poor mental health than the general population as a result of adverse childhood experiences, she said.

“This indicates that something is happening over the course of veterinary student training or once veterinarians are working to cause poor well-being outcomes,” she said. “Well-being education should be integrated into the veterinary curriculum, emphasizing resiliency behaviors and cultivating professional partnerships between veterinary medicine and mental health care.”

Substance use among veterinarians is also an understudied area, she noted. Veterinary medicine is the only medical profession in the U.S. that does not have a national monitoring program for substance use and mental health issues, she added.

While veterinarians who are dealing with mental health issues may exhibit symptoms common to all populations, such as sadness that interferes with daily activities or changes in appetite, there are a few specific warning signs to watch for in a clinical veterinary setting, according to Goldberg.

“Increased medical errors, absenteeism, client complaints and spending too little or too much time at work” are factors to watch for, she said. “For potential substance use issues, warning signs could include missing drugs or missing prescription pads.”

Goldberg said there needs to be a shift in veterinary training to better prepare veterinarians not only for the animal-related aspects of their jobs, but the human elements as well.

“We need core curricular material that focuses on coping with the emotional demands of the profession,” she said. “Mindfulness, moral stress, ethics literacy, grief and bereavement, mental health first aid and suicide awareness all have a role in veterinary education. Colleges of veterinary medicine that have embedded mental health professionals are a step ahead of those that do not, and I would like to see this become a requirement for all schools accredited by the Association of American Veterinary Medical Colleges.”

Meanwhile, Fournier’s presentation looked at employees and volunteers in animal shelters, and animal welfare and animal rights activists, who are at risk for compassion fatigue and psychological distress.

“Animal welfare agents, as these people are often called, are exposed to animal abuse, neglect and oppression on a regular basis, as well as routine euthanasia that is common in these settings,” said Fournier.

More than 2.4 million healthy cats and dogs are euthanized each year in the U.S., most often homeless animals in shelters, according to the Humane Society of the United States.

“Shelter workers are then caught in a dilemma because they are charged with caring for an animal and they may ultimately end that animal’s life,” she said. “Research suggests that this causes significant guilt, which can lead to depression, anxiety and insomnia, as well as greater family-work conflict and low job satisfaction.”

Animal welfare agents may also hear gruesome stories of animal abuse or witness the consequences firsthand when they are rehabilitating the animals, which can cause a lot of distress and lead to compassion fatigue, said Fournier.

“Experts suggest that animal welfare agents carry an even heavier burden than those in other helping professions who are susceptible to compassion fatigue because of the issues unique to working with animals, such as euthanasia and caring for living beings who have experienced pain and suffering, but cannot articulate their needs and experiences,” said Fournier.

She suggests that psychotherapists who work with animal welfare agents offer patients strategies to reframe negative experiences, identify ways in which they get fulfillment and gratification from the work they do, and establish healthy boundaries between their work and personal lives.

“There are certainly positive and negative aspects of the job and over time or during times of acute stress, it can be difficult to see the positive,” she said. “It may be necessary to help someone focus on the big picture that overall they are making a difference and animals have been saved, rather than ruminating on individual stories of crisis and loss. Self-care is also critical to ensuring the best mental health outcomes for those who work and volunteer with animals.”

Source: The American Psychological Association

Study: Trans College Students Far More Likely to Have Mental Health Issues

A new study has found that gender minority students, whose gender identity differs from the sex assigned them at birth, are between two and four times more likely to experience mental health problems than their peers.

“There has never been a more important time for colleges and universities to take action to protect and support trans, genderqueer, and nonbinary students on campus,” said study lead author Dr. Sarah Ketchen Lipson, a Boston University School of Public Health assistant professor of health law, policy & management.

For the study, the researchers looked at rates of depression, anxiety, eating disorders, self-injury, and suicidality in a sample of more than 1,200 gender minority students from 71 colleges and universities.

About 78 percent of the gender minority students included in the study met the criteria for one or more mental health problems, with nearly 60 percent screening positive for clinically significant depression, compared to 28 percent of cisgender students, whose sex assigned at birth aligns with their current gender identity.

The findings stem from an analysis of two waves of data collected between fall 2015 and spring 2017 through the Healthy Minds Study, a national, annual survey about campus mental health that Lipson co-leads with University of Michigan colleague Daniel Eisenberg.

The Healthy Minds Study, which more than 300,000 US college students have voluntarily taken since its launch in 2007, uses clinically validated methods of screening for symptoms of depression, anxiety, eating disorders, and other mental health concerns.

The survey includes space for participants to fill in their assigned gender at birth as well as their current gender identity, which allowed the researchers to filter their analysis and focus on the collective mental health of gender minority students.

“Reports that more than 40 percent of transgender people have attempted suicide in their lifetimes suggested, to me, that there is a large and disproportionate burden of disease among [people in the gender minority] that public health research can contribute to addressing,” said Dr. Julia Raifman, BU School of Public Health assistant professor of health law, policy & management.

According to the researchers, the findings from the Healthy Minds Study reinforce the disparities facing gender minority students revealed by other research, which has shown that college dropout rates are higher among transgender students, and that they experience near-constant discrimination and harassment.

Bathrooms and housing are some of the most stressful areas on college campuses for transgender students, with research showing that transgender college students are at significantly higher risk for suicide and attempted suicide when denied access to gender-appropriate bathrooms and housing on college campuses.

“Mental health outcomes, as well as negative educational outcomes like dropping out, are preventable,” says Lipson. “The most effective way to prevent them would be, from my perspective, through policy changes. Inclusive policies are necessary to advance equity. And that’s what I really want these data to speak to.”

The researchers add they hope that officials in higher education will use the study’s results as a springboard for more urgent action, such as addressing gender minority needs in housing policies, creating or revising policies that allow students to change their name in campus records, improving mental health resources on campuses, and raising awareness of gender minority issues.

The researchers plan to continue using data from the Healthy Minds Study with the eventual goal of recording longitudinal data that follows gender minority students throughout their college experience, examining mental health alongside individual, institutional, and societal factors. They say additional research is also needed to explore the intersectionality of gender identities with other identities, such as race or religious beliefs.

“We are in a time when transgender people are being denied equal rights to jobs, to housing, to healthcare, and to participation in the military. These data suggest that new policies eliminating equal rights for transgender people are affecting a population that already experiences a disproportionate burden of disease,” said Raifman, referring to recent actions initiated by the Trump administration, such as banning transgender individuals from serving in the military and rolling back Obama-era rules intended to protect transgender individuals from discrimination.

“As next steps, it will be important to evaluate whether equal rights or the elimination of equal rights for transgender people affects mental health disparities,” she concluded.

The study was published in the American Journal of Preventive Medicine.

Source: Boston University

Veterans With Traumatic Brain Injury More Than Twice as Likely to Die by Suicide

Military veterans with a history of traumatic brain injury (TBI) are more than twice as likely to die by suicide compared to veterans without a TBI diagnosis, according to a new study appearing in the Journal of Head Trauma Rehabilitation.

In addition, among all veterans who died by suicide, the odds of using firearms as a means of suicide was significantly increased for those with moderate or severe TBI compared to those without a history of TBI.

For the study, a research team led by the University of Colorado (CU) School of Medicine looked at the electronic medical records of more than 1.4 million military veterans who had received care from the Veterans Health Administration (VHA) between Oct. 1, 2005 and Sept. 30, 2015.

Combining these records with National Death Index data, the team assessed the severity of TBI, and diagnoses of psychiatric and other medical conditions. Among those that died by suicide, the method was also analyzed.

After adjusting for psychiatric diagnoses, such as depression, the research team discovered that those with moderate or severe TBI were still 2.45 times more likely to die by suicide compared to those without a TBI diagnosis.

“Together, these findings underscore the importance of understanding Veterans’ lifetime history of TBI to prevent future deaths by suicide, and support the implementation of screening initiatives for lifetime history of TBI among all individuals utilizing the VHA,” the researchers write.

The findings also support the need for more research into suicide safety among those with moderate to severe TBI.

During the period of time they studied, the rate of suicide was 86 per 100,000 person years for those with TBI compared with 37 per 100,000 person years for those without TBI.

“Person years” is a type of measurement which takes into account both the number of people in the study and the amount of time each person spends in the study.

Overall, among those in the sample who died by suicide, 68 percent used firearms. Veterans with moderate or severe TBIs had the highest proportion of suicides by firearms at 78 percent.

The corresponding author of the article is Lisa A. Brenner, PhD, professor of physical medicine and rehabilitation at the CU School of Medicine and director of the Veterans Health Administration Rocky Mountain Mental Illness Research Education and Clinical Center, which supported the project.

Source: University of Colorado Anschutz Medical Campus


Can Gun Shops Help to Prevent Suicides?

Firearms are the most commonly used and lethal means of suicide in the United states. In a new study, University of Washington (UW) researchers surveyed nearly 200 independent firearm retailers in Washington state and found that gun shop employees can potentially be key community members in helping prevent suicide.

The researchers found that many firearm retailers are willing to learn about suicide prevention and to train their employees in how to spot and act on suicide warning signs. However, factors that may inhibit progress include a lack of awareness of the role of firearms in suicide as well as a reluctance to talk to customers about personal issues.

“Suicide prevention hasn’t been an area of focus in the firearm community, and it shows,” said Thomas Walton, a UW doctoral candidate of social work at Forefront Suicide Prevention and lead author of the paper.

“But there’s a definite willingness to pass on firearm safety information, and they want to be able to see how to integrate suicide prevention into talking about firearm safety.”

According to the Centers for Disease Control and Prevention, about half of all suicides in the United States from 1999 to 2017 (the most recent statistics available) involved a firearm. The percentage is even higher in veteran suicides.

In Washington, the data is similar: From 2013 to 2017, almost half of all suicides, and 67% of veteran suicides, involved a firearm, according to the state Department of Health.

Beginning in 2017, the state Legislature helped fund Forefront’s Safer Homes, Suicide Aware campaign, which offers training, outreach and locking devices for firearms and medications in communities with high rates of firearms ownership.

As part of its mission, the Safer Homes program has identified gun retailers as a key potential stakeholder in distributing information about suicide prevention. Other states, such as New Hampshire and Colorado have been working to engage firearm retailers in the issue; the UW study is the first aimed at understanding what influences such engagement.

The first step in the study was surveying firearm retailers about their knowledge of suicide prevention and willingness to participate. Using records from the state Department of Licensing and the federal Bureau of Alcohol, Tobacco, Firearms and Explosives, Walton and Forefront director Jennifer Stuber, Ph.D., were able to find email or mailing addresses for nearly 800 independent retailers around the state. The team created a 42-question survey that was available in print or online.

Big-box stores that sell guns were not included because of corporate policies governing store-level training and outreach.

The research team also partnered with the Second Amendment Foundation and the owner of a Spokane gun shop, who together sent an introductory letter to the retailers explaining the survey.

In the end, 178 surveys were completed. Sixteen retailers contacted the researchers to refuse the survey, while 62 were minimally completed, and 33 were returned as undeliverable. The remaining 500 weren’t returned.

“There are barriers to working with this population because of distrust and incomplete contact information,” said Stuber, an associate professor in the UW School of Social Work.

“But if you get the right messengers to get people to the table, there is clearly a willingness among retailers to be involved in the solutions.”

The results can be divided into three distinct types of questions: knowledge of suicide and how to prevent it; support for learning more; and a willingness to intervene directly with customers.

About half of the retailers who responded said they were familiar with warning signs of suicide, while nearly two-thirds of respondents said they wanted to know more about how firearm retailers can help prevent suicide. About 72% said they would provide free training to employees.

At the other end of the spectrum were beliefs about suicide and the retailer’s role in talking with customers in crisis. Nearly three-quarters said asking customers about their mental health might offend them. About 45% said asking about personal issues is not their responsibility, and 66% agreed with the statement: “If a person wants to die by suicide, there is nothing I can do to stop them.”

“It is critical to work on changing this common misperception that suicide is inevitable,” Walton said. “For the vast majority of individuals, the desire to die by suicide is fleeting, so anything any of us can do to prevent or postpone a suicidal act is helping to save a life.”

Survey results also show that the more a retailer knows about suicide, and the longer they have been in business, the more comfortable they are with ideas about training employees and talking with customers.

For example, retailers for whom a majority of sales come from firearms and ammunition were more likely to support education and outreach around suicide prevention. Those with longer tenure in the industry, the authors wrote, were also more supportive of suicide prevention efforts and thus could be tapped as leaders in any future effort among retailers.

“Notably, most firearm retailers lack awareness that suicide is the most common type of firearm fatality. Education about this fact is an important first step to increasing engagement in prevention efforts,” Stuber said.

The findings are published in the journal Suicide and Life-Threatening Behavior.

Source: University of Washington



Canadian Study Probes Reduced Suicidal Thoughts in Indigenous People

The higher rates of suicide among indigenous people in Canada has been well documented, but few studies have looked at the factors linked to recovery among those who have had suicidal thoughts.

A new Canadian study from the University of Toronto and Algoma University finds that three-quarters of formerly suicidal Indigenous adults who are living off-reserve have been free from suicidal thoughts in the past year. Overall, participants who were older, spoke an Aboriginal language, were food secure, female, had at least a high school diploma and had social support were less likely to struggle with suicidal thoughts.

The findings are published in the journal Archives of Suicide Research.

“It was encouraging to discover so many formerly suicidal Aboriginal peoples were no longer seriously considering suicide, but with one-quarter of respondents still having these thoughts, there remains a dire need for improvements,” said co-author Dr. Rose Cameron who is an Anishinaabekwe elder and a tenured professor at the University of Algoma in Sault Ste. Marie, Canada.

“Individuals who spoke an Indigenous language were less likely to have been suicidal in the past year. Knowing one’s ancestral language provides valuable understandings of Aboriginal beliefs, values and traditions, and these factors may improve self-esteem and a positive identity, thereby promoting overall wellbeing and recovery.”

Social support also played a key role in remission, said co-author Alexandra Sellors, M.S.W., a recent graduate of the Factor-Inwentash Faculty of Social Work (FIFSW) at the University of Toronto.

“Individuals with at least one person to turn to for support in times of need were much more likely to be free of suicidal thoughts for the past year than those who were socially isolated (77% vs. 61%),” said Sellors. “Social connections can promote a sense of meaning and value in life. Clearly, we need targeted efforts to decrease social isolation and loneliness.”

Unfortunately, one-quarter of formerly suicidal indigenous adults reported that they had been hungry at some point in the last year but could not afford to buy food.

“It isn’t surprising that those who were so destitute were twice as likely to still be suicidal compared to those who had money for food,” said lead author Dr. Esme Fuller-Thomson, professor at the University of Toronto and director of the Institute for Life Course & Aging. “As a nation, we have an urgent responsibility to eradicate this devastating impoverishment.”

The findings also show that indiginous people with at least a high school degree were more likely to be in recovery compared to those who had not finished high school.

“Education opens doors to better careers, higher income, better access to mental-health care and more opportunities in life,” said co-author Senyo Agbeyaka, a graduate of the University of Toronto.

“Currently, many isolated reserves do not have local high schools, which forces children as young as 14 to leave their family, home and community and move to larger towns and cities in order to study. These inequities need to be addressed if we hope to improve the high school graduation rate of Indigenous youth in Canada.”

Finally, the results show that each decade of age was linked to a 17 percent greater chance of recovery from suicidal ideation.

“Indigenous elders often play a pivotal and revered role in Aboriginal communities and this respect may act to buffer against depression and suicidal ideation,” said co-author Dr. Philip Baiden, assistant professor at the University of Texas at Arlington.

Source: University of Toronto