There is an interesting term describing some patients’ experiences with health care that is gaining significant traction in social and print media: “medical gaslighting.” It refers to a situation in which a patient’s concerns or symptoms are ignored or dismissed by a health care professional.¹ This might result from delayed or missed diagnoses, failed efforts to obtain a more extensive workup of unexplained symptoms, or ignored pain concerns.

Because this problem may be more common among women and racial minorities, the behavior is hypothesized to be a reflection of existing entrenched societal power imbalances. The term was appropriated from the successful movie adaptation of the 1940 play “Gaslight” where a husband psychologically manipulates his spouse into doubting her sanity. When he dims the gaslights in the home and then denies doing so and blames his wife’s perception on her overactive imagination, she begins to increasingly doubt her own judgment.²

Thus, medical gaslighting is a term rooted in malevolence and psychological abuse. Understanding this would be a reasonable starting point for discussing communication problems between patients and physicians. From an ethics perspective, the words medical professionals choose matter as much as the words patients use to describe their concerns. The ethical practice of health care, enhanced through evidence-based, relationship-centered communication techniques, requires specificity, empathy, and clarity in language. A term like gaslighting, which implies a deliberate attempt at manipulation for one’s own gain, is not likely to engage health care professionals in problem solving.

Miscommunication

For sure, patients’ experiences matter regardless of the good intent of the health care professional. If a patient feels dismissed because they believe their persistent symptoms are being ignored by their provider, that miscommunication deserves more attention in the treatment relationship. If a patient has had to see 4 different physicians before getting a definitive diagnosis, the patient’s feelings of frustration and anger should not be unexpected.  But these situations do not necessarily mean that the physician is at fault. Even if they’re not displaying deliberate ill will and manipulation, health care professionals can still fail in their best efforts to convey empathy, concern, or due diligence when addressing patient’s concerns.

Those on the other side of the stethoscope have important perspectives that can help understand this problem and hopefully direct patients and physicians to some solutions. Some physicians may share a patient’s frustration about their persistent symptoms but also realize (and maybe inadequately communicate) that further testing or procedures is low-value care without a role in elucidating the patient’s concerns.

Some physicians lack the robust communication skills needed to manage patients with unique needs. Other physicians may be subject to bias by not considering diagnoses in patient populations with a lower probability of disease. Medical students are still advised that “when they hear hoofbeats, think horses, not zebras” because pattern recognition makes for rapid accurate diagnoses and treatments. Errors in clinical reasoning and misappreciation of distribution of disease are always potential sources of bias, but it stems from the error in applying epidemiology to the patient’s case, not individual malice.   

A Problem of Equity

Health care professionals should neither remain blameless when patients are feeling dismissed, nor should they be considered the sole etiology of the problem. From a population health perspective, when these events occur more frequently in certain minority populations and are associated with health disparities, action is required on the part of individual health care professionals and the health care system in which they work. 

Such unwarranted variation in health care practice is a problem of equity that has a direct effect on the quality of care. We will arrive at better and more directed solutions when we begin to understand the physician and health system factors, patient demographics, and patient diagnoses, among other variables that may contribute to lower patient satisfaction in certain patient populations.³  

What Physicians Can Do

What can and should physicians do to address these challenges? First, when they sense a patient’s dissatisfaction, they can acknowledge this to the patient. Physicians can share what may be their own frustration with the challenge, and openly commit to work together to figure it out. Patients who feel heard are more likely to believe their physician is empathic and trying to be helpful. Second, physicians should recognize the potential for implicit bias in clinical reasoning and when automatic pattern recognition in diagnosis may be leading them to premature closure. Third, they should share their thinking with patients. Transparency in clinical reasoning goes a long way to helping patients appreciate and agree with a diagnostic and treatment plan. Physicians should consider “thinking out loud” with patients as they explain their recommendations. When patients realize all that is being considered in the physician’s clinical reasoning, what has been ruled out and why, they are more likely to trust the physician’s judgment and that they are being adequately cared for.

Finally, health care professionals should push back against the concept of gaslighting if they are accused of deliberately misleading and manipulating patients to advance their own agenda. Such an unsubstantiated claim undermines medical professionalism and the public’s trust in health care. It is time to call medical gaslighting what it likely is: patient dissatisfaction with their health care. Physicians should make a greater effort to understand why and improve how they communicate with patients.

References

1. Wenner MM.  Women are calling out ‘medical gaslighting’. New York Times. March 28, 2022.
2. Hoberman J. Why ‘gaslight’ hasn’t lost its glow. New York Times. Aug 21, 2019. 
3. Durbhakula S, Fortin AH. Turning down the flame on medical gaslighting. J Gen Intern Med. Published online July 5, 2023. doi:10.1007/s11606-023-08302-4

HealthDay News — In a policy statement issued by the American Academy of Pediatrics (AAP) and published online August 16 in Pediatrics, recommendations are presented for improving emergency care for pediatric mental and behavioral health (MBH).

Mohsen Saidinejad, MD, from the David Geffen School of Medicine at UCLA in Los Angeles, and colleagues highlighted strategies, resources, and recommendations for improving emergency care delivery for pediatric MBH.

In an accompanying technical report, the authors note there has been an increase in MBH visits of children and youth to emergency departments in the US, with reasons for these visits ranging from suicidal ideation, self-harm, and eating and substance use disorders to behavioral outbursts, aggression, and psychosis. Despite this increase, the health care system does not have the capacity to screen, diagnose, and manage these patients.

The authors recommend developing emergency department facility transfer protocols involving emergency medical services for children, including appropriate referrals to psychiatric crisis units, which could provide short-term stabilization and referrals. Development of telehealth emergency psychiatric medical control is recommended to identify and divert low-acuity patients to facilities equipped to manage MBH conditions. In addition, the AAP recommends that existing mental health mobile crisis teams be activated to be able to respond as necessary, and resources should be provided for prehospital personnel in acute management of MBH emergencies. Emergency department staff should be provided with resources related to recognition and provision of initial care to children and youth with potentially increased risks for MBH concerns. Expansion of telehealth consultation should be explored, especially in resource-limited areas or during disease outbreaks. The AAP also recommends advocating for community-based behavioral services that use a culturally sensitive, patient-centered approach to identify and manage concerns before development of an emergency condition. An increase in MBH research funding is necessary to screen and identify those at risk and connect with the appropriate resources.

“A dedicated multipronged, multidisciplinary approach will be necessary to provide patient-centered, trauma-informed services to improve the care of children and youth with MBH emergencies,” the authors write.

Policy Statement

Technical Report

The Food and Drug Administration (FDA) has approved Abilify Asimtufii^® (aripiprazole extended-release injectable suspension) for the treatment of schizophrenia in adults and as maintenance monotherapy treatment of bipolar I disorder in adults.

Abilify Asimtufii, an atypical antipsychotic, is intended for dosing every 2 months via intramuscular injection in the gluteal muscle. The approval was based on safety and efficacy data from Abilify Maintena (once monthly dosing) trials, as well as findings from an open-label, multiple-dose, parallel-arm phase 1/2 study (ClinicalTrials.gov Identifier: NCT04030143) that included  266 adults with schizophrenia or bipolar I disorder.

Study participants were randomly assigned to receive either Abilify Asimtufii 960mg (n=132) administered every 56 days (total of 4 injections) or Abilify Maintena 400mg (n=134) administered every 28 days (total of 8 injections). Results showed that treatment with Abilify Asimtufii met the primary endpoint demonstrating similar aripiprazole plasma concentrations and comparable efficacy to Abilify Maintena.

Treatment with the every 2-month injectable was found to be safe and well tolerated; no new safety concerns were reported with multiple administrations. The most common adverse reactions reported were increased weight, akathisia, injection site pain, and sedation.

Each dose of Abilify Asimtufii is provided in a single-chamber, prefilled syringe, and is administered by a health care provider. The product is available in 720mg/2.4mL and 960mg/3.2mL dosage strengths.

Pauline Gerard, from the University of Colorado School of Medicine in Aurora, and colleagues conducted a retrospective cohort study to examine the relationship between cardiomyopathy and duration of stimulant medication use in adults diagnosed with ADHD aged 20 to 40 years. The window of analysis was limited to 30 years after ADHD diagnosis.

A total of 12,759 pairs of patients categorized by the presence or absence of stimulant medication prescription with a decade-long record were matched. The researchers found that the prevalence of cardiomyopathy was 0.36 and 0.31% in the one-year stimulant and nonstimulant groups, respectively. This prevalence increased to 0.72 and 0.53% in the 10-year stimulant and nonstimulant groups, respectively. The one-year stimulant group had higher odds of cardiomyopathy (odds ratio, 1.17), which increased at 8 years (odds ratio, 1.57), then decreased slightly at 10 years (odds ratio, 1.37).

“The longer you leave patients on these medications, the more likely they are to develop cardiomyopathy, but the risk of that is very low,” Gerard said in a statement.

Press Release

More Information

The American College of Physicians (ACP) has issued updated guidelines for the treatment of major depressive disorder (MDD). The recommendations include both nonpharmacologic and pharmacologic interventions for adults in the acute phase of MDD based on a systematic review of available evidence.

For initial treatment of moderate to severe MDD, ACP recommends monotherapy with either cognitive behavioral therapy (CBT) or a second generation antidepressant (eg, selective serotonin reuptake inhibitors [SSRIs], serotonin norepinephrine reuptake inhibitors [SNRIs], bupropion, mirtazapine, nefazodone, trazodone, vilazodone, vortioxetine). If an antidepressant is initiated, the guidelines suggest starting treatment with a low dose to reduce the chances of side effects and improve adherence. A combination of CBT and second generation antidepressant as initial treatment was also suggested as an alternative treatment option.

For patients with moderate to severe MDD who do not respond to initial treatment with an adequate dose of a second generation antidepressant, the clinical guidelines committee (CGC) recommends switching to or adding CBT or switching to a different second generation antidepressant or adding a second pharmacological agent (eg, mirtazapine, bupropion, buspirone).

For patients with mild MDD, monotherapy with CBT is suggested for initial treatment. If access or cost of CBT is a concern, or if the patient has a history of moderate to severe MDD, a second generation antidepressant may be considered for initial treatment, according to the CGC.

When making treatment decisions, the guidelines stress the importance of informed decision making, taking into account patient preferences, the potential benefits and harms of treatment, comorbidities, concomitant medications, and cost.

Additional clinical considerations are available in the full guideline.

References

1. American College of Physicians recommends cognitive behavioral therapy or second-generation antidepressants for adults with major depressive disorder. News release. January 23, 2023. https://www.eurekalert.org/news-releases/976964.
2. Qaseem A, Owens DK, et al. Nonpharmacologic and pharmacologic treatments of adults in the acute phase of major depressive disorder: A living clinical guideline from the American College of Physicians. Published online January 24, 2023. Annals of Internal Medicine. doi.org/10.7326/M22-2056

Michael Hollifield, MD, from the Tibor Rubin VA Medical Center in Long Beach, California, and colleagues randomly assigned 93 veterans seeking treatment for PTSD to verum or sham acupuncture (24 one-hour sessions, twice weekly).

The researchers found a large treatment effect of verum (Cohen d, 1.17), a moderate effect of sham (d, 0.67), and a moderate between-group effect favoring verum (mean Δ, 7.1; t₉₀ = 2.87; d, 0.63) in the intention-to-treat analysis. In the treatment-completed analysis, the effect pattern was similar (verum d, 1.53; sham d, 0.86; between-group mean Δ, 7.4; t₆₉ = 2.64; d, 0.63). For fear-potentiated startle during extinction (i.e., better fear extinction), there was a significant symptom reduction from pretreatment to posttreatment in the verum but not the sham group and a significant correlation (r = 0.31). Rates of withdrawal were low.

“These data call for more research about relative effectiveness and synergy of acupuncture to current best practices, mechanisms of action, the durability of treatment in broader populations, and perhaps most importantly early predictors of treatment response to enhance efficiency of treatment choice,” the authors write.

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HealthDay News — Neurodevelopment and growth in offspring is not negatively impacted by prenatal exposure to attention-deficit/hyperactivity disorder (ADHD) medication, according to a study published online February 9 in Molecular Psychiatry.

Kathrine Bang Madsen, PhD, from Aarhus University in Denmark, and colleagues assessed whether in utero exposure to ADHD medication was associated with adverse long-term neurodevelopmental and growth outcomes in offspring. The analysis included 898 children exposed to ADHD medication in utero and 1270 children whose mothers discontinued ADHD medication before pregnancy, who were born from 1998 to 2015 and followed through 2018.

After adjusting for demographic and psychiatric characteristics of the mother, the researchers observed no increased risk for any offspring developmental disorders for either combined (adjusted hazard ratio, 0.97; 95% CI, 0.81 to 1.17) or separate subcategories. In the negative control and sibling-controlled analyses, there was no increased risk seen for any subcategories of outcomes.

“We can see that the number of women of childbearing age who are medicated for ADHD is rapidly increasing, and therefore it is very important to garner more knowledge to be able to counsel these women,” a coauthor said in a statement. “There are still unknowns, but these results may contribute to women making informed decisions about using ADHD medication during pregnancy.”

Several authors disclosed financial ties to the pharmaceutical industry.

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Heidi Taipale, PhD, from the Karolinska Institutet in Stockholm, and colleagues examined the association between use of specific ADHD medications and hospitalization outcomes and work disability in a nationwide register-based cohort study involving adolescents and adults with ADHD during 2006 to 2021. The study cohort included 221,714 persons with ADHD.

The most commonly used ADHD medication was methylphenidate, followed by lisdexamphetamine (68.5 and 35.2%). The researchers found that amphetamine, lisdexamphetamine, ADHD drug polytherapy, dexamphetamine, and methylphenidate were associated with a reduced risk for psychiatric hospitalizations (adjusted hazard ratios, 0.74, 0.80, 0.85, 0.88, and 0.93, respectively). There were no associations seen for modafinil, atomoxetine, clonidine, or guanfacine. Use of dexamphetamine, lisdexamphetamine, and methylphenidate was associated with a reduced risk for suicidal behavior (adjusted hazard ratios, 0.69, 0.76, and 0.92, respectively). Amphetamine, lisdexamphetamine, polytherapy, dexamphetamine, methylphenidate, and atomoxetine were associated with a reduced risk for nonpsychiatric hospitalization. Regarding work disability, the results were only significant for use of atomoxetine (adjusted hazard ratio, 0.89), especially for those aged 16 to 29 years (adjusted hazard ratio, 0.82).

“Considering the high prevalence of psychiatric comorbidity in persons with ADHD, these results suggest that ADHD medication use can reduce morbidity in adolescents and adults with ADHD,” the authors write.

Several authors disclosed ties to the pharmaceutical industry.

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Lan Li, PhD, from the Karolinska Institutet in Stockholm, and colleagues examined whether initiation of ADHD pharmacotherapy was associated with reduced mortality risk among individuals with ADHD in an observational nationwide cohort study conducted in Sweden. Individuals aged 6 through 64 years with an incident diagnosis of ADHD from 2007 through 2018 and no ADHD medication dispensation before diagnosis were identified; 56.7% of the 148,578 individuals with ADHD initiated ADHD medication.

The researchers found that the two-year mortality risk was lower in the initiation treatment strategy group than the non-initiation treatment strategy group (39.1 vs 48.1 per 10,000 individuals). Significantly lower rates of all-cause mortality and unnatural-cause mortality were observed in association with ADHD medication initiation (hazard ratio, 0.79 and 0.75, respectively); no significant difference was seen in natural-cause mortality.

“ADHD medication may reduce the risk of unnatural-cause mortality by alleviating the core symptoms of ADHD and its psychiatric comorbidities, leading to improved impulse control and decision-making, ultimately reducing the occurrence of fatal events,” the authors write.

One author disclosed ties to Shire/Takeda, Evolan, and Medici.

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Shebani Sethi, MD, from Stanford Medicine in California, and colleagues investigated the effects of a four-month ketogenic diet on individuals with schizophrenia or bipolar disorder with existing metabolic abnormalities. The analysis included 23 participants in a single arm.

The researchers found improvements in metabolic health, with no participants meeting metabolic syndrome criteria by study conclusion. There were significant reductions in weight (12%), body mass index (12%), waist circumference (13%), and visceral adipose tissue (36%) among adherent individuals. There were also improvements in biomarkers, including a 27% decrease in homeostatic model assessment for insulin resistance and a 25% drop in triglyceride levels. Participants with schizophrenia showed a 32% reduction in Brief Psychiatric Rating Scale scores. Additionally, overall Clinical Global Impression (CGI) severity improved by an average of 31% and the proportion of participants who started with elevated symptomatology improved at least 1 point on the CGI (79%). Participants reported increased life satisfaction (17%) and enhanced sleep quality (19%).

“The ketogenic diet has been proven to be effective for treatment-resistant epileptic seizures by reducing the excitability of neurons in the brain,” Sethi said in a statement. “We thought it would be worth exploring this treatment in psychiatric conditions.”

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Maarten G. Poirot, from University of Amsterdam, and colleagues assessed whether a multimodal machine learning approach could predict early sertraline response in patients with major depressive disorder. The analysis included 229 adult outpatients with unmedicated recurrent or chronic major depressive disorder who underwent magnetic resonance neuroimaging and had clinical data collected before and 1 week after treatment.

The researchers found that internal cross-validation performance was significantly better than chance in predicting response to sertraline (balanced accuracy [bAcc], 68%; area under the receiver operating characteristic curve [AUROC], 0.73). Using external cross-validation on data from placebo nonresponders (bAcc, 62%; AUROC, 0.66) and placebo nonresponders who were switched to sertraline (bAcc, 65%; AUROC, 0.68) resulted in differences that suggest specificity for sertraline treatment vs placebo treatment.

“This is important news for patients. Normally, it takes 6 to 8 weeks before it is known whether an antidepressant will work,” coauthor Liesbeth Reneman, MD, PhD, also from University of Amsterdam, said in a statement. “With this method, we can already prevent two-thirds of the number of ‘erroneous’ prescriptions of sertraline and thus offer better quality of care for the patient. Because the drug also has side effects.”

Several authors disclosed ties to the pharmaceutical or medical technology industries.

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