News of ’22 In Review: The Good, The Bad, and the Ugly
By Jonathan Bauman, MD, LFAPA
Sometimes I feel I gotta get away,
And I know if I don’t I’ll go out of my mind.
Better leave her behind with the kids…they’re alright.
The kids are alright…the kids are alright.
The Kids Are Alright, The Who, My Generation, 1965
______________
Jamie had a chance, she really did…instead she dropped out and had a couple a’ kids.
Mark lives at home ‘cause he’s got no job…he just plays guitar and smokes a lot a’ pot.
Jay committed suicide…Brandon OD’d and died. What the hell is going on?
The cruelest dream, reality…chances thrown, nothing’s free.
The Kids Aren’t Alright, The Offspring, Americana, 1998
Though misogynistic and mistaken back in ’65, the Who’s lyrics were quaint compared to the Offspring’s in ’98. And compared to today, while the world has felt like it’s crumbling, our adolescent and young adult patients have been telling us as much, directly and indirectly through their words and actions. When the grown-ups are fighting – politically and literally – and nastiness and threats are common discourse – what else can we expect from the kids? When unremitting gun violence permeates our society, what else can we expect from the kids? When restrictions and divisions engendered by a global pandemic render us fearful, helpless, isolated, and depressed, what else can we expect from the kids? When our society is increasingly divided between the ‘haves’ and ‘have-nots’, what else can we expect from the kids? When a worldwide environmental catastrophe makes parts of the world uninhabitable and endangers our future, what else can we expect from the kids? When a brutal, unnecessary war rages on with no end it sight and threatens Armageddon, what else can we expect from the kids?
Okay, do I have your attention? In the rest of this article I will review some of the issues and developments that have impacted our practices as adolescent and young adult psychiatrists over the past year. This will not be an exhaustive list and, undoubtedly, I will leave much out. But these are things that have grabbed my attention.
First the good news. A study in Pediatrics, reported by the JAMA Open Network, addressed the question, “What is the association between video gaming and cognition in children.” Results of the study showed enhanced cognitive performance in children who played video games vs. those who didn’t. My wife, a retired teacher with an MA in Reading & Special Ed. (who helps me edit these articles), was highly skeptical, as perhaps many of you are. Indeed, most research has linked video gaming with increases in aggressive behavior in children. The JAMA report was long and quite technical, but fortunately a follow-up article by Lou Schuler for Medscape (Nov. 28th), written for mere mortals and entitled Struggling to Focus? Try video games, explained the research and its implications. Having little experience with video games myself (I played “Pong” on my Odyssey console in the mid-70’s and later mastered “Mike Tyson Punch-Out” on Nintendo), I dismissed gaming as mere “thumb exercise”. What caught my eye in this article was the statement that kids with ADHD have a lot in common with older adults (such as me). Schuler points out that while “kids struggle to sit still and focus on task, older adults are great at sitting but often have a hard time following the conversation at a holiday dinner.” He writes that the ADHD brain is constantly searching for new and interesting ways to distract itself, while the older adult brain has a hard time ignoring distractions.
Quoting Adam Gazzaley, MD, PhD, Professor of Neuroscience at UCSF, Schuler writes, “Focusing attention has two sides: focusing and ignoring. It’s the act of filtering out irrelevant information that declines with aging.” To help with this, Gazzaley invented a therapeutic video game called “EndeavorRX”, which was approved by the FDA in 2020 for kids with ADHD. The game adjusts to the player and as the player improves the challenges get harder. Subsequent research on the game’s effect with older adults and adults with medical disorders affecting attention (depression, lupus, MS) showed promising results, with added benefits in sustained attention and working memory. Gazzaley compares the games effect to physical exercise: whereas physical exercise builds muscle mass, mental exercise develops structural changes through neuroplasticity. I guess video games aren’t just thumb exercise.
Now for the bad news. A study reported by Lisa O’Mary in Medscape.com revealed that ED visits for suicidal ideation among 5 to 19 year-olds increased almost 60% from 2016 to 2021 (starting before covid), and hospitalizations rose 57% from the fall of 2019 to the fall of 2020. In 2021 suicide was the second leading cause of death among 10 to 19 year-olds. It was unclear whether this was a problem exacerbated by the pandemic or simply a growing trend.
And the ugly. A study out of Columbia University/NY State Psychiatric Institute found that most mass murderers do not have severe psychiatric illness. Disorders such as psychotic illness or schizophrenia were not present in the cohort. Half the mass shooters took their own lives at the scene.
As for the crisis in adolescent mental health (news that may not necessarily be good, bad or ugly – you decide), in an essay in the NY Times’ October 11th edition, Teenagers Are Telling Us That Something Is Wrong With America, Jamieson Webster, a clinical psychologist and psychoanalyst, describes adolescent patients who “immediately want to exit the world stage, as if all options are already played out and their only choice is to disappear, take medicine, get famous, detach, or other versions of disappearing, suicide being the most extreme.” He writes that while the usual reasons for the crisis in teenage mental health – social media, video games, weakening of the family unit – are trotted out, “we’ve forgotten that teenagers are lightening rods, living in the fault lines of our culture…exposing our weak spots and holding up a mirror for us to see ourselves.”
What are those weak spots? Webster explains Erik Erikson’s concern, in 1950 no less, that the danger for American adolescents was identity “diffusion” interfering with consolidation of identity. This, Ericson believed, was due to contradictions in our society such as novelty vs. tradition, competition vs. cooperation, and isolationism vs. internationalism. Webster writes, “Our identity isn’t grounded in accrued cultural sensibilities but rather the unstable ideal of being able to choose any direction at any moment.” And he wisely points out that identity politics has become the societal solution to the pain and distress of identity diffusion, a pain our teenagers know well. Also, I might add other “solutions” to the pain and confusion of identity diffusion, namely social withdrawal, drug abuse, adoption of preposterous ideas, violent acting-out, and suicide. People will go to extremes when they’re desperate for identity.
Not surprisingly, a survey in Psychiatrist.com points out that 42% of Gen Zers (those born between 1990 and 2010) have been diagnosed with a mental health condition. The most common diagnosis is anxiety, followed by depression, ADHD and PTSD. About 20% of Gen Zers have been to therapy and 60% are on psychotropic medication. Though this cohort is worried about its future, they feel they are the generation most capable of talking through their problems. The survey, conducted by Harmony Healthcare IT, reported that
· Nearly 70% reported that the pandemic made them feel lonely and concerned about the future.
· 85% worried about their future, with their top concerns being finances and the economy, work issues, the environment, politics and violence.
· Nearly 90% don’t feel set up for success and 75% feel they’re at a disadvantage compared to older generations.
Fortunately, most of this cohort feels comfortable talking about their problems with friends, siblings, and even parents. Perhaps they have even talked to you.
The issue of LGBTQ+ mental health has also been big in the news this year. A study published online September 26th in the Journal of Clinical Psychiatry showed higher rates of PTSD and Borderline Personality Disorder in transgender vs. cisgender patients, as reported by Batya Swift Yasgur for Medscape.com. Quoting Mark Zimmerman, MD, professor of psychiatry at Brown University, Yasgur wrote, “when we compared the diagnostic profiles of transgender patients to those of cisgender patients, we found an increased prevalence of PTSD and BPD,” though mood disorders, depression and anxiety were the most common diagnoses in both cohorts. A related finding was that the hypothesis that all transgender or gender-diverse individuals have BPD did not pan out. One criticism of the study was that since the study participants were all patients in a partial hospital program, they were not representative of the general population.
And here’s an issue that is bound to be controversial. In a September 9th Medscape.com commentary, Dr. William Wilkoff, a primary care and behavioral pediatrician in Brunswick, ME, tackled the question, Is Gender Dysphoria Contagious? Dr. Wilkoff describes two studies of questionable methodology. In one paper, experts postulated the existence of a condition labeled as “rapid-onset gender dysphoria (ROGD),” with “social contagion” as a potential contributor. This set off a firestorm in the transgender community, with a major concern that it would support the transphobic agenda in some state legislatures (as we know, the Florida Medical Board has banned use of puberty blockers and surgery for transgender minors, and legislatures in Tennessee and Alabama have outlawed transgender care, though this is temporarily blocked while under judicial review). In the second study, a demographic analysis of transgender individuals, the authors concluded that the findings were “incongruent with an ROGD hypothesis that posits social contagion,” and should not be used to limit gender-affirming care. Dr. Wilkoff splits the baby in half. He concludes that the “perception of an increased prevalence of gender dyphoria is very likely due to a more compassionate and educated attitude making it less challenging for gender-dysphoric youth to surface. It should not surprise us, however, that some percentage of this increased prevalence is the result of social contagion. We need more studies and must remain open to their results.”
I would add here that the social contagion of adolescent suicide is well known. In point, a case report in Psychiatrist.com describes the hospitalization of a suicidal teenage girl who had participated in “The Blue Whale Challenge,” a social media “game” that has been around since 2016 and has sometimes been considered a hoax. Participants are coaxed to perform increasingly risky tasks, including intentional self-harm, and post their participation on line, to be cheered on by other participants. This eventually culminates in their 50th task – to commit suicide – which usually occurs by the teen jumping off a building while someone records and posts the event. The name of the “game” may have something to do with blue whales beaching themselves. You can’t make this stuff up!
Finally, and getting back to gender-affirming care controversies, an article appeared in the November 14th edition of the NY Times entitled, They Paused Puberty, but Is There a Cost? by Megan Twohey and Christina Jewett. The article describes the experiences of patients (children, teens, families) and doctors (endocrinologists, pediatricians, psychiatrists) regarding the administration of puberty blockers to reduce the intense dysphoria engendered by the fear of onset of puberty among committed transgender children as they move into adolescence. While for many the treatment made a huge difference in their state of mind, it also came along with significant effects on their bone density, which normally increases significantly during adolescence. Some patients developed osteoporosis and related fractures in late adolescence, and some doctors have concerns about earlier onset of osteoporosis as patients age into their 50’s. Experience with this treatment in the Netherlands, which goes back three decades, has indicated that the safest way to proceed is to start puberty blockers at the first signs of puberty followed by gender-affirming hormones two years later, with yearly bone scans to monitor the severity of osteoporosis. Effects of puberty blockers on brain development are, however, another concern for many researchers.
Several studies financed by NIH are expected to come out this year that will, hopefully, clarify and standardize medical practice. Until then, the use of puberty blockers remains highly controversial in the medical community, not to mention the social and political controversies around transgender care that abound. Our new ABAP diplomate, Dana Hardin, a pediatric endocrinologist and psychiatrist, weighs in on this issue in our interview in our soon-to-be posted newsletter so stay tuned!.
So that’s all folks. I hope you have a joyful holiday season and will have a satisfying, if not happy, New Year.