Exercise: Psych patients' new natural prescription

Psych patients' new natural prescription

When it comes to inpatient treatment of a range of mental health and mood disorders -- from anxiety and depression to schizophrenia, suicidality and acute psychotic episodes -- a new study suggest that physical exercise is so effective at alleviating patient symptoms that it could reduce patients' time admitted to acute facilities and reliance on psychotropic medications.

"The general attitude of medicine is that you treat the primary problem first, and exercise was never considered to be a life or death treatment option. Now that we know it's so effective, it can become as fundamental as pharmacological intervention," explains David Tomasi, a lecturer at the University of Vermont, psychotherapist and inpatient psychiatry group therapist at the University of Vermont Medical Center and lead researcher of the study.

Practitioners at inpatient psychiatric facilities -- often crowded, acute settings in which patients experience severe distress and discomfort -- typically prescribe psychotropic medications first, rather than natural remedies like physical exercise, to alleviate patients' symptoms such as anger, anxiety and depression. In fact, Tomasi estimates that only a handful of inpatient psychiatric hospitals in the U.S. provide psychotherapist-supported gym facilities exclusively for these patients. Instead, practitioners rely on classical psychotherapeutic and pharmacological frameworks to treat psychiatric symptoms, which they monitor to determine when a patient is ready to be discharged from the facility.

Tomasi, in collaboration with UVMMC's Sheri Gates and Emily Reyns, built a gym exclusively for roughly 100 patients in the medical center's inpatient psychiatry unit, and led and introduced 60-minute structured exercise and nutrition education programs into their treatment plans. The psychotherapists surveyed patients on their mood, self-esteem and self-image both before and after the exercise sessions to gauge the effects of exercise on psychiatric symptoms.

Patients reported lower levels of anger, anxiety and depression, higher self-esteem, and overall improved moods. Tomasi, Gates and Reyns found an average of 95 percent of patients reported that their moods improved after doing the structured exercises, while 63 percent of the patients reported being happy or very happy, as opposed to neutral, sad or very sad, after the exercises. An average of 91.8 of patients also reported that they were pleased with the way their bodies felt after doing the structured exercises.

"The fantastic thing about these results is that, if you're in a psychotic state, you're sort of limited with what you can do in terms of talk therapy or psychotherapy. It's hard to receive a message through talk therapy in that state, whereas with exercise, you can use your body and not rely on emotional intelligence alone" explains Tomasi.

"The priority is to provide more natural strategies for the treatment of mood disorders, depression and anxiety," he adds. "In practice, we hope that every psychiatric facility will include integrative therapies -- in our case, exercise in particular -- as the primary resource for their patients' psycho-physical wellbeing."

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Materials provided by University of Vermont. Note: Content may be edited for style and length.

Opioid prescription doses are increasingly being tapered, often more rapidly than recommended

Opiods

Stigma and safety fears have made daily dose tapering of opioid prescriptions more common. New research from UC Davis Health physicians, however, shows tapering can occur at rates as much as six times higher than recommended, putting patients at risk of withdrawal, uncontrolled pain or mental health crises.

The study -- "Trends and Rapidity of Dose Tapering Among Patients Prescribed Long-term Opioid Therapy, 2008-2017" -- is published in JAMA Network Open. The results also will be presented at the Nov. 16-19 North American Primary Care Research Group meeting in Toronto.

"Tapering plans should be based on the needs and histories of each patient and adjusted as needed to avoid adverse outcomes," said study author Alicia Agnoli, assistant professor of family and community medicine. "Unfortunately, a lot of tapering occurs due to policy pressures and a rush to get doses below a specific and sometimes arbitrary threshold. That approach can be detrimental in the long run."

In 2016, the U.S. Centers for Disease Control and Prevention (CDC) recommended dose tapering, or a slow reduction in prescription opioid doses over time, if the risks of continuing opioids outweigh the benefits. That point in time is usually when a patient is taking 90 morphine milligram equivalents -- or MMEs -- each day, and that dose is no longer reducing pain or improving daily functions. The CDC advises a slow decrease of 10% MMEs per month.

The study team set out to examine trends in opioid dose tapering and if tapering rates were consistent with CDC recommendations.

"We wanted to understand how often opioid dose tapering happens, how rapidly patients' doses were being reduced when tapering, and which patients were more likely to have doses tapered," said lead author Joshua Fenton, professor of family and community medicine.

Tapering faster than recommended

Fenton and Agnoli evaluated medical and pharmacy claims and enrollment records for more than 100,000 commercial insurance and Medicare Advantage enrollees, representing a diverse mixture of ages, races, ethnicities and locations across the U.S. They focused on individuals whose opioid doses were stable for at least a year and identified tapering patients as those with a 15% or more reduction in daily MMEs during a seven-month follow-up period.

They found that dose tapering became more common throughout the study period of 2008-2017, with the biggest jump following the CDC's 2016 prescribing guidelines. Tapering increased from 10.5% to 13.7% from 2008 to 2015, and from 16.2% to 22.4% from 2016 to 2017. Tapering was much more common in patients prescribed higher opioid dosages.

They also found that the rate of dose reduction often was well beyond the CDC's recommendation of 10% per month. The average reduction overall was 27.6% per month. Nearly 20% of patients tapered at a rate of 40% per month, and 5% tapered at a rate faster than 60% per month.

The 2016 policy could have been misinterpreted, leading many prescribers and health systems to insist on faster-than-recommended tapering, according to Agnoli.

"There is definitely a lot of pressure to reduce opioid use among patients, but there also is a need for more training and guidance for prescribers on how to help them safely do so," Agnoli said.

Women and tapering

Fenton and Agnoli also identified patient variables associated with tapering and uncovered an interesting difference in tapering rates based on sex.

While men have much higher rates of opioid use disorder and adverse outcomes related to opioids, women were more likely than men to have their opioid doses tapered.

"We think this has a lot to do with the gender dynamics of pain management and the physician-patient relationship," Agnoli said. "How women experience pain and discuss pain with their physicians is perhaps very different than men. There also could be some sex bias in terms of the patients that physicians choose to initiate conversations with about dose reduction."

Minimizing tapering risks

The researchers hope to build on this work to inform best practices for safe decision-making around dose reduction for all patients prescribed opioids.

"Ultimately, we want to clarify the effects of tapering on patients and how to help them taper to maximize benefits and minimize risks," Fenton said. "We expect this line of research will have important implications for how physicians manage and monitor patients who are undergoing opioid tapering."

Collaborators on this research were Guibo Xing, Daniel Tancredi, Anthony Jerant and Elizabeth Magnan of UC Davis Health, and Lillian Hang and Aylin Altan of OptumLabs in Minneapolis.

Their study was supported by UC Davis Health and OptumLabs and is available online.

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Materials provided by University of California - Davis Health. Note: Content may be edited for style and length.