This year, more than 60 countries, representing more than 4 billion people, will hold major elections. News headlines already are reporting that voters are hanging on to hope. When things get tough or don’t go our way, we’re told to hang on to hope. HOPE was the only word printed on President Barack Obama’s iconic campaign poster in 2008.

Research on hope has flourished only in recent decades. There’s now a growing recognition that hope has a role in physical, social, and mental health outcomes, including promoting resilience. As we embark on a challenging year of news, it’s important for journalists to learn about hope.

So what is hope? And what does the research say about it?

Merriam-Webster defines hope as a “desire accompanied by expectation of or belief in fulfillment.” This definition highlights the two basic dimensions of hope: a desire and a belief in the possibility of attaining that desire.

Hope is not Pollyannaish optimism, writes psychologist Everett Worthington in a 2020 article for The Conversation. “Instead, hope is a motivation to persevere toward a goal or end state, even if we’re skeptical that a positive outcome is likely.”

There are several scientific theories about hope.

One of the first, and most well-known, theories on hope was introduced in 1991 by American psychologist Charles R. Snyder.

In a paper published in the Journal of Personality and Social Psychology, Snyder defined hope as a cognitive trait centered on the pursuit of goals and built on two components: a sense of agency in achieving a goal, and a perceived ability to create pathways to achieve that goal. He defined hope as something individualistic.

Snyder also introduced the Hope Scale, which continues to be used today, as a way to measure hope. He suggested that some people have higher levels of hope than others and there seem to be benefits to being more hopeful.

“For example, we would expect that higher as compared with lower hope people are more likely to have a healthy lifestyle, to avoid life crises, and to cope better with stressors when they are encountered,” they write.

Others have suggested broader definitions.

In 1992, Kaye Herth, a professor of nursing and a scholar on hope, defined hope as “a multidimensional dynamic life force characterized by a confident yet uncertain expectation of achieving good, which to the hoping person, is realistically possible and personally significant.” Herth also developed the Herth Hope Index, which is used in various settings, including clinical practice and research.

More recently, others have offered an even broader definition of hope.

Anthony Scioli, a clinical psychologist and author of several books on hope, defines hope “as an emotion with spiritual dimensions,” in a 2023 review published in Current Opinion in Psychology. “Hope is best viewed as an ameliorating emotion, designed to fill the liminal space between need and reality.”

Hope is also nuanced.

“Our hopes may be active or passive, patient or critical, private or collective, grounded in the evidence or resolute in spite of it, socially conservative or socially transformative,” writes Darren Webb in a 2007 study published in History of the Human Sciences. “We all hope, but we experience this most human of all mental feelings in a variety of modes.”

To be sure, a few studies have shown that hope can have negative outcomes in certain populations and situations. For example, one study highlighted in the research roundup below finds that Black college students who had higher levels of hope experienced more stress due to racial discrimination compared with Black students who had lower levels of hope.

Today, hope is one of the most well-studied constructs within the field of positive psychology, according to the journal Current Opinion in Psychology, which dedicated its August 2023 issue to the subject. (Positive psychology is a branch of psychology focused on characters and behaviors that allow people to flourish.)

We’ve gathered several studies below to help you think more deeply about hope and recognize its role in your everyday lives.

Research roundup

The Role of Hope in Subsequent Health and Well-Being For Older Adults: An Outcome-Wide Longitudinal Approach
Katelyn N.G. Long, et al. Global Epidemiology, November 2020.

The study: To explore the potential public health implications of hope, researchers examine the relationship between hope and physical, behavioral and psychosocial outcomes in 12,998 older adults in the U.S. with a mean age of 66.

Researchers note that most investigations on hope have focused on psychological and social well-being outcomes and less attention has been paid to its impact on physical and behavioral health, particularly among older adults.

The findings: Results show a positive association between an increased sense of hope and a variety of behavioral and psychosocial outcomes, such as fewer sleep problems, more physical activity, optimism and satisfaction with life. However, there wasn’t a clear association between hope and all physical health outcomes. For instance, hope was associated with a reduced number of chronic conditions, but not with stroke, diabetes and hypertension.

The takeaway: “The later stages of life are often defined by loss: the loss of health, loved ones, social support networks, independence, and (eventually) loss of life itself,” the authors write. “Our results suggest that standard public health promotion activities, which often focus solely on physical health, might be expanded to include a wider range of factors that may lead to gains in hope. For example, alongside community-based health and nutrition programs aimed at reducing chronic conditions like hypertension, programs that help strengthen marital relations (e.g., closeness with a spouse), provide opportunities to volunteer, help lower anxiety, or increase connection with friends may potentially increase levels of hope, which in turn, may improve levels of health and well-being in a variety of domains.”

Associated Factors of Hope in Cancer Patients During Treatment: A Systematic Literature Review
Corine Nierop-van Baalen, Maria Grypdonck, Ann van Hecke and Sofie Verhaeghe. Journal of Advanced Nursing, March 2020.

The study: The authors review 33 studies, written in English or Dutch and published in the past decade, on the relationship between hope and the quality of life and well-being of patients with cancer. Studies have shown that many cancer patients respond to their diagnosis by nurturing hope, while many health professionals feel uneasy when patients’ hopes go far beyond their prognosis, the authors write.

The findings: Quality of life, social support and spiritual well-being were positively associated with hope, as measured with various scales. Whereas symptoms, psychological distress and depression had a negative association with hope. Hope didn’t seem to be affected by the type or stage of cancer or the patient’s demographics.

The takeaway: “Hope seems to be a process that is determined by a person’s inner being rather than influenced from the outside,” the authors write. “These factors are typically given meaning by the patients themselves. Social support, for example, is not about how many patients experience support, but that this support has real meaning for them.”

Characterizing Hope: An Interdisciplinary Overview of the Characteristics of Hope
Emma Pleeging, Job van Exel and Martijn Burger. Applied Research in Quality of Life, September 2021.

The study: This systematic review provides an overview of the concept of hope based on 66 academic papers in ten academic fields, including economics and business studies, environmental studies, health studies, history, humanities, philosophy, political science, psychology, social science, theology and youth studies, resulting in seven themes and 41 sub-themes.

The findings: The authors boil down their findings to seven components: internal and external sources, the individual and social experience of hope, internal and external effects, and the object of hope, which can be “just about anything we can imagine,” the authors write.

The takeaway: “An important implication of these results lies in the way hope is measured in applied and scientific research,” researchers write. “When measuring hope or developing instruments to measure it, researchers could be well-advised to take note of the broader understanding of the topic, to prevent that important characteristics might be overlooked.”

Revisiting the Paradox of Hope: The Role of Discrimination Among First-Year Black College Students
Ryon C. McDermott, et al. Journal of Counseling Psychology, March 2020.

The study: Researchers examine the moderating effects of hope on the association between experiencing racial discrimination, stress and academic well-being among 203 first-year U.S. Black college students. They build on a small body of evidence that suggests high levels of hope might have a negative effect on Black college students who experience racial discrimination.

The authors use data gathered as part of an annual paper-and-pencil survey of first-year college students at a university on the Gulf Coast, which the study doesn’t identify.

The findings: Researchers find that Black students who had higher levels of hope experienced more stress due to racial discrimination compared with students who had lower levels of hope. On the other hand, Black students with low levels of hope may be less likely to experience stress when they encounter discrimination.

Meanwhile, Black students who had high levels of hope were more successful in academic integration — which researchers define as satisfaction with and integration into the academic aspects of college life — despite facing discrimination. But low levels of hope had a negative impact on students’ academic well-being.

“The present study found evidence that a core construct in positive psychology, hope, may not always protect Black students from experiencing the psychological sting of discrimination, but it was still beneficial to their academic well-being,” the authors write.

The takeaway: “Our findings also highlight an urgent need to reduce discrimination on college campuses,” the researchers write. “Reducing discrimination could help Black students (and other racial minorities) avoid additional stress, as well as help them realize the full psychological and academic benefits of having high levels of hope.”

Additional reading

Hope Across Cultural Groups Lisa M. Edwards and Kat McConnell. Current Opinion in Psychology, February 2023.

The Psychology of Hope: A Diagnostic and Prescriptive Account Anthony Scioli. “Historical and Multidisciplinary Perspectives on Hope,” July 2020.

Hope Theory: Rainbows in the Mind C.R. Snyder. Psychological Inquiry, 2002

The post Hope: A research-based explainer appeared first on The Journalist's Resource.

In her inaugural address as Dartmouth College’s new president Sept. 22, Sian Leah Beilock vowed to make student mental health a central part of her leadership agenda.

“Fortunately, understanding how anxiety and stress play out in the brain and body has been the focus of my research for the past 20 years,” said Beilock, a leading scholar and former psychology professor at the University of Chicago who was president of Barnard College the last six years.

“The single greatest service we can do for our students, our faculty, and our staff is to support them on their wellness journeys,” she added.

Choosing a cognitive scientist to lead the Ivy League school reflects a broader trend across higher education in the U.S. College presidents nationwide say they are committed to making mental health an institutional priority amid what public health researchers call a national college student mental health crisis.

In fact, when the American Council on Education asked presidents in late 2021 about the issues they consider most pressing, they cited “mental health of students” most frequently.

College student mental health has worsened over time, as has the mental health of high school students, researchers find. During the 2022-23 academic year, an estimated 41% of college students had symptoms of depression and 36% had symptoms of anxiety disorder, according to a national survey conducted by the Healthy Minds Network, a group of scholars who study mental health among U.S. adolescents and young adults.

Of the 76,406 college students who participated, 14% said they had seriously considered suicide during the previous 12 months. The same proportion had symptoms of an eating disorder.

When the organization surveyed college students back in 2018-19, 21% reported symptoms of depression and 22% had symptoms of anxiety disorder. Meanwhile, 10% of students said they had seriously considered suicide and 7% had symptoms of an eating disorder.

Mental health problems more common among minority, LGBTQ students

Published studies indicate some groups of students fare worse than others. For example, racial and ethnic minorities are more likely to experience mental health problems than white students. Likewise, LGBTQ students tend to have poorer mental health than those who aren’t sexual or gender minorities.

Another group that college administrators worry about: first-generation college students — those who are the first in their families to go to college and often must navigate their higher education careers with little to no guidance from parents and other family members.

When researchers compared first-generation students and students whose parents went to college from 2018 to 2021, they learned that symptoms of depression and anxiety disorder were common in both. However, first-generation college students were much less likely to get help from professionals.

“Just 32.8% of first-generation students with symptoms received therapy in the past year, relative to 42.8% among continuing-generation students, and this disparity widened during the COVID-19 pandemic,” the researchers write in the paper, published in June.

In December, U.S. Surgeon General Vivek Murthy issued a public health advisory calling attention to the rising number of youth attempting suicide. Last week, Murthy and seven former surgeons general traveled to Dartmouth for a historic meeting about the country’s mental health crisis.

Tips for journalists

Considering the urgency and importance of this issue, we asked two mental health experts for advice on how journalists can improve their coverage.

In the five tips we outline below, you’ll find suggestions and insights from Gino Aisenberg, an associate professor of social work and co-director of the Latino Center for Health at the University of Washington, and Tony Walker, senior vice president of academic programs for The Jed Foundation, a nonprofit that helps higher education institutions, high schools and school districts implement strategies to prevent suicide and protect emotional health.

1. Make it clear to your audiences that the COVID-19 pandemic didn’t cause this crisis. Student mental health had been declining for years before the virus reached the U.S.

Several research studies and reports chronicle this trend, including a paper published last year that finds the proportion of college students with symptoms of depression and anxiety disorder nearly doubled between 2013 and 2019. The U.S. Centers for Disease Control and Prevention announced the first laboratory-confirmed case of COVID-19 in America in January 2020.

However, the pandemic has exacerbated the problem, especially among the most marginalized students, researchers find.

“College students now face increasing housing and food insecurity, financial hardships, a lack of social connectedness and sense of belonging, uncertainty about the future, and access issues that impede their academic performance and well-being,” researchers write in the 2021 paper, “More Than Inconvenienced: The Unique Needs of U.S. College Students During the COVID-19 Pandemic.”

Psychiatrist Annelle Primm and other mental health professions have spoken out about the mental health impacts of the U.S. Supreme Court’s recent ban on affirmative action in higher education admissions. Higher education leaders expect it to reduce the number of underrepresented minorities attending the nation’s most competitive colleges and universities.

”We believe that the discontinuation of affirmative action will increase isolation and decrease a sense of belonging among students of color, both of which pose risks to mental health,” Primm, the senior medical director of the Steve Fund, a nonprofit organization that focuses on the mental health of young people of color, writes in Diverse Issues of Higher Education.

She cites a 2019 report from the University of Michigan, which stopped practicing affirmative action in 2006, as evidence. One-fourth of its Black, Latino and Native American students said they did not feel they belonged at the school — a 66% increase over 10 years, she notes.

2. Familiarize yourself with two ongoing studies of college student mental health: the Healthy Minds Study, which focuses on U.S. college students, and the World Mental Health International College Student Initiative, which collects data from college students across the globe.

Academic researchers affiliated with these two projects conduct regular surveys of college students to track the prevalence of mental health problems and better understand the factors that affect their mental health and discourage them from seeking help. These researchers also publish studies examining and interpreting the data they collect through annual, web-based surveys.

The Healthy Minds Study, launched in 2007, has been fielded at more than 530 U.S. colleges and universities. Tens of thousands of undergraduate and graduate students complete the survey each year.

Four university faculty members lead the project: Sarah Lipson, an associate professor in Boston University’s department of health law policy and management; Daniel Eisenberg, a professor of health policy of management at the University of California, Los Angeles; Justin Heinze, an associate professor of health behavior and health education at the University of Michigan; and Sasha Zhou, an assistant professor of public health at Wayne State University.

In 2019, the World Health Organization started the World Mental Health International College Student Initiative. The project, commonly referred to as WMH-ICS, aims to collect data from college students worldwide. But as of early October 2023, only the U.S. and 17 other countries, eight of which are in Europe, participate.

The two lead U.S. researchers on that project are Randy Auerbach, an associate professor of psychiatry at Columbia University, and Ronald Kessler, the McNeil Family Professor of Health Care Policy at Harvard Medical School.

3. Emphasize that improving student mental health will require much more than hiring additional campus counselors.

The Jed Foundation advises administrators to focus on the wellness of the entire student body, not just students experiencing distress and those with a diagnosed mental illness. It also encourages schools to invest in programs aimed at preventing mental health issues and detecting them earlier. 

That guidance falls in line with recommendations that a committee of the National Academies of Sciences, Engineering, and Medicine made in 2021, following an 18-month investigation into how campus culture affects college student mental health and well-being. Committee members stressed the need for a comprehensive approach — one in which everyone on campus, including faculty and staff across departments, pitch in to change campus culture.

Walker, The Jed Foundation’s senior vice president of academic programs, urges journalists to take a broader look at the problem as well.

“When we talk about mental health — and sometimes the media is inadvertently guilty of this — we tend to just focus on therapists and we tend to focus on access to mental health care,” Walker tells The Journalist’s Resource. “Mental health is not just counseling.”

Interventions that show promise, according to research studies, include peer counseling, mindfulness training and activities that connect students with similar backgrounds, such as students who are the first in their families to go to college.

4. Explain that all college students face a range of stressors, but certain groups, including racial minorities and LGBTQ students, grapple with additional ones.

College can be stressful, requiring students to juggle class assignments, work and personal relationships while preparing for careers and making sure there’s enough money for food, housing, tuition and other basic needs. A lot of students worry about shootings and other forms of violence on college campuses.

Some student groups face additional stressors, such as racism and discrimination — topics that news stories about college mental health often overlook or gloss over. Many racial and ethnic minorities experience racism throughout their lives, including at their institutions, notes Aisenberg, who co-founded the Latino Center for Health, a research center at the University of Washington focused on improving the health of Latino people across Washington and the U.S.

Sometimes, racism is blatant, he adds. Sometimes, it comes in the form of microaggressions, offensive or insensitive remarks or questions aimed at some aspect of a person’s identity, such as their race, physical appearance, immigration status or cultural traditions.

“For some individuals, one microaggression might not throw them off,” says Aisenberg, who is Mexican American. “Another microaggression I experience the same day and another one and another one — over time, it can weigh [a person] down.”

When Gallup Inc., a company known for its public opinion polls, interviewed 1,106 Black college students last fall, about 1 in 5 reported feeling “frequently” or “occasionally” discriminated against at school. Almost 1 in 3 Black students attending schools where there’s little racial or ethnic diversity among the student body indicated they feel discriminated against “frequently” or “occasionally.”

Nearly one-third of Black students enrolled at such institutions also said they feel physically unsafe, disrespected and psychologically unsafe, according to an analysis released early this year by Gallup and the Lumina Foundation, a private foundation working to increase the share of Americans who continue their education past high school.

Aisenberg says it’s important journalists understand the role racism and discrimination play in student mental health. He’d like to see colleges invest more heavily in culturally responsive counseling, hiring mental health professionals who recognize and draw on the cultural strengths of students from minoritized backgrounds to help them.

Such counselors will understand why some student groups tend to resist therapy more than others.

“Latinos might be going to an indigenous healer, a priest, a minister long before seeking mental health services,” Aisenberg says.

5. Consult style guides that mental health experts have created specifically to help journalists use correct language and avoid perpetuating stereotypes about people with mental illness.

Several U.S. and international organizations have created style guides and tip sheets to help journalists provide a more complete and more accurate picture of mental health. They often offer guidance on word choices and point out common errors.

The California Mental Health Services Authority, for instance, warns journalists to be careful not to insinuate mental illness drove someone to commit a crime.

“Most people with a mental illness don’t commit crimes; most people who commit crimes don’t have a mental illness,” according to the government agency’s style guide. “People with psychiatric issues are far more likely to be victims than perpetrators of violence.”

Some other recommendations: Consider whether someone’s mental illness is relevant to a news story before including that information. Also, don’t rely on hearsay about a person’s mental health diagnosis.

Check out these resources, too:

• The Disability Language Style Guide, created by the National Center on Disability and Journalism at Arizona State University.
• The Mental Health Media Guide, an interactive guide developed by a coalition of mental health and entertainment industry professionals.
• Safe and Effective Messaging, which features phrasing recommendations from The Jed Foundation.
• Improving College Student Mental Health: Research on Promising Campus Interventions, a roundup of research from The Journalist’s Resource on interventions that scholars have found successful.
• Trauma-Informed Journalism: What It Is, Why It’s Important and Tips for Practicing It, a tip sheet and explainer from The Journalist’s Resource that features advice from two experts.
• The Journalism Resource Guide on Behavioral Health, written by the Carter Center, a charity that focuses on issues such as public health, human rights and democracy. It also offers Rosalynn Carter Fellowships for Mental Health Journalism.
• Preventing Suicide: Information for Journalists and Others Writing About Suicide is a tip sheet from the World Health Organization that outlines what journalists should and should not do when reporting on suicide.
• Recommendations for Reporting on Suicide, developed by experts across multiple fields and based on the findings of more than 50 international studies of suicide contagion.
• Covering Suicide is a guide the Dart Center for Journalism & Trauma at Columbia Journalism School created for college media organizations and student journalists.

The post 5 tips to help you cover the college mental health crisis appeared first on The Journalist's Resource.

If you’re a journalist covering higher education in the U.S., you’ll likely be reporting this fall on what many healthcare professionals and researchers are calling a college student mental health crisis.

An estimated 49% of college students have symptoms of depression or anxiety disorder and 14% seriously considered committing suicide during the past year, according to a national survey of college students conducted during the 2022-23 school year. Nearly one-third of the 76,406 students who participated said they had intentionally injured themselves in recent months.

In December, U.S. Surgeon General Vivek Murthy issued a rare public health advisory calling attention to the rising number of youth attempting suicide, noting the COVID-19 pandemic has “exacerbated the unprecedented stresses young people already faced.”

Meanwhile, colleges and universities of all sizes are struggling to meet the need for mental health care among undergraduate and graduate students. Many schools have hired more counselors and expanded services but continue to fall short.

Hundreds of University of Houston students held a protest earlier this year, demanding the administration increase the number of counselors and make other changes after two students died by suicide during the spring semester, the online publication Chron reported.

In an essay in the student-run newspaper, The Cougar, last week, student journalist Malachi Key blasts the university for having one mental health counselor for every 2,122 students, a ratio higher than recommended by the International Accreditation of Counseling Services, which accredits higher education counseling services.

But adding staff to a campus counseling center won’t be enough to improve college student mental health and well-being, scholars and health care practitioners warn.

“Counseling centers cannot and should not be expected to solve these problems alone, given that the factors and forces affecting student well-being go well beyond the purview and resources that counseling centers can bring to bear,” a committee of the National Academies of Sciences, Engineering, and Medicine writes in a 2021 report examining the issue.

Advice from prominent scholars

The report is the culmination of an 18-month investigation the National Academies launched in 2019, at the request of the federal government, to better understand how campus culture affects college student mental health and well-being. Committee members examined data, studied research articles and met with higher education leaders, mental health practitioners, researchers and students.

The committee’s key recommendation: that schools take a more comprehensive approach to student mental health, implementing a wide range of policies and programs aimed at preventing mental health problems and improving the well-being of all students — in addition to providing services and treatment for students in distress and those with diagnosed mental illnesses.

Everyone on campus, including faculty and staff across departments, needs to pitch in to establish a new campus culture, the committee asserts.

“An ‘all hands’ approach, one that emphasizes shared responsibility and a holistic understanding of what it means in practice to support students, is needed if institutions of higher education are to intervene from anything more than a reactive standpoint,” committee members write. “Creating this systemic change requires that institutions examine the entire culture and environment of the institution and accept more responsibility for creating learning environments where a changing student population can thrive.”

In a more recent analysis, three leading scholars in the field also stress the need for a broader plan of action.

Sara Abelson, a research assistant professor at Temple University’s medical school; Sarah Lipson, an associate professor at the Boston University School of Public Health; and Daniel Eisenberg,  a professor of health policy and management at the University of California, Los Angeles’ School of Public Health, have been studying college student mental health for years.

Lipson and Eisenberg also are principal investigators for the Healthy Minds Network, which administers the Healthy Minds Study, a national survey of U.S college students conducted annually to gather information about their mental health, whether and how they receive mental health care and related issues.

Abelson, Lipson and Eisenberg review the research to date on mental health interventions for college students in the 2022 edition of Higher Education: Handbook of Theory and Research. They note that while the evidence indicates a multi-pronged approach is best, it’s unclear which specific strategies are most effective.

Much more research needed

Abelson, Lipson and Eisenberg stress the need for more research. Many interventions in place at colleges and universities today — for instance, schoolwide initiatives aimed at reducing mental health stigma and encouraging students to seek help when in duress – should be evaluated to gauge their effectiveness, they write in their chapter, “Mental Health in College Populations: A Multidisciplinary Review of What Works, Evidence Gaps, and Paths Forward.”

They add that researchers and higher education leaders also need to look at how campus operations, including hiring practices and budgetary decisions, affect college student mental health. It would be helpful to know, for example, how students are impacted by limits on the number of campus counseling sessions they can have during a given period, Abelson, Lipson and Eisenberg suggest.

Likewise, it would be useful to know whether students are more likely to seek counseling when they must pay for their sessions or when their school charges every member of the student body a mandatory health fee that provides free counseling for all students.

“These financially-based considerations likely influence help-seeking and treatment receipt, but they have not been evaluated within higher education,” they write.

Interventions that show promise

The report from the National Academies of Sciences, Engineering, and Medicine and the chapter by Abelson, Lipson and Eisenberg both spotlight programs and policies shown to prevent mental health problems or improve the mental health and well-being of young people. However, many intervention studies focus on high school students, specific groups of college students or specific institutions. Because of this, it can be tough to predict how well they would work across the higher education landscape.

Scientific evaluations of these types of interventions indicate they are effective:

• Building students’ behavior management skills and having them practice new skills under expert supervision. An example: A class that teaches students how to use mindfulness to improve their mental and physical health that includes instructor-led meditation exercises.
• Training some students to offer support to others, including sharing information and organizing peer counseling groups. “Peers may be ‘the single most potent source of influence’ on student affective and cognitive growth and development during college,” Abelson, Lipson and Eisenberg write.
• Reducing students’ access to things they can use to harm themselves, including guns and lethal doses of over-the-counter medication.
• Creating feelings of belonging through activities that connect students with similar interests or backgrounds.
• Making campuses more inclusive for racial and ethnic minorities, LGBTQ+ students and students who are the first in their families to go to college. One way to do that is by hiring mental health professionals trained to recognize, support and treat students from different backgrounds. “Research has shown that the presentation of [mental health] symptoms can differ based on racial and ethnic backgrounds, as can engaging in help-seeking behaviors that differ from those of cisgender, heteronormative white men,” explain members of National Academies of Sciences, Engineering, and Medicine committee.

Helping journalists sift through the evidence

We encourage journalists to read the full committee report and aforementioned chapter in Higher Education: Handbook of Theory and Research. We realize, though, that many journalists won’t have time to pour over the combined 304 pages of text to better understand this issue and the wide array of interventions colleges and universities have tried, with varying success.

To help, we’ve gathered and summarized meta-analyses that investigate some of the more common interventions. Researchers conduct meta-analyses — a top-tier form of scientific evidence — to systematically analyze all the numerical data that appear in academic studies on a given topic. The findings of a meta-analysis are statistically stronger than those reached in a single study, partly because pooling data from multiple, similar studies creates a larger sample to examine.

Keep reading to learn more. And please check back here occasionally because we’ll add to this list as new research on college student mental health is published.

Peer-led programs

Stigma and Peer-Led Interventions: A Systematic Review and Meta-Analysis
Jing Sun; et al. Frontiers in Psychiatry, July 2022.

When people diagnosed with a mental illness received social or emotional support from peers with similar mental health conditions, they experienced less stress about the public stigma of mental illness, this analysis suggests.

The intervention worked for people from various age groups, including college students and middle-aged adults, researchers learned after analyzing seven studies on peer-led mental health programs written or published between 1975 and 2021.

Researchers found that participants also became less likely to identify with negative stereotypes associated with mental illness.

All seven studies they examined are randomized controlled trials conducted in the U.S., Germany or Switzerland. Together, the findings represent the experiences of a total of 763 people, 193 of whom were students at universities in the U.S.

Researchers focused on interventions designed for small groups of people, with the goal of reducing self-stigma and stress associated with the public stigma of mental illness. One or two trained peer counselors led each group for activities spanning three to 10 weeks.

Five of the seven studies tested the Honest, Open, Proud program, which features role-playing exercises, self-reflection and group discussion. It encourages participants to consider disclosing their mental health issues, instead of keeping them a secret, in hopes that will help them feel more confident and empowered. The two other programs studied are PhotoVoice, based in the United Kingdom, and

“By sharing their own experiences or recovery stories, peer moderators may bring a closer relationship, reduce stereotypes, and form a positive sense of identity and group identity, thereby reducing self-stigma,” the authors of the analysis write.

Expert-led instruction

The Effects of Meditation, Yoga, and Mindfulness on Depression, Anxiety, and Stress in Tertiary Education Students: A Meta-Analysis
Josefien Breedvelt; et al. Frontiers in Psychiatry, April 2019.

Meditation-based programs help reduce symptoms of depression, anxiety and stress among college students, researchers find after analyzing the results of 24 research studies conducted in various parts of North America, Asia and Europe.

Reductions were “moderate,” researchers write. They warn, however, that the results of their meta-analysis should be interpreted with caution considering studies varied in quality.

A total of 1,373 college students participated in the 24 studies. Students practiced meditation, yoga or mindfulness an average of 153 minutes a week for about seven weeks. Most programs were provided in a group setting.

Although the researchers do not specify which types of mindfulness, yoga or meditation training students received, they note that the most commonly offered mindfulness program is Mindfulness-Based Stress Reduction and that a frequently practiced form of yoga is Hatha Yoga.

Meta-Analytic Evaluation of Stress Reduction Interventions for Undergraduate and Graduate Students
Miryam Yusufov; et al. International Journal of Stress Management, May 2019.

After examining six types of stress-reduction programs common on college campuses, researchers determined all were effective at reducing stress or anxiety among students — and some helped with both stress and anxiety.

Programs focusing on cognitive-behavioral therapy, coping skills and building social support networks were more effective in reducing stress. Meanwhile, relaxation training, mindfulness-based stress reduction and psychoeducation were more effective in reducing anxiety.

The authors find that all six program types were equally effective for undergraduate and graduate students.

The findings are based on an analysis of 43 studies dated from 1980 to 2015, 30 of which were conducted in the U.S. The rest were conducted in Australia, China, India, Iran, Japan, Jordan, Kora, Malaysia or Thailand. A total of 4,400 students participated.

Building an inclusive environment

Cultural Adaptations and Therapist Multicultural Competence: Two Meta-Analytic Reviews
Alberto Soto; et al. Journal of Clinical Psychology, August 2018.

If racial and ethnic minorities believe their therapist understands their background and culture, their treatment tends to be more successful, this analysis suggests.

“The more a treatment is tailored to match the precise characteristics of a client, the more likely that client will engage in treatment, remain in treatment, and experience improvement as a result of treatment,” the authors write.

Researchers analyzed the results of 15 journal articles and doctoral dissertations that examine therapists’ cultural competence. Nearly three-fourths of those studies were written or published in 2010 or later. Together, the findings represent the experiences of 2,640 therapy clients, many of whom were college students. Just over 40% of participants were African American and 32% were Hispanic or Latino.

The researchers note that they find no link between therapists’ ratings of their own level of cultural competence and client outcomes.

Internet-based interventions

Internet Interventions for Mental Health in University Students: A Systematic Review and Meta-Analysis
Mathias Harrer; et al. International Journal of Methods in Psychiatric Research, June 2019.

Internet-based mental health programs can help reduce stress and symptoms of anxiety, depression and eating disorders among college students, according to an analysis of 48 research studies published or written before April 30, 2018 on the topic.

All 48 studies were randomized, controlled trials of mental health interventions that used the internet to engage with students across various platforms and devices, including mobile phones and apps. In total, 10,583 students participated in the trials.

“We found small effects on depression, anxiety, and stress symptoms, as well as moderate‐sized effects on eating disorder symptoms and students’ social and academic functioning,” write the authors, who conducted the meta-analysis as part of the World Mental Health International College Student Initiative.

The analysis indicates programs that focus on cognitive behavioral therapy “were superior to other types of interventions.” Also, programs “of moderate length” — one to two months – were more effective.

The researchers note that studies of programs targeting depression showed better results when students were not compensated for their participation, compared to studies in which no compensation was provided. The researchers do not offer possible explanations for the difference in results or details about the types of compensation offered to students.

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In his 30-year career as a journalist, Manny Garcia has witnessed executions, covered murders, and once accidentally walked in to a crime scene, finding a dead person at the bottom of a pool.

While working on a story with a photographer, he came face-to-face with a drug dealer who pointed a gun at them and asked them why he shouldn’t kill them.

“Needless to say, we got out of it, but at no point, telling this to my editors, did anybody say, ‘Are you OK, Manny? Do you need to talk to somebody? No. In fact, it was like, ‘Well, you’re here. Work on the story,” Garcia, executive editor for the Austin American-Statesman, recalled during a panel about leading a newsroom during times of crisis at the 2023 Investigative Reporters and Editors conference in Orlando.

In 2020, with encouragement from his wife, he sought therapy and was diagnosed with Post-Traumatic Stress Disorder.

“I’ve been open about this, because you not ever suffer in silence,” Garcia said. “It’s very important to support each other now more than ever, because this is a beautiful profession. You can change lives.”

Garcia’s career unfolded during a time when there were barely any discussions about journalists’ safety and mental health. But that has changed dramatically, for the better, in recent years in light of the COVID-19 pandemic, a seemingly never-ending string of mass shootings, and increasing hostility toward journalists, particularly online.

Today more than ever there are resources for newsrooms to keep journalists’ safe, including from leading organizations such as the Dart Center for Journalism & Trauma, PEN America and the ACOS Alliance.

And more journalism groups and conferences are devoting time to this topic.

During the IRE panel, Garcia, along with Cristi Hegranes, chief executive officer and publisher of Global Press, shared how they bring a culture of safety to their newsrooms — Garcia, managing a regional newspaper, and Hegranes, leading independent news bureaus, staffed by local, women reporters, in some of the world’s least-covered places. I helped moderate the panel.

Below are six tips from my conversation with Garcia and Hegranes.

1. Make safety and security a priority and part of newsroom culture.

At Global Press, safety practices are part of daily newsroom operations instead of being a reactive response.

“It’s making sure that duty of care and security is alive every single day,” Hegranes said. “It’s not just something we talk about when an emergency happens. It’s part of how the newsroom operates. We very intentionally don’t have one person who’s like the director of security or the director of duty of care. Duty of care is written into every single person’s job description. Everyone is responsible for their own security, the security of their colleagues and the risk management of the organization.”

2. Invest in mental health.

“There is oftentimes a misconception of like, ‘Oh, you have to be one of like those big newsrooms in order to afford resources for your reporter.’ And that’s false. We all need to stop believing that because there are so many resources,” Hegranes said.

At Global Press, 3% of every dollar they raise goes toward duty of care. Hegranes shared the three components of wellness at Global Press:

1. Psycho-education. “Psycho-education is critical,” she said. It’s about “giving reporters the tools to understand what is burnout. How do you mitigate it? How do you bounce back from it? What is stress? What is trauma? What is resilience?”
2. Culture. “We have wellness ambassadors for each region, who are responsible for making sure that their reporters in each region of the world know what services are available to them,” Hegranes said.
3. Wellness Network: The Global Press Wellness Network is a network of more than 30 counselors who speak the languages of the organization’s reporters all around the world and are available for free, unlimited sessions. A full-time wellness network manager recruits and trains the counselors. Reporters use a confidential system to request sessions.

“Prior to the pandemic, about 40% of our reporters were using the Wellness Network,” Hegranes said. “Today, more than 80% of reporters at Global Press use the Wellness Network. Most reporters use it for more than 12 weeks in a year.”

To provide services for its core staff in the U.S. and parts of Europe, Global Press has partnered with Talkspace, an online counseling resource. Global Press pays for every employee to have two counseling sessions a month on Talkspace.

3. Remember that framing matters.

When building safety programs, focus on resilience and wellness, not crisis response and trauma.

“It’s not about, ‘You’re in crisis, go get help.’ It’s about, ‘You’re well, stay well.’ If you’re well, let’s figure out how to keep you well,” Hegranes said.

4. Assess reporters’ risk tolerance.

Global Press has developed a tool that allows reporters to do a risk-profile assessment. There are four levels: Aggressive, moderate, conservative and casual.

The aggressive risk profile means the reporter is willing and able to tolerate a high degree of risk, while the casual risk profile denotes a reporter who is often surprised and unprepared for risk.

“This has been such a game changing tool for us because it allows reporters to really think critically about how they approach risk and so that we can help them prepare for big stories and mitigate that risk,” Hegranes said.

It also helps editors to better understand their reporters.

“If you’re sending your most conservative risk profile reporter out to a big protest where tear gas is being shot, the reality is you’re probably not going to get the story that you want, because the reporter is just fundamentally telling you, ‘Hey, that’s not my jam.’ And that’s okay,” she said. “So having frank conversations about risk and really diagnosing it, I think is one of the most powerful, simple tools that newsrooms can do.”

5. Stay in communication with reporters in the field.

Garcia said as part of his newsroom’s practice, editors check in with reporters before they begin a high-risk assignment: Where are they going? Where are they staying? Is their cell phone charged? Do they have backup battery? Do they have cash? Do they have pencils?

Before the reporter goes out the editor knows where they are going, especially if they are going somewhere with spotty cell service.

In some cases, the editor texts a reporter in the field to check on them.

6. Make reporters part of the safety planning process.

Too often the burden of security is on the journalist alone, Hegranes said.

“‘Oh, go take a hostile environments training. Oh, you should secure your social media. Oh, you should do this. You should do that.’ At Global Press, we know after 17 years that the best way for our journalists to find security is in solidarity with the newsroom,” she said. “It is absolutely a partnership and the newsroom has to take a heavy responsibility for the reporter security, both planning for how to mitigate it but also the services on the response after the fact.”

Hegranes advised newsroom managers to design their security and safety protocols with reporters.

“We just have to really shift this top-down mechanism where we tell you this is our security policy. It needs to flip for the reporter to say this is what I need in order to cover that story,” she said.

And sometimes that can be done with a simple survey to find out what the reporters need.

For example, a couple of years ago, Global Press conducted a survey of 300 journalists across East Africa and found that a vast majority of reporters said the most common physical injury in the field was to the palms of their hands from falling off the backs of Boda Boda motorcycle taxis.

“And the lesson there is not, ‘Don’t ride a motorcycle taxis,’” Hegranes said. “It’s, ‘We can equip reporters with the tools they need to mitigate risks and keep themselves safe.’ So we added to our training a very simple physical security training about what to carry with you and how to pack wounds on your own hand or somebody else’s hand.”

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This piece was originally published in July 2020. In light of the Republicans’ debt ceiling negotiations with the Biden administration in 2023, which involve discussions of a federal Medicaid work requirement, we updated it on May 24 with some updated statistics and a list of additional studies published as recently as April 2023.

The two largest U.S. health plans share a birthday, July 30, 1965, but they have different roles and public images.

A law signed by President Lyndon B. Johnson created Medicare, which serves people age 65 and older, and Medicaid, which covers people considered to be poor by government standards. Both programs also cover people with disabilities, contributing to overlap between Medicaid and Medicare. About 12.2 million people of the about 60 million people enrolled in Medicare in 2018 also had Medicaid coverage.

People tend to remain enrolled in Medicare. In 2022, 55.5 million of the the 63.8 million participants were age 65 and older, according to the 2022 Medicare trustees report. The rest of the enrollees qualified due to disabilities.

Not so with Medicaid, where there is more churn.

For example, about 86.7 million people were covered by the state-federal program at some point during fiscal 2018, according to a December 2019 report from Medicaid and CHIP Payment and Access Commission (MACPAC). But fewer might be covered by the program at any given point in the year, as can be tracked through Medicaid’s website.  (The program posts a monthly snapshot of recent enrollment as well as releasing more extensive data.)

People gain Medicaid coverage when they lose jobs — for instance, during the recession stemming from the COVID-19 pandemic — and drop it when they become employed again. Some people with disabilities also rely on Medicaid coverage while waiting to qualify for Medicare.

While Medicaid is a safety-net program for many Americans, Medicare is more of an aspiration, which enjoys a significant base of bipartisan support.

“You couldn’t move my mother out of Medicare with a bulldozer,” then House Energy and Commerce Chairman Billy Tauzin, a Louisiana Republican, said in 2003, while working on the last major expansion of the federal health program. “She trusts in it, believes in it. It’s served her well.”

But there’s a sharp partisan divide about Medicaid. There were no Republican votes for the 2010 Affordable Care Act (ACA), which set the stage for a major expansion of Medicaid that’s still unfolding. Instead Republicans have since tried repeatedly to repeal the ACA, while also reviving in recent years attempts to convert federal funding of Medicaid from an open-ended commitment based on formulas to more limited support though block grants.

GOP’s unsuccessful ACA repeal bids in 2017 foundered, though, in part due to growing support for Medicaid, according to Richard Sorian, a former assistant secretary for public affairs at the Department of Health and Human Services in the Obama administration. Sorian looked at how the 2014 expansion had allowed more people to get access to health care in several states with Republican governors, such as Ohio, as well as in those dominated by Democrats.

“For most of its history, Medicaid took a back seat to Medicare, the health benefits program for seniors and others,” Sorian writes, adding that some politicians still seek Medicaid budget cuts. “But many more are leery of touching the program and facing the wrath of the people who elected them.”

A few statistics show how Medicaid underpins much of U.S. health care.

• About 1 in 5 Americans get health insurance through Medicaid, which is run by the states with federal financial support and oversight. As of January 2023, more than 85.9 million people in the U.S. were enrolled in Medicaid, according to the latest data posted by the Centers for Medicare and Medicaid Services (CMS). There were about  7 million participants in the Children’s Health Insurance Program (CHIP), considered a sister initiative to Medicaid.
• Medicaid paid for 43% of all births in the U.S. in 2018, while private insurance plans paid for 49%. Policymakers now are looking to expand Medicaid coverage to try to lower the high rate of maternal mortality in the United States. There are bills pending in Congress that would require Medicaid coverage of new mothers from a 60-day period to the entire year following giving birth.
• Medicaid is the largest U.S. purchaser of what it calls behavioral health services, which include mental health treatment and services to treat addiction and substance abuse.
• Medicaid is the primary tool through which the Affordable Care Act (ACA) of 2010 expands the public’s access to health care.

News coverage of the federal government’s implementation of the ACA in 2014 focused heavily on hitches with the startup of the online state and federal exchanges through which people who did not get health plans from their employers can buy medical coverage. These were primarily intended to help people whose employers do not offer health plans. Many people get subsidies to purchase their insurance on these exchanges. Without this help, they might not be able to afford insurance.

About 11.4 million people were covered by these health plans sold on the exchanges for 2020, according to a report from the Centers for Medicare and Medicaid Services (CMS).

These include plans sold by for-profit companies as well as ones from nonprofit insurers.

But, by late 2018, about 15.1 million people were enrolled in Medicaid due to expansion created by the ACA, CMS reported.

States have varied eligibility criteria, including income cutoffs, for Medicaid. Before the ACA, many states largely excluded adults who do not have disabilities,  no matter how little they earned.

President Barack Obama and congressional Democrats intended for all states to raise their Medicaid eligibility requirements to allow adults who work but have incomes just above the federal poverty level to get health insurance. CMS last year authorized Utah’s Medicaid expansion, which will allow coverage for single people with annual income of as much as 138% of the federal poverty level ($17,608). For a family of four, this income cutoff would be $36,156.

Under the ACA, states initially were required to set their cutoff for Medicaid eligibility at a level that allowed people with household incomes as high as 138% above the federal poverty level to enroll. It’s important to note that while the actual text of the ACA sets this level at 133%, other provisions of the law have effectively nudged the cap to 138%.

In 2012, the U.S. Supreme Court decided that states could choose whether they wanted to raise the threshold for Medicaid eligibility under ACA. In an effort to encourage states to raise their income thresholds to allow more people to qualify for Medicaid, the federal government offered to cover the majority of the cost of covering these new enrollees.

Many states led by Republican governors initially balked at the offer and GOP political candidates campaigned on pledges to repeal the ACA.

Several Republican leaders, including Gov. Gary Herbert of Utah and then Indiana Gov. Mike Pence, later took the federal government up on its offer. The U.S. opioid epidemic helped persuade GOP holdouts to expand Medicaid. As of May 2023, 10 states have not taken formal action to expand Medicaid, according to a tally kept by the Kaiser Family Foundation.

In some states that have expanded their Medicaid coverage, Republican governors have added conditions for people who are able to enroll thanks to increased income thresholds, including payments of premiums. Congressional and state Democrats have objected to Republican attempts to add work requirements to Medicaid participation for adults who do not have disabilities. They have argued that many people added as a result of the expansion already work and documenting employment is a significant administrative burden.

To help journalists report on Medicaid, we’ve summarized a few studies below to help reporters understand the key debates happening about this program.

At the heart of Medicaid research are persistent questions about how well the massive state-federal health program works. Studies published to date show mixed results on questions of whether having Medicaid coverage helps participants improve or maintain their health.

For example, one study found middle-aged people who live in states that expanded Medicaid under the ACA are less likely to die of heart disease.

But discussions about Medicaid often quickly loop back to the somewhat surprising findings of a 2008 experiment in Oregon involving Medicaid, which is discussed more fully in a section below.

After Oregon officials found they had funds for a limited expansion of the state’s Medicaid program, they used a lottery to select about 30,000 people from a waiting list of almost 90,000. This approach allowed economists a rare opportunity to study the effects of Medicaid coverage in a group of people randomly selected to enroll in the state-federal health plan.

Some findings from studies of the Oregon experiment disappointed advocates for Medicaid expansion. These findings include research that seems to contradict a common theory that people newly enrolled in Medicaid  would use emergency rooms less often for basic health care needs if they could afford to see a primary care doctor by participating in Medicaid. Visits to a primary care clinic cost significantly less than emergency room visits.

In recent years, many researchers have sought to assess the early impacts of the ACA’s Medicaid expansion. The results of the Oregon experiment cast doubt about the possible benefits of Medicaid coverage for a group that had been randomly selected to receive coverage, writes Sarah Miller, an assistant professor at the University of Michigan’s Ross School of Business, and her co-authors in a 2019 paper.

“The inconclusive nature of these results has led to skepticism among some researchers, policymakers, and members of the media as to whether Medicaid has any positive health impacts for this group,” write Miller and her co-authors.

In their paper, though, Miller and her co-authors estimate Medicaid expansion may have prevented 4,800 deaths in their sample population among people ages 55 to 64, or roughly 19,200 fewer deaths over the first four years alone. Miller and her co-authors also offer an estimate of what many states’ decisions against Medicaid expansion meant for their citizens.

“Our estimates suggest that approximately 15,600 deaths would have been averted had the ACA expansions been adopted nationwide as originally intended by the ACA,” Miller and her co-authors write.

Below are the summaries of the Miller paper and other research on Medicaid, including a section on the Oregon Medicaid experiment.

Medicaid and Mortality: New Evidence from Linked Survey and Administrative Data
Sarah Miller, et al. National Bureau of Economic Research working paper No. 26081, Revised August 2019.

Broader access to Medicaid appeared to lower the mortality rate in a study focused on people ages 55 to 64, Miller and her co-authors find.

They analyzed the potential effect of the Medicaid expansion by using data from the federal American Community Survey (ACS). This national survey draws information from about 4 million respondents a year. The survey asks for such details as income level and citizenship status, which allow researchers to make observations about people’s potential Medicaid eligibility.

In their study, Miller and her co-authors focused on adults aged 55 to 64 who appeared likely to qualify for the Medicaid due to the expansion. The researchers  excluded adults living in Delaware, Massachusetts, New York, Vermont and the District of Columbia from the study. Medicaid programs in those areas earlier had allowed coverage of adults living in poverty.

Miller and her co-authors then compared data for the people in the selected expansion states  to ACS data for a similar group of people from states that had not expanded Medicaid. They find that the probability of dying in the first year of the expansion declined by about 0.089 percentage points for the Medicaid expansion group. In the second and third year, the probability of death dropped a little over 0.1 percentage points, the researchers explain. By the fourth year, it declined 0.2 percentage points.

Limitations to this research include the possible effect of instances where people’s income may have risen between 2008 and 2014, the years studied, making them ineligible for the expansion.

Some participants in the ACS also may have moved to different states, causing misclassification about whether those people were eligible for the expansion, Miller and her co-authors write.

The nonpartisan, nonprofit Center on Budget and Policy Priorities released a report that discusses the findings of the paper in simple terms. The University of Michigan produced a press release on Miller’s findings.

Medications for Opioid Use Disorder Among Pregnant Women Referred by Criminal Justice Agencies Before and After Medicaid Expansion: A Retrospective Study of Admissions to Treatment Centers in the United States
Tyler Winkelman, et al. PLOS Med, May 18, 2020.

Pregnant women referred by courts and other criminal justice agencies for opioid abuse treatment were more likely to get medications to help them manage their condition if they lived in states that had expanded their Medicaid eligibility, wrote Tyler Winkelman of the Hennepin Healthcare Research Institute of Minneapolis, and his co-authors.

The rate at which medication for opioid use disorder was prescribed for pregnant women rose from 21.4% to 36% in the states studied that had expanded their Medicaid eligibility. In the states that did not expand Medicaid, the rate increased from 7.0% to 9.6%.

For the study, Winkelman and co-authors analyzed data collected from 1992 to 2017, identifying records for cases of 131,838 pregnant women with opioid use disorder. They drew these from the Treatment Episode Data Set-Admissions (TEDS-A) program, an annual national survey conducted by the federal Substance Abuse and Mental Health Services Administration (SAMHSA). More than half — 63.3% — percent of the women in the sample studied were between the ages aged 18–29.

They acknowledge limits to their paper, including gaps in the TEDS-A data.

Although TEDS-A is the most comprehensive survey of treatment admissions in the U.S., some states only report cases of people whose care was publicly funded. Omitting data about pregnant women who used private insurance to pay for their treatment could potentially alter the reported results, the authors write.

Examination of Changes in Health Status Among Michigan Medicaid Expansion Enrollees From 2016 to 2017
Minal R. Patel, et al. JAMA Network Open, July 10, 2020.

People in Michigan who enrolled in Medicaid through the ACA expansion were less likely to report themselves as being in fair or poor health over time, finds a study by Minal R. Patel, an associate professor at the University of Michigan School of Public Health, and her co-authors.

In 2016, 30.7% of study participants reported being in fair or poor health, while 27.0% did the following year, Patel and co-authors find. They used a longitudinal panel survey, an approach that allows for repeated observations over time, to assess changes in health status for people enrolled in the Medicaid expansion in Michigan. The researchers analyzed the answers that  more than 3,000 people gave during their telephone survey in both 2016 and 2017.

Patel and her co-authors did not find any statistically significant differences in the other aspects of health they studied — for example, the number of days participants reported being in poor mental health or the number of days of usual activities they reported missed owing to poor physical or mental health over time.

Effects Of Medicaid Expansion On Postpartum Coverage And Outpatient Utilization
Sarah H. Gordon, et al. Health Affairs, Jan. 6, 2020.

A comparison of medical claims for women living in Colorado and Utah suggests expanding Medicaid may help new mothers get needed medical care. Sarah H. Gordon, an assistant professor at the Boston University School of Public Health, and her co-authors studied how Medicaid eligibility rules affect women’s access to care after delivery, noting concerns about the high maternal mortality rates in the U.S. compared to other rich nations.

In their paper, Gordon and her co-authors describe this as the first study to examine the impact of the ACA’s Medicaid expansion on postpartum coverage and outpatient medical care among pregnant women. They obtained information about Medicaid claims through agreements with state agencies in Colorado and Utah.

In Colorado in 2013, pregnant women with incomes below 185% of federal poverty level and parents with incomes below 105% of the poverty level were eligible for Medicaid. The state in 2014 expanded its Medicaid program to cover all adults with incomes below 138% of the federal poverty threshold. Utah did not expand its Medicaid eligibility until 2019.

The mean (average) number of months of Medicaid coverage in the six months after delivery rose from 5.3 months in the January-June 2013 period to 5.4 months in the January 2014-June 2015, but dropped in Utah from 4.6 months to 3.6 months.

Gordon and her co-authors compared the treatment that women in the two states received between January and June 2013 and between January 2014 and June 2015. At the time, Utah’s Medicaid eligibility cap was 33% above the poverty line for pregnant women and 44% below the poverty line for parents.

Among the key findings: Mothers in Colorado, on average, had more outpatient medical visits during the first six months after delivery. The average number of outpatient visits rose from 3.0 to 3.3. In Utah, mothers had fewer outpatient visits – an average of 1.8 in the six months post-delivery, down from 2.0.

There was an even larger gain in Colorado for new mothers who had experienced difficulty during pregnancy and delivery, termed maternal morbidities, such as hemorrhage. For these women, the average number of outpatient visits in that state in the six months after delivery rose from 2.7 to 3.4. In Utah, the average number of visits for women in this category slipped from 1.8 to 1.6.

Gordon and her co-authors note in their paper that their findings apply only to women in the two states. They also note that the claims databases used in their work lacked detailed information on patient race, ethnicity and socioeconomic status.

Medicaid Work Requirements — Results from the First Year in Arkansas
Benjamin D. Sommers, et al. New England Journal of Medicine, Sept. 12, 2019. Published online June 19, 2019.

An Arkansas initiative linking work requirements to Medicaid eligibility is associated with a rise in the percentage of uninsured people in the state but no significant change in employment status, finds this study, led by Benjamin D. Sommers, a professor at the Harvard T.H. Chan School of Public Health.

Sommers and his co-authors looked at what happened after Arkansas, in 2018, became the first state to implement a work requirement in connection with the Medicaid expansion. (Subsequent federal court decisions put a halt to this Arkansas requirement, as detailed by the Kaiser Family Foundation on a page where it tracks Medicaid policy changes approved by federal waivers.)

Many Republicans, including Arkansas Gov. Asa Hutchinson, have argued in favor of tying coverage through the Medicaid expansion to work requirements. His state received permission from the federal government to ask Medicaid beneficiaries who were 30 to 49 years old to meet requirements such as working 80 hours per month or participating in another so-called “community engagement activity” such as job training or community service. Pregnant women and people with disabilities could get exemptions from these rules.

Sommers and his co-authors used telephone surveys to assess changes in work patterns before and after the Arkansas work requirements took effect. They studied changes among four groups: people in Arkansas aged 30 to 49, Arkansans 19 to 29 years of age, Arkansans aged 50 to 64, and adults in three comparison states — Kentucky, Louisiana and Texas.

The researchers find that the percentage of people in the group representing Arkansans aged 30 to 49 who worked 20 hours or more a week dropped from 42.4% in 2017 to 38.9% in 2018.

Similar results were seen in control groups used in the study, including the three comparison states.

The percentage of uninsured respondents among Arkansans 30 to 49 years of age increased

from 10.5% in 2016 to 14.5% in 2018, with smaller or no changes in the other groups. The percentage of Arkansans 30 to 49 years of age with employer-sponsored coverage increased slightly, from 10.6% to 12.2%

Sommers and his co-authors note that more than 95% of people in Arkansas who were targeted by the new policy already met the work requirement or should have been exempt.

The researchers note that the study did not determine whether individuals’ loss of coverage was a direct result of the new work requirements or prompted by other factors such as income changes or failure to complete renewal paperwork.

The nonprofit, nonpartisan Commonwealth Fund has a brief about Sommers’ paper, summarizing its findings in simple terms.

The Oregon experiment

The Oregon Experiment — Effects of Medicaid on Clinical Outcomes
Katherine Baicker, et al. New England Journal of Medicine, May 2, 2013.

The findings of this paper often are cited by critics of Medicaid. Katherine Baicker and her co-authors find that expanding Medicaid coverage in Oregon in 2008 had no statistically significant effect on the prevalence or diagnosis of hypertension or high cholesterol levels or on the use of medication for these conditions.

While Medicaid coverage increased the probability of a diagnosis of diabetes and the use of diabetes medication, Baicker and co-authors observed no statistically significant effect on a measure of control of blood-sugar for diabetes.

But Baicker and her co-authors did find increased use of health care services, lower rates of depression and reduced financial strain among people who were able to get Medicaid coverage through the lottery.

“We found a pretty mixed bag there, which I think was surprising to a lot of people,” Baicker said during a panel discussion about the ACA at the Harvard Kennedy School of Politics in 2017.

The Oregon experiment offered a rare opportunity for researchers like Baicker and her co-authors on this paper, including Amy N. Finkelstein of the Massachusetts Institute of Technology.

Economists studying the effects of different insurance policies and plans often work to create valid comparison groups by pulling data from claims records. In contrast, researchers studying the effects of medicines see how these treatments work on people randomly selected to get a drug or placebo.

Oregon officials in 2008 prepared to allow new enrollment in the state’s Medicaid program after capping it. They knew there would be more demand for coverage than the state had budgeted, so they used a lottery to determine who could participate.

This created randomized groups that Baicker and her co-authors could study. The results of their research make clear how tough it is to make decisions about whether and how to use Medicaid to help more people obtain medical care. Policymakers have to weigh the benefits of expanding Medicaid against the expense, as the state-federal health plan competes with other priorities in government budgets.

“You cannot expect to save money in the healthcare system by expanding Medicaid. It costs money because people use more care, so you’ve got to find a way to finance it,” Baicker said during the 2017 Harvard Kennedy School panel discussion.

Baicker and her co-authors have continued to examine the results of the Oregon Medicaid experiment. Recent papers include:

The Effect of Medicaid on Management of Depression: Evidence From the Oregon Health Insurance Experiment
Katherine Baicker, et al. Milbank Quarterly, March 5, 2018.

Having Medicaid coverage appeared to reduce the prevalence of undiagnosed depression by almost 50% and untreated depression by more than 60% in a study comparing adults who enrolled in Oregon’s state health program to fellow applicants who were not selected in a lottery, Baicker and her co-authors find. They write that Medicaid coverage increased use of medications frequently prescribed to treat depression and related mental health conditions and reduced the share of people reporting unmet mental health care needs by almost 40%.

Between September 2009 and December 2010, Baicker and her colleagues collected information on 12,229 people via interviews and questionnaires. They selected people living in the Portland area, of whom 6,387 had been able to enroll in Medicaid through the lottery. The remaining respondents served as a control group.

Effect of Medicaid Coverage on ED [Emergency Department] Use — Further Evidence from Oregon’s Experiment
Amy N. Finkelstein, et al. New England Journal of Medicine, Oct. 20, 2016.

This paper is a follow-up to one published in Science in 2014. In that first paper, Sarah L. Taubman of the National Bureau of Economic Research and co-authors, including Baicker and Finkelstein, reported a 40% increase in emergency department (ED) visits among people who were chosen by lottery to receive Medicaid coverage.

That was a surprising finding, as there had been widespread belief that expanding Medicaid coverage would encourage more use of primary care and thus reduce ED visits, Finkelstein and her co-authors wrote.

In this 2016 paper, Finkelstein and her co-authors present an analysis of additional data to determine whether the increase in emergency department visits was short term.

There had been speculation that people who obtained Medicaid through the lottery would reduce use of emergency departments as they established relationships with primary care physicians.

At the 720-day mark, though, about 21.1% of the Medicaid group had visited an emergency department, while only 15.7% of the control group had, Finkelstein and her co-authors find.

Finkelstein and her co-authors found no such decline in use of emergency departments by people whose Medicaid enrollment should have made primary care visits more affordable.

Instead, “if anything, Medicaid made them more likely to use both,” Finkelstein and co-authors write in a summary of their results posted on the National Bureau of Economic Research (NBER) website.

The NBER’s Oregon Health Insurance Experiment website offers a list of publications based on this work. The MIT  Technology Review provides a history of this project in an April 2020 article, “A healthy understanding: Amy Finkelstein has changed what we know about Medicaid, Medicare, the economics of health care — and, increasingly, medical care itself.”

Additional reading

• “Medicaid Section 1115 Waivers: From Work Requirements To Social Determinants Of Health.” Alexander P. Phillips, Eli Y. Adashi, MaryBeth Musumeci. Health Affairs, April 2023.
• “Medicaid Work Requirements are Back on the Agenda.” Kaiser Family Foundation. Madeline Guth, April 2023.
• “Able-bodied Characters and the Appeal of Medicaid Work Requirements in Arkansas.” Kellan McNally. Journal of Policy Practice and Research, February 2023.
• “Lingering Legacies: Public Attitudes about Medicaid Beneficiaries and Work Requirements.” Simon F. Haeder, Steven M. Sylvester, Timothy Callaghan. Journal of Health Politics, Policy and Law, April 2021.
• “Levels of Employment and Community Engagement among Low-Income Adults: Implications for Medicaid Work Requirements.” Aparna Soni, Cong Gian, Kosali Simon, Benjamin D. Sommers. Journal of Health Politics, Policy and Law, December 2020.

For more information, see our 6 reporting tips for covering Medicaid during the COVID-19 pandemic. 

Additional reporting by Naseem S. Miller

The post The expanding role of Medicaid in US health care: A research roundup appeared first on The Journalist's Resource.

The number of times children and adolescents were treated for eating disorders at 38 U.S. pediatric hospitals approximately doubled during the first year of the COVID-19 pandemic and remained elevated in 2022, finds a recent paper in Pediatrics, a journal of the American Academy of Pediatrics.

Even before the pandemic, emergency rooms at these hospitals were seeing more kids aged 10 years and older needing help for eating disorders — a group of psychiatric conditions characterized by an unhealthy relationship with food, including avoiding it, eating it in large quantities or purging it. Anorexia nervosa, binge eating disorder and laxative abuse are common types of eating disorders.

From January 2018 to March 2020, emergency room visits for eating disorders increased by 1.5 visits per month, on average, for youth. After COVID-19 began to spread and many schools and businesses closed, emergency room visits jumped by an average of 12.9 visits a month in the first year of the pandemic and then began to decline by 6.3 visits per month during the second.

The hospitals saw similar increases in inpatient admissions for children and adolescents with eating disorders, according to the study, led by Carly Milliren, a biostatistician at Boston Children’s Hospital’s Institutional Centers for Clinical and Translational Research.

Milliren’s coauthors are Tracy Richmond, the director of Boston Children’s Hospital’s Eating Disorder Program and an assistant professor of pediatrics at Harvard Medical School, and Joel Hudgins, an emergency medicine physician at Boston Children’s Hospital and assistant professor of pediatrics and emergency medicine at Harvard Medical School.

A ‘second pandemic of mental health’

The paper adds to a growing body of academic literature chronicling young people’s mental health struggles amid the pandemic. Two recent meta-analyses — a top-tier form of scientific evidence — find spikes in attempted suicide and depression across several countries, including the U.S.

“The stress of the pandemic is clear,” Milliren wrote in an email to The Journalist’s Resource. “We now talk about a second pandemic of mental health particularly in children/adolescents, the effects of which are still lingering, though the exact cause of this is unknown.”

Not only did inpatient admissions increase, but patients also required longer hospital stays, partly because it took so long for some kids to seek out or receive care, Milliren noted.

It can take many years to recover from eating disorders. The average course of an eating disorder is about three to six years, Milliren explained.

“We see many individuals who got sick with an eating disorder during the pandemic who continue to struggle,” she added. “Because care was difficult to access, many patients who got sick during the pandemic had delayed care and presented with more severe illness. This sets them up for [a] more protracted course of illness.”

To measure changes in the volume of youth seeking eating disorder-related care, Milliren, Richmond and Hudgins looked at medical billing data for kids diagnosed with eating disorders in the 27 months leading up to and 27 months after the pandemic began.

They extracted information for their analysis from the Pediatric Health Information System, a database containing clinical and financial details for millions of young patients within a network of not-for-profit pediatric hospitals.

Here are some of the other key findings outlined in their paper, “Emergency Department Visits and Hospitalizations for Eating Disorders During the COVID-19 Pandemic”:

• The average age of a child or adolescent treated for an eating disorder at one of the 38 hospitals during the pandemic was 15.5 years. Slightly more than one-third of the patients studied were 14 or 15 years old.
• The share of patients coming from higher-income communities rose slightly during the study period. Prior to the pandemic, about 7% of patients came from communities with a median income of $90,000 per year or higher. Post-COVID, 8.2% did.
• The percentage of youth using private health insurance also grew. For example, prior to the pandemic, 65.9% of patients used private insurance to cover the cost of emergency room treatments for eating disorders. That number increased to 69.1% from April 2020 to June 2022. At the same time, the proportion of patients using public health insurance dipped — from 30.7% to 28.1%.
• Anorexia nervosa was, by far, the most common eating disorder diagnosis. During the pandemic, 64.2% of children and adolescents who sought help for eating disorders from emergency department physicians were diagnosed with anorexia nervosa, as were 73.8% of youth admitted for inpatient care.

Tips for covering eating disorders

The Journalist’s Resource asked Milliren how journalists can improve their coverage of eating disorders. She made these four suggestions:

1. Stress that eating disorders are but one component of a larger mental health crisis affecting children and adolescents nationwide today.

“The needs of these kids are dire and need to be brought to national attention to really enact change,” Milliren wrote.

2. Make clear that eating disorders often are not obvious. Having a healthy weight does not mean a child or teenager does not have an eating disorder.

“Some of our most severely impacted patients are those who started at a higher weight, were encouraged by family, medical providers to lose weight, and present with what appears to be a normal or healthy weight,” Milliren wrote.

Some of those kids are profoundly ill, their vital organs weakened by sustained starvation, malnutrition or dehydration. They might have the same thoughts and disordered eating patterns as someone whose weight is very low as a result of anorexia nervosa, she added.

3. Correct the misconception that eating disorders only affect girls, particularly white girls from higher-income families.

Milliren pointed out that eating disorders often are under-recognized and under-diagnosed in boys and racial and ethnic minorities.  

A meta-analysis published in February in JAMA Pediatrics, a journal of the American Medical Association, suggests a substantial portion of boys have feelings about food and their body size that are associated with what researchers call “disordered eating.” The term refers to abnormal eating behaviors that may not meet the diagnostic criteria for an eating disorder.

The authors of this meta-analysis examined data from 32 academic studies published between 2008 and 2022, representing a total of 63,181 kids aged 6 to 18 years across 16 countries. The studies focus on how often boys and girls said ‘yes’ to the five questions on a common screening measure for eating disorders. Examples of the questions asked are, “Do you make yourself sick because you feel uncomfortably full?” and “Do you believe yourself to be fat when others say you are too thin?” and “Do you worry you have lost control over how much you eat?”

Across the countries studied, 22% of kids — and 17% of boys — reported having disordered eating. The authors note they only looked at data collected prior to the pandemic, which means their results do not reflect any shifts in disordered eating that may have occurred in recent years.

Milliren, Richmond and Hudgins found that about 80% of the kids treated for eating disorders post-pandemic at the 38 pediatric hospitals were white. About 4% were Black, 3% to 4% were Asian American and 7% were “another race.” About 14% of patients were Hispanic.

4. Ask local schools how they are helping identify and support students with eating disorders.

“Since kids spend so much time at school, they can be an important first line of defense for recognizing and dealing with eating disorders or other mental health conditions,” Milliren wrote. “Early identification is key for eating disorders to prevent serious complications and schools can help by providing environments where kids feel supported and able to share their concerns, especially for those with challenging home environments.”

Schools can also help students by encouraging discussions around nutrition, exercise and body image and promoting healthy habits “to try and counteract all the stigmatizing messages around weight and shape that are so prevalent on social media and just media in general,” Milliren noted.

For more details

Emergency Department Visits and Hospitalizations for Eating Disorders During the COVID-19 Pandemic
Carly E. Milliren, Tracy Richmond and Joel D. Hudgins. Pediatrics, January 2023.

Global Proportion of Disordered Eating in Children and AdolescentsA Systematic Review and Meta-analysis
José Francisco López-Gil; et al. JAMA Pediatrics, February 2023.

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The number of times children and adolescents came to hospital emergency rooms after attempting suicide jumped 22% across 18 countries, including the U.S., during the first two years of the COVID-19 pandemic, according to a new study in Lancet Psychiatry.

A second study, written by many of the same researchers and published this week by JAMA Pediatrics, finds that kids in the U.S. and 11 other countries experienced more symptoms of depression during the pandemic, especially girls and youth from higher-income households.

The two papers synthesize the academic research to date on these two issues to answer the ongoing question: Has the pandemic — and the myriad changes at home and school that came with it — really harmed kids’ mental health?

While many earlier studies have suggested more youth experienced depression, attempted suicide and developed other mental health issues after COVID-19 began to spread, some small studies have indicated no change or even improvement.

The two new papers are meta-analyses, or a study of studies on a given topic — a top-tier form of scientific evidence. One represents the findings of 42 studies on attempted suicide and self-harm among young people during the pandemic. The other represents 53 studies examining changes in youth depression and anxiety.

Together, they confirm that child and adolescent mental health worsened in the U.S. and many other countries, the lead author of both papers, clinical psychologist Sheri Madigan, wrote in an email to The Journalist’s Resource.

“The widespread uncertainty, at times severe restrictions, and repeated disruptions during the pandemic might have pushed some youth, especially female individuals and adolescents, beyond their typical stress threshold,” Madigan and her colleagues write in the JAMA Pediatrics paper.

A spike in youth suicide attempts

The researchers examined the rate at which people aged 18 years and younger went to emergency rooms after attempting suicide. They analyzed a total of 11.1 million visits, looking for differences in rates before the pandemic began and two years afterward.

They estimate the rate jumped 27% in the U.S. It rose 22%, on average, across the 18 countries studied: the U.S., Canada, South Korea, Australia, New Zealand, England, Scotland, Ireland, Austria, Germany, Spain, Italy, Hungary, Serbia, Switzerland, Slovenia, Turkey, Oman and the United Arab Emirates.

“Specifically, we found that, on average, in any given emergency department setting, there were 102 child and adolescent visits per month for suicide attempts before the pandemic, which increased to 125 during the months of the pandemic,” Madigan, director of the Determinants of Child Development Lab at the University of Calgary, explained via email.

Madigan added that the rise in visits for attempted suicide is especially noteworthy considering youth emergency room visits, as a whole, dropped during the pandemic, partly because many families delayed care and avoided leaving their homes.

A separate paper forthcoming in The American Journal of Emergency Medicine looks at the decline in all emergency department visits for people of all ages in the U.S. from January 2019 to April 2022. It finds these visits dropped 42% in spring 2020, compared to spring 2019, and remained below pre-pandemic levels until the second quarter of 2021.

Other key findings

Madigan and her colleagues also found “strong evidence” of an increase in depression symptoms for children aged 18 and younger. Because they analyzed changes in depression and anxiety using standardized averages, they do not present the magnitude of changes as percentage increases in their paper. They describe changes, as well as the strength of the evidence, using adjectives such as “strong,” “good” and “slight.”

For that paper, researchers examined data collected on a total of 40,807 kids between 2017 and 2021 in 12 countries: the U.S., Canada, China, Australia, England, Scotland, Ireland, Germany, Italy, Spain, Switzerland and the Netherlands.

Some other main takeaways from the two studies:

• The rate at which emergency rooms treated kids for attempted suicide or suicide ideation — the medical term for thinking about or planning suicide — rose 39% for girls and 6% for boys, on average, in the countries studied.
• Researchers found no change in emergency room visits for self-harm when they looked at data for kids of all ages. But when they focused on older youth — those aged 13 to 18 years — they saw that visits increased an estimated 18% for that group. Meanwhile, visits related to self-harm dropped an estimated 15% for children aged 12 years and younger.
• There is “very good evidence” of an increase in depression symptoms among kids from Europe and “good evidence” of an increase among kids from North America. There also is “good evidence” of a slight change in Asia.
• There is “good evidence” that depression symptoms increased among girls and “slightly increased” among boys. The authors find “some evidence” of increased depression symptoms among kids from middle- to high-income households specifically.

Solving the mental health problem

While neither study attempts to determine what caused the increase in depression symptoms or emergency room visits for attempted suicide, the authors note that kids’ lives changed dramatically during the pandemic.

In the JAMA Pediatrics paper, researchers list some of the changes that could have affected their mental health:

• Social isolation and orders to quarantine.
• Increased screen time.
• Decreased physical activity.
• School closures and disruptions, including switching between online and in-person learning.
• Cancellation of extracurricular activities.
• Parental job loss.
• Other family members experiencing increased anxiety or depression.
• Family violence.

Madigan pointed out that as children and adolescents faced new stressors amid the pandemic, they also lost access to key sources of help when schools closed: guidance counselors, social workers, school psychologists, athletic coaches and the other people on campus they tended to go to for guidance and problem-solving.

“Schools are often a primary location for receiving psychological services, with 80% of children relying on school-based services to address their mental health needs,” she wrote by email.

The next big question needing to be answered, according to Madigan: What should be done to help kids thrive in the aftermath of a pandemic that impacted their mental health?

The findings outlined in the two meta-analyses can inform policymakers’ and public health leaders’ responses to the problem.

“Our results, as well as those of many other scholars, sound a clarion call to policy makers that a response is needed to directly address the mental health crisis being experienced by children and adolescents,” write the authors of the JAMA Pediatrics paper. “The development and widespread availability of timely and evidence-based global mental health prevention and intervention efforts to address childhood mental illness are critical and urgently needed.”

For more details

Changes in Depression and Anxiety Among Children and Adolescents From Before to During the COVID-19 Pandemic: A Systematic Review and Meta-analysis
Sheri Madigan; et al. JAMA Pediatrics, published online May 1, 2023.

Comparison of Paediatric Emergency Department Visits for Attempted Suicide, Self-Harm, and Suicidal Ideation Before and During the COVID-19 Pandemic: A systematic review and Meta-Analysis
Sheri Madigan; et al. The Lancet Psychiatry, May 2023.

If you feel suicidal, please talk to somebody. Dial 988 to call the National Suicide Prevention Lifeline. You can call the Trans Lifeline at 877-565-8860 or the Trevor Project at 866-488-7386. You can speak to someone via text message by texting “START” to the Crisis Text Line at 741741. If you don’t like the phone, consider using the Lifeline Chat. The Veterans Crisis Line connects service members veterans in crisis and their family members and friends with qualified Department of Veteran’s Affairs responders through a confidential, toll-free hotline, online chat, or text messaging service. Dial 1-800-273-8255 and Press 1 to talk to someone or send a text message to 838255 to connect with a VA responder. You can also start a confidential, online chat session at Veterans Crisis Chat. This text was adapted from the American Association of Suicideology’s reporting recommendations and the National Institute of Mental Health.

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Journalists are often encouraged to be active on social media and engage with their audiences, but their newsroom social media policies do little to protect them when they’re attacked or harassed online, according to a recent study that adds to a growing body of research based on surveys of reporters and editors across North America.

Women and journalists of color are particularly vulnerable to these attacks, notes Jacob Nelson, an assistant professor in the Department of Communication at the University of Utah, and author of a recent study, “‘Worse than the Harassment Itself.’ Journalists’ Reactions to Newsroom Social Media Policies.”

His study, published last month in Digital Journalism, is based on in-depth interviews with 37 reporters, editors, publishers, freelancers, and social media and audience engagement managers in the U.S. and Canada, who were current or former employees of local, national, for-profit, nonprofit, print, digital and broadcast outlets.

It’s worth noting that Nelson’s study may or may not apply to other countries, as newsroom cultures and approaches to social media, free speech and online harassment vary depending on the country. It also focuses on how journalists perceive their newsroom’s social media policies, rather than textual data collected from the policies themselves. In addition, not all the journalists voiced the same criticisms of their newsrooms, he notes.

But his findings echo what previous small studies based on interviews with journalists have found, highlighting the complicated role of social media in journalism today. While many journalists find platforms like Facebook and Twitter invaluable in their reporting, they also see them as dangerous and unsettling places. And while many newsrooms encourage journalists to have a presence on social media, they do little to protect them when they’re trolled or attacked online.

Several studies in recent years have urged news leaders and organizations to find ways to protect their journalists when they’re harassed online.

“The Chilling: A Global Study of Online Violence Against Women Journalists,” published by the International Center for Journalists in November 2022, is a three-year study among 1,100 participants covering 15 countries, including the U.S., which finds 73% of respondents identifying as women said they experiences online violence. Black, Indigenous, Jewish, Arab, Asian and lesbian women journalists participating experienced the highest rates and most severe impacts of online violence. The authors emphasize the role of various entities, including news organizations, in developing “gender-aware protocols to respond to online violence, stop victim-blaming, and avoid disproportionate restraint on the speech of women journalists when they come under attack.”

A 2021 study published in Journalism Practice, based on interviews with 31 U.S. journalists finds “almost no system-level interventions regarding harassment from audiences on social media or journalists’ long-term mental health.”

The authors of that study find journalists face three types of harassment: “acute harassment such as generalized verbal abuse, chronic harassment occurring over time and often from the same social media users and escalatory harassment that is more personalized and directly threatening.” Women were most likely to experience chronic and escalatory harassment, the authors write.

Studies have shown that online harassment of journalists — particularly women journalists and journalists of color — can affect their mental health.

In the commentary “What Will it Take for Newsroom Leaders to Support and Defend Journalists?” published in September 2022 in Journalism & Communication Monographs, Tracy Everbach, a journalism professor at the University of North Texas, writes, “It shouldn’t require someone vandalizing a supervisor’s house to get newsroom leaders’ attention. We all bear responsibility for preparing, training, placing, and retaining journalists in safe and inclusive environments.”

“Have your own voice, but don’t use certain language, certain words. … There’s a lot of policing of language. How can you have your own voice when you have all these restrictions?”

Shree Paradkar, a social and racial justice columnist for the Toronto Star

Walking a “tightrope”

In many newsrooms, journalists are encouraged or even required to have a presence on social media and build an audience for themselves and the news organization. Many journalists also find social media an integral part of their reporting to find sources, connect with their community and even galvanize efforts such as union drives.

At the same time, newsroom social media policies can be confusing for journalists who want to be more authentic in their posts and interact with their audience.

Nelson quotes several journalists in his study.

Shree Paradkar, a social and racial justice columnist for the Toronto Star, told Nelson, “On social media, we are told to have your own voice because [the news organization] recognizes that, if you’re on social media, then your authenticity is really important if you want to have more followers. … Have your own voice, but don’t use certain language, certain words. … There’s a lot of policing of language. How can you have your own voice when you have all these restrictions?”

It’s a tension between mass media’s focus on neutrality and independence, and social media’s rewards for authenticity, popularity and connectivity, Nelson writes.

And even if a journalist strictly follows a newsroom’s social media guidelines, no amount of policing and policy can predict how the public is going to respond to a post or a tweet.

As a result, many journalists end up having to navigate a “tightrope,” where the social media platforms they depend on are accompanied by the very real risk of professional, physical, and emotional harm, Nelson writes.

His interviewees expressed deep frustration that they couldn’t control when they might face punitive measures from their newsroom managers for something they posted, because they couldn’t predict what might cause the online audience to perceive something undercutting the neutrality of their publication.

They also were frustrated that the enforcement of newsroom social media policies focused on the organization’s credibility tended to skew unequally toward women and journalists of color.

“As the interviewees consistently explained, because social media policies tend to focus on how posts get perceived rather than how they are written in the first place, enforcement most frequently occurred when the online audience was upset about something,” writes Nelson. “And because the online audience tended to get more upset more often at things posted by women journalists and journalists of color, those journalists paid professional penalties for their use of social media more often than their male, white counterparts.”

“I think a lot of journalists feel like they’re out there on their own, and they are.”

Carla Murphy, a former editor for The View from Somewhere podcast and board member of the Journalism & Women Symposium

In their own words

Nelson’s 37 interviewees included 22 women and 18 journalists of color. They were based in print and digital newsrooms in the U.S. and Canada. One was based in the U.K. They were primarily women journalists and journalists of color. The interviews were done between July and September 2021 via Zoom.

Nelson lists four key findings from his interviews. Considering the risk of professional consequences, the interviewees could choose to be quoted by name, anonymously, or not at all. They also had a chance to review their quotes.

1. Participants consistently said social media platforms, particularly Facebook and Twitter, played an integral role in their work.

Sewell Chan, editor-in-chief of the Texas Tribune, told Nelson the potential for bringing new audiences to journalism was one of the biggest draws of social media platforms.

“When I’ve talked to journalists about reasons to be on social media, I have emphasized that, at the very, very least, you need to recognize at the point your content is published, that’s actually the beginning of a process, not the end of a process,” Chan told Nelson. “We are in the fight for our lives, for the lives of our institutions, and we need to find readers wherever they are.”

Renata Cló, Arizona schools reporter with The Arizona Republic, told Nelson that social media “gives us an opportunity for people to easily reach out to me and say what they think of my story or leave a suggestion or a criticism to my story or something I hadn’t thought about. When people call me or send me an email about any story, they are usually very mad, and they are very disrespectful. [When I respond to them,] it’s just a matter of me trying to tell people, ‘Hey, I’m not a robot.’”

2. Interviewees said online harassment was their biggest concern when using social media.

One journalist told Nelson when she shared the news about her pregnancy on Facebook, she was thrilled by the thousands of positive comments at first. But when some of her followers realized she wasn’t married, people attacked her for being a “bad role model.”

“They wished death upon my child because I wasn’t married … They were so absolutely horrendous and that emotionally took a toll on me,” she said.

Another reporter, Barbara VanDenburgh, the books editor for USA Today, told Nelson, “It is scary … for people to be calling you a ‘bitch’ or a ‘whore,’ and to come after you on Twitter in a really personal way.”

3. When asked what their newsrooms did to help support them in the face of online harassment, many voiced dissatisfaction.

One journalist summed it up to Nelson in one word, three times: “Nothing. Nothing. Nothing.”

Some said the social media policies of their news organizations did not include protections or resources for journalists facing either acute or recurring online harassment.

Jessie Shi, the former social media editor for the San Antonio Express-News, told Nelson, “Reporters are usually on their own when it comes to trolls.”

“The response to online harassment can genuinely be worse than the harassment itself,” Jamie Landers, a former health disparity reporter with Arizona PBS, and a former breaking news reporter with the Arizona Republic, told Nelson.

“You’re constantly told to ‘tough it out,’ which is possibly the most immature piece of advice I’ve heard in my life,” Paradkar told him. “Because not only does it mean that you are not allowed to acknowledge the fear and pain, possibly trauma, depending on the level of abuse, but it also puts in place the ability for someone to do it again to somebody else.”

“This lack of interest in addressing the threats, harassment, and abuse journalists face — particularly women journalists and journalists of color — left some of the journalists I spoke with feeling as though their editors were implicitly suggesting that online abuse was just an inevitable part of working in journalism in an era of social media,” Nelson writes.

4. Interviewees told Nelson their newsroom policies focused on advising journalists how they should or should not use social media instead of telling them what they should do when they’re harassed online.

“It’s pretty wild that there’s this double-edged sword where you’re not sure if you’re going to be punished for using social media, and yet you need to use social media in order to represent the outlet and the brand,” said Gabe Schneider, the editor of The Objective, told Nelson.

Carla Murphy, a former editor for The View from Somewhere podcast and board member of the Journalism & Women Symposium, said, “I think a lot of journalists feel like they’re out there on their own, and they are. They get hung out to dry. But then which journalists get hung out to dry? Some get hung out to dry more than others. Women, right? Black women. Black men. Some people get second and third chances. The penalties aren’t applied equally.”

“The response to online harassment can genuinely be worse than the harassment itself.”

Jamie Landers, a former health disparity reporter with Arizona PBS, and a former breaking news reporter with the Arizona Republic

Advice for news managers

“If I were to take this study to a newsroom, I would say, ‘Look, you’re not just looking at a crisis when it comes to your relationship with your audiences, but you’re looking at a labor crisis, because your journalists feel like they are being really left out in the cold by the policies,” Nelson tells The Journalist’s Resource. “It’s very clear from these interviews that [the lack of policies] is creating ill will between journalists and managers, because they feel like they’re being pushed to do something that carries a risk, but then they’re not given any protection from the organization when it comes to combating those.”

The Media Manipulation Casebook, a research platform on misinformation and disinformation at Harvard Kennedy School’s Shorenstein Center on Media, Politics and Public Policy, which is also home to The Journalist’s Resource, offers several tips for newsrooms to support journalists targeted by online harassment:

• Provide every journalist with an annual check-up of their digital security, and prioritize those whose coverage puts them more at risk.
• Provide every journalist with a subscription to a password manager
• Have at least one person in the newsroom or on call who is a digital security specialist.
• Regularly communicate to staff that your newsroom cares about their well-being and demonstrate it by offering reporters an intake mechanism for sharing when they’re undergoing harassment.
• Have a chain of support ready to help.
• Validate reporters’ experiences and provide places to communicate about their well-being safely.
• Build email filters that scan for racist, sexist, and bigoted language.
• Monitor and report the journalists’ social media threats for them.

Research roundup

• “Occupational Hazards: Individual and Professional Factors of Why Journalists Become Victims of Online Hate Speech.” Magdalena Obermaier. Journalism Studies, January 2023.
• “Online Harassment and Hate Among Media Professionals: Reactions to One’s Own and Others’ Victimization.” Magdalena Celuch, Rita Latikka, Reetta Oksa and Atte Oksanen. Journalism & Mass Communication Quarterly, January 2023.
• “You Have to Do That for Your Own Sanity”: Digital Disconnection as Journalists’ Coping and Preventive Strategy in Managing Work and Well-Being.” Maja Šimunjak. Digital Journalism, January 2023.
• “Dark Participation” Without Representation: A Structural Approach to Journalism’s Social Media Crisis.” Kaitlin C. Miller and Jacob L. Nelson. Social Media + Society, October 2022.
• “Tackling the Emotional Toll Together: How Journalists Address Harassment with Connective Practices.” Anu Kantola and Anu Harju. Journalism, December 2021.
• “Journalists on Instagram: Presenting Professional Identity and Role on Image-focused Social Media.” Diana Bossio. Journalism Practice, November 2021.
• “Hostility Toward the Press: A Synthesis of Terms, Research, and Future Directions in Examining Harassment of Journalists.” Kaitlin C. Miller. Digital Journalism, October 2021.
• “Not Their Fault, but Their Problem”: Organizational Responses to the Online Harassment of Journalists.” Avery E. Holton, Valérie Bélair-Gagnon, Diana Bossio and Logan Molyneux. Journalism Practice, July 2021.
• “A Conceptual Framework for Journalistic Identity on Social Media: How the Personal and Professional Contribute to Power and Profit.” Claudia Mellado and Alfred Hermida. Digital Journalism, May 2021.
• “Online Harassment and Its Implications for the Journalist–Audience Relationship.” Seth Lewis, Rodrigo Zamith and Mark Coddington. Digital Journalism, Septemeber 2020.
• “Dimensions of Social Media Logics: Mapping Forms of Journalistic Norms and Practices on Twitter and Instagram.” Alfred Hermida and Claudia Mellado. Digital Journalism, August 2020.
• “Attacks and Harassment: The Impact on Female Journalists and Their Reporting.” Michelle Ferrier, founder of TrollBusters. International Women’s Media Foundation, 2018.
• “Don’t Tweet This! How Journalists and Media Organizations Negotiate Tensions Emerging From the Implementation of Social Media Policy in Newsrooms.” Vittoria Sacco and Diana Bossio. Digital Journalism, March 2016.
• “Violence and Harassment Against Women in the News Media: A Global Picture.” Alana Barton and Hannah Storm. International Women’s Media Foundation, February 2014.

Resources for newsrooms and journalists

• “A Guide to Protecting Newsrooms and Journalists Against Online Violence.” International Women’s Media Foundation.
• “A Mental Health Guide for Journalists Facing Online Violence.” International Women’s Media Foundation.
• “Online Harassment Field Manual.” PEN America.
• Digital Safety Snacks. PEN America, the Online News Association and the International Women’s Media Foundation.
• Digital Security Resource. A collection of resources by ACOS Alliance.
• “Protect Your Staff from online Abuse with a Formal Policy and A Response Plan.” Naomi Ishisaka and Danny Gawlowski. Better News, January 2021.
• Coalition Against Online Violence.
• “Keeping Journalists Safe Online: A Guide for Newsrooms.” Reuters Institute and the University of Oxford.
• “Online Abuse: A Self-Defense Guide.” Dart Center for Journalism & Trauma.
• “How Newsrooms, Journalists, and Their Peers Can Combat Online Violence.” Nieman Reports.
• “Practical and Legal Tools to Protect the Safety of Journalists.” Thomson Reuters Foundation.
• “Resources for Protecting Against Online Abuse.” Committee to Protect Journalists.
• “‘Women journalists more vulnerable to online harassment’.” Rappler.com, December 2017.
• “Resources for Female-Identifying Journalists: Safety, Discrimination & Harassment.” Global Investigative Journalism Network.
• “Our Reporter’s Work on COVID-19 Has Saved Lives. She’s Getting Death Threats.” Matt DeRienzo. Center for Public Integrity, June 2021.
• From The Journalist’s Resource:
  • “13 Security Tips for Journalists Covering Hate Online.” April Glaser. May 2020.
  • “Study Shows Female Journalists Face ‘Rampant’ Online Harassment.” Denise-Marie Ordway. August 2018.
  • “Self-Care Tips for Journalists – Plus a List of Resources.” Naseem Miller. July 2021.

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About a decade ago, Dave Seglins covered the trial of a Canadian military commander who had turned into a serial killer. The trial was graphic, and it was not easy to sit through.

“A couple days after the sentencing, I had a total break, which I wouldn’t have used that word at the time,” recalled Seglins, an investigative reporter and well-being champion with CBC News in Toronto, during a one-hour virtual session about prioritizing mental health in newsrooms on Jan. 17. “I just thought I was dying, and I couldn’t get out of bed and I was having all of these responses that I did not understand.”

A family doctor referred him to a trauma specialist who told him that what he was experiencing was a normal reaction to what he had witnessed during the trial. He was having a post-traumatic stress response.

“We are incredibly good in this business to prioritize the story and the content and the product,” said Seglins, who recently co-authored a study on the mental health and well-being of Canadian media workers. “What we’re not great at is managing the people and making it okay for people to be imperfect and to be affected by the work.”

Along with Seglins, the webinar included Scott Blanchard, director of journalism at public media station WITF in Harrisburg, Pa., a board member for the Trust for Trauma Journalism; Sewell Chan, editor-in-chief of the Texas Tribune, who led his newsroom in the coverage of the 2022 mass shooting at Robb Elementary School in Uvalde; and Dr. Elana Newman, research director of the Dart Center for Journalism & Trauma and McFarlin Professor of Psychology at the University of Tulsa. I moderated the session, which was hosted by The Journalist’s Resource.

Below is the recording of the session and you can read the transcript here. I’ve also highlighted five of my favorite takeaways from the discussion and listed several resources, including two books mentioned by the panelists.

1. Learn about basic trauma terminology.

Trauma, stress and burnout are not the same and should not be treated the same.

Stress is not being able to meet the demands at that time, Newman explained. “We all have stress and stress can make traumatic stress worse. And in fact, I have research with my students that I have discovered that it’s trauma plus a toxic organizational environment for journalists that’s the lethal combination. And that’s why we can’t always reduce the exposure, but we can make the organization safer,” she said.

Trauma is a complex and ambiguous noun and can refer to a physical wound or psychologic injury, according to The Dart Center Style Guide for Trauma-Informed Journalism. “It can refer to a one-time experience or aftermath of overwhelming fear, or the cumulative, complex impact of ongoing abuse and threat, or both,” according to the guide.

Meanwhile, burnout is separate from trauma, Newman said. “It can be related, but burnout is when you have just too much to do and it overwhelms your resources and it usually leads to exhaustion, cynicism,” she said.

There’s also vicarious trauma, which refers to psychological changes resulting from cumulative, empathetic engagement with trauma survivors in a professional context, according to Dart’s style guide. It refers to a changed worldview. “And it’s actually technically refers to both positive and negative ways that your worldview may be changed,” Newman said. “You may see danger everywhere. You may see the world as only a terrible place.

“The world is a dangerous place, but there’s also safety in it. There’s also beauty in it, and trying to keep that balance is important,” she said.

2. Become a champion for mental health in your newsroom.

In Seglins’ case, he took an online course through Harvard Medical School, to learn about the concepts of global mental health and trauma, and the brain science of stress and trauma. He was a fellow of Dart Center’s 2022 Ochberg Fellowship, a program that deepens journalists’ reporting of violence and tragedy.

Holding a town hall meeting was one of the first things Seglins did at CBC News in his role as well-being champion.

He and his colleagues started with a simple question: What can we do to build a culture of well-being around here? They recorded ideas, sent out short survey to their colleagues, published the results internally and prompted a company-wide discussion.

 “If you’re a reporter in the newsroom, own it. Just do it,” Seglins said. “Say, ‘Hey, let’s get together. Let’s have an event.’ We all know how to run a Zoom call now. Doesn’t take much.”

3. Develop protocols for covering traumatic events and hold training sessions.

Blanchard helped create a committee among several newsrooms on the East Coast and together, they developed a guide on how a trauma-awareness and peer-support program in a newsroom would operate.

They followed that with a day-long training for Central Pennsylvania newsrooms with experts, including Newman and a psychologist with a local healthcare system. That training included role-playing for peer support. They held another training, led by the Dart Center, for the broader East Coast newsroom cohort.

“We can change newsroom by newsroom, person by person. We can change. We can make the change happen,” Blanchard said.

Dart Center provides a range of training sessions to news organization and journalism-related nonprofits around the world.

4. Have a specific plan for covering mass tragedies.

“We should recognize and our default should be that covering a massively traumatic event demands that we think about the processing of it and the aftermath of it, and offer people the help, rather than waiting for them to come forward and say that they need it,” said Chan.

At Texas Tribune, following the Uvalde mass shooting, Chan reached out to the Dart Center and Trust for Trauma Journalism for guidance.

The news managers insisted that reporters who had been on the ground for a certain number of days had to leave even if they wanted to stay on this story. The newsroom held sessions for the entire staff to talk about processing what they had just seen and observed. And they brought in a counselor to help smaller set of journalists who were dealing specifically with very graphic material footage that had emerged from the tragedy.

“We can’t say anymore, ‘Well, these are exceptions.’ You have to actually build into your newsroom protocols [with the thought] that something traumatic is probably going to happen,” said Chan, whether it’s a natural or human-caused tragedy.

5. Put people first.

“We do need to be results-oriented as organizations, but we also need to be people-centered,” said Chan. “There’s a human capital crisis in much of journalism. If we’re losing people because we have not supported them, really shame on us, because that’s not only a sign of institutional failure, but also it’s not efficient.”

He hoped that people on the finance side of news operations hear the message and realize that there’s a cost associated with losing and replacing journalists.

“It’s much better to help your existing people to succeed than see a portion of them leave out of frustration or burnout,” said Chan. “There’s this opportunity cost. It doesn’t seem like a cost unless you think about all the other things that you now have to do to make up for that lost work or that lost talent. And that’s really a tragedy.”

Answers to some of the audience questions post-panel

Following the panel, Blanchard volunteered to answer some of the audience questions not addressed during the discussion because we ran out of time. We’ve included the questions and Blanchard’s responses below.

Q: I have conducted research among South African editors on how they are handling journalism related trauma in the newsroom. Firstly, many did not feel equipped to provide trauma support so I agreed with you, we need additional trauma support through in-house psychologists. However, the media economy is under severe strain. There is no money within media organisations. Budgets are tight. How does the panel propose for newsrooms that don’t have the resources that the BBCs and New York Times of this world?

Blanchard: Look for free training opportunities through the Dart Center or other organizations working in this space. Try to connect with a local clinician who understands, respects and/or is a ‘fan’ of journalism, to see if they can provide help with training or resources.

In the U.S. many communities have courses in Mental Health First Aid, which can be free and often don’t cost a lot, and can be helpful for newsroom editors or staff. If you can get a core of people in your newsroom (even just 2 or 3) who can get some training, you may be able to then train others in the newsroom.

Q: This is amazing! Thank you all for your work and leadership in this field. Curious to hear your thoughts on how we can extend these conversations with the people we cover? I recently worked on a project about military sexual violence, and had many conversations with some of the survivors about their experiences with journalists, and how we can better empower them to set boundaries or to care for themselves. Any thoughts on this?

Blanchard: One thing we did not do, but should have, with the program we put together at the York Daily Record, was bring in trauma survivors — including those who have been the subject of news coverage — to talk with staff so that we could more deeply understand the effect trauma has in peoples’ lives and do journalism that is smarter and more respectful of what survivors are going through. I also admit I never thought of it the way you presented it — how could a trauma survivor help others set boundaries/care for themselves? That’s really interesting.   

Q: I’ve been working on an important but difficult, traumatic story for the last year — since January 2022 — on human trafficking in our community. The personal safety of sources and myself have been a concern all along, The newsroom has been wonderful giving me time to investigate — and to walk away from the story and cover other things for my sanity. The time has come to write the first part of the story and I feel paralyzed, hesitating to immerse myself in this person’s trauma long-enough to write it. Do you have any advice for a journalist in the thick of it needing to produce the final product?

Blanchard: In working with both journalists and clinicians in the trauma-journalism space, I hear a common thread that once a person trusts you with their story, you can return that trust by telling their story authentically, truthfully, with humanity … in hopes that through your work, the survivor and their story will be understood. I don’t know if this helps at all, but I think by investing your time and heart in receiving this person’s story and then telling it to a wider world, you are doing something honorable.  

Q: Our newsroom is intentional in addressing trauma from journalism and general mental health, which is what most mental health stories and tipsheets deal with. How can managers support staffers who come to the job with generational trauma, trauma from racism, trauma from their everyday lives or are neurodiverse?

Blanchard: If you can establish a newsroom culture where trauma and mental health conversations are normal and accepted as a sign of a strong newsroom, and not something viewed as unusual or exceptional or to be avoided, I think you open the door for staffers and managers to discuss whatever individuals bring to the job. 

Q: “Any culture change is hard.” Very true. How would y’all suggest or have experience challenging ‘shame’ when it comes to needing to have mental health conversations in a newsroom? For young journalists in particular for whom it’s just occurring that they may be having trouble.

Blanchard: See if you can figure out ways to normalize conversations around trauma and mental health in the newsroom. You can do it in part by linking it to best practices as a journalist: The more you understand about these issues, the stronger your reporting and writing will be. If people feel comfortable in that space, they may feel more comfortable talking about issues they may be having. 

Q: What are some ways a small short-staffed newsroom start to address burnout?

Blanchard: If you’re sensing that there is staff-wide burnout, or that there could be, you could consider talking to staff about what’s going on and seeing if there are problem-solving opportunities. Just acknowledging it can be a big deal — I have heard a lot of people say that the thing that grinds on them the most is that leadership is clueless as to what is going on. I can speak from experience when I say that even well-intentioned managers will miss things or not be as aware/responsive as they should be. You may also find that some staffers just need to be heard and supported regarding frustrations they’re having, and simply having a conversation can be a helpful start to meeting challenges in the newsroom.     

Q: As a professor who teaches university students hoping to go into journalism, what would be the most important wisdom you would impart to them? What should they do to prepare?

Blanchard: As a manager who has hired his share of young reporters, I would say that they should understand that as journalists, they may or will be involved in or exposed to stories of trauma. They should learn as much as they can about trauma awareness, self-care and peer support. When they interview for jobs, they should ask newsrooms what is in place — infrastructure, training, commitment etc. — with regard to those issues.

Additional resources:

• The Dart Center for Journalism & Trauma has a wide range of resources for journalists and news managers, including a style guide on trauma-informed reporting.
• Here’s the Taking Care Report, resulting from a survey of 1,200 Canadian media workers.
• The panelists mentioned two books about journalism and trauma. One was “The Bang-Bang Club: Snapshots from a Hidden War” and the other was “Journalists Under Fire: The Psychological Hazards of Covering War.”
• Check out this resource list on self-care and coping with trauma for journalists.
• On The Journalist’s Resource website, you can find several articles on journalism and trauma:
  • Trauma-informed journalism: What it is, why it’s important and tips for practicing it.
  • Journalists are under stress. What’s the solution?
  • Self-care tips for journalists – plus a list of resources.

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On April 25, 2014, the city of Flint, Michigan, changed its municipal water supply source from the Detroit-supplied water coming from Lake Huron to the Flint River as a cost-saving measure. The new water source, however, was not treated and tested adequately, so it corroded the old water pipes, resulting in lead and other contaminants to enter drinking water.

By September 2015, a Virginia Tech research team found “serious levels of lead in the city water.” On Oct. 16, 2015, the city switched back to the Detroit water supply.

But the crisis didn’t end there.

By 2020, the rates of mental health disorders such as depression and post-traumatic stress disorder remained higher than average, according to a recent study in JAMA Network Open.

One in 5 Flint residents met the criteria for depression, 1 in 4 for PTSD and 1 in 10 for both depression and PTSD, estimates that exceed regional, national and global averages, according to “Prevalence of Depression and Posttraumatic Stress Disorder in Flint, Michigan, 5 Years After the Onset of the Water Crisis.” The study is based on in-depth online and mail surveys of 1,970 adult Flint residents between 2019 and 2020.

“We can’t know what percent is directly attributable to the crisis versus preexisting issues that have been around in Flint for a number of years, including disinvestment and concentration of poverty, which can influence mental health problems,” says Aaron Reuben, the study’s lead author and a postdoctoral scholar at Duke University and the Medical University of South Carolina. “But we find that when you compare Flint to the wider country or to Michigan, depression and PTSD are significantly elevated and we were able to connect this elevation to experiences people had during the crisis.”

Although the statistical findings of the study may not be generalizable to other regions, they add to the existing body of literature documenting the mental health effects of human-caused disasters on communities.

“Environmental disasters have significant mental health consequences, particularly when they involve toxic chemicals, misinformation being distributed, possibly criminal negligence by public officials, and they last a long time,” Reuben says.

For public official and decision makers, the message is to make mental health response part of the crisis response, Reuben says. “And it should start at day one with the assessment of need.”

The study finds several factors associated with persistent mental health conditions following the Flint water crisis, including being female, an annual income below $25,000 and previous traumatic experiences. Those who felt the water crisis had affected their health or their family’s health were also significantly more likely to meet the criteria for depression or PTSD.

Low confidence in public officials and lack of trust in the accuracy of information given by them was also linked to whether people had mental health problems later, as they continued to worry about potential health complications from exposure to contaminated water or didn’t understand what they’ve been exposed to.

“Those things are psychologically stressful and can be limited by good communication campaigns” by public officials, Reuben says.

Also significant among the findings is access and use of mental health services.

Among the respondents, 34.8% said they were offered mental health services. Among those who were offered the service, 79.3% accepted it.

“We found that when you offer services, people do want them,” Reuben says.

Despite the study’s findings, Reuben emphasized that the Flint community is remarkably resilient.

“When you look at all of the crises, the stressors, the disinvestment that the community has gone through over not just the last few years, but decades, in a way, they’re doing remarkably well,” he says. “What we want to do is just highlight that there are a number of folks who are not doing as well as they could and that we want this to be bringing attention to the lingering needs in the community.”

More on the study and its findings

The survey was conducted between Aug. 13, 2019 and April 10, 2020. Most of the data were collected before COVID-19 was declared a pandemic in March 2020, the authors write. Respondents were compensated with $35.

Slightly more than half of respondents were women. In total, 53.5% were Black, 42.5% white, 0.1% Asian, 0.3% Native American and 1.6% checked “other.” About 2% said they were more than one race.

Of the responding households, 56.8% had an annual income below $25,000 and 6.3% had an income above $75,000.

The authors say the final sample was demographically representative of Flint’s adult population. The city’s population was 80,628 in July 2021, according to the U.S. Census Bureau.

Most of the respondents — 86.8% — lived in homes directly affected by the water crisis.

In total, 97.7% said they changed their behavior to avoid or reduce exposure to contaminated water by avoiding drinking, cooking or cleaning with it. Of the respondents, 76.9% reported spending money to lower their risk by taking measures such as buying bottled water for cooking and cleaning or replacing all pipes and fixtures in their homes.

At the time of survey, 80.1% said they were concerned that exposure to the contaminated water would have long-term effects on their health.

Based on survey results, the study estimates prevalence of depression in the city was 22.1% during 2019-2020, more than double that in Michigan (9.4%), the U.S. (7.8%) and globally (7.2%), according to the study.

Prevalence of PTSD was two-to-five times greater than rates among U.S. veterans after deployment (12.1%), the general U.S. population (4.7%) and estimated global averages (2.8%), the study estimates.

Aside from factors such as gender, income and lack of trust in public officials, previous traumatic experiences were also associated with higher risk of depression and PTSD after the water crisis.

Respondents who had past exposure to any potentially traumatic events were twice as likely to experience depression, 4.5 times as likely to meet the criteria for PTSD and 5 times as likely to report both depression and PTSD compared with the general populations.

Rates were even higher for individuals who reported past physical or sexual trauma. They were 3 times as likely to report depression, 6 times as likely to have PTSD and 7 times as likely to report both compared with the general populations.

“There’s plenty of reasons the mental health problems we’re seeing today will continue unless additional services [are provided in Flint],” says Reuben. “The crisis isn’t done necessarily.”

The study has several limitations. Researchers’ estimates of depression and PTSD are presumptive because the conditions were not diagnosed by a clinician. Also, the estimates could be low if those who responded to the survey were less impaired than those who did not participate, or, high if those with unmet mental health needs were more motivated to participate.

In addition, the study doesn’t establish causal relationships between the water crisis and mental health condition, the authors note. The study also didn’t measure actual lead exposure, but the perception of it.

More research on the mental health effects of environmental disasters

Researchers have long known that natural and human-caused disasters are stressful events, and that a certain portion of the affected population will develop mental health conditions. Most studies recommend including mental health outreach early in the crisis response.

Here are a few studies on the mental health effects of environmental disasters in the U.S.:

Jackson County, Mississippi: In November 1996, one of the largest human-caused disasters in U.S. history at the time was confirmed by officials in Jackson County, Mississippi: 1,800 homes and businesses had been contaminated with the pesticide methyl parathion during a 10-year period.

The chemical, approved by the Environmental Protection Agency for spraying over fields to control insects, was being used indoors, mainly by exterminators, to kill insects, especially cockroaches. The chemical affects the nervous system and high doses can cause death. By 1997, the EPA had spent $69 million to decontaminate homes and businesses. No deaths or serious injuries were linked to the pesticide, according to Stephen Braun’s 1997 narrative piece in the Los Angeles Times.

A 2000 study, published in the journal Health & Social Work, finds 55% of those affected by the contamination, regardless of contamination levels, had symptoms of depression. The study was based on phone or in-person surveys of 115 households, between October and December 1997.

“Mental health services and support groups should be made available immediately after the disaster and remain accessible for a couple of years after the cleanup begins,” the authors write. “Because victims are unlikely to actively pursue formal providers, public awareness campaigns should begin soon after the disaster and attempt to legitimize formal mental health services and make them more readily available and accessible for low-income people.”

Graniteville, South Carolina: In January 2005, a large chlorine spill in Graniteville, South Carolina, led to death of nine people and hospitalization of 72. At least 840 people received medical treatment at area hospitals and doctors’ offices.

A survey of 225 survivors about 10 months after the spill showed that 36.9% had symptoms of post-traumatic stress, according to a study published in Social Psychiatry and Psychiatric Epidemiology in November 2011. Also, 27% of respondents reported panic attacks.

“Our findings suggest that personnel providing mental health services should be especially considerate of those with serious physical injuries,” the authors write. “Perhaps even more important than exposure, the physical morbidity resulting from a disaster is a strong risk factor for psychological distress.”

Flint, Michigan: Researchers have also studied mental health outcomes of the Flint water crisis shortly after it happened.

A 2017 study, published in the Journal of Community Psychology, used online and mail surveys of 786 Flint residents, conducted between September 2015 and September 2016, to examine the relationship between perceptions of household tap water quality and post-traumatic stress disorder symptoms.

Researchers find those who experienced poorer tap water quality during the water crisis experienced greater PTSD symptoms.

“The findings of our study underscore the negative effects of the Flint water crisis on adults and demonstrate the need for psychological interventions addressing the psychosocial effects of the crisis,” the authors write.

Jackson, Mississippi: The water crisis in Jackson, Mississippi, resulting from the failure of the city’s water treatment plants in August 2022, is a more recent example of a water disaster.

A December 2022 study, published in the journal Sustainability, uses health data from the Centers for Disease Control and Prevention to statistically compare the city of Jackson with eight nearby cities. It finds worse health status and health outcomes in Jackson compared with nearby cities, pointing to issues with the city’s hygiene and environmental health system.

“The urban water crisis in Jackson may already result in immense public health inequities, and the black communities experience significantly higher public health diseases than the majority-white cities,” writes the study’s author, Qingmin Meng. “The significantly worse mental and physical health status and the nine types of health outcomes in Jackson and Canton, which are majority-black cities in the Jackson region, than other seven non-majority black cities have showed Jackson may have started a critical degradation in public health that is still significantly threatening the black communities in Jackson, and likewise, the city of Canton.”

Meng compares the Jackson water crisis to Flint’s.

“Currently, the Jackson water crisis is significant yet overlooked for many years that may end up causing public health consequences even worse than Flint,” he writes.

Take-home message

Reuben says just providing more mental health services isn’t enough. Rather, there needs to be a holistic look at factors driving depression and PTSD in the community beyond a water crisis.

“We can’t go back and undo the crisis, but we can create a situation in which people feel that their needs are being looked after, that the information being provided by public officials are accurate,” he says.

He encouraged journalists to hold officials accountable, especially after published research points out the existing problems.

“We’ve got this study. Now what? Who’s going to do something with it?” he asks. “Get the response of folks in positions to make those decisions. What do they think of these findings? Go into the community and find people willing to be the representative, the voice and face of some of these problems.”

Additional reading

• “Experiences of the Flint Water Crisis Among Reproductive-Age Michigan Women in Communities Outside of Flint: Differences by Race and Ethnicity,” Sidonie K. Kilpatrick, et al. Journal of Racial and Ethnic Health Disparities, March 2022.
• “Lead-Laced Water In Flint: A Step-By-Step Look At The Makings Of A Crisis,” Merrit Kennedy, published on NPR in April 2016, details the timeline of the Flint water crisis.
• “‘Roach Men’ Left Toxic Trail,” Stephen Braun, published in October 1997 in the Los Angeles Times, explains the methyl parathion crisis in Jackson County, Mississippi.
• “Water, but not everywhere: Research sheds light on race and water access in metro areas,” Clark Merrefield of The Journalist’s Resource, published in November 2020, details a study that finds householders of color in the 50 largest metropolitan areas were 34% more likely to lack what the U.S. Census Bureau calls “complete plumbing” compared with white, non-Hispanic householders.
• “Racial disparities in access to running water: 5 studies to know,” Clark Merrefield of The Journalist’s Resource, published in November 2020, highlights five academic on the link between race and access to indoor running water.
• “Investigating stories on water access, affordability and safety: 5 tips to get started,” Clark Merrefield of The Journalist’s Resource, published in December 2020, lists five reporting tips for journalists.

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From failures to include older adults in clinical trials for treatments meant for older patients to internet tropes like #OKBoomer, ageism is so ubiquitous in Western society that unabashedly ageist acts often go unrecognized and unaddressed. Ageism can be structural, interpersonal, or self-directed, and it encompasses age-based thoughts (stereotypes), feelings (prejudice) and actions (discrimination).

Ageism can be overt, subtle, or even unconscious. Older adults often encounter comments, jokes, and representations of older people that perpetuate negative stereotypes and refer to them as a monolithic group, despite wide diversity in experiences and health status among older people. New research by Julie Ober Allen, an assistant professor and ageism researcher in the health and exercise science department at the University of Oklahoma, and her colleagues finds that encounters with “everyday ageism” — jokes about getting old on birthday greeting cards, for example, or comments made about older drivers — have a significant impact on health.

Older adults “are systematically disempowered, devalued and excluded from many aspects of contemporary society,” Allen said during a July 27 panel discussion on ageism convened online as part of the Journalists in Aging Fellowship Program, which helps reporters improve their aging-related coverage. “… Many examples [of everyday ageism] are perceived as humorous or considerate or even complimentary, yet they strip older adults of their individuality, and they’re used to justify treating them with less respect and fewer rights.”

Ageism may serve as a source of chronic stress in the lives of older adults, Allen explained during the panel discussion. Alternatively, older adults who believe that loneliness and depression are a normal part of aging might be less likely to seek care, take medications as prescribed, and adhere to their health care providers’ recommendations. Older adults who experience ageism in a health care setting might also be less likely to seek care.

“And I’m not just talking about their interactions with their health care providers, but also with the front office staff, with the ways that messages around them are framed and even things like systemic issues, such as procedures for making health care appointments,” Allen said.

A systemic problem

In the United States, ageism resulted in more than $63 billion in excess health care costs in 2018 alone, according to a 2020 article in The Gerontologist. Medical ageism among health care providers has been found to lead to both the overtreatment and undertreatment of disease and negative experiences that discourage older adults from seeking care. For example, negative attitudes about aging, such as the idea that depression is a normal part of getting older, often result in older people feeling demeaned or brushed off.

“Older people are more likely to have high health care needs, so you would think that the health care system would be built uniquely to serve them, but it’s not,” says Kevin Prindiville, executive director of Justice in Aging, a national legal advocacy organization. “You talk to doctors about their training in medical school, and very little of that training is specific to the needs and unique concerns of older adults. Yet when they’re out practicing medicine, they’re finding that many of the people they’re working with and serving are older people, so there’s a misalignment there.”

“Older people are more likely to have high health care needs, so you would think that the health care system would be built uniquely to serve them, but it’s not.”

— Kevin Prindiville, executive director of Justice in Aging.

At the individual level, median survival is seven and half years longer for people with a positive outlook on growing older, compared with people who internalize negative beliefs about aging, according to a longitudinal study by Yale psychologist Becca Levy and her colleagues. Decades of research by Levy and her team, employing a variety of methods to measure how negative attitudes about aging affect health, has shown that internalizing negative stereotypes about aging increases the risk of dementia, heart attack, mental illness and more.

These issues are particularly acute in Western society — with its youth-obsessed culture and “anti-aging” industries — but ageism is present elsewhere as well. More than half of the world’s population is ageist against older adults, according to the World Health Organization’s Global Report on Ageism, which also found that ageism is more prevalent in developing countries, and that women, minority groups, and people with lower levels of education are more likely to experience its adverse health effects.

Despite the ubiquitous and deeply ingrained nature of ageism, however, research also suggests that ageist views can be changed through education and increased intergenerational contact.

“We have found evidence that that these [ageist] processes can occur unconsciously, and if people don’t know it’s happening, it’s harder to challenge it and fight it,” Levy, author of Breaking the Age Code: How Your Beliefs about Aging Affect How Long and Well You Live, tells The Journalist’s Resource. “But on the other hand, our research has found that it is possible that these age beliefs are malleable, and they can be changed. So, I think there is definitely room to increase awareness of these negative beliefs and find ways to overcome them.”

Policy efforts at the federal level

In broad economic terms, the consequences of ageism are astronomical, with one study by AARP estimating unrealized gross domestic product growth in the U.S. at $850 billion for 2018, due to discrimination against a burgeoning population of older workers. That figure could reach $3.9 trillion by 2050, according to the report. As a result, older Americans are increasingly experiencing housing vulnerability and homelessness, which greatly exacerbates negative health outcomes, says Justice of Aging’s Prindiville.

Although the proportion of people over age 65 is growing quickly in the United States, policies to address issues that are common among people in this age group have historically been low priority at the state and federal level. Some research even suggests that aging-related policies can have the unintended consequence of intensifying age discrimination. Recently, however, the federal Centers for Medicare and Medicaid Services (CMS) rolled out proposed changes to section 1557 of the Affordable Care Act, which includes anti-discrimination provisions for protected groups, including older adults and people with disabilities.

Other policy work at the federal level is focused on making it easier for older people to receive the same medical care in their homes that they are entitled to receive in nursing facilities under Medicaid, explains Prindiville. These efforts are modeled on the success of advocacy groups for younger people with developmental disabilities who have worked to transition care for that population from institutions to homes and community-based programs.

“We’re looking to make a similar shift for other people with disabilities and for older adults,” Prindiville tells The Journalist’s Resource. “There is a coalition of people working on this in DC, and there are coalitions that are growing and building at the state level.”

States Undertake Master Plans for Aging

A few months before the start of the COVID-19 pandemic, California embarked on a campaign to collect input about aging-related issues and supports from stakeholders, policymakers and the public. This information-gathering effort kicked off a process to develop a 10-year master plan to prepare the state to better serve its fastest-growing population segment. Now, two years into implementation, the far-reaching California Master Plan for Aging is propelling an aging-related policy agenda in the state, says Prindiville, a member of the advisory committee that worked on the plan.

“Having the master plan has helped educate the state administration and different government agencies and departments about the aging population in California, has helped identify particular needs and priorities, and then has helped those agencies develop more specific action they can take for a community that otherwise, sometimes, is overlooked,” he says.

Other states are following California’s lead. The governors of New York and New Jersey have signed executive orders aimed at beginning similar planning efforts. The nonprofit Center for Healthcare Strategies is working with a coalition of 10 states — Colorado, Illinois, Indiana, Minnesota, North Carolina, North Dakota, Oregon, South Carolina, Tennessee, and Vermont — on master plans for aging.

“At the state level, sometimes it’s difficult to get momentum to take political and policy action on aging issues because they’re not seen as hot button political issues,” says Prindiville. “The master plans provide a vehicle and a framework to help a state get organized and to start to educate and elevate some of the issues.”

Research roundup

Recent research has examined the prevalence and health effects of ageism and negative age beliefs, as well as the efficacy of various policies and direct interventions, including intergenerational interactions or “cogeneration.” Below are summaries of seven curated peer-reviewed studies on ageism and health, including two by Levy and her team and one systematic review that she participated in as part of the WHO campaign.

Among the key findings in this research roundup:

• People with positive beliefs about aging live longer than those who internalize negative beliefs and stereotypes about getting older.
• Negative beliefs about aging increase a person’s risk of experiencing a cardiovascular event, such as angina attacks or stroke, later in life.
• More than 95% of studies that have examined the connection between ageism and health over the past 25 years have found that ageism results in worse health outcomes.
• In the U.S., 1 out of every 7 dollars (15.4%) spent on the eight most-expensive health care conditions among people ages 60 and older is linked to ageism.
• Research suggests 93.4% of people ages 50-80 regularly experience some form of ageism in their daily lives.
• Educating people about the aging process and providing opportunities for younger people to interact with older people are effective ways of reducing negative attitudes toward older people.

Longevity Increased by Positive Self-Perceptions of Aging
Becca Levy, Martin Slade, Suzanne Kunkel and Stanislav Kasl. Journal of Personality and Social Psychology, August 2002.

This was the first longitudinal study that connected negative health outcomes with individuals internalizing negative beliefs about growing old. Levy and her team relied on a comprehensive survey of residents from the town of Oxford, Ohio, which has a population of about 15,000 and is home to Miami University, and studied the effects of their perceptions about aging as they got older, for up to 23 years. They found that participants who held positive beliefs about aging “lived 7.5 years longer” compared with those who had internalized negative stereotypes.

The research included 660 individuals aged 50 and older who participated in the community-based survey known as the Ohio Longitudinal Study of Aging and Retirement (OLSAR). These participants were first recruited to take the OLSAR by a professor at Miami University starting in 1975, and participants were interviewed in six waves. Levy and her team conducted the survival analysis by matching the OLSAR data to mortality data from the National Death Index.

Although the study’s findings were in keeping with previous research showing that self-perceptions of stigmatized group identities, such as those related to race and gender affect behavior and functioning for people in those groups, the researchers theorized that self-perceptions of aging operate differently.

“Unlike race and gender stereotypes, which individuals encounter while developing group self-identities, individuals acquire age stereotypes several decades before becoming old,” they write. “Thus, younger individuals are likely to automatically accept age stereotypes without questioning their validity.”

In a follow-up longitudinal study, Levy and her team found that negative age beliefs acquired earlier in life significantly increased the likelihood that a person would experience a cardiovascular event later in life. The 89 cardiovascular event types studied included angina attacks, congestive heart failures, and strokes.

Global Reach of Ageism on Older Persons’ Health: A Systematic Review
E-Shien Chang; et al. PLoS One, January 2020.

This systematic review, conducted in conjunction with the World Health Organization’s Global Campaign to Combat Ageism, included more than 7 million participants in 422 studies from 45 countries on five continents over a span of 25 years. 

“Ageism led to significantly worse health outcomes in 95.5% of the studies and 74% of the 1,159 ageism-health associations examined,” the researchers write. “The studies reported ageism effects in all 45 countries, 11 health domains, and 25 years studied, with the prevalence of significant findings increasing over time (p < .0001).”

The study specifically examines “individual ageism” which refers to the “impact of culture-based negative age stereotypes and negative self-perceptions of aging on the health of older persons.” The review, which draws on the Stereotype Embodiment Theory developed by Levy, finds that ageism is more prevalent in less developed countries and that people with less education are more likely to experience the adverse health effects of ageism.

Ageism Amplifies Cost and Prevalence of Health Conditions 
Becca Levy; et al. The Gerontologist, February 2020.

This was the first study to examine the financial costs of ageism in terms of its health effects. The study, conducted by Levy and her team at the Yale School of Public Health, concludes that ageism resulted in $63 billion in excess health costs related to the eight most-expensive conditions (cardiovascular disease, chronic respiratory disease, musculoskeletal disorders, injuries, diabetes mellitus, treatment of smoking, mental disorders, and non-communicable diseases) for people ages 60 and older in 2018. In other words, 1 out of every 7 dollars (15.4%) spent on those conditions was linked to ageism, after adjusting for age, sex, and overlapping costs.

“This is greater than the total amount the United States spent on health care costs of morbid obesity for the same year,” the researchers write.

The costs were further broken down; $11.1 billion was attributed to age discrimination, $28.5 billion was attributed to negative age stereotypes, and $33.7 billion was linked to negative self-perceptions of aging. The study authors also estimated that ageism was responsible for 17.04 million cases of those eight most-expensive health conditions in 2018. The highest expenses were attributed to cardiovascular disease.

The research combined the results of previous ageism-health studies with 2013 data on health care spending from the Institute of Health Metrics and Evaluation. The research team used a variety of statistical checks to reduce the likelihood of health affecting ageism, as opposed to the other way around.

Experiences of Everyday Ageism and the Health of Older US Adults
Julie Ober Allen; et al. JAMA Open Network, June 2022.

This study made use of data from the University of Michigan National Poll on Healthy Aging that was collected in December 2019 from a nationally representative sample of 2,035 people aged 50-80. The analysis found that 93.4% of respondents regularly experienced at least some form of everyday ageism in their daily lives.

“Everyday ageism” was broken down into three groups: exposure to ageist messages; ageism in interpersonal interactions; and internalized or self-directed ageism.

Participants with lower levels of education, lower income, retirees not working for pay and people living in rural areas reported higher levels of everyday ageism than their counterparts. Older adults who spent more time online, watching television and reading magazines also reported being exposed to higher levels of everyday ageism, according to the study.

These higher levels of everyday ageism were associated with all four physical and mental health indicators the researchers examined — fair or poor physical health, number of chronic health conditions, fair or poor mental health, and depressive symptoms.

Interventions to Reduce Ageism Against Older Adults: A Systematic Review and Meta-Analysis
David Burnes; et al. American Journal of Public Health, August 2019.

This was the first systematic review and meta-analysis to assess the relative effects of interventions aimed at reducing ageism, the effectiveness of which remain poorly understood, according to the WHO’s global ageism report. Three types of interventions designed to reduce ageism among youths and adults were assessed — education providing information and addressing misperceptions about the aging process, intergenerational contact and combined education and intergenerational contact.

The review looked at 63 studies, including five randomized controlled trials, with a total of 6,124 participants, with most of the studies conducted in the United States. The research team found that ageism interventions had a significant effect on participants’ attitudes, knowledge and comfort level in interacting with older adults, but had no significant effect on anxiety about one’s own aging or interest in working with older adults (in the fields of geriatrics or gerontology). Interventions that included both education and contact between older and younger generations had the largest effects on attitudes. The effects were strongest among women and adolescent and young adult groups.

The paper also notes that “studies that examined the effect of ageism interventions among older adults themselves were lacking.”

Disparate Inclusion of Older Adults in Clinical Trials: Priorities and Opportunities for Policy and Practice Change
Angelica P. Herrera; et al. American Journal of Public Health, April 2010.

This paper looks at the issue of under-representation of older adults in clinical trials through a policy lens, reporting on the severity of the problem through a review of past research and outlining potential policy solutions.

Older people are sometimes excluded from clinical trials if they have multiple diseases, or they may have lower-functioning organs, such as the kidneys, which are important for drug processing. The result of this exclusion is underrepresentation. For example, two out of three cancer patients are older than 65, but only about 25% of participants in clinical trials for cancer treatments are in that age group, according to a 2003 study.

“Clinical trial participation of older adults is also low in research on Alzheimer’s disease, arthritis, epilepsy, incontinence, and cardiovascular disease,” the researchers write. “These failings may limit generalizability, provide insufficient data about positive or negative effects of treatment among specific populations, and hinder much-needed access to new treatments.”

The study recommends the development of standardized protocols for recruiting clinical trial participants, establishing guidelines for the inclusion of older people based on physiological rather than chronological age, using age-friendly methods of communication, making trial participation less costly and improving education and federal monitoring.

Ageism and Psychological Well-Being Among Older Adults: A Systematic Review
Hyun Kang and Hansol Kim. Gerontology and Geriatric Medicine, April 2022.

The authors of this paper reviewed 13 quantitative studies of the relationship between ageism and the mental health of older adults. The study confirmed that an increase in experiences of ageism has a negative effect on older adults’ psychological well-being, but it also identified some important mitigators.

According to the research, older adults with a “high level of psychological well-being,” especially those who were proud of their age group, were more optimistic about aging and their future, were more self-confident about their bodies, were flexible in setting goals, and were more resilient to the negative effects of ageism on their mental health. 

The researchers conclude that, overall, studies on the efficacy of interventions to combat the harmful effects of ageism are lacking. “Significant scholarly attention should be given to ageism,” they write, “considering its importance and universality, as it encompasses every generation and the growth of the population of older adults.”

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For several years now, studies have shown that social media images, including those on Instagram, that promote thinness and unrealistic ideals of beauty can have a negative impact on the viewers’ body image, particularly teen girls and young women.

Most of those studies are based on surveys and interviews with participants. But the authors of a new study took a technological approach. They used eye-tracking technology to determine which type of images the participants focused on and how the participants’ own body satisfaction impacted what parts of the images they fixated on.

They find image content and the users’ own body satisfaction influence the when and where of eye movements when viewing images on Instagram.

The 60 young female participants paid more attention to Instagram posts that included bodies rather than just faces, and that they preferred looking at underweight and average weight images to the images of overweight people. They also avoided looking at images that reflected areas of their own body with which they were not satisfied, researchers find.

“These results provide insight into the mechanisms of a potentially dangerous cycle promoted by social media platforms,” the authors write. Exposure to damaging images leads to negative social comparison and as result personal dissatisfaction in users. “This in turn could promote a perceptual bias to selectively attend to more damaging [images],” they write.

“‘Thinstagram’: Image Content and Observer Body Satisfaction Influence the When and Where of Eye Movements During Instagram Image Viewing,” by Graham Scott, Zuzana Pinkosova, Eva Jardine and Christopher Hand, was published online in August 2022 in the journal Computers in Human Behavior.

“Future research can build on this and come up with some proposed guidelines for social media companies, particularly around filters and algorithms, which may expose vulnerable users to damaging content,” Scott, the lead author of the study and Reader in Psychology in the School of Education and Social Sciences at University of the West of Scotland, wrote in an email to The Journalist’s Resource.

The findings also can help social media users be more aware of how they consume content.

“Often being aware of the potential problem is important so that you can monitor your own behavior and are aware of the potential impact of what you’re viewing,” he added.

Research suggests that actively engaging with social media, such as commenting on others’ posts and posting about yourself, is more beneficial to mental health than just passively observing content created by others, Scott explained. “This may be especially true when viewing potentially harmful content,” he wrote.

Before the Facebook Files

The association between Instagram and young women’s body image and mental health came to the spotlight in September 2021, when the Wall Street Journal published the Facebook Files, revealing internal research by Facebook and Instagram, both of which are owned by Meta. One slide from an internal presentation by researchers at Facebook found Instagram makes, “body image issues worse for one in three teen girls,” the Journal reported.

Outside the company, researchers have been reporting these negative associations for several years.

One study, published in the journal Body Image in December 2017, finds that among 259 women between ages 18 and 29 years old, those who followed appearance-focused accounts on Instagram were more likely to want to be thin.

In severe cases, body image issues can lead to eating disorders, which can be life threatening. One study published in the Journal of the Academy of Nutrition and Dietetics in September 2017, finds “a strong and consistent association between social media use and eating concerns in a nationally-representative sample of young adults ages 19 to 32 years.” Another study, published the journal Eating and Weight Disorders in March 2017, finds that higher Instagram use was associated with greater tendency towards orthorexia nervosa, an obsession with healthy eating and associated restrictive behaviors.

How the eye-tracking study was conducted

Researchers recruited 60 women who were 21 years old on average. None reported an eating disorder diagnosis. The participants viewed 12 images organized in a 3×4 grid, similar to Instagram.  The images included underweight, average weight and overweight women. The researchers also collected the participants’ body satisfaction data using the Body Satisfaction Scale questionnaire. They then recorded the participants’ eye movements.

Eye-tracking relies on sensor technology that follows what someone is looking at in real time. The eye movement is then converted into data. Eye-tracking has been used to study how women view their own bodies and the bodies of others.

Researchers recorded participants’ gaze as they viewed the Instagram-like grid. They analyzed two types of eye movement that have been commonly used in eye-tracking studies investigating social media: the bottom-up eye movement, which relates to the viewers’ initial attention to features of the image, and the top-down eye movement, which relates to personal beliefs and values, and in this study, the participants’ own body satisfaction.

The results of the study shouldn’t be generalized to all social media platforms, especially those that are more text-focused, the authors write. The authors also note several limitations to their study, including their focus on Instagram only and having only healthy female volunteers. “Future research should look to expand the current findings by focusing specifically on vulnerable populations,” including those who may be prone to eating disorders, they write.

They add that the “impact of exposure to idealized and sexualized images of men on male participants should also be investigated, as eating disorders are a significant problem for males as well as females.” Future research could examine how male participants view images of underweight, average, and overweight faces and bodies, and compare viewing patterns between genders, they write.

What other recent studies show

Several other new studies have found an association between social media use, including Instagram use, and negative body image. Some of those studies offer solutions.

Many papers focus on girls and women, because research has shown that female social media users are more likely than males to look at photos of members of their own gender and compare themselves.

In a review article, “Social Media and Body Image: Recent Trends and Future Directions,” published in the journal Current Opinion in Psychology in December 2021, researchers found platforms that were more image-based, including Instagram, were more likely to be associated with negative body image than those that are mostly text-based, including Facebook. They also found the process of taking and editing selfies before they were posted was associated with negative body image. And body positivity content had a positive effect on body image.

“Social media clearly does not impact all people equally,” the authors write. “Future research is needed to examine individual differences that may moderate the relationship between different aspects of social media use and body image and the mechanisms that may be relevant to different people.”

They add: “Given the pervasive use of social media globally, it is vital that we understand the impact of social media on body image and find ways to create a more positive social media experience for users.”

The authors of “Instagram Use and Body Dissatisfaction: The Mediating Role of Upward Social Comparison with Peers and Influencers among Young Females,” published in The International Journal of Environmental Research and Public Health in February 2022, found “browsing on Instagram was associated with lower levels of body appreciation, fully mediated by upward social comparison with social media influencers, not close or distant peers.” Adolescent girls and women who had higher Body Mass Index were more likely to have worse appreciation of their own bodies.

The study was based on the survey of 291 adolescent girls and young women across Europe with an average age of 20 years.

“The findings of our study highlight the need for public health interventions to raise awareness about the posting practices of social media influencers and to strengthen a positive body image, with special attention to particularly vulnerable girls,” the authors write.

In “The Looking Glass Selfie: Instagram Use Frequency Predicts Visual Attention to High-Anxiety Body Regions in Young Women,” published in Computers in Human Behavior in July 2020, researchers used eye-tracking technology to study the Instagram viewing behavior of 157 U.S. women between ages 18 and 35 years. They found participants who were satisfied with their bodies selectively paid attention to Instagram images that didn’t cause them a lot of anxiety in their own bodies — and avoided looking at images that images that related to areas of their body that caused them more anxiety. In contrast, individuals who were not satisfied with their bodies spent as much time on images that reflected the high-anxiety regions of their bodies as low-anxiety areas.

“Images of our bodies may be more commonly encountered on social media than in ‘real’ life, offering a visual reminder of appearance and repeated opportunities for self-evaluation within the context of social comparisons,” the authors write.

In “The Psychological Consequences of Envying Influencers on Instagram,” published in the journal Cyberpsychology, Behavior and Social Networking in October 2022, researchers surveyed 305 U.S. participants who viewed posts of were shown the 20 most recent Instagram posts of a randomly assigned social media influencer who specialized in entertainment, beauty, fitness or fashion, found a “direct negative relationship between envy and affective well-being, but a positive indirect effect through inspiration.”

Some studies offer solutions

There are some optimistic findings related to Instagram.

In “Experiences of First Year Undergraduate Nursing Students Using Instagram in Their Clinical Practicum During COVID-19 Pandemic: A Qualitative Study,” published in the journal Nurse Education Today in October 2022, interviews with 15 first-year nursing-degree students at the Nursing Department of the Universidad Europea de Madrid revealed that the use of an internal Instagram account improved the students’ interactions with their professors..

The professors uploaded key information related to the training activity in clinical courses by posting on “feed” and “stories.” Their aim was to encourage student engagement using internal Instagram tools such as surveys, questions, videos, and images, according to the study.

“The participants described that Instagram helped them to stay in contact and established an important connection between the hospitals where they performed the practicums and the university,” the authors write.

And some studies point to possible ways to improve the body image of Instagram users.

In “Women’s Response to, Awareness of, and Interest in Body Functionality Content on Instagram,” published in the journal Body Image in August 2022, researchers examined 318 women’s responses to “body functionality” content on Instagram, which emphasizes what the body can do instead of how it looks. The participants’ satisfaction with their appearance and bodies was highest after viewing Instagram images that focused on body functionality. It was also high among those who viewed inspirational “fitspiration” images that included messages that encouraged women to value and appreciate what their body can do. (Fitspiration images contain athletic, toned and often thin models who are engaged in physical activity.)

“Diversifying content on social media, particularly with content relating to ways in which to appreciate, value, and respect the functionality of one’s body, may be helpful in buffering the negative effects of social media,” the authors write.

In “A Meta-Analytic Review of the Relationship Between Social Media Use and Body Image Disturbance,” published in the journal Computers in Human Behavior in July 2019, researchers analyzed 63 studies from around the world and found an association between social media use and negative body image.

The authors of the review offer that one way to combat this negative impact is through programs that raise awareness about the digital manipulation of images on social media.

“If users are aware that appearance-focused use of social media, like making social comparisons, can be damaging to their body image, then if social comparisons are indeed inefficient, users should be able to focus on more positive types of use when engaging and viewing content on social media instead,” the authors write.

The authors also emphasize that their findings show an association not causation.

Another study, “The Effects of Body-Positive Instagram Posts on Body Image in Adult Women,” published in the journal Body Image in September 2022, found “viewing body-positive Instagram content would result in greater levels of body satisfaction and body appreciation compared to thin-ideal and appearance-neutral content on Instagram.”

The study of 205 women between 18 and 76 years old assessed how viewing body-positive content affected the women’s view of their own bodies. Body positivity is defined as “an all-encompassing love and respect for one’s body, founded on attitudes such as the appreciation for the beauty and function of one’s body and acceptance of one’s body despite idealized societal messages,” the authors write.

“In order to counteract the negative effects of social media on body image, we suggest that women diversify their content by following and interacting with diverse body-positive influencers and accounts,” the authors write. “The findings of the current study can be used to encourage women of all backgrounds, shapes, and sizes to embrace the beauty of their diversity and uniqueness.”

Additional Resources

• The National Eating Disorders Association (NEDA) is the largest nonprofit organization dedicated to supporting individuals and families affected by eating disorders.
• The International Association of Eating Disorders Professionals Foundation provides education and training standards for professionals who treat eating disorders.
• National Association of Anorexia Nervosa and Associated Disorders (ANAD) is a nonprofit in the U.S. that provides free, peer support services to anyone struggling with an eating disorder.
• Eating Disorder Hope provides information and resources to people with eating disorders and their families.

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This piece about 988 suicide prevention hotline, originally published in August 2022, was updated on Oct. 18, 2022, with new research.

Suicide prevention hotlines are implemented in many countries and are considered an important part of suicide prevention efforts. In the U.S., the National Suicide Prevention Lifeline network of crisis centers not only serve people who are in a mental health crisis, but also connect individuals with resources in their communities.

On July 16, the 988 Suicide & Crisis Lifeline launched in the United States, building on the existing National Suicide Prevention Lifeline and switching from the 10 digit number, 800-273-8255. The 800 number remains available and will be routed to 988.

The three-digit number was created after the National Hotline Designation Act was signed into law in 2020, in response to calls by lawmakers and advocates and a collaboration between the U.S. Department of Health and Human Services, the Federal Communications Commission and the U.S. Department of Veterans Affairs.

One of the main reasons advocates have been calling for a three-digit number is because when we are in a crisis, “our cognitive recall is not as present,” explains Amelia Lehto, chief of staff at the American Association of Suicidology. “So, remembering 800-273-8255 or even 800-273-TALK [can be] challenging, and the idea was to simplify it.”

The 24-hour 988 Suicide and Crisis Lifeline is funded by Substance Abuse and Mental Health Services Administration, which is part of the National Institutes of Health, and is administered by Vibrant Emotional Health, a nonprofit organization in the U.S. that has run the national Lifeline since it was established in 2005.

The Lifeline received 46,000 calls in its first year. In 2021 it received 3.6 million calls, chats and texts. In total, the Lifeline received 23,044,100 calls from 2005 through 2021. The number is expected to double within the first year after the 988 transition, according to the FCC.

The Lifeline includes more than 200 independently operated and funded local call centers, including 38 chat and text centers and three Spanish language centers. The centers are funded by local and state sources and SAMHSA.

“I think one of the greater benefits of the 988 crisis Lifeline is that they are a national network of local centers, who are familiar with their local resources,” says Lehto.

But it’s not clear how quickly the local centers can ramp up their capacity. A recent New York Times data analysis finds that 18% of about 1 million calls to Lifeline centers in the first half of this year were not answered. Other news stories have also started to document the need for more funding at local crisis centers. In December SAMHSA announced a $282 million investment to transition the National Suicide Prevention Lifeline to 988 to help strengthen the exiting Lifeline infrastructure and build staffing in local centers.

Suicide is among the leading causes of death in the U.S. and around the world, making it a serious public health problem. In the U.S., it was the 12^th leading cause of death and the second leading cause of death for people ages 10-14 and 25-34 that year in 2020, according to the Centers for Disease Control and Prevention.

Nearly 46,000 people died by suicide in the U.S. in 2020 and 1.2 million people attempted suicide but didn’t die, according to the CDC.

Worldwide, 703,000 people died by suicide in 2019, according to the latest data from the World Health Organization.

For journalists covering the launch of 988, it helps to be familiar with the research on suicide prevention lifelines. We have complied several peer-reviewed research studies on the topic, including text and online chats. The studies focus on the U.S. and many are based on surveys of crisis counselors and/or callers.

Reporting guides recommend including information about suicide hotlines when reporting on the topic. You can download and use this infograph.

Research roundup

Third‐Party Callers to the National Suicide Prevention Lifeline: Seeking Assistance on Behalf of People at Imminent Risk of Suicide
Madelyn Gould; et al. Suicide & Life-Threatening Behavior, February 2022.

The study: Researchers wanted to gain a better understanding of the types of calls that were made to the National Suicide Prevention Lifeline by people who were concerned for another person. They analyzed 172 such calls based on questionnaires completed by 30 crisis counselors in six Lifeline crisis centers between December 2016 and October 2018. Counselors handled on average 7.5 suicide calls per seek, with a range from 1 to 20 calls.

Key findings: Third‐party callers were most likely to be calling about a family member or friend. They were also significantly more likely to be female and middle‐aged or older, compared with the person at risk. Counselors were able to identify at least one intervention to help the person at risk. In 58.1% of the calls, emergency services were contacted. The most common source of the callers’ information was face‐to‐face contact with the person at risk, and other modes including interactions via text messaging, phone calls and social media.

Key takeaway: Negative help‐seeking attitudes are greatest among individuals with the greatest mental health needs, the authors note. “Given the reluctance of many suicidal individuals to seek help for themselves, suicide prevention initiatives often encourage people in the social networks of at‐risk individuals to seek help on their behalf,” they write. “In contrast to a third‐party calling 911, which only dispatches an emergency service — frequently involving the police — calling the Lifeline yields alternative and adjunctive interventions.”

Suicide Mortality and Related Behavior Following Calls to the Veterans Crisis Line by Veterans Health Administration Patients
Claire Hannemann; et al. Suicide & Life-Threatening Behavior, October 2020.

The study: The Veterans Crisis Line, which was established in 2007, serves veterans and is staffed by Veterans Affairs clinical staff. (The Veterans Crisis Line is part of the national Lifeline and veterans can reach it by dialing 988 and then pressing 1.) Researchers analyzed 158,927 calls to the Veterans Crisis Line between 2010 and 2015 to assess the rates of suicide deaths and suicide attempts following calls. The study was not designed to assess the crisis line’s effectiveness.

Key findings: The Veterans Crisis Line serves a high-risk Veterans Health Administration patient subpopulation, with particularly high rates of suicide deaths and attempts in the first month after the initial call to the crisis line. While suicide rates decreased over the 12 months after the initial call, the rates remained elevated compared with the overall VHA patient population. The suicide rate in the first month following an initial documented call was 797 per 100,000, and it was 298 per 100,000 at 12 months. In comparison, the overall suicide rate for VHA patient population was 36 per 100,000 in 2016, the authors note. Men were twice as likely as women to die by suicide within 12 months after the initial call.

Key takeaway: “This study documents substantially elevated risk of suicide and suicide-related behavior among VHA patients who call the Veterans Crisis Line,” the authors write. “Study findings may also inform work to enhance services for callers to non-VA crisis lines, and they confirm the importance of integrating crisis line services within healthcare systems.”

Individuals Who Text Crisis Text Line: Key Characteristics and Opportunities for Suicide Prevention
Anthony Pisani; et al. Suicide & Life-Threatening Behavior, June 2022.

The study: Researchers explored the demographics of the population that uses Crisis Text Line, the largest crisis text service in the U.S. Established in 2013, it is a nonprofit based in New York, unaffiliated with 988. The findings are based on anonymous reports from crisis counselors and surveys from 85,877 texters who contacted Crisis Text Line between October 2017 and October 2018. More than half of the texters were white; 13% were Hispanic; 8.2% were Black; 3.5% were Asian; and 1.1% were American Indian/Alaska native.

Key findings: Results show 76% of texters were under 25 years old and 66% were between 14 and 24 years old; 79% were female; 48% identified as other than heterosexual; and 23% had thoughts of suicide. Meanwhile, 23% of texters reported having received assistance from a doctor or a therapist when in crisis and 28% had not asked for help from any other source, a situation that was even worse for younger texters, the authors note.

Key takeaway: “[Crisis Text Line] reaches a highly distressed, young, mostly female population, including typically underserved minorities and a substantial percentage of individuals who do not receive help elsewhere,” the authors write. “Providing crisis support for males, who account for the vast majority of suicide deaths remains a challenge for the field, including for text-based crisis interventions.”

Related study: “Crisis text-line interventions: Evaluation of texters’ perceptions of effectiveness,” by Madelyn Gould; et al., published in Suicide & Life-Threatening Behavior in June 2022, assesses the perception of texters as to the effectiveness of the Crisis Text Line interventions. It finds 90% of suicidal texters found the conversations helpful and nearly half reported being less suicidal by the end of the text-based conversation.

National Suicide Prevention Lifeline Crisis Chat Interventions: Evaluation of Chatters’ Perceptions of Effectiveness
Madelyn Gould; et al. Suicide & Life-Threatening Behavior, December 2021.

The study: Researchers assesses the effectiveness of the Lifeline Crisis Chat, which was established in 2013 and is the online typed chat feature of the National Suicide Prevention Lifeline, answering 231,335 chats in 2020. The authors analyzed data from 39,911 pre-chat surveys and 13,130 linked pre- and post-chat surveys from October 2017 to June 2018. About 65% of the chat users were female and more than 70% of were younger than 24 years. Nearly half said feeling depressed was the main reason for which they reached out. Almost 84% of callers said they had suicidal thoughts in the past 24 hours or in the past few days.

Key findings: By the end of the chat, two-thirds of the people who reached out via online chat and were suicidal reported that the correspondence had been helpful and 45% reported being less suicidal, while 30% said they felt the same as when they began the chat and 12% said they were more suicidal.

Key takeaway: “For a single‐session chat intervention to achieve a reduction in suicidality in nearly half of chatters can be considered a significant accomplishment,” the authors write. “While a single chat session could not be expected to eradicate suicide risk permanently, any reduction in risk at a moment of crisis for these individuals could open a window of opportunity for further help‐seeking and for engagement in additional interventions that could have a more sustained impact.”

Increases in Demand for Crisis and Other Suicide Prevention Services After a Celebrity Suicide
Rajeev Ramchand; et al. Psychiatric Services, April 2019.

The study: Researchers examined data on increases in suicides, help and information seeking, and capacity of crisis centers within 30 days after the death of actor and comedian Robin Williams on Aug. 11, 2014. Data included call volume to the National Suicide Prevention Lifeline and the number of visits to two suicide prevention websites — the Suicide Prevention Resource Center and Suicide Awareness Voices of Education.

Key findings: Before Aug. 11, in 2012, 2013 and 2014, daily suicide deaths in the U.S. averaged between 113 and 117. For the 30 days after Aug. 11, 2014, the count increased to 142. The number of calls to the Lifeline increased by 300% to 12,972 calls on August 12 and decreased afterward, but answered calls decreased from 71% before August 11 to 57% on August 12, indicating a gap in capacity, the authors note. Visits to both websites also increased dramatically on August 12 and decreased on the following days.

Key takeaway: “As a critical component of crisis mental health services in the United States, suicide prevention hotlines need to develop contingency plans to accommodate anticipated increases in demand, including for at least two days after a celebrity suicide,” the authors write.

Association of Logic’s Hip Hop Song “1-800-273-8255” with Lifeline Calls and Suicides in the United States: Interrupted Time Series Analysis
Thomas Niederkrotenthaler; et al. The BMJ, December 2021.

The study: Researchers examined the changes in daily call volumes to the National Suicide Prevention Lifeline after the release of hip-hop artist Logic’s song ‘1-800-273-8255’ in April 2017. They analyzed tweets that mentioned Logic’s song from March 2017 to April 2018. Their main interests in call volumes were around three events: the song’s release, and Logic’s performance of the song at the MTV Video Music Awards in August 2017 and Grammy Awards in January 2018. They also obtained total number of calls to the Lifeline from January 2010 to December 2018.

Key findings: The number of calls to the Lifeline increased by 6.9% — 9,915 additional calls — during the 34 days when public attention to the song was substantial, the authors report, compared with average call volumes. There was also some evidence of reduction in suicides, by 5.5%. “Although the reduction in suicides was small, this finding shows that the song did not result in harmful effects on suicide occurrence, which would have been indicated by an increase in suicides,” the authors write.

Key takeaway: “The effectiveness of the song on calls to a helpline is a novel finding,” the authors write. “The results show that it is possible to promote help-seeking for suicidal crises in the absence of negative news, and indicate that suicides could potentially be reduced with prevention focused campaigning, such as Logic’s song.”

Related study: “Public Awareness of the National Suicide Prevention Lifeline Following the Release of a Hip-Hop Song,” by Trevor Torgerson; et al., published in BMJ Evidence-Based Medicine in July 2021, finds Google searchers for “Suicide Hotline” and Twitter engagement with Lifeline’s account @800273talk increased following the release of Logic’s song ‘1-800-273-8255.’

Follow-up with Callers to the National Suicide Prevention Lifeline: Evaluation of Callers’ Perceptions of Care
Madelyn Gould; et al. Suicide & Life-Threatening Behavior, March 2017.

The study: Researchers evaluated the effectiveness of a national initiative to have crisis centers in the National Suicide Prevention Lifeline network provide follow-up care to callers who were suicidal. Data was pulled from questionnaires filled out by 41 crisis counselors in six centers and telephone interviews with 550 clients.

Key findings: Nearly 80% of the interviewed clients reported that the intervention stopped them from killing themselves and 91% said it kept them safe. Individuals at higher risk of suicide at the time of their calls to the Lifeline perceived the follow-up intervention to be more valuable — so did those who had lower levels of education or had been homeless — than those at lower suicide risk, the authors note.

Key takeaway: “Our findings add to the mounting evidence that follow-up is a key intervention to enhance the continued safety of individuals at risk of suicide,” the authors write. “Our findings lay the groundwork for later initiatives to have crisis hotlines provide follow-up to at-risk individuals following inpatient psychiatric hospitalization or discharge from emergency departments, when enhanced continuity of care can be equally lifesaving.”

National Suicide Prevention Lifeline: Enhancing Mental Health Care for Suicidal Individuals and Other People in Crisis
Madelyn Gould, Jimmie Munfakh, Marjorie Kleinman, and Alison Lake. Suicide & Life-Threatening Behavior, February 2012.

The study: Researchers explored the extent to which callers to the Lifeline are referred to longer-term mental health services. The study is based on phone interview with 376 suicidal and 278 non-suicidal callers to the National Suicide Prevention Lifeline between January 2006 and December 2007. Sixteen centers in the Lifeline network from 14 states across the U.S. participated in the study.

Key findings: Nearly 83% of the callers reported having received mental health treatment at some point in their lives and 46% were in treatment at the time of their call. However, only 35% of callers referred to mental health resources followed through with the referral. “It is particularly alarming that a third of callers reported a lack of trust or negative experience with mental health providers as their reason for not accessing mental health care after the call,” the authors write. Barriers to accessing mental health services included denying the severity of one’s mental health problem, financial problems and not having health insurance

Key takeaway: The caller’s perception of mental health problems was the most prevalent barrier to using mental health services and was cited more often than other barriers such as stigma and financial barriers. “A further function of hotline counseling may be to address callers’ attitudinal and perceptual barriers to formal service use and to help callers to overcome them,” the authors write.

An Evaluation of Crisis Hotline Outcomes Part 2: Suicidal Callers
Madelyn Gould, John Kalafat, Jimmie Lou Harris Munfakh, and Marjorie Kleinman. Suicide & Life-Threatening Behavior, December 2010.

The study: In a follow-up study on nonsuicidal callers, researchers evaluated the effectiveness of telephone crisis hotlines in changing the callers’ suicide state from the start to end of the call in eight centers in the U.S., and again within three weeks of their calls, between March 2003 and July 2004, before the launch for the National Suicide Prevention Lifeline. They assessed 1,085 suicide calls; 35% of the callers participated in the follow-up assessment.

Key findings: Researchers found significant decreases in suicidality during the telephone session, and continuing decreases in hopelessness and psychological pain in the following weeks. However, 43.2% of the callers continued to express suicidal ideation a few weeks after the initial call and nearly 3% had made a suicide attempt after their call, the authors note.

Key takeaway: “Our study provides empirical evidence that seriously suicidal individuals are reaching out to telephone crisis services,” the authors write. “Our findings also suggest that follow-up outreach strategies may need to be heightened, particularly for suicidal callers with a history of suicide attempts, who were significantly over-represented among those who reattempted shortly after their call to the center.”

Related study: “An Evaluation of Crisis Hotline Outcomes Part 1: Nonsuicidal Crisis Callers,” published in the same issue by the same researchers, finds significant decreases in callers’ crisis states and hopelessness during the course of the telephone session. The crisis state and hopelessness continued to decrease in the following weeks.

Additional studies

“Taking a Look at 988 Suicide & Crisis Lifeline Data, One Month After Launch,” published in October 2022 by the Kaiser Family Foundation, examines 988 implementation. Among other findings, it reports “there was a 28% increase in calls, texts, and chats in July 2022, the month that 988 was implemented, compared to the month before, but the growth slowed in August, to a 2% increase.”

“The Effectiveness of Crisis Line Services: A Systematic Review,” by Adam Hoffberg, Kelly Stearns-Yoder and Lisa Brenner, published in Frontiers in Public Health in January 2020, finds that high-quality evidence demonstrating crisis line effectiveness is limited, but overall, the results provide support for such services. “However, such support is largely from uncontrolled studies indicating the positive effect of crisis line calls on immediate proximal outcome measures (e.g., changes in distress over the course of the crisis line call) and short-term distal effects. Many studies evaluating distal effects after the crisis service suffered from substantial dropout, thereby increasing the risk of bias interpreting findings,” the authors write.

“Helping Callers to the National Suicide Prevention Lifeline Who Are at Imminent Risk of Suicide: Evaluation of Caller Risk Profiles and Interventions Implemented,” by Madelyn Gould; et al., published in Suicide & Life-Threatening Behavior in August 2015, offers four different profiles for callers who are at imminent risk of suicide: High-risk calls with a moderate-to-high rate of engagement with the crisis line counselor; relatively low-risk calls with high engagement; moderate-to-high-risk calls with a moderate amount of missing information due to modest engagement; and very high-risk calls with a large amount of missing information due to low engagement. “Our findings provide a first step toward an empirical formulation of imminent risk warning signs and recommended interventions,” the authors write.

“Systematic Review of Research and Interventions With Frequent Callers to Suicide Prevention Helplines and Crisis Centers,” by Brian Mishara, Louis-Philippe Côté, and Luc Dargis, published in Crisis in January 2022, reviews 27 studies to identify characteristics of frequent callers and compiles recommendations about how best to help them.

“Mental Health Concerns During the COVID-19 Pandemic As Revealed by Helpline Calls,” by Marius Brülhart, Valentin Klotzbücher, Rafael Lalive, and Stephanie Reich, published in Nature on November 2021, finds a 35% increase in calls in the first six week after the initial COVID-19 outbreak, mainly driven by fear, loneliness and concerns about physical health. “Relationship issues, economic problems, violence and suicidal ideation, however, were less prevalent than before the pandemic,” the authors write.

“Safety Planning on Crisis Lines: Feasibility, Acceptability, and Perceived Helpfulness of a Brief Intervention to Mitigate Future Suicide Risk,” by Christa Labouliere, Barbara Stanley, Alison Lake, and Madelyn Gould, published in Suicide & Life-Threatening Behavior in February 2020, explores the effectiveness of the use of an established intervention called Safety Planning Intervention to help manage suicidal crises on hotlines. While found feasible and helpful, the authors note that some centers may have difficulty implementing it due to factors like high call volumes.

“Implementation and Early Utilization of a Suicide Hotline for Veterans,” by Kerry Knox, Janet Kemp, Richard McKeon, and Ira R. Katz, published in the American Journal of Public Health in March 2012, is one of the first reports on the Veterans Crisis Line. “These are the first data to demonstrate that a population consisting primarily of men is willing to call a suicide hotline and accept follow-up referrals; this finding is unprecedented in the history of suicide hotlines,” the authors write.

Further reading

• “‘988’ is the three-digit, nationwide phone number to connect directly to the 988 Suicide and Crisis Lifeline,” a fact sheet by the Federal Communications Commission provides a timeline of 988 establishment.
• Crisis Call Center Metrics. Part 1: Services and Efficiency, a 69-page report on the National Suicide Prevention Lifeline, provides an in-depth look of call centers operations.
• “988 Frequently Asked Questions,” by SAMHSA, provides answer for many basic and technical questions about 988.
• “What is 988?” A Q&A by Veterans Crisis Line.
• Find a list of your local crisis centers here.
• Find your state’s Lifeline centers’ reports here.
• Learn more about 988 Suicide & Crisis Lifeline here.
• “The new 988 mental health hotline is live. Here’s what to know,” by Rhitu Chatterjee for NPR, provides a comprehensive overview of the program and some of the existing and future challenges for it.

Resources for your audience

• The 988 Suicide & Crisis Lifeline: Call or text 988, or start an online chat at 988lifeline.org/chat. For deaf and heart of hearing, use your preferred relay service or dial 711 then 988. The old suicide prevention lifeline number, 800-273-TALK (8255), remains available and is routed to 988.
• To reach Veterans Crisis Line, dial 988 then press 1. To text, Veterans Crisis Lifeline, text 838255. For online chat, visit veteranscrisisline.net/get-help-now/chat.
• To reach Crisis Text Line, text HOME to 741741 for English, and AYUDA to 741741 for Spanish. The service is also available on WhatsApp at 443-SUPPORT for English and 442-AYUDAME for Spanish.
• Find a helpline, helps individuals in any country to find free, confidential support from a real person over phone, text or online chat. Its key partners include the International Association for Suicide Prevention and the American Association of Suicidology.
• LGBTQ+ youth can also reach out to The Trevor Project at 866-488-7386 or text 678678 to talk to someone.
• Suicide prevention resources from the American Foundation for Suicide Prevention.
• BeThe1To: Five steps you can take to help someone in suicidal crisis.
• Safe Space: Coping resources has a list of free resources and tools for individuals who need some extra support in an emotionally safe environment.

Resources for reporting on suicide

• ReportingonSuicide.org, a website dedicated to recommendation for reporting and created by more than a dozen partners, including the National Institute of Mental Health and The Poynter Institute.
• Best practices for covering suicide from 988 Suicide & Crisis Lifeline.
• Reporting recommendations from the American Association of Suicidology.
• Responsible Reporting on Suicide for Journalists, a free course on Coursera by Johns Hopkins University.
• Responsible reporting recommendations from SAVE, a nonprofit organization dedicated to suicide prevention and education
• Resources for reporting on suicide from the American Foundation for Suicide Prevention.
• The Suicide Reporting Toolkit for journalists and journalism educators.
• Suicide Prevention Resource Center (SPRC) provides technical assistance, training and resources on suicide prevention.

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Loneliness is a distressed feeling arising from the perception that one’s social needs are not being met. For decades, it was considered strictly an emotional and mental health concern, studied mainly by psychologists, philosophers, and poets.

Today, however, health researchers and clinicians across specialties recognize it as a social determinant of health, a factor, like economic stability or access to high-quality education, that greatly influences overall health outcomes. In recent years, loneliness has also been described as an epidemic and elevated to a public health crisis, one intensified by social distancing guidelines during the COVID-19 pandemic.

But unlike most other public health crises, loneliness isn’t all bad. About 20% of the population is experiencing a normal, even helpful level of loneliness at any given time, says Liz Necka, a program director in the Division of Behavioral and Social Research at the National Institute on Aging. “That should be expected, because loneliness can be motivating to promote social connection,” Necka says. “The issue is when loneliness becomes chronic.”

Neuroscience and studies of isolated animals suggest that when left untended loneliness triggers an immune response in the body, sparking cycles of inflammation that can lead to a variety of illnesses, ranging from depression and anxiety to high blood pressure, diabetes, stroke, and heart disease. The resultant state of hypervigilance is associated with shifts in personality and decision-making and puts people at higher risk for cognitive impairment and dementia. Oft-cited research places the increased risk of premature death among lonely people at 26%, a rate on par with smoking.

Despite these troubling correlations, however, new evidence suggests that even chronic loneliness might bestow some benefits. Recent neurological research has found that brain regions dealing with reminiscing, imagining, and self-reflection are bulkier and more strongly wired in lonely people.

Loneliness is complicated and hard to measure, and much remains unknown about how and when it predicts poor health or early death. But those and other questions have motivated an explosion of new research over the past few years, particularly since social distancing during the pandemic gave rise to new fears about loneliness levels worldwide.

All the lonely people

Research suggests that 15-30% of the general population is chronically lonely. In the U.S., before the pandemic, about 19% of adults over age 55 were “frequently” lonely, according to data from the Health and Retirement Study (HRS), which is considered the gold standard of representative surveys and is conducted biennially at the University of Michigan.

Contrary to narratives suggesting a growing rate of loneliness among seniors, the prevalence of self-reported “frequent loneliness” among older adults in the U.S. remained relatively flat from 1998 to 2016, according to a recent analysis by James Raymo, a demographer and sociology professor at Princeton University.

“There are little bumps and blips here and there,” says Raymo, who used HRS data and population statistics to identify the effects of loneliness on life expectancy among different population segments, “but it is largely stable over this period, which is a period of time in which attention to and concern about loneliness, and the description of the loneliness epidemic has, from my perspective, grown.”

Polling data suggests that the rate of loneliness among older adults spiked during the pandemic, but younger people seem to have suffered from loneliness at even higher rates as a result of social distancing.

People experience loneliness at all stages of life, but older adults are at a much higher risk of experiencing the related adverse health outcomes, says Necka.

“Older adults have generally been much more resilient than younger adults to social distancing, which I think is somewhat surprising to a lot of people,” she says. Early evidence suggests that, with the reopening of businesses and the easing of social distancing guidelines, loneliness is returning to pre-pandemic levels, Necka adds.

Research hurdles and future directions

Loneliness is complex, nuanced and confusing in that there’s a lack of uniformly accepted terminology surrounding it. For example, social isolation – defined as an objective lack of social contacts – is often conflated with loneliness. But these concepts are distinct; a person can be content without social contact, or lonely despite plentiful social ties, if those connections are not perceived as meaningful.

In addition, while loneliness is linked with increased risk of developing serious health conditions, many of those conditions also increase a person’s risk of experiencing loneliness. This creates a vicious cycle in the lives of patients and a potential endogeneity problem for researchers. (Endogeneity – when a variable not included in a statistical model is related to a variable that is included – can obscure causality in research.)

“I really struggle when I see patients who, without even a moment’s hesitation, get approved for a $50,000 Alzheimer’s drug that probably won’t make a difference in their quality of life or wellbeing, but it’s impossible to get funding for some of these social programs that can have a huge impact on their quality of life.”

Dr. Ashwin Kotwal

Loneliness is also difficult to measure, in part due to problems with pinpointing when loneliness starts and stops and when it persists for too long, as well as the use of various assessments. Further, because it’s unethical to conduct randomized experiments in which people are assigned to be lonely, researchers rely on survey data. But whether those surveys are conducted over the phone or in writing can change the results (research suggests people are more willing to identify as lonely in writing).

The prevalence of loneliness varies among different population segments. Much research has been devoted to understanding which groups are most at risk for experiencing chronic loneliness. People living in poverty and those who suffer from cognitive impairments, mobility issues, and sensory impairments, such as hearing and vision loss, are at the highest risk. A 2020 report by the National Academies of Science, Engineering and Medicine also highlights immigrants and people who identify as LGBTQ+ as being at higher risk.

Medical professionals are increasingly recognizing their role on the front lines of the battle against loneliness. Indeed, for the millions of chronically lonely older adults in the U.S., a quick chat with a doctor is one of very few conversations about their own health and wellbeing.

Dr. Ashwin Kotwal, a researcher and palliative care physician at the University of California in San Francisco, says the pandemic helped to destigmatize loneliness, and more clinicians are now asking their patients about their social wellbeing. But systemic change is needed, he says, to accelerate social prescribing  (when patients are prescribed social support from community programs) and funding for existing programs.

“We need to start breaking down these boundaries between social needs and medical needs,” says Kotwal. “I really struggle when I see patients who, without even a moment’s hesitation, get approved for a $50,000 Alzheimer’s drug that probably won’t make a difference in their quality of life or wellbeing, but it’s impossible to get funding for some of these social programs that can have a huge impact on their quality of life.”

A broad range of interventions

Because the experience of loneliness varies at the individual level, there is no universally effective intervention.

“You can think of loneliness like setting your thermostat,” explains Necka, of the NIA. “I might prefer my house a little bit warmer; you might prefer your house a little bit colder. What will make us feel socially connected, in terms of the objective interactions we’re having, will differ from person to person.”

Prior to the pandemic, many interventions focused on developing cognitive skills – teaching people how to socialize, an approach based largely on a 2010 meta-analysis of intervention studies. More recently, researchers have seen promising results associated with enrolling lonely people to help others through volunteer programs, Necka says, but these findings have not yet been published. Training social support personnel, such as Meals on Wheels delivery drivers, to practice empathetic listening has also shown promise as a potentially scalable intervention.

The pandemic forced many older people to become comfortable with technologies like videoconferencing to keep in touch with friends and family. This has led to a growing emphasis on digital technology, with many newer intervention studies involving the provision of direct social contact via videoconferencing. Robot companions have also been shown to reduce feelings of loneliness and anxiety.

Both inside and outside of the health care community, there’s a broad recognition of the need for holistic approaches that bring together various disciplines and stakeholders. Experts in a variety of fields, ranging from psychology to public transportation to the arts, have already spent decades studying loneliness and ways to provide relief.

Amy McLennan, a senior fellow in the school of cybernetics at Australian National University, expressed concern in a 2018 letter to the Lancet that health care professionals run the risk of stifling broad-based collaboration by describing loneliness as a health problem to be solved by the medical community. McLennan, who primarily researches obesity, says she’s seen this phenomenon before.

“It’s been really hard to have a conversation around obesity as more than a medical concern because the public imagination of it by now has taken on board this idea of it being a medical thing that needs to be treated by doctors and diagnosed by doctors,” she tells The Journalist’s Resource. “The narratives that we put into the public domain do get picked up by the public, and they’re very hard to unwind later.”

Kotwal, who treats terminally ill patients, sees the pandemic and the growing volume of loneliness-related research as fueling important progress toward an inflection point in health care. Ultimately, he says, without systemic changes that facilitate increased social prescribing and spending on patients’ social wellbeing, the potential for clinicians to help alleviate suffering from chronic loneliness will be severely limited.

“How can we take a little bit of what we’re spending on medical care and redirect it to social care?” asks Kotwal. “I think clinicians have to be advocates for that change. Many of these other disciplines have been trying to do this for a long time, and we are playing catch-up, honestly. We’ve been behind for a long time here. I’m hopeful that the pandemic and some of the growing evidence in this space will push people to start doing this.”

Studies published in recent years have examined the prevalence of loneliness and links between low levels of human contact and poor health outcomes, as well as the efficacy of intervention delivery methods and specific interventions. Below is a curated list of seven peer-reviewed studies on loneliness and social isolation, along with summaries of their most important findings and additional insights from interviews with some of the authors.

Research Roundup:

Loneliness and Social Isolation as Risk Factors for Mortality: A Meta-Analytic Review

Julianne Holt-Lunstad, Timothy Smith; et al. Perspectives in Psychological Science, March 2015.

One of the most-cited studies on loneliness and social isolation, this paper concludes that a lack of human connection is as detrimental to health as other established risk factors, like smoking and obesity. The researchers examined 70 studies conducted between 1980 and 2014, for a total sample size of more than 3.4 million adults with an average age of 66, in an effort to determine the extent to which social isolation, loneliness, and living alone influenced the likelihood of death among the sample population.

They concluded that the increased likelihood of death was 26% for reported loneliness, 29% for social isolation, and 32% for living alone. The differences in these effect sizes was not statistically significant, explains Julianne Holt-Lunstad, a professor of psychology and neuroscience at Brigham Young University, and most of the studies included in the analysis did not look at more than one condition to determine overlap (i.e. whether someone who lived alone was also lonely). All of the studies did, however, control for initial health status, as a way to rule out reverse causality. The results suggest that social isolation and living alone are as much a predictor of early death as loneliness, but the reasons why are presumed to be different.

“If you’re having a heart attack, and there’s no one in your home to call 9-1-1, that’s going to have a significant effect on whether you survive that heart attack or not,” Holt-Lunstad tells The Journalist’s Resource.

While age and prior health status were significant in determining effect size, the results were consistent across genders and world regions, according to the study. Social isolation was more predictive of death in people younger than age 65, the researchers found.

A Meta-Analysis of Interventions to Reduce Loneliness

Christopher Masi; et al. Personality and Social Psychology Review, August 2010.

In this meta-analysis, the researchers examined 50 randomized group comparison studies on the efficacy of various loneliness interventions, concluding that the most effective among them addressed issues with social cognition, or how people process and apply information about other people.

A lonely person, in other words, might interpret social interactions as more negative than they are and use these negative interpretations to confirm thoughts about their own lack of social abilities or worthiness, thus perpetuating loneliness. The researchers theorize that this pattern stems from the state of hypervigilance associated with persistent loneliness, which can impair executive function and decision-making.

This led to a series of intervention strategies addressing “maladaptive social cognition,” though many proved ineffective after further study.

The Epidemiology of Social Isolation and Loneliness Among Older Adults During the Last Years of Life

Ashwin Kotwal; et al. Journal of the American Geriatrics Society, August 2021.

In this study, the researchers looked to understand the rates and risk factors of social isolation and loneliness among people who were within four years of death. By modeling data from the Health and Retirement Study combined with other data sources, the researchers found that about 19% of people in the study sample experienced social isolation, 18% experienced loneliness, and 5% experienced both.

Risk factors for both isolation and loneliness included having an individual net worth of less than $6,000, hearing impairment and difficulty preparing meals. Factors associated with loneliness, but not social isolation, included being female, having pain, incontinence, and cognitive impairment.

“We really are now thinking about addressing these social needs as an important opportunity to improve people’s quality of life when people are seriously ill or even finding ways to integrate them into their medical goals,” says Kotwal.

Accompanying the research paper, in the same issue of the journal, is an editorial, written by two physicians at Icahn School of Medicine at Mount Sinai in New York. Drs. Diane Meier and Sean Morrison advocate for increasing government support for addressing the social determinants of health, which play a considerable role in the health experiences of older adults in America.

“Despite recognition of the foundational role of social factors in achieving health, we continue to put nearly all of our taxpayer-funded healthcare dollars into direct medical services (more than 95% of healthcare dollars at a cost of >$10,000 per person per year),” they write. “This mismatch between spending and need results in our healthcare quality being ranked 37th among that of 100 developed nations, behind Costa Rica, and just ahead of Cuba and Slovenia.”

Loneliness at Older Ages in the United States: Lonely Life Expectancy and the Role of Loneliness in Health Disparities

James Raymo and Jia Wang,. Demography, June 2022.

Using data from the University of Michigan’s Health and Retirement Study, the researchers applied the statistical tools of demography to calculate a measure they call “lonely life expectancy” to understand the impact of loneliness on average life expectancy for various population segments. For example, men 55 years and older, on average, spend about 3.4 years lonely, which equates to roughly 14% of their total average life expectancy. This study also found that rates of loneliness among older adults remained relatively steady from 1998 to 2006.

One of the surprising findings from the research was that disparities in rates of loneliness along racial lines depended on how loneliness was defined, says lead study author James Raymo, a demographer and sociology professor at Princeton University. Using scales that measure respondents’ “sense of belonging” and “feeling left out” resulted in higher discrepancies in rates of loneliness among racial and ethnic minorities compared with whites.

The study also showed that higher rates of loneliness among disadvantaged groups do not directly correlate to higher rates of mortality or disease, Raymo says.

“We show that Blacks are lonelier than whites,” Raymo tells The Journalist’s Resource. “We show that less educated people are lonelier than higher educated people. But [further] analysis shows that, despite the fact that we know loneliness to be related to health outcomes and mortality, the concentration of higher levels of loneliness among more disadvantaged people does not account for their higher levels of mortality or higher probability of onset of disability and things like that. So that was a little bit surprising – how little salience loneliness had in accounting for, at least in a statistical sense, the differences in these various health outcomes across the racial, ethnic, and educational groups.”

Friends from the Future: A Scoping Review of Research into Robots and Computer Agents to Combat Loneliness in Older People

Norina Gasteiger, Kate Loveys, Mikaela Law, and Elizabeth Broadbent. Clinical Interventions in Aging, May 2021.

Based on a review of 29 studies, this paper concludes that current research points to “social robots” as an effective way to reduce loneliness in older adults, “using features that encourage direct companionship and facilitate social interactions.” Because the majority of the studies reviewed (24) dealt with robots – like Paro, a robotic baby seal used to comfort nursing home residents – the research was inconclusive on the efficacy of “computer agents,” like chatbots.

Elizabeth Broadbent, a professor in the Department of Psychological Medicine at the University of Auckland in New Zealand, was an author on this paper, as well as past research on Paro, which was developed in Japan.

“It makes these little seal noises, like helpless animal noises,” she says. “And that makes you want to pick it up and comfort it and cuddle it and pat it and talk to it as well.”

The majority of studies showed that robots or computer agents positively impacted at least one loneliness outcome measure. Some unintended negative consequences on social outcomes were reported, such as sadness when a robot was taken away from a study participant.

Overall, the robots helped combat loneliness by acting as a direct companion (69%), a catalyst for social interaction (41%), facilitating remote communication with others (10%) and reminding users of upcoming social engagements (3%).

Evaluation of the Effectiveness of Digital Technology Interventions to Reduce Loneliness in Older Adults: Systematic Review and Meta-analysis

Syed Ghulam Sarwar Shah; et al. Journal of Medical Internet Research, June 2021.

This paper outlines results from an evaluation of six studies of loneliness interventions designed to facilitate increased social connections using digital technologies, including five clinical trials. A total of 646 people (66% of them women) with an average age of 73-78 participated in the six studies, each lasting three months or more, examining interventions involving live videoconferencing, as well as Alexa-like audio and televised video support.

The overall effect estimates showed no statistically significant difference in the effectiveness of digital technology interventions compared with that of usual care or other interventions. However, the researchers note that the quality of evidence was very low to moderate in the trials.

Lead researcher Syed Ghulam Sarwar Shah, a physician and senior research fellow at Oxford University, says he believes the results demonstrate that digital technology interventions are no substitute for human interaction in the real world. As a result, he is working on developing an app called Evzein, which seeks to leverage local restaurants and pubs as places where lonely people can meet and connect.

Shah says additional research is needed to determine whether digital technology interventions are effective in reducing loneliness among young people and other specialized groups that were disproportionately affected by loneliness during the pandemic.

Improving Social Connectedness for Homebound Older Adults: Randomized Controlled Trial of Tele-Delivered Behavioral Activation Versus Tele-Delivered Friendly Visits

Namkee G. Choi, Renee Pepin, C. Nathan Marti, Courtney J. Stevens, and Martha L. Bruce. American Journal of Geriatric Psychology, July 2020

These researchers modified a short-term intervention known as “behavioral activation” that is usually used to address mild depressive symptoms in older adults, with the goal of reducing loneliness. A randomized controlled trial showed promising results for the intervention, both initially and during a follow-up study conducted a year later.

Behavioral activation involves educating recipients about the condition it is looking to address, in this case loneliness, in an effort to normalize it. An interventionist trained in BA assists people in identifying activities that hold particular value for them and finding new ways to engage in them, despite the functional or health limitations they might be experiencing. If church is really important to someone, for example, but they no longer attend because they don’t have a driver’s license, behavioral activation focuses on helping them find another way to get there, explains Renee Pepin, an assistant professor of community and family medicine at Dartmouth College’s Geisel School of Medicine.

In the study, Meals on Wheels recipients in New Hampshire and Texas were split into two groups. One group received regular behavioral activation sessions via teleconference; the other group received friendly chats via teleconference, without the specialized intervention. Compared to the group that received friendly visits, the behavioral activation group experienced a 10% greater increase in social interaction, 20% greater decrease in loneliness, 39% greater decrease in depressive symptoms, and 21% greater decrease in disability.

“The intervention holds promise for scalability in programs that already serve homebound older adults,” the researchers write.

Pepin says participants hired to deliver the intervention in the study were not Meals on Wheels drivers. “We tried to select people with similar characteristics as people who work for home-delivered meals,” she said. “A next step for this line of research is absolutely to see, does it work the same way or similarly if we actually do employ people who work within these agencies to deliver this intervention?”

Tips for Reporters Covering Loneliness Among Older Adults

1. Know the difference between social isolation and loneliness. Social isolation is defined as an objective lack of social contact, whereas loneliness is the subjective desire to have more or higher-quality social connections than one is currently experiencing. Some people can be socially isolated without feeling distressed, and others can feel lonely despite having regular social contact; it’s rare for people to experience both at the same time. Research suggests that chronic social isolation and chronic loneliness are associated with negative health outcomes, but in different ways.

2. Seek sources outside of health care. Clinicians know how to address problems within the confines of the health care system, but loneliness is a social issue addressed by a variety of other community stakeholders. Senior centers, nonprofit support programs, arts organizations, public social services agencies, and others have been confronting and working hard to address the problem of loneliness for decades.

3. Tell personal stories. Because the experience of loneliness is personal and varies at the individual level, it’s important to talk to people who are experiencing it, as this can help to reduce stigma and spur policy change. Home meal-delivery services and other local nonprofits serving seniors can be good starting points for finding sources.

4. Explain where people can go for help. Many older people who are lonely as well as those who care about seniors experiencing loneliness don’t know where to turn. Urging readers, viewers and listeners in these situations to reach out to a trusted family member, physician or community support worker is helpful, as are lists of resources, such as the Eldercare Locator.

5. Check your bias. Because loneliness is universal, people often think back to their own experiences for context, but that can unknowingly introduce bias into the conversation. People tend to remember what helped them overcome a specific bout of loneliness and believe the same solution would be helpful to others. However, because social needs and circumstances vary so much, there is no universally effective intervention for loneliness.

Additional Resources

Commit to Connect – a public-private campaign and resource clearinghouse hosted by the federal Administration for Community Living.

Foundation for Social Connection – nonprofit charitable organization promoting evidence-based research and interventions.

Coalition to End Social Isolation and Loneliness (CESIL) – Advocacy group supporting policy changes aimed at reducing loneliness and associated negative health effects.

Social Isolation and Loneliness Outreach Toolkit – This page from the National Institute on Aging features videos, graphics, flyers and brochures for use by media and community organizations to raise public awareness and reduce stigma surrounding loneliness and social isolation.

Eldercare Locator – A service of the US Administration on Aging, the Eldercare Locator connects people to local services for older adults and their families.

Project UnLonely – This national initiative by the Foundation for Art and Healing raises awareness about the negative effects of loneliness and empowers people to connect with each other through the arts.

Programs Promoting Interaction

The AARP recommends the following intergenerational programs to ease loneliness in older adults:

Big & Mini – An organization that matches older people with younger people for online chats and friendship.

SAGEConnect – a phone-buddy program that matches older LGBT people with volunteers for weekly phone calls.

Eldera – This service pairs mentors 60 and older in the U.S. with children ages 5 to 18 from 22 countries for video chats.

Dorot Caring Calls – Connects older adults with volunteers 18 and up for weekly phone calls, based on participants’ preferences.

Create the Good – This AARP site lists thousands of local and national volunteer opportunities and pairs seniors with volunteer work that matches their preferences.

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The Health Parity and Addiction Equity Act of 2008 requires that health insurers provide the same coverage for mental health treatment as they do physical health care.

While a variety of factors, including a shortage of mental health professionals in some parts of the U.S., have made the goals of the federal law easier said than done, there is at least one other avenue for many Americans to seek mental health treatment: employee assistance programs.

Employee assistance programs are free for workers, paid for by employers and often staffed by counselors who are either contractors or company employees themselves. Counselors often have at least a master’s degree in a relevant field, such as psychology, and may also be certified by the International Employee Assistance Professionals Association.

These programs may offer trained professionals to talk with employees about immediate mental health or substance use challenges, or they may provide a more holistic approach, including providing referrals to outside mental health professionals and helping workers through the process of securing longer-term care.

From struggles with child care to concerns about the health of family members and friends, stress related to the COVID-19 pandemic has only increased the need for mental health care. Nearly 8 in 10 U.S. employees now experience work-related stress, with burnout at “all-time highs across professions,” according to an online survey of 1,501 workers the American Psychological Association conducted in July and August 2021.

The economic costs of depression alone are at least $210 billion per year, in the form of medical costs and lost productivity, according to a widely cited 2015 study in the Journal of Clinical Psychiatry.

Still, one-third of people who thought they may have needed mental health help during the pandemic did not seek it, according to a Kaiser Family Foundation survey of 1,862 U.S. adults conducted by phone in March 2021.

Employee assistance programs are most commonly offered by medium-to-large companies. Roughly half of U.S. workers have access to employee assistance programs, according to the federal Bureau of Labor Statistics. For every $1 companies put into workplace mental health programs, they get $4 back in increased productivity and better health outcomes, according to the World Health Organization.

Employee assistance programs are related to but distinct from employee wellness programs, which encourage physical health through efforts such as smoking cessation, weight loss and nutrition education programs.

Employer-sponsored mental and physical health programs date as far back as the 1940s, when employer-sponsored efforts focused on addressing alcoholism among employees. They expanded over subsequent decades to address a range of mental health challenges that can affect work performance.

Here, we summarize five recent studies on employee assistance programs.

• The first study explores what the future of these programs might look like — more virtual, more on demand — post-pandemic.

• Two studies recount how employee assistance programs at two large health systems responded to the immediate shockwaves of the pandemic. In sum, having employee assistance infrastructure for mental health in place before the crisis unfolded was critical in helping frontline health workers manage the stress of caring for patients and losing colleagues to COVID.

• And two of the studies, published pre-pandemic, explore the overall effectiveness of these programs. Both find improvements in presenteeism, which refers to how “present” and productive an employee is during work hours after they receive counseling through an employee assistance program.

Finally, it’s worth noting that mental health treatment through employee assistance programs is unevenly available. Some 78% of union employees have access to these programs, compared with 52% of nonunion employees, according to the Bureau of Labor Statistics. And while 75% of people among the highest quarter of wage earners have access, 33% of those among the lowest quarter of wage earners have access to employee assistance programs, the federal data show.

Usage rates, however, remain low, despite 1-in-5 adults in the U.S. experiencing mental illness. Employees on average use assistance programs at a rate of 10% or less, according to the Society for Human Resource Management, a trade group. The Bureau of Labor Statistics used to ask about the number of hours employees used assistance programs in its Survey of Employer-Provided Training, but that survey was discontinued in 1995.

EAP 2.0: Reimagining the Role of the Employee Assistance Program in the New Workplace
Alan Langlieb, Marin Langlieb and Willa Xiong. International Review of Psychiatry, January 2022.

What the authors studied: How employee assistance programs are currently structured and how they may need to adapt, in light of the COVID-19 pandemic, to new ways that employees seek mental health care, such as through telemedicine.

What they found: Employee assistance programs usually are designed to incorporate the life cycle of employee mental health care from assessment to referral to mental health professionals to ongoing case management. Still, some programs focus on short-term problem solving while others may offer more comprehensive mental health services, such as counseling with licensed professionals. The authors note that technology like on-demand video conferencing makes 24-hour counseling a possibility, which could encourage employees to take advantage of mental health services when they need them. Employees are more likely to seek employer-provided counseling if executives promote a workplace culture that encourages good mental health.

In their words: “The [employee assistance program] of the future might be as close as reaching for one’s smartphone or iPad. In light of past terrorist activities and the recent pandemic, [employee assistance programs] will also need to develop strategies for providing increased counseling and social support to large numbers of individuals at a moment’s notice.”

The COVID Chronicles: An Employee Assistance Program’s Observations and Responses to the Pandemic
Daniel Hughes and Acanthus Fairley. Journal of Workplace Behavioral Health, December 2020.

What the authors studied: How an employee assistance program at a major academic health system responded to sudden strains on the system and a spike in employee stress brought on by the COVID-19 pandemic. The health system, Mount Sinai in New York City, comprises eight hospitals and employs 42,000 people. As the pandemic began to unfold, the employee assistance program core staff consisted of a director, four counselors, three graduate students of social work and an administrative assistant.

What they found: The health system mobilized an executive-level task force to organize support to staff, some on the frontlines and others working remotely. Morale fell when a popular young nurse who tested positive for COVID died on March 24, 2020. An employee assistance counselor and the health system’s chaplain began working with the nurse’s colleagues to help them cope with the loss. Employee assistance program staff continued this method of reaching out to work groups when one of their members died.

The employee assistance program also deployed a “cluster-ball” approach with proactive outreach to clusters of employees likely to be experiencing stress, such as those working in emergency rooms, along with follow-up to specific employees asking if they had concerns about colleagues, in order to “snowball” support to staff in need. A hotline was also set up to direct employees to mental health and other services. One counselor with military experience engaged emergency medical technicians by sending them self-care messages and techniques via text.

In their words: “Employees should be offered a range of self-help options from spiritual care to exercise. Psychotherapy should be available, especially for those with preexisting psychological risk factors. Communication concerning available services should be straight forward and easily digestible. Some employees will need assistance to navigate complex systems of care. Employee assistance programs are well positioned to provide this service.”

Employee Assistance Program Response and Evolution in Light of COVID-19 Pandemic
Gregory Couser, Jody Nation and Mark Hyde. Journal of Workplace Behavioral Health, October 2020.

What the authors studied: Why staff turned to an employee assistance program serving 39,000 employees at the Mayo Clinic in Rochester, Minnesota, during the pandemic. At the outset of the pandemic, the program employed five on-site counselors with referrals for child, legal and other services provided by an outside vendor.

What they found: Stress over contracting COVID and running out of personal protective equipment were top of mind among many employees early on. Initial use of employee assistance services was low, consistent with other research finding that during stressful periods employees may be reluctant to show vulnerability. The authors also suggest that employees newly working from home may not have been aware of mental health services offered by telephone.

Take-up of services increased as statewide stay-at-home orders eased in June 2020. That month, the authors surveyed employee assistance counselors to learn why staff were using their services. Before the pandemic, employees sought help for various reasons, including relationship and work problems. During the pandemic, employees sought help primarily for mental health issues such as anxiety and depression.

In their words: “[Employee assistance programs] should be prepared for [a] potential influx of mental health and relationship concerns as the pandemic wanes. In uncertain times, [employee assistance programs] especially have an opportunity to show value to their respective organizations through the capturing of data regarding ability to rapidly respond and evolve to meet their organization’s needs.”

Demonstrating Value: Measuring Outcome & Mitigating Risk: FOH EAP Study Utilizing the Workplace Outcome Suite
Jeffrey Mintzer, Veronica Morrow, Melissa Back Tamburo, David Sharar and Patricia Herlihy. International Journal of Health & Productivity, December 2018.

What the authors studied: 2016 and 2017 data on outcomes from employees who used the Federal Occupational Health assistance program, which serves more than 900,000 federal workers and fields 8,100 monthly requests, on average. In all, 4,800 employees completed a five-item scored questionnaire before receiving services, and filled out the same questionnaire three months later. The questionnaire, called the Workplace Outcome Suite, is a standard survey used to evaluate employee assistance programs. Survey takers self-report levels of absenteeism, presenteeism (when an employee is present but not fully productive), work engagement (measuring how passionate the employee is about their job), life satisfaction and workplace distress.

What they found: The employee assistance program was most effective in reducing absenteeism, defined as missing work due to a personal problem. In 2016 and 2017, scores for absenteeism fell nearly 70%. Presenteeism improved by more than 20% each year, with life satisfaction also improving nearly or more than 20% each survey year. Workplace distress improved by roughly 10% each year, and work engagement improved by less than 3% each year.

In their words: “All five items were found to be statistically significant which indicates that they demonstrate a positive response to [employee assistance program] counseling.”

EAP Works: Global Results from 24,363 Counseling Cases with Pre-Post Data on the Workplace Outcome Suite
Mark Attridge, David Sharar, Gregory DeLapp and Barbara Veder. International Journal of Health & Productivity, December 2018.

What the authors studied: Results from an international survey of 24,363 people who sought help through employee assistance counseling, with more than three-quarters of survey takers based in the U.S. and most of the remainder from China. The employees completed the five-part Workplace Outcome Suite before counseling and then three months later. Four in 10 worked in health care, roughly one quarter worked in manufacturing and government each, and the remainder worked in the technology sector.

What they found: Half of people struggled with presenteeism before counseling, a rate that dropped to one quarter after counseling. Absenteeism also fell by about half after counseling — from missing 7.4 hours per month, on average, to 3.9 hours. Workplace engagement and distress improved slightly. The rate of employees reporting significant issues with life satisfaction fell from 38% before to 17% after counseling.

In their words: “When [employee assistance program] counseling is provided with adherence to basic quality standards the results are usually positive. There is considerable evidence from reviews of studies conducted in North America and in Europe that brief counseling provided by [employee assistance programs] typically reduces stress, improves symptoms of behavioral health problems and restores higher work functioning.”

The Journalist’s Resource is part of the Mental Health Parity Collaborative, a group of news organizations that are covering challenges and solutions to accessing mental health care in the U.S. The collaborators on this project include The Carter Center, The Center for Public Integrity, and newsrooms in Arizona, California, Georgia, Illinois, Pennsylvania and Texas.

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