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When caught early through routine screening, cervical cancer is curable. In the US, roughly 92% of women with early-stage cervical cancer survive five years or longer, compared with only 17% of women with late-stage cervical cancer. So recent research that shows a steep rise in new cases of advanced cervical cancer among white Southern women, and underscores the disproportionate burden of advanced cases among Black Southern women, is worrisome.

What factors might be at play, and how can people best protect themselves? Two Harvard experts share their insights.

Human papilloma virus and cervical cancer: What to know

Human papilloma virus (HPV) causes nine out of 10 cervical cancers. In 2023, 13,960 women in the US will be diagnosed with cervical cancer and 4,310 will die from it, according to American Cancer Society estimates.

Pap test screening can detect this cancer early, when it’s easiest to treat. And testing for HPV has been approved as an additional screening test for cervical cancer. It can be used alone or with a Pap test.

What did the research focus on and learn?

The study was published online in International Journal of Gynecological Cancer. Researchers combed through cervical cancer data submitted to the United States Cancer Statistics program between 2001 and 2018, and national survey findings on Pap screening and HPV vaccination. During this period, nearly 30,000 women were diagnosed with late-stage cervical cancer, which has spread to other parts of the abdomen and body.

Early-stage cervical cancer cases have been dropping for most groups in the US in recent years. But advanced cervical cancer cases have not declined within any US racial, ethnic, or age group over the last 18 years.

New diagnoses of advanced disease rose 1.3% annually during the study period. Southern white women ages 40 to 44 saw an annual rise of 4.5% in advanced cases. Southern Black women ages 55 to 59 were diagnosed nearly twice as often as white women with early and advanced cases.

What else is important to understand?

The new study showed that women living in the South are less likely to be vaccinated against HPV or screened for cervical cancer. But lower screening rates likely don’t fully explain the rise in late-stage cases in that region, says Dr. Ursula Matulonis, chief of the Division of Gynecologic Oncology at Dana-Farber Cancer Institute.

“Most cervical cancer cases continue to be diagnosed early,” Dr. Matulonis says. “These new findings suggest that cases involving a more aggressive cell type called adenocarcinoma are also increasing. Often found higher up in the cervical canal, this is harder to detect with a Pap smear.”

Older women are especially vulnerable. Rates of late-stage cervical cancer are higher — and survival is worse — among women 65 and older than among younger women, according to a study in California. One possible reason? They may not have received the recommended number of screening tests with normal results before they stopped having Pap smears, says Dr. Sarah Feldman, a gynecologic oncologist at Brigham and Women’s Hospital.

HPV vaccine protects against cervical cancer

The HPV vaccine is FDA-approved for use in females ages 9 through 26. The first group of vaccinated adolescents, now in their 20s, have clearly benefited: invasive cervical cancer rates among women 20 to 24 dropped by 3% each year from 1998 through 2012.

“That’s pretty impressive,” Dr. Matulonis says. “And those decreases span race and ethnicity, which isn’t always the case in women’s cancers.”

What steps can you take to protect against cervical cancer?

Dr. Feldman offers this guidance around cervical cancer prevention and detection.

• HPV vaccination. All children should be vaccinated against HPV between ages 9 and 12, well before sexual activity begins. “The most important thing for future generations in cervical cancer prevention is vaccinating that generation,” Dr. Feldman says.
• Routine screening. Regardless of vaccination status or whether they’re sexually active, women should begin having screening tests for cervical cancer in their 20s and continue through age 65. Discuss the right intervals with your doctor. Current screening guidelines take into account when you start screening and whether results of tests are normal:
  • If you start at 21: Have a Pap test every three years until 30.
  • If you start at 25: Seek an HPV test first.
  • At age 30: If all screening tests so far have been normal, have HPV testing every five years. Continue this screening until age 65.
  • Don’t stop screening at 65 unless all test results are normal, including at least two results in the last 10 years and one in the last five years.
  • If any testing led to abnormal results, you may need to continue screening beyond age 65.

An HPV infection, rather than sexual activity alone, is the factor that places people at risk, Dr. Feldman says.

“A lot of older women may have a new sexual partner in their 50s. A new HPV infection raises risk for cervical cancer roughly 20 years later,” Dr. Feldman says. “If HPV test results are persistently negative through age 65, the risk of developing cervical cancer in your 70s is low.”

About the Author

Maureen Salamon, Executive Editor, Harvard Women's Health Watch

Maureen Salamon is executive editor of Harvard Women’s Health Watch. She began her career as a newspaper reporter and later covered health and medicine for a wide variety of websites, magazines, and hospitals. Her work has … See Full Bio View all posts by Maureen Salamon

About the Reviewer

Howard E. LeWine, MD, Chief Medical Editor, Harvard Health Publishing

Howard LeWine, M.D., is a practicing internist at Brigham and Women’s Hospital in Boston, Chief Medical Editor at Harvard Health Publishing, and editor in chief of Harvard Men’s Health Watch. See Full Bio View all posts by Howard E. LeWine, MD

Understandably, the sensitive topic of weight in children and teens often focuses on the health costs of overweight and obesity. Sometimes, though, a child needs to gain some weight. And while there are lots of ways to make that happen, not all of them are healthy.

What to do if your child seems underweight

If you are worried about whether your child needs to gain weight, it’s very important to check with your doctor before getting to work on fattening them up. It’s entirely possible that your child’s weight is absolutely fine. Given that one in five children in the US is obese and another one in six is overweight, it’s easy to see how a parent might think their child is too thin in comparison. One way to find out if your child’s weight is healthy is to check their body mass index, a calculation using height and weight that is used for children ages 2 and up.

Losing weight or being underweight can be a sign of a medical or emotional problem, so be sure to let your doctor know about your concerns. They may want to see your child to help decide if any evaluations are needed. If your child is less than 2 years old, it’s particularly important that you check in with your doctor about weight concerns, and follow their advice exactly.

Choosing healthy foods when a child needs to gain weight

If your child is older than 2 and the doctor agrees that gaining weight is a good idea, the best way to approach it is by using healthy foods and healthy habits.

Three ways to help encourage healthy weight gain:

• Give your child three meals (breakfast, lunch, and dinner) and two healthy snacks (mid-morning and mid-afternoon). If your child eats dinner early, you could consider a small snack before bedtime. Try to avoid snacks in between or drinking anything other than some water; you want them to be hungry when you give them food.
• Offer healthy high-calorie foods. Think in terms of healthy fats and protein. Some examples are:
  • nuts and nut butters, as well as seeds like pumpkin or sunflower seeds
  • full-fat dairy, such as whole milk, heavy cream, cream cheese, and other cheeses
  • avocados
  • hummus
  • olive oil and other vegetable oils
  • whole grains, such as whole-wheat bread or granola (look for granola sweetened with juice or fruit rather than sugar)
  • meat if your diet includes it
• Every time you prepare a meal or snack, think about how you might add some calories to it. For example, you could add some extra oil, butter, or cheese to pasta — or some nut butter on a slice of apple or piece of toast.

Three traps to avoid:

• Giving your child more sweets or junk food. It’s tempting, as children generally want to eat sweets and junk food, and both have calories. But they aren’t healthy foods, and it’s not a good idea to build a sweets and junk food habit.
• Giving your child unlimited access to food. This, too, is tempting — after all, you want them to eat! But not only does that make it hard to be sure that what they are eating is healthy, snacking can make them less hungry when it’s time for an actual meal.
• Letting your child fill up on milk and other drinks — including nutritional supplement drinks. This, too, makes it less likely that they will eat at mealtime, and they are unlikely to get all the nutrients they need. Don’t give your child nutritional supplements unless your doctor advises you to do so.

Be sure you schedule regular check-ins with your doctor to monitor your child’s progress. Hopefully your child will soon be at a healthier weight that helps them to thrive as they grow.

Follow me on Twitter @drClaire

About the Author

Claire McCarthy, MD, Senior Faculty Editor, Harvard Health Publishing

Claire McCarthy, MD, is a primary care pediatrician at Boston Children’s Hospital, and an assistant professor of pediatrics at Harvard Medical School. In addition to being a senior faculty editor for Harvard Health Publishing, Dr. McCarthy … See Full Bio View all posts by Claire McCarthy, MD

Many people know the form of dementia called Alzheimer’s disease. But what is frontotemporal dementia (FTD)? Damage to nerves in certain parts of the brain causes a group of frontotemporal disorders, affecting behavior and language as I’ll describe below.

Early signs of frontotemporal dementia

Have you noticed someone behaving differently? Is your coworker doing odd things, such as slapping each door as they walk down the hall? Or has your previously kind and caring spouse lost their capacity for empathy, such that when you told them about your cancer diagnosis, they complained that your treatment schedule would interfere with their golf game? If so, they might be showing early signs of the behavioral variant of FTD.

Maybe there’s a problem with language, rather than behavior. Perhaps it started with difficulty finding words (like any older adult), but is your sibling now having trouble with grammar and getting out an intelligible sentence? Or does your friend not know the meaning of some ordinary words, like pizza, lemonade, wood, or metal? If so, they might be showing signs of primary progressive aphasia, which may also be due to FTD.

A common pathology inside the brain

What’s the connection between these behavior and language problems? Why are they both part of FTD?

Both have the same underlying causes: a family of abnormal proteins that can be seen under the microscope. In fact, more than a dozen different pathologies can cause FTD. Each of them can lead to either behavioral variant frontotemporal dementia or the language difficulties of primary progressive aphasia.

Location, location, location

How can the same pathology — the same abnormal protein — lead to either behavior problems or language problems, or sometimes both? The answer is, it depends on where the pathology is.

The frontal lobes of your brain, behind your forehead, regulate and guide your personality, judgement, and behavior. So, if the frontotemporal pathology is in this region, it will cause changes in personality, judgement, and behavior.

The left temporal lobe (near your left ear and temple) and a part of the left frontal lobe just above it are the critical brain regions for language. When these areas are affected by frontotemporal pathology, language problems develop.

How does frontotemporal dementia compare with Alzheimer’s disease?

Frontotemporal dementia affects people in middle age, usually between ages 45 and 65, although one-quarter of individuals are diagnosed after age 65. Alzheimer’s usually affects people over 65.

In terms of symptoms, people with frontotemporal dementia experience either language or behavior problems, whereas people with Alzheimer’s disease — the most common cause of dementia — usually have memory problems.

Because more than 12 different abnormal proteins can cause frontotemporal dementia, it has a very variable time course. From the time of diagnosis, people with frontotemporal dementia need nursing home–level care in two to 20 years. The typical range with Alzheimer’s disease is four to 12 years.

Who is at risk for FTD?

Up to 40% of cases of frontotemporal dementia run in families, but that means at least 60% of cases do not. Unfortunately, everyone is at risk for frontotemporal dementia as they approach middle age.

What are common signs of the behavioral variant?

There are six common signs of behavioral variant frontotemporal dementia, and most people with the disorder have at least three of them. They are:

• loss of self-control
• apathy or inertia (not wanting to do anything)
• loss of sympathy or empathy
• repetitive or compulsive, ritualistic behavior
• uncontrolled or unusual eating
• difficulty doing complicated tasks.

One individual I cared for with this disorder would walk up to strangers, stand closer than would be comfortable, and say loudly, “You’re handsome!” Another would eat almost anything left out in the kitchen. One woman I treated with this disorder tried to pick up men from a restaurant — while her husband was sitting at the next table. A previously kind and shy grandfather with frontotemporal dementia began to ask his daughter-in-law for sexual favors.

What are common signs of the language variants?

Two variants of primary progressive aphasia are part of the frontotemporal dementia family of diseases. Common signs are:

• difficulty getting words and sentences out, although the meaning of words is preserved (nonfluent or agrammatic variant). People become frustrated because they know what they want to say but find it difficult or impossible to do so.
• losing the meaning of words (semantic variant). I had one patient who did not know the meaning of the words shoe, pants, foot, knee, elbow, and many other words related to clothing and parts of the body.

Can frontotemporal dementia be treated?

Currently, there is no cure or way to slow these disorders down, so treatment is supportive. SSRI medications (selective serotonin reuptake inhibitors) can help with some disinhibited behaviors.

Speech therapy can be helpful, at least initially, with primary progressive aphasia, but thus far no medications are effective.

What can I do if I suspect that someone has frontotemporal dementia?

FTD is difficult to diagnose. Because it affects people in middle age, dementia is usually not suspected. Early in the disease, people are often thought to be having a midlife crisis, depression, or perhaps a drug or alcohol problem. Many marriages end prior to the diagnosis because the spouse with the disorder has grown self-absorbed and inconsiderate over several years.

If you do suspect the disorder, start by simply asking the person if there is anything that you can help with. You may find out that it is another problem entirely. But if it is becoming clear that this or another form of dementia may be involved, encourage them and their family to discuss this possibility with their doctor.

About the Author

Andrew E. Budson, MD,

Contributor; Editorial Advisory Board Member, Harvard Health Publishing

Dr. Andrew E. Budson is chief of cognitive & behavioral neurology at the Veterans Affairs Boston Healthcare System, lecturer in neurology at Harvard Medical School, and chair of the Science of Learning Innovation Group at the … See Full Bio View all posts by Andrew E. Budson, MD

Love isn’t the only reason your heart may skip a beat. While abnormal heartbeats can be alarming, they’re usually harmless. They occur for different reasons. Which types are common — and when should you be concerned?

Palpitations

Your heartbeat normally keeps a predictable pace: speeding up when you’re active and slowing down when you rest. But many people notice odd heart sensations called palpitations at least once in a while. People usually say it feels as though their heart has skipped a beat, or is racing or pounding.

“One common scenario is a person who feels their heart is racing, but if you look at their electrocardiogram (ECG), It’s totally normal,” says cardiologist Alfred E. Buxton, professor of medicine at Harvard Medical School.

A heightened awareness of normal heart rhythms may occur more in people who wear smartwatches with heart rate monitors, he adds. “People with a resting heart rate of 60 beats per minute are concerned when their heart rate goes up to 90, but that’s still in the normal range,” he says.

Ectopic beats

The sensation that your heart has skipped a beat also occurs when the heart’s upper chambers (atria) or lower chambers (ventricles) contract slightly earlier than normal.

During the next beat, the atria pause a bit longer to get back into a normal rhythm. The heart’s lower chambers (ventricles) then squeeze forcefully to clear out the excess blood that accumulates during that pause. They also can contract earlier than usual, which may make you feel like your heart has briefly stopped and restarted.

Known as ectopic beats, both types of these premature contractions may cause a brief pounding sensation. However, this is nothing to worry about. “I often tell my patients that the fact they feel these beats is usually a sign that their heart is healthy. A weak, sick heart can’t exert a forceful beat,” says Dr. Buxton.

AV block and bundle branch block

Electrical impulses tell your heart to pump. They travel through the right and left sides of your heart. But sometimes the impulses travel more slowly than normal or irregularly, causing a condition called AV block. There are various degrees of AV block, some benign, others associated with extremely slow heart rates that may be dangerous.

Another electrical conduction irregularity is a bundle branch block. This results from an abnormal activation pattern of the ventricles that squeeze blood out of the heart to the rest of the body. The most common is right bundle branch block, which usually doesn’t cause obvious symptoms. It may be spotted during an ECG, and can simply reflect the gradual aging of the heart’s conduction system. However, sometimes a right bundle branch block is caused by underlying damage from a heart attack, heart inflammation or infection, or high pressure in the pulmonary arteries.

A left bundle branch block may occur as an isolated phenomenon, or may be caused by a variety of underlying conditions. In some cases, left bundle branch block may lead to abnormal function of the left ventricle, a condition that is sometimes corrected by special pacemakers.

Atrial fibrillation

An electrical misfire in the atria can cause atrial fibrillation, an uncoordinated quivering of the atria that raises the risk for stroke. Commonly known as afib, this heart rhythm problem can come and go, lasting only a few minutes or sometimes for days or even longer. And while some people report a fluttering sensation in their chest or a rapid, irregular heartbeat during an episode of afib, other people don’t have any symptoms.

Certain smartwatches that can record a brief ECG may be able to detect afib. But Dr. Buxton says they’re not sensitive or specific enough to reliably diagnose the problem. “Sometimes the watch tells you that you have afib when you don’t, or vice versa,” he says.

The heart rate monitoring feature may be helpful, however. In people younger than 65, the heart rate can soar to 170 beats per minute or higher during a bout of afib. But for those in their 70s and 80s, who are more likely to have afib, the heart rate usually doesn’t get that high.

When should you be concerned about irregular heartbeats?

An irregular heartbeat, such as racing, fluttering, or skipping a beat, is usually harmless. Even in cases when palpitations are frequent and bothersome (which occurs rarely), reassurance may be the only treatment needed.

But you should contact your doctor if you notice other symptoms accompanying an unusual heartbeat, such as feeling

• chest pain
• dizzy
• lightheaded
• tired
• breathless
• as though you’re going to faint.

People who have been told they have a bundle branch block may need periodic ECGs to monitor their condition. They should also be alert to symptoms such as dizziness or fainting, which can happen if the blockage worsens or occurs on both sides and causes a low heart rate.

About the Author

Julie Corliss, Executive Editor, Harvard Heart Letter

Julie Corliss is the executive editor of the Harvard Heart Letter. Before working at Harvard, she was a medical writer and editor at HealthNews, a consumer newsletter affiliated with The New England Journal of Medicine. She … See Full Bio View all posts by Julie Corliss

About the Reviewer

Robert H. Shmerling, MD,

Senior Faculty Editor, Harvard Health Publishing; Editorial Advisory Board Member, Harvard Health Publishing

Dr. Robert H. Shmerling is the former clinical chief of the division of rheumatology at Beth Israel Deaconess Medical Center (BIDMC), and is a current member of the corresponding faculty in medicine at Harvard Medical School. … See Full Bio View all posts by Robert H. Shmerling, MD

Imagine this as a morning routine that replaces your first cup of coffee:

You wake up feeling a bit foggy, so you slip on a wearable device that looks like an extra-thick headband. You turn on the power source and settle in while electrical current flows into your brain. Twenty minutes later, feeling more focused and energized, you start your busy day feeling grateful for this new technology.

If this scenario sounds strange to you, I’m with you. And yet, hype around transcranial direct current stimulation (tDCS) is growing for an expanding list of conditions such as depression, ADHD, and even Alzheimer’s disease. A recent ad for one tDCS device urges you to “elevate your performance.” But before you give this a try, read on.

What is transcranial direct current stimulation?

Brain stimulation therapies aim to activate or inhibit parts of the brain. tDCS has been around for years, but its popularity has spiked over the last decade.

tDCS devices use headgear that may look like a swim cap or headband to position electrodes against the scalp. When a power source is switched on, the electrodes deliver low levels of electrical current to the brain. A typical session lasts 20 to 30 minutes and may be repeated over days or weeks.

Three better-known brain stimulation therapies are:

• Transcranial magnetic stimulation (TMS): A device worn over the forehead stimulates specific areas of the brain by changing nearby magnetic fields. TMS is cleared by the FDA to treat depression that hasn’t responded to standard medicines, and for obsessive-compulsive disorder.
• Electroconvulsive therapy (ECT): An electric current flowing through electrodes placed at specific locations on the scalp causes a brief seizure while a patient is under anesthesia. In use since the late 1930s, ECT can be highly effective for severe depression that hasn’t responded to standard therapies. It uses higher levels of electrical current than tDCS. That’s why it requires close medical supervision and is generally administered in a hospital or specialized clinic.
• Deep brain stimulation (DBS): Electrodes surgically implanted in specific areas of the brain generate electrical pulses. DBS is used to treat conditions such as Parkinson’s disease, epilepsy, or tremors that don’t improve with medicines.

What claims are made for tDCS?

The brain normally functions by sending and receiving tiny electrical signals between nerve cells. Stimulating specific regions of the brain with low levels of electricity might improve focus or memory, mood, or even dementia, according to tDCS advocates.

Some claims say tDCS can

• improve mental clarity, focus, and memory
• increase energy and motivation
• relieve so-called brain fog following COVID-19, Lyme disease, or other conditions
• reduce depression or anxiety
• reduce cravings among smokers or people with drug addiction
• improve symptoms of ADHD or Alzheimer’s disease.

Does tDCS work?

The jury is still out. Research suggests that tDCS holds promise for certain conditions, but techniques tested through research may differ from devices sold commercially for at-home use. For example, electrodes may be positioned more precisely over an area of the brain, and how current is delivered, session length, or number of sessions may differ.

Currently, small, short-term studies show that tDCS may benefit people with:

• Depression: An analysis of 10 randomized trials found some participants were more likely to report fewer symptoms of depression, or remission of depression, after a course of tDCS treatment compared with sham treatment.
• Alzheimer’s disease: A review of seven studies found that tDCS lasting 20 to 40 minutes improved memory and other cognitive measures in people with mild to moderate Alzheimer’s disease.
• ADHD: One randomized trial of 64 adults with ADHD found improved attention after 30 minutes of tDCS daily for a month.

The FDA has not cleared tDCS for any health condition, and it is considered investigational. More research with positive results and reassuring safety data are needed before tDCS gets a thumbs-up from regulators.

That’s probably why some ads for tDCS note in fine print that it is not a medical device and is only for recreational use.

Does tDCS have downsides?

While the FDA assesses tDCS as safe for adults, there are downsides to consider. For example, treatment may cause itching, irritation, or small burns at the sites of the electrodes. Some users complain of fatigue or headache.

There are no large, long-term studies of tDCS, so overall safety is uncertain. Some experts believe at-home use raises many questions, such as how much of the brain beyond targeted areas is affected, what inconsistent approaches to tDCS use might do, and how long changes in the brain — intended or not — could last.

Very limited research has been done in children. So, the consequences for a child’s developing brain aren’t clear.

Finally, tDCS devices can be expensive (several hundred dollars or more), and generally are not covered by health insurance.

The bottom line

It’s not yet clear how tDCS should be used, or who is most likely to benefit from it. If you’re interested in pursuing tDCS, understand that there’s still a lot we don’t know.

If you’re more skeptical and risk-averse (like me), you may want to wait for more definitive research regarding its benefits and risks — and for now, stick with your morning coffee to clear your mind.

Follow me on Twitter @RobShmerling

About the Author

Robert H. Shmerling, MD,

Senior Faculty Editor, Harvard Health Publishing; Editorial Advisory Board Member, Harvard Health Publishing

Dr. Robert H. Shmerling is the former clinical chief of the division of rheumatology at Beth Israel Deaconess Medical Center (BIDMC), and is a current member of the corresponding faculty in medicine at Harvard Medical School. … See Full Bio View all posts by Robert H. Shmerling, MD

Ketamine is an unusual type of psychedelic drug — called a dissociative — that is undergoing a resurgence in popularity. Originally derived from PCP, or “angel dust,” ketamine has been used in hospitals and veterinary clinics as an anesthetic for decades, and has been cited as a drug of misuse under the moniker “special K.”

It is the effects that ketamine reliably produces that underlie both its medical and recreational uses: pain control, forgetfulness, intoxication, disassociation, and euphoria. Recently, it has been used more widely due to its approval for treatment-resistant depression (TRD) — that is, severe depression that has not improved via other therapies, including people who are experiencing suicidal thoughts.

Evidence of the benefit of ketamine

A prescription version of ketamine called esketamine (Spravato), given through a nasal spray, was approved in 2019 by the FDA for TRD; however, according to the guidelines, it is only to be used “under the supervision of a health care provider in a certified doctor’s office or clinic.” That means medical professionals need to watch you use it, and then follow you after you’ve taken your dose, checking your vital signs and how you are doing clinically.

The effectiveness of ketamine for TRD was first demonstrated for short-term treatment in research that resulted in clinically and statistically significant decreases in depression scores for ketamine versus placebo (In both groups in this study, the patients continued with their regular antidepressants because of concern of not treating TRD in the placebo arm.) Nasal ketamine was shown to have longer-term efficacy, in a study where ketamine (plus the regular antidepressant) helped people stay in stable remission 16 weeks into treatment.

Relief from TRD with ketamine happens rapidly. Instead of waiting for an SSRI to hopefully provide some relief over the course of weeks, people who are suffering under the crushing weight of depression can start to feel the benefits of ketamine within about 40 minutes.

Is ketamine the right treatment for you?

This is a discussion that should include your primary care doctor, your mental health provider, and any other health care professionals who care for you. It’s important to remember that ketamine isn’t a first-option treatment for depression, and it is generally used only when other, more longstanding treatments haven’t been effective. It is not thought to be curative; rather, it improves symptoms for a certain amount of time. It is easier to say who isn’t appropriate for ketamine treatment, based on the side effects.

Should you go to a ketamine clinic for treatment?

Independent, outpatient ketamine clinics are popping up all over the place. It is estimated that there are currently hundreds to thousands of these clinics — almost all of which were established in 2019 when ketamine was approved for TRD. Typically, these clinics are for-profit enterprises that are staffed by some combination of either a psychiatrist or an anesthesiologist (who can administer the infusion), a nurse, a social worker, and (of course) the businesspeople who make it all work.

In writing this piece, I called several ketamine clinics, posing as a patient, to investigate what would be involved in receiving ketamine therapy. Most of them seemed as if they would provide ketamine for me without any major hurdles, after an introductory medical interview by a nurse or a social worker. A few clinics required communication or a diagnosis from my psychiatrist — and this seemed quite sensible.

The clinics operate on a fee-for-service arrangement, so you would pay out of pocket, as insurance rarely covers this treatment. In the Boston area where I live, the ketamine infusions cost about $600 each, and a course of six infusions and a clinical re-evaluation are typically recommended. (I should note that the ketamine clinics affiliated with medical academic institutions seem to have more safeguards in place, and they may also be enrolling people in clinical trials.)

Are ketamine clinics safe?

These ketamine clinics raise many questions — namely, what does one look for in a reputable and safe ketamine clinic? Currently, we don’t yet have definitive answers to that question. One wonders if a ketamine infusion, which can cause a profound dissociation from reality, would be better controlled in a hospital setting, where there are protocols for safety in case anything goes wrong. It was unclear (in part because I didn’t actually go through with the therapy) how much communication, if any, there would be between the ketamine clinic staff and your health care providers, and typically the treatments you receive would not be included in your primary electronic medical record.

What are the side effects?

Ketamine is generally considered safe, including for those who are experiencing suicidal ideation (thoughts or plans for suicide). The main side effects are dissociation, intoxication, sedation, high blood pressure, dizziness, headache, blurred vision, anxiety, nausea, and vomiting. Ketamine is avoided or used with extreme caution in the following groups:

• people with a history of psychosis or schizophrenia, as there is concern that the dissociation ketamine produces can make psychotic disorders worse
• people with a history of substance use disorder, because ketamine can cause euphoria (likely by triggering the opioid receptors) and some people can become addicted to it (which is called ketamine use disorder)
• teenagers, as there are some concerns about the long-term effects of ketamine on the still-developing adolescent brain
• people who are pregnant or breastfeeding
• older adults who have symptoms of dementia.

More detailed research needs to be done on the longer-term benefits and side effects of ketamine treatment, and on its safety and effectiveness for teens and older adults, as well as for the emerging indications of ketamine therapy for PTSD, OCD, alcohol use disorder, and other mental health conditions.

Finally, there is some concern that, with repeated dosing, ketamine can start to lose its effectiveness and require larger doses to produce the same effect, which is not sustainable.

Ketamine could provide hope for people with serious depression

Serious, treatment-resistant depression can rob people of hope for the future and hope that they will ever feel better. Ketamine can provide help and hope to patients who have not found relief with any other treatments. Given its efficacy in people considering suicide, it is plausible that ketamine may be lifesaving.

As we learn more from research on ketamine and from people’s experiences in newer clinics, we will be better able to answer the questions of ketamine’s longer-term effectiveness and what safeguards are needed for treatment. We may also learn who is most likely to safely benefit from ketamine therapies, and the best method of administration: intravenous infusion, a nasal spray, or a pill.

About the Author

Peter Grinspoon, MD, Contributor

Dr. Peter Grinspoon is a primary care physician, educator, and cannabis specialist at Massachusetts General Hospital; an instructor at Harvard Medical School; and a certified health and wellness coach. He is the author of the forthcoming book Seeing … See Full Bio View all posts by Peter Grinspoon, MD

The wait is finally over: after 40 weeks of medical appointments, nursery planning, and anticipation, your baby has finally arrived. She is perfect in your eyes, healthy and adorable. Yet over the next few weeks, your initial joy is replaced by all-consuming worries: Is she feeding enough? Why is she crying so often? Is something medically wrong with her? These worries are constant during the day and keep you up at night. You feel tense and irritable, your heart races, and you feel panicky. Your family members start to express their concern —not just about the baby, but about you. You wonder whether your anxiety is normal.

Baby blues, postpartum depression, or postpartum anxiety?

Chances are, you have heard about the baby blues or postpartum depression. You may have even filled out questionnaires about your mood during your postpartum doctor’s visit. The baby blues are a very common reaction to decreasing hormone levels after delivery, and may leave you feeling sad, weepy, and overwhelmed. However, these symptoms are mild and only last for a couple of weeks. When the symptoms persist and become debilitating, something else could be going on.

Many symptoms overlap between postpartum depression and postpartum anxiety (such as poor sleep, trouble relaxing, and irritability). Mothers experiencing postpartum depression commonly experience symptoms of anxiety, although not all mothers suffering from anxiety are depressed. Establishing the correct diagnosis is important, as women with postpartum anxiety may not respond as well to certain treatments for depression, such as interpersonal psychotherapy or medications such as bupropion (Wellbutrin).

Similar to postpartum depression, postpartum anxiety may spike due to hormonal changes in the postpartum period. It may also increase as a response to real stressors — whether it’s the health of the baby, finances, or in response to navigating new roles in your relationships. A history of pregnancy loss (miscarriage or stillbirth) also increases your risk for developing postpartum anxiety. If you have a history of anxiety before or during pregnancy, postpartum anxiety symptoms may also return after delivery. Anxiety and sadness may also appear after weaning from breastfeeding due to hormonal changes.

Some women experience panic attacks or symptoms of obsessive-compulsive disorder (OCD) in the postpartum period. Panic attacks are distinct episodes of intense anxiety accompanied by physical symptoms including a rapidly beating heart, feelings of doom, shortness of breath, and dizziness. Obsessions are intrusive, unwanted thoughts and may be accompanied by compulsions, or purposeful behaviors to relieve distress. These symptoms may be frightening to a new mother, especially when these thoughts involve harming the baby. Fortunately, when obsessions are due to an anxiety disorder, mothers are extremely unlikely to harm their babies.

What are the treatments for postpartum anxiety?

In general, postpartum anxiety is less studied than its cousin postpartum depression; however, it is estimated that at least one in five women has postpartum anxiety. We do know that therapies such as cognitive behavioral therapy (CBT) are excellent treatments for anxiety disorders, including OCD. For some women, medications can be helpful and are more effective when combined with therapy. Selective serotonin reuptake inhibitors (SSRIs) are generally the first-line medications (and the best studied medication class) for anxiety disorders, whereas benzodiazepines are rapidly acting anti-anxiety medications that are often used while waiting for an SSRI to take effect.

Should you take medications when breastfeeding?

Breastfeeding provides many benefits to the baby: it’s the perfect nutrition, it helps build a baby’s immune system, it may help prevent adulthood obesity, and it provides comfort and security. Breastfeeding also provides benefits for the mother: it releases prolactin and oxytocin (the love and cuddle hormones), which help a mother bond with her baby and provide a sense of relaxation. When considering whether to start a medication, it is important to be aware that all psychiatric medications are excreted into the breast milk. Your doctor can help you think through the risks and benefits of medications based on the severity of your illness, medication preference, and previous response, as well as factors unique to your baby, such as medical illness or prematurity.

What non-medication strategies are helpful in decreasing postpartum anxiety?

• Cuddle your baby (a lot). This releases oxytocin, which can lower anxiety levels.
• Try to maximize sleep. Although the baby may wake you every three hours (or 45 minutes) to feed, your partner should not. Sleeping in separate rooms or taking shifts caring for the baby may be necessary during the first few months. Aim for at least one uninterrupted four-hour stretch of sleep, and be mindful about caffeine intake.
• Spend time with other mothers. Although you may feel like you don’t have the time, connecting with other mothers (even online) can do wonders in lowering your fears and validating your emotions. Chances are you are not the only one worrying up a storm.
• Increase your physical activity. In spite of the physical toll that pregnancy, delivery, and milk production take on your body, physical activity is one of the most powerful anti-anxiety strategies. Activities that incorporate breathing exercises, such as yoga, may be particularly helpful.
• Wean gradually. If you are breastfeeding and make the decision to wean, try to do so gently (when possible) to minimize sudden hormonal changes.
• Ask for help. Caring for a baby often requires a village. If you are feeding the baby, ask someone else to help with household chores. There is an old saying “sleep when the baby sleeps.” You may prefer “do laundry when the baby does laundry.”

And finally, give yourself a break — after all, you just had a baby. Postpartum anxiety is common, and in many cases, it will pass with time.

About the Author

Stephanie Collier, MD, MPH,

Contributor; Editorial Advisory Board Member, Harvard Health Publishing

Dr. Stephanie Collier is the director of education in the division of geriatric psychiatry at McLean Hospital; consulting psychiatrist for the population health management team at Newton-Wellesley Hospital; and instructor in psychiatry at Harvard Medical School. … See Full Bio View all posts by Stephanie Collier, MD, MPH

The current shortage of semaglutide (Ozempic), an important diabetes drug, has an unusual origin: too many people without diabetes are taking it. Here’s how that happened, and how we might course-correct to help ensure that those with the greatest need for this medicine can get it.

A diabetes drug with an important side effect: Weight loss

Semaglutide (Ozempic) was first approved by the FDA in 2017 to help people with type 2 diabetes keep blood sugar under control. But during pre-approval studies, researchers noticed a remarkable side effect: people lost weight. For example, in one pivotal study, average losses for those receiving one milligram a week of semaglutide were:

• nearly 10 pounds lost over 30 weeks
• nearly 5% overall body weight lost
• waist size shrank 1.6 inches.

This side effect helped people with type 2 diabetes because excess weight is a major risk factor for the condition. Among other health benefits, weight loss can lower blood sugar and blood pressure, and reduce the need for other diabetes medications.

Turning a side effect into a selling point

Unintended weight loss would usually be listed as a side effect for a study medication. But ads for Ozempic didn’t list it with the other possible side effects; instead, it was featured as a benefit. The Ozempic “Tri-Zone” (a phrase concocted by marketers, not medical experts) promised improved blood sugar control, lower cardiovascular risk, and weight loss.

At the bottom of the ad, fine print that’s easy to miss states: “Ozempic is not a weight loss drug.” Talk about mixed messages!

The makers of Ozempic saw the potential of semaglutide as a weight loss drug for people without diabetes. Sure enough, clinical trials confirmed that overweight and obese people taking semaglutide also lost substantial weight. Semaglutide received FDA approval in 2021 for people with obesity (BMI of 30 or greater), or who were overweight (with a BMI of 27 to 29.9) and had a medical problem related to excess weight, such as high blood pressure or high cholesterol. As a weight loss drug, it was rebranded as Wegovy.

The only difference between the two drugs? The maximum approved dose of semaglutide is a bit higher with Wegovy than Ozempic.

How social media fueled the Ozempic shortage

Soon after the approval of Wegovy, celebrities and social media influencers began taking it and sharing glowing weight loss experiences. What’s more, medicines approved for specific uses in the US can be prescribed off-label for any use: up to 38% of all prescriptions written in the US are off-label (note: automatic PDF download). So, it’s likely some of the viral run on Wegovy was fueled by people who wanted to lose weight but had no medical reason to take it.

After high demand put Wegovy in short supply, many turned to Ozempic to lose weight. And that contributed to a shortage of Ozempic, threatening the health of people with type 2 diabetes who rely on the drug.

Readjust priorities and limit irresponsible prescribing

This situation couldn’t have happened without physicians or other health care professionals willing to write Ozempic prescriptions for people who did not have diabetes or another medical reason to use semaglutide. And that suggests an obvious solution: limit prescriptions for Ozempic to people with diabetes. For many drugs, a prior authorization process requires certain conditions be met before a prescription can be filled. This could be done for Ozempic.

And of course, we should encourage people who don’t have diabetes not to request a prescription for Ozempic. While that message is unlikely to show up in a drug ad, public service announcements could do the trick.

The bottom line

Drug ads often urge you to ask your doctor if a treatment is right for you. But we already know a key piece of the answer for Ozempic: if you don’t have diabetes, don’t ask for a diabetes medicine to help with weight loss. There are better ways to get the help you need to reach a healthy weight if you are overweight or obese. Talk to your doctor about a full range of treatment options. And if your weight is already in a healthy range, it’s not a good idea to take a medication to become thinner.

Finally, to keep vitally important medicines available for those who need them most, health care professionals must prescribe them responsibly. Responsible requests by their patients could help.

About the Author

Robert H. Shmerling, MD,

Senior Faculty Editor, Harvard Health Publishing; Editorial Advisory Board Member, Harvard Health Publishing

Dr. Robert H. Shmerling is the former clinical chief of the division of rheumatology at Beth Israel Deaconess Medical Center (BIDMC), and is a current member of the corresponding faculty in medicine at Harvard Medical School. … See Full Bio View all posts by Robert H. Shmerling, MD

Parents like to think that they know what is going on with their children — and that they would know if their teen was suicidal. However, research shows that this is not always the case.

Teens may consider suicide more often than parents realize

In a study published a few years ago in the journal Pediatrics, researchers interviewed more than 5,000 adolescents ages 11 to 17. In those interviews, they asked them if they had ever thought about killing themselves — or if they had ever thought a lot about death or dying. The teens' parents were asked if they believed that their teens had ever thought about killing themselves, or had thought a lot about death or dying.

There wasn’t a whole lot of match-up. Half of the parents of the adolescents who thought of killing themselves were unaware — as were three-quarters of the parents of adolescents who thought often about death.

This disconnect looms larger as research shows mental health problems are on the rise in youth. According to the 2021 Youth Risk Behavioral Survey, 42% of high school students reported persistent feelings of sadness and hopelessness; 22% seriously considered suicide, and 10% attempted it.

The numbers were higher for girls and youth who identify as LGBTQ+:

• Almost 60% of girls experienced persistent sadness and hopelessness; 30% seriously considered attempting suicide, and 13% attempted it.
• Among LGBTQ+ youth, 70% experienced persistent sadness and hopelessness; 45% seriously considered attempting suicide, and 22% attempted it.

Many factors contribute to this. Stress and isolation caused by the pandemic clearly played a role. While teens are back in school, re-entry has been difficult for many. Social media clearly plays a role, inviting unrealistic comparisons, reinforcing negative thoughts and ideas, and encouraging doomscrolling. It is also a source of bullying: in the report, 16% of high school students reported being bullied electronically, including 20% of girls and 27% of those who identify as LGBTQ+.

Why the disconnect between teens and parents?

It’s not that surprising that parents don’t always know that their teens are considering suicide. Teens may not always realize how bad they are feeling, and may not want to tell their parents when they do — both for fear of worrying them, and also because of uncertainty about how their parents might react.

Parents may miss signs of depression in their teens, or quite genuinely misinterpret them or attribute them to something innocent; after all, it’s natural to want to believe that your child is fine, rather than thinking that they might be suicidal. And given how much drama can be intrinsic to the life of a teen, it’s understandable that parents could misinterpret statements about death or dying as, well, just teen drama.

What can parents do?

• Be aware of signs of depression in teens, and never ignore them. Acting sad is one of them, but there are many others:
  • dropping grades
  • being irritable or angry often
  • acting bored all the time, and/or dropping out of activities
  • difficulty with relationships, including changing peer groups or becoming more isolated
  • dangerous or risky behavior
  • persistent physical complaints such as headaches or stomachaches
  • fatigue.
• Listen to your teen, and never assume that statements like “nobody cares if I live or die” are just drama. Instead of saying, “You don’t mean that,” ask them if they do mean it. Often parents worry that asking about suicide might “give them ideas,” but asking may be the only way to know — and the best way to show your teen that you are taking them seriously.
• Learn how to have tough conversations about mental health and suicide. The American Academy of Pediatrics has many tips and resources for parents.
• Get help. Call your doctor, call a mental health professional, call the new nationwide number 988 that can link you to local help like a suicide hotline, or take your child to a local emergency room. This is crucial. If counseling is recommended, do your best to schedule it, letting your doctor know if you are having trouble finding a provider. Make sure your teen sticks with it.
• If you suspect your teen may be depressed or suicidal, take precautions. If you have a gun in your house, make sure it is locked up with the ammunition locked separately. Take stock of prescription medications and alcohol in your house that could be used for self-harm, and either get rid of them or be sure they are stored safely.

Sometimes it is just drama — or short-term blues after a breakup or another one of life’s inevitable disappointments. And in the study, half of the teens whose parents thought they were suicidal, and two-thirds of those whose parents believed their teens thought about death, said they were fine. But when it comes to suicide, it’s always better to be safe than sorry. So ask the questions — and ask for help.

About the Author

Claire McCarthy, MD, Senior Faculty Editor, Harvard Health Publishing

Claire McCarthy, MD, is a primary care pediatrician at Boston Children’s Hospital, and an assistant professor of pediatrics at Harvard Medical School. In addition to being a senior faculty editor for Harvard Health Publishing, Dr. McCarthy … See Full Bio View all posts by Claire McCarthy, MD

I admit it: I’m not a fan of drug ads. I think the information provided is often confusing and rarely well-balanced. Plus, there are just so many ads. They show up on TV and streaming programs, on social media, on billboards and the sides of busses, on tote bags, and in public bathrooms. Yes, there’s no refuge — even there — from the billions spent on direct-to-consumer ads in the US.

I’ve often wondered how highly-promoted, expensive new drugs stack up against other available treatments. Now a new study in JAMA Network Open considers exactly that.

Many advertised drugs are no better than older drugs

The study assessed 73 of the most heavily advertised drugs in the US between 2015 and 2021. Each drug had been rated by at least one independent health agency. Researchers tallied how many of these drugs received a high therapeutic value rating, indicating that a drug had at least a moderate advantage compared with previously available treatments.

The results? Only about one in four of these heavily advertised drugs had high therapeutic value. During the six years of the study, pharmaceutical companies spent an estimated $15.9 billion promoting drugs on TV that showed no major advantage over less costly drugs!

Why drug ads are not popular

Only the US and New Zealand allow direct-to-consumer medication marketing. The American Medical Association recommended a ban in 2015. While I’ve often written about reasons to be skeptical, let’s focus here on three potential harms to your wallet and your health.

Drug ads may

• raise already astronomical health care costs by increasing requests for unnecessary treatment and promoting much costlier medicines than older or generic drugs.
• create diseases to be treated. Everyday experiences, such as fatigue or occasional dryness in the eyes, may be framed in drug ads as medical conditions warranting immediate treatment. Yet often, such symptoms are minor, temporary experiences. Another example is “low T” (referring to low blood testosterone). While it’s not a recognized illness on its own, ads for it have likely contributed to increased prescriptions for testosterone-containing medicines.
• promote new drugs before enough is known about long-term safety. The pain reliever rofecoxib (Vioxx) is one example. This anti-inflammatory medicine was supposed to be safer than older medicines. It was withdrawn from the market when evidence emerged that it might increase the risk of heart attack and stroke.

Four questions to ask your doctor if you’re curious about a drug ad

Wondering whether you should be taking an advertised drug? Ask your doctor:

• Do I have a condition for which this drug is recommended?
• Is there any reason to expect this drug will be more helpful than what I’m already taking?
• Is this drug more expensive than my current treatment?
• Do my health conditions or the medications I already take make the drug in the ad a poor choice for me?

The bottom line

The AMA recommended banning drug ads nearly a decade ago. But a drug ad ban seems unlikely, given strong lobbying by the pharmaceutical companies and concerns about violating their freedom of speech.

Still, cigarette commercials were banned in 1971, so it’s not an impossible dream. Meanwhile, my advice is to be skeptical about information in drug ads, and rely on more reliable sources of medical information, including your doctor. Consider contacting the Federal Communications Commission if you have complaints about these ads — a step few Americans seem to take. And try this: mute the TV, fast-forward your podcast, and close pop-ups as soon as drug ads appear.

About the Author

Robert H. Shmerling, MD,

Senior Faculty Editor, Harvard Health Publishing; Editorial Advisory Board Member, Harvard Health Publishing

Dr. Robert H. Shmerling is the former clinical chief of the division of rheumatology at Beth Israel Deaconess Medical Center (BIDMC), and is a current member of the corresponding faculty in medicine at Harvard Medical School. … See Full Bio View all posts by Robert H. Shmerling, MD