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  • Plenty of People Could Quit Therapy Right Now

    Plenty of People Could Quit Therapy Right Now

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    About four years ago, a new patient came to see me for a psychiatric consultation because he felt stuck. He’d been in therapy for 15 years, despite the fact that the depression and anxiety that first drove him to seek help had long ago faded. Instead of working on problems related to his symptoms, he and his therapist chatted about his vacations, house renovations, and office gripes. His therapist had become, in effect, an expensive and especially supportive friend. And yet, when I asked if he was considering quitting treatment, he grew hesitant, even anxious. “It’s just baked into my life,” he told me.

    Among those who can afford it, regular psychotherapy is often viewed as a lifelong project, like working out or going to the dentist. Studies suggest that most therapy clients can measure their treatments in months instead of years, but a solid chunk of current and former patients expect therapy to last indefinitely. Therapists and clients alike, along with celebrities and media outlets, have endorsed the idea of going to therapy for extended stretches, or when you’re feeling fine. I’ve seen this myself with friends who are basically healthy and think of having a therapist as somewhat like having a physical trainer. The problem is, some of the most commonly sought versions of psychotherapy are simply not designed for long-term use.

    Therapy comes in many varieties, but they all share a common goal: to eventually end treatment because you feel and function well enough to thrive on your own. Stopping doesn’t even need to be permanent. If you’ve been going to therapy for a long time, and you’re no longer in acute distress, and you have few symptoms that bother you, consider taking a break. You might be pleasantly surprised by how much you learn about yourself.

    Therapy, in both the short and long term, can be life-altering. Short-term therapy tends to be focused on a particular problem, such as a depressed mood or social anxiety. In cognitive behavioral therapy, usually used for depressive and anxiety disorders, a clinician helps a client relieve negative feelings by correcting the distorted beliefs that he has about himself. In dialectical behavior therapy, commonly used to treat borderline personality disorder, patients learn skills to manage powerful emotions, which helps improve their mood and relationships. Both treatments typically last less than a year. If you start to get rusty or feel especially challenged by life events that come your way, you simply return for another brief stint. Termination is expected and normal.

    Read: What’s the smallest amount of therapy that’s still effective?

    Some types of therapy, such as psychodynamic therapy and psychoanalysis, are designed to last for several years—but not forever. The main goal of these therapies is much more ambitious than symptom relief; they aim to uncover the unconscious causes of suffering and to change a client’s fundamental character. At least one well-regarded study found that long-term therapy is both highly effective and superior to briefer treatment for people diagnosed with a clinically significant psychiatric illness; other papers have shown less conclusive evidence for long-term therapy. And few studies compare short and extended treatment for clients with milder symptoms.

    In fact, there’s reason to believe that talk therapy in the absence of acute symptoms may sometimes cause harm. Excessive self-focus—easily facilitated in a setting in which you’re literally paying to talk about your feelings—can increase your anxiety, especially when it substitutes for tangible actions. If your neurotic or depressive symptoms are relatively mild (meaning they don’t really interfere with your daily functioning), you might be better served by spending less time in a therapist’s office and more time connecting with friends, pursuing a hobby, or volunteering. Therapists are trained to use the tools they’ve learned for certain types of problems, and many of the stress-inducing minutiae of daily life are not among them. For example, if you mention to your therapist that you’re having trouble being efficient at work, he might decide to teach you a stress-reduction technique, but your colleagues or boss might provide more specific strategies for improving your performance.

    One of my childhood friends, whose parents were both psychoanalysts, went to weekly therapy appointments while we were growing up. He was a happy, energetic kid, but his parents wanted him and his sister to be better acquainted with their inner lives, to help them deal with whatever adversity came their way. My friend and his sister both grew up to be successful adults, but also highly anxious and neurotic ones. I imagine their parents would say the kids would have been worse without the therapy—after all, mental illness ran in their family. But I can find no substantial clinical evidence supporting this kind of “preventive” psychotherapy.

    Read: What it’s like to visit an existential therapist

    Beginning therapy in the first place is, to be clear, a privilege. Therapy is not covered by many insurance plans, and a very large number of people who could benefit from it can’t afford it for any duration. Only 47 percent of Americans with a psychiatric illness received any form of treatment in 2021; in fact, federal estimates suggest that the United States is several thousand mental-health professionals short, a gap that is likely to grow in the coming years. Stopping therapy when you’re ready opens up space for others who might need this scarce service more than you do.

    I do not mean to suggest that a therapy vacation should be considered lightly, or that it’s for everyone. If you have a serious mental-health disorder, such as major depression or bipolar disorder, you should discuss with your mental-health provider whether ending therapy is appropriate for your individual situation. (Keep in mind that your therapist might not be ready to quit when you are. Aside from a financial incentive to continue treatment, parting with a charming, low-maintenance patient is not so easy.) My rule of thumb is that you should have minimal to no symptoms of your illness for six months or so before even considering a pause. Should you and your therapist agree that stopping is reasonable, a temporary break with a clear expiration date is ideal. At any time, if you’re feeling worse, you can always go back.

    Psychiatrists do something similar with psychiatric meds: For example, when I prescribe a depressed patient an antidepressant, and then they remain stable and free of symptoms for several years, I usually consider tapering the medication to determine whether it’s still necessary for the patient’s well-being. I would do this only for patients who are at a low risk of relapse—for example, people who’ve had just one or two episodes, rather than many over a lifetime. Pausing therapy should be even less risky: The beautiful thing about therapy is that, unlike a drug, it equips you with new knowledge and skills, which you carry with you when you leave.

    Read: The quick therapy that actually works

    About a year after my patient and I first talked about ending therapy, I ran into him in a café. He told me that stopping had taken him six months, but now he was thriving. Maybe you, like my patient, are daunted by the idea of quitting cold turkey. If so, consider taking a vacation from treatment instead. It might be the perfect way to see how far you’ve really come.

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    Richard A. Friedman

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  • The Pregnancy Risk That Doctors Won’t Mention

    The Pregnancy Risk That Doctors Won’t Mention

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    The nonexhaustive list of things women are told to avoid while pregnant includes cat litter, alfalfa sprouts, deli meat, runny egg yolks, pet hamsters, sushi, herbal teas, gardening, brie cheeses, aspirin, meat with even a hint of pink, hot tubs. The chance that any of these will harm the baby is small, but why risk it?

    Yet few doctors in the U.S. tell pregnant women about the risk of catching a ubiquitous virus called cytomegalovirus, or CMV. The name might be obscure, but CMV is the leading infectious cause of birth defects in America—far ahead of toxoplasmosis from cat litter or microbes from hamsters. Bafflingly, the majority of babies infected in the womb are unaffected, but an estimated 400 born with CMV die every year. Thousands more end up with hearing and vision loss, epilepsy, developmental delays, or microcephaly, in which the head and brain are unusually small. Exactly why the virus so dramatically affects some babies but not others is unknown. There is no cure and no vaccine.

    Amanda Devereaux’s younger child, Pippa, was born with CMV, which caused damage to her brain. Pippa is prone to seizures. She could not walk until she was 2 and a half, and she is nonverbal at age 7. “I was just flabbergasted that no one told me about CMV,” says Devereaux, who is now the program director for the National CMV Foundation, which raises awareness of the virus. The nonprofit was founded by parents of children with congenital CMV. “Every single one of them says, ‘Why didn’t I hear about this?’” Devereaux told me.

    One reason that doctors have hesitated to spread the word is that the most obvious way to avoid this virus is to avoid infected toddlers. Symptoms from CMV are usually mild to nonexistent in healthy adults and children. Toddlers, who frequently pick up CMV at day care, can continue shedding the virus in their bodily fluids for months and even years while totally healthy. “I’ve encountered a classroom of 2-year-olds where every single child was shedding CMV,” Robert Pass, a retired pediatrician and longtime CMV researcher at the University of Alabama, told me when we spoke in 2021. (He recently died, at age 81.)

    This creates a common scenario for congenital CMV: A toddler in day care brings CMV home and infects Mom, who is pregnant with a younger sibling. One recent study found that congenital CMV is nearly twice as common in second-born children than in firstborns. Devereaux’s toddler son was in day care when she was pregnant. “I was sharing food with him because he would not finish his breakfast,” she told me. She had no idea that his half-eaten muffin could end up harming her unborn daughter. In hindsight, she says, “I wish I had spent less time worrying about not eating deli meat and more time focused on, Hey I’ve got this toddler at day care. I’m at risk for CMV.”

    CMV is such a tricky virus because few things about it are absolute. A mother cannot avoid her toddler categorically. Most pregnant women infected with CMV do not pass it to their babies. Most infected babies end up just fine. Doctors warn patients against many risks in pregnancy—see the list above—but in this case thousands of parents every year are blindsided by a very common virus. No one has a perfect answer for how to stop it.

    Day cares have been known as hot spots for CMV since at least the 1980s, when Pass, in Alabama, and other researchers in Virginia first began tracking congenital cases back to child-care centers. The virus is rampant in day cares for the same reason that other viruses are rampant in day cares: Young children are born with no immunity, and they aren’t very diligent about avoiding one another’s saliva, urine, snot, and tears, all of which harbor CMV. Of mothers with infected toddlers in day care, a third who have never had the virus catch it within a year. And getting CMV for the first time while pregnant is the riskiest scenario; these so-called primary infections are most likely to result in serious complications for the fetus. But recent research has found that reinfections and reactivations of the virus can lead to congenital CMV too. (CMV remains inside the body forever after the first infection, much like chickenpox, which is caused by a related virus.)

    So eliminating the risk of congenital CMV entirely is impossible. But some CMV experts advocate giving women a short list of actions to reduce their risk during the nine months of pregnancy: Avoid sharing food or utensils with toddlers in day care; kiss them on the top of the head instead of on the mouth; wash your hands frequently, especially after diaper changes; and clean surfaces that come in contact with saliva or urine. A study in Italy found that pregnant women who were taught these measures cut their risk of catching CMV by sixfold. A study in France found that it lowered risk too.

    In the U.S., patients are unlikely to hear this advice from their obstetricians, though. The American College of Obstetricians and Gynecologists doesn’t recommend telling patients about ways to reduce CMV risk. According to ACOG, the evidence that behavioral changes can make a difference—from just a handful of studies—is not strong enough, and the organization sees downsides to the approach. Advice such as not kissing babies and toddlers could harm “a mother’s ability to bond with her children,” and these hygiene recommendations could “falsely reassure patients” about their risk of CMV, Christopher Zahn, ACOG’s interim CEO, said in a statement to The Atlantic.

    The CMV community disagrees. “I think they’re being a bit paternalistic,” says Gail Demmler-Harrison, a pediatric-infectious-diseases doctor at Texas Children’s Hospital. A group of international CMV experts, including Demmler-Harrison, endorsed patient education in a set of consensus recommendations in 2017. Devereaux, with the CMV Foundation, frames it as a matter of choice. It shouldn’t be “somebody else is saying, ‘You can’t handle this information; I’m not going to share that with you,” she told me. Without knowing about CMV, women can’t decide what kind of risk they’re comfortable with or what kind of hygiene changes are too burdensome. “It’s your choice whether you make them or not,” she says. “Having that choice is important.”

    More data on how well these behavioral changes work might be coming soon: Karen Fowler, an epidemiologist at the University of Alabama at Birmingham, is enrolling hundreds of pregnant women in a clinical trial. Only 8 percent of participants had heard of CMV before joining the study, she says. Patients get a short information session about CMV and then 12 weeks of text-message reminders. Importantly, she says, “we’re keeping our message very simple”: Reduce saliva sharing: no eating leftover food, no sharing utensils, and no cleaning a pacifier in your mouth. This simple rule cuts off the most probable routes of transmission. Sure, CMV is also shed in urine, tears, and other bodily fluids—but mothers aren’t routinely putting any of those in their mouth.

    Prevention of CMV ends up the focus of so much attention because once a fetus is infected, the treatment options are not particularly good. The best antiviral against CMV is not considered safe to use during pregnancy, and another antiviral, although safer, is not that potent. After infected babies are born, antiviral therapy can help preserve hearing in those with other moderate to severe symptoms from CMV, but it can’t reverse damage in the brain. And it’s unclear how much antivirals help those with only mild symptoms. When does benefit outweigh risk? “There’s a big gray area,” says Laura Gibson, a pediatric-infectious-diseases doctor at the University of Massachusetts Chan Medical School. For these reasons, policies of whether to screen all newborns vary state to state, even hospital to hospital. Knowledge can be power—but with a virus as confusing as CMV, knowledge of an infection doesn’t always point to an obvious best choice.

    In an ideal world, all of this could be made obsolete with a CMV vaccine. But such a vaccine has proved elusive despite a lot of interest. In the U.S., the Institute of Medicine deemed a CMV vaccine the highest priority around the turn of the millennium, and about two dozen vaccine candidates have been or are being studied. All of the completed clinical trials, though, have failed. “The immunity may look robust in the first month or year, but then it wanes,” Demmler-Harrison says. And even vaccines that elicit some immune response are not necessarily able to elicit one strong enough to protect against CMV infection entirely.

    CMV is such a challenging virus to vaccinate against because it knows our immune system’s tricks. “It’s evolved with humans for millions of years,” Gibson says. “It knows how to get around and live with our immune system.” Our immune system is never able to eliminate the virus, which emerges occasionally from our cells to replicate and try to find another host. And so a vaccine that completely protects against CMV would need to prompt our immune system to do something it cannot naturally do. It would need to be better than our immune system. “As time goes on, I think fewer and fewer people are thinking that might work,” Gibson says. But a vaccine doesn’t have to protect against all infections to be useful. Because first infections are the riskiest for fetuses, being vaccinated could still reduce risk of congenital CMV.

    Whom to vaccinate is another complicated question to answer for CMV. We could vaccinate all toddlers, as we do against rubella, which is also most dangerous when passed from mother to fetus. This has the potential advantage of promoting widespread immunity that tamps down circulation of CMV, period. But the virus doesn’t actually harm toddlers much, and immunity could wane by the time they grow up to childbearing age. Or we could vaccinate teenagers, as we do against meningococcal disease, but teens are more likely to miss vaccines and again, immunity could wane too soon. So what about all pregnant women? By the time someone shows up at the doctor pregnant, it’s probably too late to protect during CMV’s highest risk period, in the first trimester. A better understanding of CMV immunity and spread could help scientists decide on the best strategy. Gibson is conducting a study (funded by Moderna, which is testing a CMV-vaccine candidate) on how the virus spreads and what kinds of immune responses are correlated with shedding.

    Until a vaccine is developed—should it happen at all—the only way to prevent CMV infection is the very old-tech method of avoiding bodily fluids. It’s imperfect. Its exact effectiveness is hard to quantify. Some people might not find it worthwhile, given the small absolute risk of CMV in any single pregnancy. There are, after all, already so many things to worry about when expecting a baby. Yet another one? Or, you might think of it, what’s one more?

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    Sarah Zhang

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  • Do You Really Want to Read What Your Doctor Writes About You?

    Do You Really Want to Read What Your Doctor Writes About You?

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    You may not be aware of this, but you can read everything that your doctor writes about you. Go to your patient portal online, click around until you land on notes from your past visits, and read away. This is a recent development, and a big one. Previously, you always had the right to request your medical record from your care providers—an often expensive and sometimes fruitless process—but in April 2021, a new federal rule went into effect, mandating that patients have the legal right to freely and electronically access most kinds of notes written about them by their doctors.

    If you’ve never heard of “open notes,” as this new law is informally called, you’re not the only one. Doctors say that the majority of their patients have no clue. (This certainly has been the case for all of the friends and family I’ve asked.) If you do know about the law, you likely know a lot about it. That’s typically because you’re a doctor—one who now has to navigate a new era of transparency in medicine—or you’re someone who knows a doctor, or you’re a patient who has become intricately familiar with this country’s health system for one reason or another.

    When open notes went into effect, the change was lauded by advocates as part of a greater push toward patient autonomy and away from medical gatekeeping. Previously, hospitals could charge up to hundreds of dollars to release records, if they released them at all. Many doctors, meanwhile, have been far from thrilled about open notes. They’ve argued that this rule will introduce more challenges than benefits for both patients and themselves. At worst, some have fretted, the law will damage people’s trust of doctors and make everyone’s lives worse.

    A year and a half in, however, open notes don’t seem to have done too much of anything. So far, they have neither revolutionized patient care nor sunk America’s medical establishment. Instead, doctors say, open notes have barely shifted the clinical experience at all. Few individual practitioners have been advertising the change, and few patients are seeking it out on their own. We’ve been left with a partially implemented system and a big unresolved question: How much, really, should you want to read what your doctor is writing about you?

    The debate about open notes can be boiled down to a matter of practicality versus idealism. You’d be hard-pressed to find anyone, doctor or otherwise, who argues against transparency for patients in principle. At the same time, few people I spoke with for this article believe that the new rule has been put in place all that smoothly. For care providers, the primary concern has been the trouble that can come with writing notes for a new audience. Notes, generally scribbled in shorthand incomprehensible to the unknowing eye, have traditionally served doctors, and doctors alone. They allowed physicians to stay up to date on their patients and share information with colleagues for input on cases.

    Some doctors told me they worry that open notes could result in distress for patients who read something they don’t understand, and that highly technical language could make something sound worse than it is. Oncology, for instance, can involve an onslaught of potentially concerning terminology. (Psychotherapy notes are exempt from the new rule.) Other doctors fear that valuable information can be lost if they go too far in de-jargonizing notes to make them patient-friendly. Or that de-jargonizing notes is simply unfeasible. “Let’s say you came to me with pain and pointed to your mid-clavicular line. I’d just put ‘MCL,’” says Aldo Peixoto, a nephrologist at Yale. “But if I were writing for you to understand, I’d have to say ‘pain on the top-right portion of her abdomen in the line that runs from the middle of her clavicle,’ and so on. Rather than writing four lines of prose, I could’ve used literally three letters.”

    If that sounds quibbling, consider the trade-offs. Less time for doctors can translate into less time for patients. Many clinicians already write notes well into the evening. Certainly, the pandemic hasn’t helped. Some doctors told me that if they find themselves in a dilemma of either writing notes in less-efficient, plain language or fielding worried patient calls and messages, exhausted practitioners will face yet another burden. And then there’s the matter of trust. Jack Resneck, the president of the American Medical Association, the nation’s largest professional group of doctors and medical students, told me that doctors can need time and space with patients to get them to open up and be receptive to guidance through difficult situations. If these patients were to see notes too soon, Resneck said, they might “immediately flee and not come back to see you.”

    As doctors have spent more time dealing with open notes, many have eased off their strongest objections. Some, including Resneck and the AMA, have warmed up to the new rule as certain exceptions have been granted, such as allowing doctors whose patients have parents or partners with access to their notes to omit certain details from their write-ups for privacy reasons. Other physicians seem to be coming to a somewhat awkward realization: On a practical level, many concerns about how this change affects patients are irrelevant, because most patients don’t yet know they have instant access to their notes in the first place. Every doctor I spoke with for this story told me that their patients were largely unaware. Many doctors and hospitals are not going out of their way to inform people about the new rule, so unless patients are particularly on top of shifting rules within our convoluted health-care system, they’re unlikely to encounter the notes on their own. Kerin Adelson, an oncologist at Yale, admitted she didn’t know how to find notes in her own patient portal. She spent several minutes with me on the phone fumbling through different tabs to locate them.

    Fans of open notes are frustrated that there is not a greater push for awareness. Even acknowledging that the new system has its shortcomings, many argue that the only way to make things better is to get people invested in the access they’ve recently been granted. Lydia Dugdale, a primary-care doctor at Columbia University, worries about ensuring equity. “Things like socioeconomic status, education, literacy: All of those issues affect the degree to which any given patient is going to want to read and correct and interrogate his or her health record,” she told me. Tom Delbanco, a Harvard doctor and one of the co-founders of OpenNotes, an initiative that spearheaded the push for access to doctors’ notes in the U.S., believes that the effort required to refrain from using “bad words” in notes is minor, and that it shouldn’t make any significant demands on clinicians’ schedules. Doctors who are now taking more time to write notes because of the change, he told me, “probably ought to because they’ve been writing lousy notes.”

    Open notes can be valuable for people with chronic conditions and their caregivers, who need to stay in the know. Liz Salmi, the communications and patient-initiatives director at OpenNotes, told me about pulling her full medical record eight years into dealing with brain cancer, before notes were easily and freely available. The document was 4,839 pages. To get a PDF, she said, she had to pay $15 for each DVD it was uploaded to, and her records spanned multiple discs. But the information was worth it: Having access to the record gave Salmi a way to remember all of the crucial bits of information she’d gotten piecemeal from various doctors.

    The fact that many people have no idea open notes exist doesn’t change the deeply personal questions at stake in the debate about whether the notes do more good or harm—questions that everyone must confront in one way or another in dealing with America’s medical system, whether or not they fully realize it. How much information do you truly want about your health, and how much do you trust your doctor to deliver it to you? What is a doctor’s role in informing people about their health?

    Open notes are only part of this conversation. The new law also requires that test results be made immediately available to patients, meaning that patients might see their health information before their physician does. Although this is fine for the majority of tests, problems arise when results are harbingers of more complex, or just bad, news. Doctors I spoke with shared that some of their patients have suffered trauma from learning about their melanoma or pancreatic cancer or their child’s leukemia from an electronic message in the middle of the night, with no doctor to call and talk through the seriousness of that result with. This was the case for Tara Daniels, a digital-marketing consultant who lives near Boston. She’s had leukemia three times, and learned about the third via a late-night notification from her patient portal. Daniels appreciates the convenience of open notes, which help her keep track of her interactions with various doctors. But, she told me, when it comes to instant results, “I still hold a lot of resentment over the fact that I found out from test results, that I had to figure it out myself, before my doctor was able to tell me.”

    As Americans continue to age, get sick, and navigate the health-care system, many of us may become more invested in the idea of open notes. Until they play a more widespread role in people’s lives, however, the most pressing question about whether you truly want instant access to all your medical information might be how it affects your doctor’s life. Many physicians have come around to open notes, or at least have realized that allowing patients to see what has been written about them is not always a huge bother. But the bigger question of just how quickly patients should be able to access medical information, and how soon doctors should be available to help patients process it, continues to plague physicians. The advent of immediate data sharing “has been a major problem in terms of physician quality of life, and that’s eroded across the board,” Peixoto told me. “Doctors don’t want to be connected all the time. They actually have their lives.”

    Where we have landed, then, is an in-between. Patients can read their doctor’s notes and view test results at any hour of the day, but we can access our providers only at certain times. There is likely room for refinement. Allowing a patient to select whether they receive test results from their physician or their portal, or see notes only after their doctor has had the opportunity to walk them through the terminology used, for instance, could make all the difference, some doctors told me. For now, it’s worth asking yourself whether you want to access your patient portal alone, or want to wait until you can get your doctor on the line.

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    Zoya Qureshi

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