Episode 234 -- July 2025 -- Part 2 AFP: American Family Physician

Summary

Podcast Summary: AFP: American Family Physician Podcast

Episode 234 — July 2025 (Part 2)
Date: July 31, 2025
Hosts: Jake Anderson, Austin Cotter, Justin Chetiak (Residents and Faculty, University of Arizona College of Medicine – Phoenix Family Medicine Residency)
Main Topics: Intimate partner violence, top 20 primary care studies, carpal tunnel syndrome treatments, Benz Galantamine for Alzheimer's, bright light therapy for depression, VA/DoD suicide risk guideline

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Episode Overview

This episode focuses on the latest clinical best practices and new research relevant to family physicians. The hosts break down important content from the July 2025 issue of American Family Physician, including:

• Identification and management of intimate partner violence (IPV)
• Highlights from the top 20 research studies of 2024 for primary care
• Updates on surgical/non-surgical carpal tunnel syndrome treatments
• A STEPS review of Benz Galantamine for Alzheimer’s
• The efficacy of bright light therapy for non-seasonal depression
• The new VA/DoD guideline for suicide risk assessment and management

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Key Discussion Points & Insights

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1. Intimate Partner Violence (IPV) [01:28–05:20]

• Prevalence & Demographics

  • "Intimate partner violence... affects nearly half of adult women and men in the United States." (Austin Cotter, 01:56)
  • Especially severe in multiracial, American Indian/Alaska Native women; transgender individuals are at highest risk.
  • Among youth under 18, 16–25% exposed; makes up ~20% of all childhood maltreatment (Austin Cotter, 02:16).

• Health Impacts

  • IPV linked to depression, suicidality, chronic pain, arthritis, and substance use (Justin Chetiak, 02:34).
  • In pregnancy: risk for preterm birth, fetal loss, maternal death (Austin Cotter, 02:47).
  • For children: increased risk for mental health issues and cycle of violence (Justin Chetiak, 02:58).

• Screening Recommendations

  • USPSTF: Screen all reproductive age women; no specific interval.
  • ACOG & HHS: Emphasize routine integration into women's health visits.
    • Screening tools: HARK, HITS (Justin Chetiak, 03:23)
  • WHO: No universal screening, recommend inquiry with related symptoms (Austin Cotter, 03:30).

• Universal Education vs. Universal Screening

  • Instead of only asking about violence, educate all patients on healthy relationships regardless of suspicion (Austin Cotter, 03:58).
  • Models like CUES and PAR help guide these conversations (Jake Anderson, 04:08).
  • Key: Disclose reporting laws, educate without pressuring disclosure, let patients decide what to share (Austin Cotter, 04:28).

• Trauma-Informed Care

  • "Empathetic listening, survivor-centered care, and multidisciplinary support are crucial..." (Jake Anderson, 05:00).
  • Advocacy is vital: "Your awareness and compassion can change lives." (Austin Cotter, 05:08)

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2. Top 20 Research Studies of 2024 for Primary Care [05:20–11:24]

• Methodology

  • Annual review by experts scrutinizes over 20,000 studies; narrows to 20 most practice-changing.
  • POEMs = Patient-Oriented Evidence that Matters (Justin Chetiak, 06:03).

• Select Study Highlights

  • Probiotics for UTIs
    • Vaginal/oral probiotics reduce recurrence in premenopausal women.
      • "At 4 months... 70% [recurrence] placebo vs. 32% with both probiotics..." (Justin Chetiak, 07:42)
  • Gallstones: Watchful Waiting
    • Uncomplicated, symptomatic gallstones can be safely monitored.
      • "No need to rush to surgery without complications." (Austin Cotter, 07:51)
  • CGM in Type 2 Diabetes
    • No added benefit over traditional monitoring; may increase stress.
      • "Continuously watching that glucose causes stress." (Jake Anderson, 09:04)
  • Beta Blockers Post-MI with Preserved EF
    • No mortality or MI reduction in this group. (Austin Cotter, 09:25)
  • CBT for Long Covid Fatigue
    • NNT of 3 at 26 weeks for reducing severe fatigue. (Justin Chetiak, 09:57)
  • Bad News Delivery by Phone
    • No difference in anxiety, depression, or satisfaction compared to in-person.
      • "Use patient preference since knowing may be preferable to waiting." (Jake Anderson, 10:45)

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3. Carpal Tunnel Syndrome: Surgical vs. Non-Surgical Treatment [11:24–13:40]

• Epidemiology & Diagnosis
  • Most commonly diagnosed musculoskeletal nerve compression; classic symptoms described.
• Treatment Evidence
  • 2024 Cochrane review:
    • Surgery leads to higher long-term satisfaction vs. splinting (NNT=4), but evidence unclear compared to steroid injections.
    • Lack of consistency in surgical techniques or comparator data (Austin Cotter, 13:00; Jake Anderson, 13:16).
  • Shared decision-making emphasized due to gaps in comparative research.

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4. STEPS Review: Benz Galantamine for Mild/Moderate Alzheimer’s [14:01–17:53]

• Background

  • Benz Galantamine is a new delayed-release form, not directly studied in RCTs, but approved based on bioequivalence to galantamine.
    • "No published clinical trials of Benz Galantamine. It was approved for marketing based on evidence from bioavailability studies..." (Austin Cotter, 14:38)

• Safety & Tolerability

  • May cause rare skin reactions, bradycardia, GI symptoms (typical for cholinesterase inhibitors).

• Effectiveness

  • Based on galantamine data: modest improvements in cognition and function (score increase ~2.86 points ADA scale).

• Price

  • ~$800/month vs. ~$30 for regular galantamine (Austin Cotter, 16:54).

• Recommendation

  • Begin with galantamine due to cost; consider Benz Galantamine only if intolerant, given similar efficacy and a high price.
    • "Given the frequent intolerance of galantamine, Benz Galantamine can be considered if intolerance occurs." (Austin Cotter, 17:30)

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5. POEM: Bright Light Therapy for Non-Seasonal Depression [17:53–20:05]

• Findings
  • Meta-analysis of 11 RCTs: Bright light therapy (10,000 lux for 30 minutes/day) improves remission rates for non-seasonal depression.
    • "Remission rates: 40.7% in the bright light group vs. 23.5% in the non-bright light group." (Jake Anderson, 19:34)
  • Benefits persist both short- and long-term (Austin Cotter, 19:06).
  • Recommendation: Offer/discuss bright light therapy with adults suffering from non-seasonal depression (Evidence Level 1A).

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6. Practice Guideline: Assessment & Management of Suicide Risk (VA/DoD) [20:09–22:11]

• Guideline Highlights

  • Columbia Suicide Severity Rating Scale is recommended for screening.
  • Acknowledges screening tools predict less than half of completed suicides.
  • Key risk factors: MH illness, adverse events, physical illness, lethal means, social determinants.
  • Effective Interventions:
    • CBT reduces repeat attempts by >50%.
    • Brief follow-up (calls/texts/letters) also cuts attempt rates at 1 year (Jake Anderson, 21:07).
    • Means restriction works (firearms, drug quantities, physical barriers), though evidence "weak but favorable."
    • Clozapine (for schizophrenia) and single ketamine infusion (for acute suicidality) have supporting evidence.
    • Insufficient evidence for hotlines, gatekeeper training, or peer outreach.

• Notable Quote:

  • "It's encouraging that we have a low cost, low barrier intervention that empowers anyone with a phone or a piece of paper to potentially save a life." (Jake Anderson, 21:07)

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Notable Quotes & Memorable Moments

• On the value of Universal Education for IPV:
  "This empowers patients to disclose if they choose and to share information with others." — Jake Anderson, [04:08]

• On negative findings for continuous glucose monitoring:
  "Continuously watching that glucose causes stress." — Jake Anderson, [09:04]

• On the beta blocker findings post-MI:
  "My hat just fell on the floor." — Jake Anderson, [09:49]

• On delivering bad news by phone:
  "Use patient preference since knowing may be preferable to waiting for many patients." — Jake Anderson, [10:45]

• On light therapy for depression:
  "Remission rates: 40.7% in the bright light group and 23.5% in the non-bright light group. So that seems substantial." — Jake Anderson, [19:34]

• On brief interventions for suicide prevention:
  "It's encouraging that we have a low cost, low barrier intervention that empowers anyone with a phone or piece of paper to potentially save a life." — Jake Anderson, [21:07]

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Timestamps for Key Sections

• 01:28 — Intimate Partner Violence: Epidemiology to Trauma-Informed Care
• 05:20 — Top 20 Research Studies of 2024 Starts
• 06:57 — UTIs & Probiotics
• 07:44 — Gallstones: Watchful Waiting
• 08:16 — CGM for Type 2 Diabetes
• 09:25 — Beta Blockers after MI
• 09:57 — CBT for Long Covid
• 10:34 — Delivering Bad News by Phone
• 11:24 — Carpal Tunnel Syndrome: Surgical vs. Non-Surgical
• 14:01 — STEPS: Benz Galantamine for Alzheimer’s
• 17:53 — Bright Light Therapy for Non-Seasonal Depression
• 20:09 — VA/DoD Suicide Risk Guidelines

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Summary

This episode delivers practice-changing insights and covers challenging primary care topics ranging from trauma-sensitive care to surgical decision-making. The hosts keep the tone conversational, evidence-based, and focused on actionable guidance for family physicians, echoing the mission of American Family Physician to bridge current research and daily clinical care.

Transcript

[Narrator]

The AFP Podcast is brought to you by the American Academy of Family Physicians and by Mayo Clinic. Mayo Clinic proudly supports this AFP podcast. Mayo Clinic Family Medicine puts patients first by pursuing innovations that change lives and the future of care. Learn more about joining our [e-mail] familymedicine.

[Jake Anderson]

Hey listeners, before we jump into this episode, a trigger warning. Topics discussed during this episode include intimate partner violence and suicide welcome to the American Family Physician podcast for part two of the July 2025 issue. I'm Jake.

[Austin Cotter]

I'm Austin.

[Jake Anderson]

And I'm Justin, and we are residents and faculty, mostly residents, of the University of Arizona College of Medicine, Phoenix Family Medicine Residency. Today on the podcast we'll talk about intimate partner violence, the top 20 research studies of 2024 surgical versus non surgical treatments for carpal tunnel syndrome, Benz Galantamine for the treatment of mild to moderate Alzheimer's disease, Bright light therapy and assessment and management of patients at risk for suicide.

[Justin Chetiak]

The opinions expressed in the podcast are our own and do not represent the opinions of the American Academy of Family Physicians. The editor of American Family Physician or Banner Health do not use this podcast for medical advice. Instead, see your own family doctor for medical care.

[Jake Anderson]

We're on a mission Delivering the Best from American Family Position Automation Delivering the Best from American Family Position this episode kicks off with a main topic, Intimate Partner Violence, and it comes to us from Dr. Halloran from the St. Vincent Family Medicine Residency Program in Toledo, Ohio, and Dr. Ho from the University of Utah School of Medicine.

[Austin Cotter]

While exact numbers are difficult to capture due to underreporting, intimate partner violence, or ipv, affects nearly half of adult women and men in the United States.

[Justin Chetiak]

Sadly, most of these individuals experienced their first encounter before age 25.

[Jake Anderson]

Women face more severe physical and sexual violence, especially those who identify as multiracial American Indian or Alaska Native American.

[Austin Cotter]

Transgender individuals are at an even higher risk facing IPV at two to three times the national average. And for youth under 18, estimates suggest 16 to 25% have been exposed, making up about a fifth of childhood maltreatment cases.

[Jake Anderson]

So let's talk about the health impacts of IPV on these populations.

[Justin Chetiak]

So the health impacts of IPV are vast and deeply concerning. For women, IPV is linked to depression, suicidal ideation, and several chronic conditions, including chronic pain, arthritis, and substance use disorders.

[Austin Cotter]

Pregnant individuals face specific risks like preterm birth, fetal loss and maternal mortality, and homicide, often committed by a current or former partner, is the leading cause of maternal death in the United States.

[Justin Chetiak]

For children, exposure to IPV correlates with mental health issues, learning challenges, and increased risk of becoming perpetrators as adults.

[Austin Cotter]

So how do we screen for intimate partner violence?

[Jake Anderson]

The USPSTF recommends screening all reproductive age women, though they offer no frequency guidelines. ACOG and the U.S. department of Health and Human Services also recommend integrating IPV screening into routine women's health visits.

[Justin Chetiak]

Tools like Hark, Hark and hits, which can be found in the AFP article, can help.

[Austin Cotter]

Alternatively, the World Health Organization does not recommend universal screening, instead advising clinicians to ask when investigating related symptoms like depression or substance use disorders.

[Jake Anderson]

Transparency about reporting duties is critical, especially given legal mandatory reporting obligations tied to gun violence or child abuse, which vary by state.

[Justin Chetiak]

But there is an alternative to universal screening, which is helpful since screening poses barriers such as stigma, time limits, and mandatory reporting fears.

[Austin Cotter]

And that is universal education, which offers an alternative. Instead of directly asking about violence, physicians educate all patients about healthy relationships and and available resources.

[Jake Anderson]

This empowers patients to disclose if they choose and to share information with others. Models like cues, C, U E S and par par, which can be found in the AFP journal article as well, guide clinicians in these conversations, fostering safer, more informed environments.

[Austin Cotter]

Important features of universal education that both of these models include are 1 starting with disclosing mandatory reporting laws 2 focusing on educating and providing resources instead of forcing or asking for disclosure and three giving patients the space to decide what information they want to disclose.

[Justin Chetiak]

Lastly, when someone does disclose ipv, trauma informed care is essential.

[Austin Cotter]

Clinicians must recognize systemic inequities like poverty and housing instability that fuel gender based violence. Empathetic listening, survivor centered care, and multidisciplinary.

[Jake Anderson]

Support are crucial handoffs to case managers. Behavioral health providers and others should be warm and supportive.

[Austin Cotter]

Above all, advocacy is key because survivors may not be able to speak up for themselves. Whether you're a clinician or a community member, your awareness and compassion can change lives.

[Jake Anderson]

All right, guys, we're going to shift gears a little bit because it's that time of year again. The July issue of the American Family Physician has probably my favorite annual article.

[Justin Chetiak]

Probably.

[Jake Anderson]

I have lots of favorites, as the listeners know, but this is probably my favorite. This is the favoriteist. It's the top 20 research studies for Primary Care Physicians.

[Austin Cotter]

So as a reminder for our listeners, each year for more than 25 years now, a team of six clinicians, including experts in family medicine, pharmacology, hospital medicine, and women's health, have systematically reviewed 110 medical journals each month to find the research most likely to change and improve primary care practice.

[Justin Chetiak]

They look for poems. No, not the ones by Amanda Gorman.

[Jake Anderson]

Oh, she's awesome though.

[Justin Chetiak]

She is great. But I'm talking about the ones that are patient oriented. Evidence that matters, which must report at least one patient oriented outcome. Additionally, the research must also be free of important methodologic bias, and the results, if applied in practice, must change what some physicians do.

[Austin Cotter]

Of more than 20,000 research studies published in 2024 in the journals reviewed by the POEMS team, 253 met criteria for validity, relevance, and practice change.

[Jake Anderson]

And from that, the top 20 are identified and summarized in this article by Drs. Roland Grad from McGill University and Dr. Abel from Michigan State University. And of course we would love to share all 20. Can we share? No, we can't. Instead, we're going to share our two favorites because we respect your time. Some we've included in past podcast episodes you might recognize them, and some you've certainly seen in the Essential Evidence, plus.

[Justin Chetiak]

Daily emails all right, I'm up first. So the clinical question here is do oral or vaginal probiotics reduce the likelihood of UTI recurrence in premenopausal women with frequent UTIs? The answer is yes. A study of premenopausal women with frequent UTIs randomized patients to placebo, an oral probiotic, a vaginal probiotic, or both. At four months, asymptomatic UTI occurred in 70% of the placebo group, 61% of the oral probiotic group, 41% of the vaginal probiotic group, and 32% of the group receiving both probiotics. The oral probiotic contained 112.5 billion live lyophilized lactic acid bacteria and bifidobacteria. The vaginal probiotic contained 1 billion units of three lactobacilli strains.

[Jake Anderson]

Practice changing.

[Austin Cotter]

All right, onto the next one. Is it safe to watch patients with symptomatic gallstone disease without complications?

[Jake Anderson]

Nope. Take out the gallbladder, right?

[Austin Cotter]

No. The answer is yes. Uncomplicated gallstones can be managed over time with analgesia and monitoring. What? Although approximately 25% of patients will eventually undergo cholecystectomy after 18 months, there appears to be no need to rush to surgery without evidence of common bile duct blockage or acute pancreatitis. This comes from a randomized control trial that found an NNT of 3 to have avoided surgery at the 18 month mark.

[Justin Chetiak]

Well, color me shocked.

[Jake Anderson]

Oh, okay. My favorite or one of my favorites is about CGMs and this poem looked at does continuous glucose monitoring offer a Benefit compared with traditional self monitoring in patients with type 2 diabetes. The answer is no, and it actually might be harmful. These surprising results come from a Meta analysis of 26 randomized controlled studies of glucose monitoring in patients with type 2 diabetes. This study compared continuous glucose monitors with intermittently scanned continuous glucose monitors. On average, A1C decreased by a very modest 0.2 to 0.3% among those using either device, and there was no effect on blood pressure or lipids. Some of the other outcomes they looked at compared with continuous glucose monitoring, intermittent monitoring was associated with improved user satisfaction and less psychological stress. That's so interesting. Continuously watching that glucose causes stress.

[Justin Chetiak]

Who would have thought?

[Austin Cotter]

All right, I've got another potentially surprising one.

[Justin Chetiak]

Austin. I don't think I can handle any more surprises.

[Austin Cotter]

This clinical question is, in patients with preserved ejection fraction following acute mi, does long term use of a beta blocker reduce the likelihood of death or subsequent acute mi? No.

[Justin Chetiak]

What?

[Austin Cotter]

For patients with acute MI and preserved ejection fraction, the use of a beta blocker for a median of 3.5 years did not reduce the likelihood of death or subsequent acute mi.

[Justin Chetiak]

Well, don't tell your neighborhood cardiologist. Jeez.

[Jake Anderson]

Yeah, I feel like beta blocker after MI is like one of the things you can hang your hat on and guys, my hat just fell on the.

[Justin Chetiak]

Floor Here, I'll pick it up for you. All right, let me bring it home for us. Does CBT improve fatigue in patients with long Covid? For patients with severe fatigue at least three months after COVID 19, CBT offers significant improvement in symptoms versus usual care. This was based on an RCT from the Netherlands where at 26 weeks they found an NNT of 3 for CBT, resulting resolution of severe fatigue.

[Jake Anderson]

That's awesome.

[Austin Cotter]

Very helpful. Wow. What can't CBT do?

[Justin Chetiak]

I don't know. I think it could probably fix heart failure after an acute mi.

[Jake Anderson]

All right, and you said you were going to bring it home, but I actually have one more too, if that's okay. Justin.

[Justin Chetiak]

Sorry, I can't read.

[Jake Anderson]

My other favorite one is does delivery of bad news via telephone increase psychological stress more than in person communication? We often wonder this right when we have some tough results to talk about or tough news to deliver to patients. Well, the study found that delivering bad news by telephone does not affect levels of anxiety, depression, or satisfaction with care compared with delivering the news in person. So the authors recommend using patient preference since knowing may be preferable to waiting for many patients.

[Justin Chetiak]

This is helpful to know, considering our patients often see the results of their labs at the same time that we do. And every minute that goes by is just a minute waiting for guidance from us.

[Jake Anderson]

Yeah, very true.

[Austin Cotter]

A phone call can often be much better.

[Jake Anderson]

Next up, we have a medicine by the numbers. Surgical versus non surgical treatments for carpal tunnel syndrome. And it comes to us from Dr. Neubauer from Fort Carson, Colorado, and Dr. Alisonco from Fort Jackson, South Carolina.

[Justin Chetiak]

All right, carpal tunnel syndrome feels like one of the most common musculoskeletal diagnoses I make in clinic. It typically presents with pain, numbness, or paresthesia in the first three digits and the radial half of the fourth.

[Austin Cotter]

Severe cases can lead to thenar muscle weakness and atrophy, impacting hand dexterity. It's also about three times more common in women than it is in men.

[Jake Anderson]

Surgical referral is generally reserved for severe symptoms, thenar atrophy or positive electrodiagnostic findings. Mild to moderate cases are usually treated with splinting injections and occupational therapy.

[Justin Chetiak]

A 2024 Cochrane review looked at surgery versus non surgical treatments, including splinting, steroid injections, splinting plus injections, platelet rich plasma, manual therapy, multimodal therapy and other supportive measures.

[Austin Cotter]

The review analyzed 1,293 symptomatic wrists, which I found to be a rather amusing phrase.

[Jake Anderson]

Yeah, well, you know, everybody has two wrists, but not everybody has two carpal tunnel wrists, right?

[Justin Chetiak]

I guess not. True.

[Jake Anderson]

The primary outcome was patient reported satisfaction in the short term, which was defined as less than three months, and the long term which was greater than three months.

[Justin Chetiak]

Interestingly, moderate certainty evidence showed surgery improved long term satisfaction compared to splinting alone, with a number needed to treat of four. So for all of you who love conservative management, this might be a stab to the heart.

[Austin Cotter]

However, evidence was less clear when comparing surgery to steroid injections. And most studies lacked consistency in surgical technique, disease severity, symptom duration, or how they defined clinical improvement. There was also little data comparing surgery to placebo or no treatment at all.

[Justin Chetiak]

I knew it.

[Jake Anderson]

So yeah, while surgery may be more satisfying long term than splinting, we're left without solid data on comparative risks or how it stacks up against other common treatments like steroid injections.

[Justin Chetiak]

In true family medicine fashion, we're left with one of our most important tools, shared decision making. We'll be back after this message.

[Narrator]

The AFP podcast is brought to you by the American Academy of Family Physicians and by the AAFP's board review express Livestream Happening this September. Improve performance for a first exam or by mastering longitudinal assessment goals. Complete Details [e-mail] BoardReview Guys, we have a STEPS.

[Jake Anderson]

Remember, STEPS stands for Safety, tolerability, effectiveness, price and simplicity. And it's a great way to evaluate new drugs. This one comes to us from physician and pharmacist team of Dr. Johnston and Lounsbury.

[Austin Cotter]

This steps looks at Benz Galantamine, brand name Zunveil, which is labeled for the treatment of mild to moderate Alzheimer's disease in adults.

[Jake Anderson]

How does it work?

[Justin Chetiak]

I'm glad you asked, Jake. So it's metabolized to galantamine, which is a competitive and reversible cholinesterase inhibitor. Benz galantamine is thought to prevent degradation of acetylcholine and enhance cholinergic function.

[Jake Anderson]

Okay, I'm listening. Let's jump right in. Talk to us about safety.

[Austin Cotter]

Wait, hold on. Can we just point out that there are no published clinical trials of Benz galantamine? It was approved for marketing based on evidence from bioavailability studies comparing it with galantamine, immediate release tablets and extended release capsules.

[Jake Anderson]

What? So Ben's glantamine is simply riding the coattails of galantamine? All right, well, okay, super important to know there's a big asterisk grain of salt that comes with this one. But, Justin, let's get to safety.

[Justin Chetiak]

Yeah, let's get down to the brass tacks here. In less than 1% of patients, Benz galantamine may cause rare serious skin reactions such as Steven Johnson syndrome and acute generalized exanthemat pustulosis. Other risks include bradycardia and heart block, again in 1% or less of patients. And because it is a colonomimetic, it can cause urinary obstruction, bronchoconstriction, and increased gastric secretion. And it may affect the effectiveness of other cholinergic or acetylcholinesterase inhibitors. It's not recommended in patients with a creatinine clearance of less than 9 and used with caution in those with kidney or liver disease.

[Jake Anderson]

Okay, what about tolerability?

[Austin Cotter]

The most common adverse effects of galantamine are gastrointestinal related, like nausea in 21% of patients and vomiting in 11%. But Benz galantamine is supposed to minimize these effects due to different binding in the enteric nervous system. Dizziness and headache are also potential side effects as they are commonly seen with galantamine.

[Justin Chetiak]

Is there a medication that doesn't potentially cause nausea, vomiting, dizziness, and headache? I genuinely ask. Having done residency for two years now, I have not run into that as a Possibility?

[Austin Cotter]

I don't think I've prescribed it yet.

[Jake Anderson]

All right, well, let's hit on effectiveness. Is it at least effective?

[Justin Chetiak]

Well, again, Ben's Galantamine has not been directly evaluated. 21 studies of almost 11,000 participants with dementia due to Alzheimer's disease or with mild cognitive impairment have investigated Galantamine. On average, galantamine improves cognitive function as assessed with the cognitive subscale of the Alzheimer's Disease Assessment Scale, improving scores by 2.86 points, which is considered a clinically noticeable difference. It also improves functional disability and behavioral function compared with the placebo during the first six months of treatment as assessed with the Disability Assessment for Dementia Scale and Neuropsychiatric Inventory.

[Jake Anderson]

What's the p price?

[Austin Cotter]

A 30 day supply of Benz galantamine delayed release tablets costs about $800. It is currently on the formulary of most Medicare plans. In comparison, a one month supply of Galantamine extended release tablets or Memantine extended release capsules costs approximately $30.

[Jake Anderson]

All right, so lastly, talk to us about simplicity. Justin?

[Justin Chetiak]

Gladly, Jake. Benzgalantamine is a delayed release tablet taken twice daily with or without food. The initial dose is 5mg twice daily and can be titrated after four weeks based on tolerance and response to a maximum dosage of 15 milligrams twice daily.

[Jake Anderson]

Bottom line it for us, Austin.

[Justin Chetiak]

Take us home.

[Austin Cotter]

Benz Galantamine should improve cognitive and behavioral symptoms in patients with mild to moderate Alzheimer's disease over the short term, similarly to galantamine. Given the frequent intolerance of galantamine, benzelantamine can be considered if intolerance occurs. However, with the high cost and twice daily dosing regimen of Benz Galantamine, patients should begin with a trial of galantamine for any initial therapy.

[Jake Anderson]

Next up, we have a poem. Still not Amanda Gorman. I'm sorry, Jesse.

[Justin Chetiak]

Okay, fine.

[Jake Anderson]

This one actually comes to us from Dr. David Slosson.

[Austin Cotter]

The clinical question being answered here. Is bright light therapy effective for adults with non seasonal depressive disorder?

[Jake Anderson]

The authors sought to answer this question with a meta analysis involving English language randomized controlled trials from multiple databases. These trials compared either one bright light therapy alone or bright light therapy plus antidepressant to either placebo, antidepressant monotherapy or dim red light treatment.

[Justin Chetiak]

All recruited adults. 858 individuals across 11 trials had diagnoses of non seasonal depression. In these studies, bright light therapy was defined as 10,000 lux of white light for at least 30 minutes every day.

[Jake Anderson]

How bright are these lights you think?

[Justin Chetiak]

3426 I took a class in college.

[Austin Cotter]

Two independent reviewers used the Cochrane Risk of Bias tool and all 11 trials were scored as low risk. Analysis of the data also revealed minimal heterogeneity among them.

[Justin Chetiak]

Give me the results.

[Jake Anderson]

Alright, Coming at you. Across the studies, higher remission rates were observed in the bright light groups compared.

[Austin Cotter]

With the non bright light groups and on subgroup analysis. This benefit persisted in both trials lasting less than four weeks and in trials lasting longer.

[Justin Chetiak]

In addition to helping those suffering from seasonal depression, bright light therapy, either alone or in combination with antidepressants, should also be offered to and discussed with adults suffering from non seasonal depression. The study being a meta analysis, low heterogeneity among the included trials and low risk of bias in all 11 trials earns this recommendation a level of evidence of 1a.

[Jake Anderson]

Yeah, that's pretty cool. The remission rates between the two groups 40.7% remission in the bright light group and 23.5% remission in the non bright light group. So that that seems substantial.

[Justin Chetiak]

Seems meaningful for sure.

[Jake Anderson]

I can't help but feel bad for the group that was randomized to the dim red light. Experience like that just seems sad.

[Justin Chetiak]

Just get shoved into a closet.

[Jake Anderson]

Yeah.

[Justin Chetiak]

Reminds me of middle school.

[Austin Cotter]

Good thing we live in Phoenix. We have bright light all year round.

[Jake Anderson]

All year round. We're going to close this episode out with a practice guideline, Assessment and Management of patients at Risk for Suicide. And this is a Guideline from the VA and Department of Defense put together by Dr. Michael Arnold, Assistant Medical Editor for the American Family Physician.

[Justin Chetiak]

The VA and Department of Defense have published updated guidelines on assessing and managing suicide risk.

[Jake Anderson]

The Columbia Suicide Severity Rating Scale is among the most useful screening tool. But even with all of our ways to screen less than half of suicide deaths are predicted.

[Austin Cotter]

Clinicians should be aware of additional risk factors psychiatric illness, adverse life events, physical conditions, access to lethal means, and social determinants of health.

[Justin Chetiak]

CBT reduces repeat suicide attempts by over 50% at follow up, though this benefit isn't seen with other therapies. Evidence is limited for interventions such as crisis response plans, safety planning, peer to peer outreach or gatekeeper training.

[Jake Anderson]

However, brief follow up contact, like short texts or letters after hospitalization, reduces suicide attempts at one year compared to usual care. That's helpful. It's encouraging that we have a low cost, low barrier intervention that empowers anyone with a phone or piece of paper to potentially save a life.

[Austin Cotter]

Means restriction also shows weak but favorable evidence reducing access to firearms, limiting drug quantities, or installing physical barriers can decrease suicidal behavior. On the other hand, there is insufficient evidence supporting the effectiveness of crisis hotlines.

[Justin Chetiak]

While transcranial magnetic stimulation helps depressive symptoms, its impact on suicidality may largely reflect a placebo effect.

[Jake Anderson]

For medication based interventions, clozapine is recommended for patients with schizophrenia or schizoaffective disorder who have suicidal ideation or prior attempts. Additionally, a single ketamine infusion has been shown to eliminate suicidal ideation in about 60% of such patients.

[Austin Cotter]

These guidelines highlight both the tools we have and the significant limitations we still face in preventing suicide.

[Justin Chetiak]

And while a lot of this evidence may seem like it's not encouraging, these tools that we do have generally don't pose harms. And so it's not to say we should not utilize things like crisis response hotlines.

[Jake Anderson]

Send us your thoughts by emailing [e-mail].

[Justin Chetiak]

Follow on Instagram fpjournal. Please subscribe and rate us wherever you get your podcasts.

[Austin Cotter]

Escuchenos en Espanol Aravista Medica A FAP.

[Jake Anderson]

Our podcast team is Jake Anderson, Puneet Bharot, Steve Brown, Justin Chetiak, Sarah Coles.

[Justin Chetiak]

Austin Cotter, Rachel Dunn, Emily Eisenberg, Elena Kelly, Chisum Okuwagu, and Kari Staus.

[Austin Cotter]

Our sound and technical guru is Tyler Coles. Our theme song is written and recorded by family physicians Bill Dabbs, Ryan Evans, and Justin Jenkins.

[Justin Chetiak]

This podcast is brought to you by the residents and faculty of the University of Arizona College of Medicine, Phoenix Family Medicine Residency Programs. We'll talk to you soon for the next edition of the American Family Physician Podcast.