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Infertility is a remarkably common problem. It affects up to one in five people in the US who are trying to become pregnant, and 186 million people worldwide. A thorough medical evaluation can spot key contributing issues in many cases — whether in a woman, a man, or both partners — that might respond to treatment, or call for assisted reproductive tools like in vitro fertilization (IVF).

But in a substantial number of cases, no cause is found for infertility. Could inflammation be to blame for some of those cases, as recent research suggests? And if so, will an anti-inflammatory diet or lifestyle boost fertility?

Exploring the connection between inflammation and infertility

Chronic inflammation has been linked to many health conditions, such as cardiovascular disease, stroke, and cancer.

While its importance in infertility is far from clear, some evidence supports a connection:

• The risk of infertility is higher in conditions marked by inflammation, including infection, endometriosis, and polycystic ovary syndrome.
• Bodywide (systemic) inflammation may affect the uterus, cervix, and placenta, thus impairing fertility.
• Women with infertility who had IVF and followed an anti-inflammatory diet tended to have higher rates of successful pregnancy than women who did not follow the diet.

Could an anti-inflammatory diet improve fertility?

It’s a real possibility. Decades ago, researchers observed that women following a prescribed fertility diet ovulated more regularly and were more likely to get pregnant. Now a 2022 review of multiple studies in Nutrients suggests that following an anti-inflammatory diet holds promise for people experiencing infertility. The research was done years apart, but the diets in these two studies share many elements.

The 2022 review found that an anti-inflammatory diet may help

• improve pregnancy rates (though exactly how is uncertain)
• increase success rates of assisted reproductive measures, such as IVF
• improve sperm quality in men.

The authors add that improving diet might even reduce the need for invasive, prolonged, and costly fertility treatments. However, the quality of studies and consistency of findings varied, so more high-quality research is needed to support this.

Will adopting an anti-inflammatory lifestyle improve fertility?

While recent research is intriguing, there’s not enough evidence to show that an anti-inflammation action plan will improve fertility. A plant-based diet such as the Mediterranean diet, and other measures considered part of an anti-inflammatory lifestyle, improve heart health and have many other benefits.

It’s not clear if this is directly due to reducing inflammation. But this approach comes with little to no risk. And abundant convincing evidence suggests it can improve health and even fight disease.

What is an anti-inflammatory lifestyle?

Health experts have not agreed on a single definition. Here are some common recommendations:

• Adopt a diet that encourages plant-based foods, whole grains, and healthy fats like olive oil while discouraging red meat, highly processed food, and saturated fats.
• Stop smoking or vaping.
• Lose excess weight.
• Be physically active.
• Get enough sleep.
• Treat inflammatory conditions, such as rheumatoid arthritis or allergies.
• Avoid excessive alcohol consumption.
• Control stress.

Anti-inflammatory medicines may help in certain situations — for example, treatments for autoimmune disease. However, they are not warranted for everyone. And for people trying to conceive, it’s far from clear that any potential benefit would exceed the risk of side effects for parent and child.

The bottom line

It’s possible that inflammation plays an important and underappreciated role in infertility and that an anti-inflammatory diet or lifestyle could help. But we need more evidence to confirm this. Until we know more, taking measures to improve your overall health and possibly reduce chronic inflammation makes sense.

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

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

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

It used to be that doctors would automatically recommend treating all men with prostate cancer, even if their initial biopsies suggested the disease would grow slowly (or at all). But during the last several decades, the pendulum on treatment has swung the other way.

Doctors are now likely to advise active surveillance for low- to intermediate-risk cancers that may never turn deadly over the course of a man’s life. Active surveillance involves routine PSA checks, follow-up biopsies, and more recently, magnetic resonance imaging of a patient’s tumor. Treatment is initiated only when — or if — the disease shows signs of progression.

Recent evidence from Johns Hopkins University shows that the long-term risks of metastasis and death from low-grade prostate cancer among men on active surveillance averages just 0.1%. But doctors who care for such men also face a nagging question: which of their patients might have more aggressive cancer that should require closer monitoring? New findings published by the Johns Hopkins team in January provide useful insights.

The researchers’ approach

The researchers in this case zeroed in on the prognostic value of so-called perineural invasion, or PNI, on tumor biopsy samples. PNI simply means that cancer cells are moving into the perineural space between nerves in the prostate and their surrounding tissues. A finding of PNI raises red flags because the perineural space “provides a conduit by which tumor cells can potentially escape the prostate and grow elsewhere in the body,” says Dr. Christian Pavlovich, a urologic oncologist at Johns Hopkins who led the research.

Dr. Pavlovich’s team wanted to know if PNI detected on initial or follow-up biopsies would be associated with higher risks for cancer progression. So they analyzed long-term follow-up data from 1,969 men who had enrolled in an active surveillance research protocol at Johns Hopkins between 1995 and 2021. All the men were diagnosed initially with Grade Group 1 prostate cancer (the least risky form of the disease) and had undergone at least one follow-up biopsy since then.

What did the results show?

Among the 198 men with PNI, 44% of them (87 men in all) eventually progressed to Grade Group 2 prostate cancer, which is a more advanced form of the disease with an intermediate risk of further spread. Conversely, just 26% of the remaining 1,771 men without PNI (461 men) had progressed to Grade Group 2.

Pavlovich emphasizes that despite the new findings, PNI “does not make patients ineligible for active surveillance.” Importantly, the research showed that PNI was not associated with high-risk features, such as cancer in the lymph nodes of patients who wound up having surgery, or post-surgical elevations in PSA that show cancer still lurks in the body.

“What we’ve really shown here is that PNI puts men at a slightly higher risk of extraprostatic extension (cancer cells located just beyond the confines of the prostate),” Pavlovich says. “This is not necessarily a new finding. But PNI only occurs in about 10% of Grade Group 1 patients, and this is the boldest statement yet from the largest study conducted so far.” Pavlovich and his colleagues concluded that PNI provides an inexpensive and readily available indicator for identifying which men on active surveillance will benefit from more intensive monitoring protocols, including MRI and genetic tests.

Dr. Marc B. Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, agrees, while pointing out that PNI evaluations aren’t performed often enough. A PNI analysis of pathology specimens, he says, “along with emerging and sophisticated genetic testing of the tissue samples, may lead to more certainty in our recommendations to patients.”

About the Author

Charlie Schmidt, Editor, Harvard Medical School Annual Report on Prostate Diseases

Charlie Schmidt is an award-winning freelance science writer based in Portland, Maine. In addition to writing for Harvard Health Publishing, Charlie has written for Science magazine, the Journal of the National Cancer Institute, Environmental Health Perspectives, … See Full Bio View all posts by Charlie Schmidt

About the Reviewer

Marc B. Garnick, MD, Editor in Chief, Harvard Medical School Annual Report on Prostate Diseases; Editorial Advisory Board Member, Harvard Health Publishing

Dr. Marc B. Garnick is an internationally renowned expert in medical oncology and urologic cancer. A clinical professor of medicine at Harvard Medical School, he also maintains an active clinical practice at Beth Israel Deaconess Medical … See Full Bio View all posts by Marc B. Garnick, MD

A visit with a surgeon can be overwhelming. You may feel anxious about your planned surgery. Many questions could be swirling in your head during a rushed visit. While surgeons have a reputation as technical specialists, bedside manner may be lacking at times.

It sounds simple, but setting the right expectations — on both sides — can ease your anxiety and help you feel more comfortable during a visit with your surgeon. So what exactly does this mean? And how can you accomplish it?

Tell your story

Tell your story to help set clear goals. Beyond simply stating what hurts or what is not working, be sure to include details such as

• how your current condition limits what you enjoy doing
• your daily activities
• how your condition affects your relationship with your social circle and family
• upcoming plans or goals such as travel, or life events like vacations or weddings.

Sharing details like these helps you collaborate to define a successful outcome for surgery.

Listen with your goals in mind

When explaining surgical options, surgeons are obligated to discuss key information, including risks, potential complications, and likely outcomes. Encourage your surgeon to put these facts into context based on what is important to you.

• Ask questions about how surgery will affect things you enjoy doing, such as playing pickleball, taking walks, cooking, reading, or listening to music.
• Ask what you should realistically expect during recovery and once you have recovered. For example, if you have a vacation or travel planned, be sure to discuss how surgery will affect your plans.

Define success before your surgery

Once you are confident that you have told your story and feel like you and your surgeon have set appropriate expectations, take the next step. Ask whether this discussion affects your surgeon’s approach to surgery, and explore how you each define surgical success.

Often, both surgeon and patient agree on a definition of success: for example, remove the entire tumor. But this simple definition may leave room for misalignment. Let’s say a surgeon is able to entirely remove a thyroid tumor, but now the patient speaks in a hoarse voice. While technically successful, this surgery may feel like a failure unless the person understood and accepted the risk that it could affect how they speak.

This highlights the importance of setting expectations. In this example, clear speech after surgery might be your expectation as a patient. Your surgeon must balance explaining how surgical risks might affect that expectation with the reality of treating the condition. Surgery is more likely to feel successful if both sides discuss and align their expectations.

Give yourself time when possible

Processing information about surgery can take time. A surgeon may have to provide realistic expectations that do not align with your initial expectations and hopes.

Some surgeries are urgent, others are not. If you do not need to make an immediate decision, be open with your surgeon. Let them know that you need time to consider the surgeon’s definition of success and your own. Reflecting on the discussion can reduce the stress and anxiety you’re likely to feel during an initial visit.

The bottom line: Making the most of your appointment

Communication goes two ways during a good pre-surgery visit. Do your best to tell your story and emphasize details of your life that are important. When listening, ensure that your surgeon acknowledges these details and describes how surgery may affect your life, as opposed to simply stating technical facts about the surgery. Setting expectations together will help you achieve a common goal and establish a strong surgeon-patient relationship that is essential for a positive surgical outcome.

About the Author

James Naples, MD,

Contributor; Editorial Advisory Board Member, Harvard Health Publishing

Dr. James Naples is a physician at Beth Israel Deaconess Medical Center, and a clinical instructor at Harvard Medical School in Boston, MA. He earned his medical degree from the University of Connecticut School of Medicine, … See Full Bio View all posts by James Naples, MD

Loneliness is complicated. You can feel lonely when you lack friends and miss companionship, or when you’re surrounded by people — even friends and family.

Either way, loneliness can have devastating health effects. It boosts risk for coronary artery disease, stroke, depression, high blood pressure, declining thinking skills, inability to perform daily living tasks, and even an early death. The remedy? Below we offer three ways to ease loneliness and add happiness by helping you expand your social network.

Taking the first steps

Not all loneliness can be solved by seeking out people. Loneliness that occurs despite relationships may require talk therapy and a journey that looks inward.

Reducing loneliness caused by a lack of relationships is more of an outward journey to make new friends. “That’s a challenge as we get older, because people are often established in their social groups and aren’t as available as they might have been in a different phase of life. So you have to be more entrepreneurial and work harder to make friends than you once did,” says Dr. Jacqueline Olds, a psychiatrist at Harvard-affiliated McLean Hospital and the coauthor of two books on loneliness.

Trying these strategies can help.

1. Seek like-minded souls

Being around people who share your interests gives you a head start on making friends: you already have something in common.

Start by considering your interests. Are you a voracious reader, a history lover, a movie aficionado, a gardener, a foodie, a puppy parent, or an athlete? Are you passionate about a cause, your community, or your heritage? Do you collect things? Do you love classic cars? Do you enjoy sprucing up old furniture? Maybe you want to learn something new, like how to cook Chinese food or speak another language. Search for online groups, in-person clubs, volunteer opportunities, or classes that match any of your interests or things you’d like to try.

Once you join a group, you’ll need to take part in it regularly to build bonds. If you can gather in person, it’s even better. “The part of our brain involved in social connection is stimulated by all five senses. When you’re with someone in the same room, you get a much stronger set of stimuli than you do by watching them on an electronic screen,” Dr. Olds says.

2. Create opportunities

If joining someone else’s group is unappealing, start your own. Host gatherings at your place or elsewhere. “All it takes is three people. You can say, ‘Let’s read books or talk about a TV show or have a dinner group on a regular basis,’” Dr. Olds says.

Other ideas for gatherings — either weekly or monthly — include:

• game nights
• trivia nights
• hikes in interesting parks
• beach walks
• bird-watching expeditions
• running or cycling
• meditation
• museum visits
• cooking
• knitting, sewing, or crafting
• shopping
• day trips to nearby towns
• jewelry making
• collector show-and-tell (comic books, antique dolls, baseball cards).

The people you invite don’t have to be dear friends; they can just be people you’d like to get to know better — perhaps neighbors or work acquaintances.

If they’re interested in a regular gathering, pin down dates and times. Otherwise, the idea might stay stuck in the talking stages. “Don’t be timid. Say, ‘Let’s get our calendars out and get this scheduled,’” Dr. Olds says.

3. Brush up your social skills

Sometimes we’re rusty in surface social graces that help build deeper connections. “It makes a huge difference when you can be enthusiastic rather than just sitting there and hoping someone will realize how interesting you are,” Dr. Olds says.

Tips to practice:

• Smile more. Smiling is welcoming, inviting, and hospitable to others.
• Be engaging. Prepare a few topics to talk about or questions to ask — perhaps about the news or the reason you’ve gathered (if it’s a seminar, for example, ask how long someone has been interested in the subject). Or look for a conversation starter. “Maybe the person is wearing a pretty brooch. Ask if there’s a story behind it,” Dr. Olds suggests.
• Be a good listener. “Listen in a way that someone realizes you’re paying attention. Hold their gaze, nod your head or say ‘Mm hmm’ as they’re talking so you give feedback. Assume everyone in the world is just yearning for your feedback,” Dr. Olds says.
• Ask follow-up questions. Don’t ignore signals that someone has interesting stories to tell. “If they allude to something, your job is to look fascinated and ask if they can tell you more. They’re dropping crumbs on a path to a deeper exchange,” Dr. Olds notes.

Even chats that don’t lead to friendships can be enriching. A 2022 study found that people who had the most diverse portfolios of social interactions — exchanges with strangers, acquaintances, friends, or family members — were much happier than those with the least diverse social portfolios.

Ultimately, a wide variety of interactions contributes to well-being, whether you’re talking to the cashier at the supermarket, a neighbor, an old friend, or a new one. And all of these connections combined may go a long way toward helping you feel less lonely.

About the Author

Heidi Godman, Executive Editor, Harvard Health Letter

Heidi Godman is the executive editor of the Harvard Health Letter. Before coming to the Health Letter, she was an award-winning television news anchor and medical reporter for 25 years. Heidi was named a journalism fellow … See Full Bio View all posts by Heidi Godman

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

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

Hot flashes and sleep or mood changes are well-known, troublesome symptoms that may occur during perimenopause and menopause. Now, one survey suggests nearly 80% of midlife women use cannabis to ease certain symptoms, such as mood issues and trouble sleeping.

Mounting numbers of US states have legalized marijuana for medical or recreational use in recent years. This wave of acceptance runs alongside skepticism in some quarters concerning FDA-approved menopause treatment options, including hormone therapy. But a lack of long-term research data surrounding cannabis use has led one Harvard expert to question how safe it may be, even while acknowledging its likely effectiveness for certain menopause woes.

“More and more patients tell me every year that they’ve tried cannabis or CBD (cannabidiol, an active ingredient in cannabis), particularly for sleep or anxiety,” says Dr. Heather Hirsch, head of the Menopause and Midlife Clinic at Harvard-affiliated Brigham and Women’s Hospital. “Adding to its appeal is that cannabis is now legal in so many places and works acutely for a couple of hours. You don’t need a doctor’s prescription. Socially, it may be easier to justify than using a medication. But why is there a movement toward saying okay to something that has unknown long-term effects, more than something that’s been studied and proven safe?” she asks.

Survey reports on who uses cannabis, why, and how

The new Harvard-led survey, published in the journal Menopause, looked at patterns of cannabis use in 131 women in perimenopause — the often years-long stretch before periods cease — along with 127 women who had passed through menopause. Participants were recruited through online postings on social media sites and an online recruitment platform. Nearly all survey respondents were white and most were middle-class, according to income reporting.

The vast majority (86%) were current cannabis users. Participants were split on whether they used cannabis for medical reasons, recreational purposes, or both. Nearly 79% endorsed it to alleviate menopause-related symptoms. Of those, 67% said cannabis helps with sleep disturbance, while 46% reported it helps improve mood and anxiety.

Perimenopausal women reported worse menopausal symptoms than their postmenopausal peers, as well as greater cannabis use to address their symptoms. More than 84% of participants reported smoking cannabis, while 78% consumed marijuana edibles, and nearly 53% used vaping oils.

One glaring limitation of the analysis is its self-selected group of participants, which lacked diversity and might skew results. But Dr. Hirsch wasn’t surprised by the high proportion reporting regular cannabis use. “I wouldn’t be surprised if those numbers reflect the broader population,” she says.

How might cannabis help menopause symptoms?

It makes sense that midlife women reported cannabis improves anxiety, mood, and sleep, Dr. Hirsch says. The drug likely helps all of these symptoms by “dimming the prefrontal cortex, the decision-making part of our brain.”

For many women, anxiety spikes during perimenopause, she notes. Common stressors during that time, such as aging parents or an emptying nest, add to the effects of dipping hormones. “It’s that feeling of, ‘I can’t turn my brain off.’ It’s really disturbing because they get in bed and can’t fall asleep, so they’re more tired, moody, and cranky the next day,” she explains. Dimming the prefrontal cortex enables people to calm down.

Hot flashes, often cited as the most common menopause symptom, did not improve as much from cannabis use, according to survey respondents. That too makes sense, Dr. Hirsch says, because the hypothalamus — the brain region considered the body’s thermostat — isn’t believed to be significantly affected by the drug.

No research yet on long-term effects

Given a lack of clinical trials objectively testing the effectiveness and safety of cannabis to manage menopause symptoms, more research is clearly needed.

“If people are finding relief from cannabis, great. But is it safe? We think so, but we don’t know,” she says. “There are no studies of middle-aged women using cannabis for 10 years, for as long as menopause symptoms often last. Are there going to be long-term effects on memory? On lung function? We don’t know.”

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

A simple word we all hear often — exercise — makes many people cringe. Unhappy childhood memories of school sports or gym classes, flat-out physical discomfort, guilty reluctance, or trouble finding time or pleasurable activities may help explain this. Additionally, for some people with obesity, fear of falling or injury is a high barrier to activity, recent research suggests.

That finding has important implications for health and well-being. So, how can we make movement safe and joyful for people of all weights?

Why be active?

As you may know, being physically active helps combat anxiety and depression. It prevents bone from thinning and tones muscle, helps you sleep better, lowers your blood pressure and blood sugar, and improves your cholesterol levels. It would take numerous medications to do all that routine physical activity can do for you.

Weight loss programs often incorporate exercise. Research shows that exercise helps with weight maintenance and may help with weight loss. Beyond burning calories, regular exercise also builds muscle mass. This matters because muscles are metabolically active, releasing proteins that play a role in decreasing appetite and food intake.

What does this study tell us?

The study found that many people with obesity fear injury and falling, which interferes with willingness to exercise. It followed 292 participants enrolled in an eight-week medical weight loss program in Sydney, Australia. All met criteria for obesity or severe obesity. The average age was 49; one-third of participants were male and two-thirds were female.

At the beginning of the study, participants filled out a 12-question injury perception survey. The majority reported fear of injury or falling, and believed their weight made injury more likely to occur. One-third said that their fear stopped them from exercising. The researchers also recorded weight, height, and waist circumference, and administered strength tests during the first, fourth, and last sessions.

When the study ended, the researchers found that the participants most concerned about getting injured hadn’t lost as much weight as those who did not express this fear. Those who hadn't lost as much weight also tended to have the highest scores of depression, anxiety, and sleepiness.

Fear of injury fuels a dangerous cycle

As noted, exercise is healthy at every weight: it protects your heart, lowers your blood sugar, boosts your mood, and tamps down anxiety. It also builds balance. Weight-bearing exercise such as walking prevents bone thinning.

If worries about injury or falls cause people to avoid exercise, they miss out on the balance-building, muscle-and-bone-strengthening, and mood-enhancing benefits of regular activity. They may be more likely to fall — and possibly more likely to experience fractures if they do.

Find a blend of activities that will work for you

Everyone, at every weight, needs to find ways to exercise safely, confidently, and joyfully.

• Start low and go slow. If you’re not currently active, start by simply sitting less and standing more. Try walking for two minutes every half hour. If you’re afraid of falling, try walking in place or alongside a friend or loved one who can provide security and comfort.
• Ask for guidance. Consider joining a YMCA where you can engage in supervised activities, or ask your doctor for a prescription to physical therapy to help you improve your balance and build your confidence.
• Try different activities to see what works for you. Walking is a simple, healthful activity, but it’s not the only form of activity you can try. You might enjoy swimming or water aerobics. Try pedaling a seated bike or an arm bike (upper body ergometer) that allows you to stay seated while you propel pedals with your arms instead of your feet. Adaptive activities and sports designed for people with physical limitations and disabilities are an option, too. Depending on your fitness level and interests, you might also consider dancing, biking, or anything else that gets you moving more often.

Lastly, keep in mind that many people suffer from anxiety, and a fear of falling is not insurmountable. If you’re really struggling, talk to your doctor or a mental health professional.

About the Author

Elizabeth Pegg Frates, MD, FACLM, DipABLM,

Contributor

Dr. Beth Frates is a trained physiatrist and a health and wellness coach, with expertise in lifestyle medicine. She is an award-winning teacher at Harvard Medical School, where she is an assistant clinical professor. Dr. Frates … See Full Bio View all posts by Elizabeth Pegg Frates, MD, FACLM, DipABLM

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