Covid ICYMI

As the COVID-19 pandemic continues and evidence evolves, clinical judgment is the bottom line for clinical care, according to Adarsh Bhimraj, MD, of the Cleveland Clinic, and James Walter, MD, of Northwestern Medicine, Chicago.

In a debate/discussion presented at SHM Converge, the annual conference of the Society of Hospital Medicine, Dr. Bhimraj and Dr. Walter took sides in a friendly debate on the value of remdesivir and tocilizumab for hospitalized COVID-19 patients.

Dr. Bhimraj argued for the use of remdesivir or tocilizumab in patients hospitalized with COVID-19 pneumonia, and Dr. Walter presented the case against their use.
 

Referendum on remdesivir

The main sources referenced by the presenters regarding remdesivir were the WHO Solidarity Trial (N Engl J Med. 2021 Feb 11. doi: 10.1056/NEJMoa2023184) and the Adaptive Covid-19 Treatment Trial (ACCT) final report (N Engl J Med. 2020 Nov 5. doi: 10.1056/NEJMoa2007764).

“The ‘debate’ is partly artificial,” and meant to illustrate how clinicians can use their own clinical faculties and reasoning to make an informed decision when treating COVID-19 patients, Dr. Bhimraj said.

The ACCT trial compared remdesivir with placebo in patients with severe enough COVID-19 to require supplemental oxygen, mechanical ventilation, or extracorporeal membrane oxygenation. The primary outcome in the study was time to recovery, and “the devil is in the details,” Dr. Bhimraj said. The outcomes clinicians should look for in studies are those that matter to patients, such as death, disability, and discomfort, he noted. Disease-oriented endpoints are easier to measure, but not always meaningful for patients, he said. The study showed an average 5-day decrease in illness, “but the fact is that it did not show a mortality benefit,” he noted.

Another large, open-label study of remdesivir across 30 countries showed no survival benefit associated with the drug, compared with standard of care, said Dr. Bhimraj. Patients treated with remdesivir remained in the hospital longer, but Dr. Bhimraj said he believed that was a bias. “I think the physicians kept the patients in the hospital longer to give the treatment rather than the treatments themselves prolonging the treatment duration,” he said.

In conclusion for remdesivir, “the solid data show that there is an early recovery,” he said. “At least for severe disease, even if there is no mortality benefit, there is a role. I argue that, if someone asks if you want to use remdesivir in severe COVID-19 patients, say yes, especially if you value people getting out of the hospital sooner. In a crisis situation, there is a role for remdesivir.”

Dr. Walter discussed the “con” side of using remdesivir. “We can start with a predata hypothesis, but integrate new data about the efficacy into a postdata hypothesis,” he said.

Dr. Walter made several points against the use of remdesivir in hospitalized COVID-19 patients. First, it has not shown any improvement in mortality and may increase the length of hospital stay, he noted.

Data from the ACCT-1 trial and the WHO solidarity trial, showed “no signal of mortality benefit at all,” he said. In addition, the World Health Organization, American College of Physicians, and National Institutes of Health all recommend against remdesivir for patients who require mechanical ventilation or extracorporeal membrane oxygenation, he said. The efficacy when used with steroids remains unclear, and long-term safety data are lacking, he added.
 

Taking on tocilizumab

Tocilizumab, an anti-inflammatory agent, has demonstrated an impact on several surrogate markers, notably C-reactive protein, temperature, and oxygenation. Dr. Bhimraj said. He reviewed data from eight published studies on the use of tocilizumab in COVID-19 patients.

Arguably, some trials may not have been powered adequately, and in combination, some trials show an effect on clinical deterioration, if not a mortality benefit, he said.

Consequently, in the context of COVID-19, tocilizumab “should be used early in the disease process, especially if steroids are not working,” said Dr. Bhimraj. Despite the limited evidence, “there is a niche population where this might be beneficial,” he said.

By contrast, Dr. Walter took the position of skepticism about the value of tocilizumab for COVID-19 patients.

Notably, decades of research show that tocilizumab has shown no benefit in patients with sepsis or septic shock, or those with acute respiratory distress syndrome, which have similarities to COVID-19 (JAMA. 2020 Sep 3. doi: 10.1001/jama.2020.17052).

He cited a research letter published in JAMA in September 2020, which showed that cytokine levels were in fact lower in critically ill patients with COVID-19, compared with those who had conditions including sepsis with and without ARDS.

Dr. Walter also cited data on the questionable benefit of tocilizumab when used with steroids and the negligible impact on mortality in hospitalized COVID-19 patients seen in the RECOVERY trial.

Limited data mean that therapeutic decisions related to COVID-19 are more nuanced, but they can be made, the presenters agreed.

Ultimately, when trying to decide whether a drug is efficacious, futile, or harmful, “What we have to do is consider the grand totality of the evidence,” Dr. Bhimraj emphasized.

Dr. Bhimraj and Dr. Walter had no relevant financial conflicts to disclose.

As the COVID-19 pandemic continues and evidence evolves, clinical judgment is the bottom line for clinical care, according to Adarsh Bhimraj, MD, of the Cleveland Clinic, and James Walter, MD, of Northwestern Medicine, Chicago.

In a debate/discussion presented at SHM Converge, the annual conference of the Society of Hospital Medicine, Dr. Bhimraj and Dr. Walter took sides in a friendly debate on the value of remdesivir and tocilizumab for hospitalized COVID-19 patients.

Dr. Bhimraj argued for the use of remdesivir or tocilizumab in patients hospitalized with COVID-19 pneumonia, and Dr. Walter presented the case against their use.
 

Referendum on remdesivir

The main sources referenced by the presenters regarding remdesivir were the WHO Solidarity Trial (N Engl J Med. 2021 Feb 11. doi: 10.1056/NEJMoa2023184) and the Adaptive Covid-19 Treatment Trial (ACCT) final report (N Engl J Med. 2020 Nov 5. doi: 10.1056/NEJMoa2007764).

“The ‘debate’ is partly artificial,” and meant to illustrate how clinicians can use their own clinical faculties and reasoning to make an informed decision when treating COVID-19 patients, Dr. Bhimraj said.

The ACCT trial compared remdesivir with placebo in patients with severe enough COVID-19 to require supplemental oxygen, mechanical ventilation, or extracorporeal membrane oxygenation. The primary outcome in the study was time to recovery, and “the devil is in the details,” Dr. Bhimraj said. The outcomes clinicians should look for in studies are those that matter to patients, such as death, disability, and discomfort, he noted. Disease-oriented endpoints are easier to measure, but not always meaningful for patients, he said. The study showed an average 5-day decrease in illness, “but the fact is that it did not show a mortality benefit,” he noted.

Another large, open-label study of remdesivir across 30 countries showed no survival benefit associated with the drug, compared with standard of care, said Dr. Bhimraj. Patients treated with remdesivir remained in the hospital longer, but Dr. Bhimraj said he believed that was a bias. “I think the physicians kept the patients in the hospital longer to give the treatment rather than the treatments themselves prolonging the treatment duration,” he said.

In conclusion for remdesivir, “the solid data show that there is an early recovery,” he said. “At least for severe disease, even if there is no mortality benefit, there is a role. I argue that, if someone asks if you want to use remdesivir in severe COVID-19 patients, say yes, especially if you value people getting out of the hospital sooner. In a crisis situation, there is a role for remdesivir.”

Dr. Walter discussed the “con” side of using remdesivir. “We can start with a predata hypothesis, but integrate new data about the efficacy into a postdata hypothesis,” he said.

Dr. Walter made several points against the use of remdesivir in hospitalized COVID-19 patients. First, it has not shown any improvement in mortality and may increase the length of hospital stay, he noted.

Data from the ACCT-1 trial and the WHO solidarity trial, showed “no signal of mortality benefit at all,” he said. In addition, the World Health Organization, American College of Physicians, and National Institutes of Health all recommend against remdesivir for patients who require mechanical ventilation or extracorporeal membrane oxygenation, he said. The efficacy when used with steroids remains unclear, and long-term safety data are lacking, he added.
 

Taking on tocilizumab

Tocilizumab, an anti-inflammatory agent, has demonstrated an impact on several surrogate markers, notably C-reactive protein, temperature, and oxygenation. Dr. Bhimraj said. He reviewed data from eight published studies on the use of tocilizumab in COVID-19 patients.

Arguably, some trials may not have been powered adequately, and in combination, some trials show an effect on clinical deterioration, if not a mortality benefit, he said.

Consequently, in the context of COVID-19, tocilizumab “should be used early in the disease process, especially if steroids are not working,” said Dr. Bhimraj. Despite the limited evidence, “there is a niche population where this might be beneficial,” he said.

By contrast, Dr. Walter took the position of skepticism about the value of tocilizumab for COVID-19 patients.

Notably, decades of research show that tocilizumab has shown no benefit in patients with sepsis or septic shock, or those with acute respiratory distress syndrome, which have similarities to COVID-19 (JAMA. 2020 Sep 3. doi: 10.1001/jama.2020.17052).

He cited a research letter published in JAMA in September 2020, which showed that cytokine levels were in fact lower in critically ill patients with COVID-19, compared with those who had conditions including sepsis with and without ARDS.

Dr. Walter also cited data on the questionable benefit of tocilizumab when used with steroids and the negligible impact on mortality in hospitalized COVID-19 patients seen in the RECOVERY trial.

Limited data mean that therapeutic decisions related to COVID-19 are more nuanced, but they can be made, the presenters agreed.

Ultimately, when trying to decide whether a drug is efficacious, futile, or harmful, “What we have to do is consider the grand totality of the evidence,” Dr. Bhimraj emphasized.

Dr. Bhimraj and Dr. Walter had no relevant financial conflicts to disclose.

As the COVID-19 pandemic continues and evidence evolves, clinical judgment is the bottom line for clinical care, according to Adarsh Bhimraj, MD, of the Cleveland Clinic, and James Walter, MD, of Northwestern Medicine, Chicago.

In a debate/discussion presented at SHM Converge, the annual conference of the Society of Hospital Medicine, Dr. Bhimraj and Dr. Walter took sides in a friendly debate on the value of remdesivir and tocilizumab for hospitalized COVID-19 patients.

Dr. Bhimraj argued for the use of remdesivir or tocilizumab in patients hospitalized with COVID-19 pneumonia, and Dr. Walter presented the case against their use.
 

Referendum on remdesivir

The main sources referenced by the presenters regarding remdesivir were the WHO Solidarity Trial (N Engl J Med. 2021 Feb 11. doi: 10.1056/NEJMoa2023184) and the Adaptive Covid-19 Treatment Trial (ACCT) final report (N Engl J Med. 2020 Nov 5. doi: 10.1056/NEJMoa2007764).

“The ‘debate’ is partly artificial,” and meant to illustrate how clinicians can use their own clinical faculties and reasoning to make an informed decision when treating COVID-19 patients, Dr. Bhimraj said.

The ACCT trial compared remdesivir with placebo in patients with severe enough COVID-19 to require supplemental oxygen, mechanical ventilation, or extracorporeal membrane oxygenation. The primary outcome in the study was time to recovery, and “the devil is in the details,” Dr. Bhimraj said. The outcomes clinicians should look for in studies are those that matter to patients, such as death, disability, and discomfort, he noted. Disease-oriented endpoints are easier to measure, but not always meaningful for patients, he said. The study showed an average 5-day decrease in illness, “but the fact is that it did not show a mortality benefit,” he noted.

Another large, open-label study of remdesivir across 30 countries showed no survival benefit associated with the drug, compared with standard of care, said Dr. Bhimraj. Patients treated with remdesivir remained in the hospital longer, but Dr. Bhimraj said he believed that was a bias. “I think the physicians kept the patients in the hospital longer to give the treatment rather than the treatments themselves prolonging the treatment duration,” he said.

In conclusion for remdesivir, “the solid data show that there is an early recovery,” he said. “At least for severe disease, even if there is no mortality benefit, there is a role. I argue that, if someone asks if you want to use remdesivir in severe COVID-19 patients, say yes, especially if you value people getting out of the hospital sooner. In a crisis situation, there is a role for remdesivir.”

Dr. Walter discussed the “con” side of using remdesivir. “We can start with a predata hypothesis, but integrate new data about the efficacy into a postdata hypothesis,” he said.

Dr. Walter made several points against the use of remdesivir in hospitalized COVID-19 patients. First, it has not shown any improvement in mortality and may increase the length of hospital stay, he noted.

Data from the ACCT-1 trial and the WHO solidarity trial, showed “no signal of mortality benefit at all,” he said. In addition, the World Health Organization, American College of Physicians, and National Institutes of Health all recommend against remdesivir for patients who require mechanical ventilation or extracorporeal membrane oxygenation, he said. The efficacy when used with steroids remains unclear, and long-term safety data are lacking, he added.
 

Taking on tocilizumab

Tocilizumab, an anti-inflammatory agent, has demonstrated an impact on several surrogate markers, notably C-reactive protein, temperature, and oxygenation. Dr. Bhimraj said. He reviewed data from eight published studies on the use of tocilizumab in COVID-19 patients.

Arguably, some trials may not have been powered adequately, and in combination, some trials show an effect on clinical deterioration, if not a mortality benefit, he said.

Consequently, in the context of COVID-19, tocilizumab “should be used early in the disease process, especially if steroids are not working,” said Dr. Bhimraj. Despite the limited evidence, “there is a niche population where this might be beneficial,” he said.

By contrast, Dr. Walter took the position of skepticism about the value of tocilizumab for COVID-19 patients.

Notably, decades of research show that tocilizumab has shown no benefit in patients with sepsis or septic shock, or those with acute respiratory distress syndrome, which have similarities to COVID-19 (JAMA. 2020 Sep 3. doi: 10.1001/jama.2020.17052).

He cited a research letter published in JAMA in September 2020, which showed that cytokine levels were in fact lower in critically ill patients with COVID-19, compared with those who had conditions including sepsis with and without ARDS.

Dr. Walter also cited data on the questionable benefit of tocilizumab when used with steroids and the negligible impact on mortality in hospitalized COVID-19 patients seen in the RECOVERY trial.

Limited data mean that therapeutic decisions related to COVID-19 are more nuanced, but they can be made, the presenters agreed.

Ultimately, when trying to decide whether a drug is efficacious, futile, or harmful, “What we have to do is consider the grand totality of the evidence,” Dr. Bhimraj emphasized.

Dr. Bhimraj and Dr. Walter had no relevant financial conflicts to disclose.

It’s pretty clear that, at least globally, we have not reached a steady state with the SARS-COV-2 virus. And here in the United States we should remain concerned that if we can’t convince our vaccine-hesitant population to step forward for their shots, this country may slide back into dangerous instability. Despite these uncertainties, it may be time to polish up the old retrospectoscope again and see what the last year and a half has taught us.

Although it took us too long to discover the reality, it is now pretty clear that the virus is spread in the air and by close personal contact, especially indoors. There continues to be some misplaced over-attention to surface cleaning, but for the most part, the bulk of the population seems to have finally gotten the picture. We are of course still plagued by our own impatience and the unfortunate mix of politics and the disagreement about how personal freedom and the common good can coexist.

A year ago, while we were still on the steep part of the learning curve and the specter of the unknown hung over us like a dark cloud, schools and colleges faced a myriad of challenges as they considered how to safely educate their students. Faced with a relative vacuum in leadership from the federal government, school boards and college administrators were left to interpret the trickle of information that filtered down from the media. Many turned for help to hired consultants and a variety of state and local health departments, all of whom were relying on the same information sources that were available to all of us – sources that often were neither peer reviewed nor based on hard facts. In this land that prides itself on free speech, we were all college administrators, local school board members, and parents basing our decision on the same smorgasbord of information that was frequently self-contradictory.

As I look around at the school systems and colleges with which I have some familiarity it has been interesting to observe how their responses to this hodgepodge of opinion and guesstimates have fallen into two basic categories. Some institutions seem to have been primarily motivated by risk avoidance and others appeared to have struggled to maintain their focus on how best to carry out their primary mission of educating their students.

This dichotomy is not surprising. Institutions are composed of people and people naturally self-sort themselves into pessimists and optimists. When a study is published without peer review suggesting that within schools transmission of the virus between children is unusual the optimist may use the scrap of information to support her decision to craft a hybrid system that includes an abundance of in-class experience. The pessimist will probably observe that it was only one study and instead be more concerned about the number of multi-system-inflammatory syndrome cases reported among children in New York City. He will be far less likely to abandon his all-remote learning system.

There is risk inherent in any decision-making process, including incurring a greater risk by failing to make any decision. The person whose primary focus is on avoiding any risk often shuts off the process of creative thinking and problem solving. At the end of the day, the risk avoider may have achieved his goal with a policy that includes aggressive closings but has fallen far short of his primary mission of educating students.

Here in New England there are several examples of small colleges that have managed to create more normal on-campus educational environments. To my knowledge, their experience with case numbers is no worse and may even be better than that of schools of similar size and geographic siting that chose more restrictive policies. You could argue that the less restrictive schools were just lucky. But my hunch is that the institutions that were able to put risk in perspective and remain focused on their mission were able to navigate the uncharted waters more creatively. The bottom line is that we aren’t talking about right or wrong decisions but grouped together they should provide a foundation to build on for the next turmoil.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

It’s pretty clear that, at least globally, we have not reached a steady state with the SARS-COV-2 virus. And here in the United States we should remain concerned that if we can’t convince our vaccine-hesitant population to step forward for their shots, this country may slide back into dangerous instability. Despite these uncertainties, it may be time to polish up the old retrospectoscope again and see what the last year and a half has taught us.

Although it took us too long to discover the reality, it is now pretty clear that the virus is spread in the air and by close personal contact, especially indoors. There continues to be some misplaced over-attention to surface cleaning, but for the most part, the bulk of the population seems to have finally gotten the picture. We are of course still plagued by our own impatience and the unfortunate mix of politics and the disagreement about how personal freedom and the common good can coexist.

A year ago, while we were still on the steep part of the learning curve and the specter of the unknown hung over us like a dark cloud, schools and colleges faced a myriad of challenges as they considered how to safely educate their students. Faced with a relative vacuum in leadership from the federal government, school boards and college administrators were left to interpret the trickle of information that filtered down from the media. Many turned for help to hired consultants and a variety of state and local health departments, all of whom were relying on the same information sources that were available to all of us – sources that often were neither peer reviewed nor based on hard facts. In this land that prides itself on free speech, we were all college administrators, local school board members, and parents basing our decision on the same smorgasbord of information that was frequently self-contradictory.

As I look around at the school systems and colleges with which I have some familiarity it has been interesting to observe how their responses to this hodgepodge of opinion and guesstimates have fallen into two basic categories. Some institutions seem to have been primarily motivated by risk avoidance and others appeared to have struggled to maintain their focus on how best to carry out their primary mission of educating their students.

This dichotomy is not surprising. Institutions are composed of people and people naturally self-sort themselves into pessimists and optimists. When a study is published without peer review suggesting that within schools transmission of the virus between children is unusual the optimist may use the scrap of information to support her decision to craft a hybrid system that includes an abundance of in-class experience. The pessimist will probably observe that it was only one study and instead be more concerned about the number of multi-system-inflammatory syndrome cases reported among children in New York City. He will be far less likely to abandon his all-remote learning system.

There is risk inherent in any decision-making process, including incurring a greater risk by failing to make any decision. The person whose primary focus is on avoiding any risk often shuts off the process of creative thinking and problem solving. At the end of the day, the risk avoider may have achieved his goal with a policy that includes aggressive closings but has fallen far short of his primary mission of educating students.

Here in New England there are several examples of small colleges that have managed to create more normal on-campus educational environments. To my knowledge, their experience with case numbers is no worse and may even be better than that of schools of similar size and geographic siting that chose more restrictive policies. You could argue that the less restrictive schools were just lucky. But my hunch is that the institutions that were able to put risk in perspective and remain focused on their mission were able to navigate the uncharted waters more creatively. The bottom line is that we aren’t talking about right or wrong decisions but grouped together they should provide a foundation to build on for the next turmoil.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

It’s pretty clear that, at least globally, we have not reached a steady state with the SARS-COV-2 virus. And here in the United States we should remain concerned that if we can’t convince our vaccine-hesitant population to step forward for their shots, this country may slide back into dangerous instability. Despite these uncertainties, it may be time to polish up the old retrospectoscope again and see what the last year and a half has taught us.

Although it took us too long to discover the reality, it is now pretty clear that the virus is spread in the air and by close personal contact, especially indoors. There continues to be some misplaced over-attention to surface cleaning, but for the most part, the bulk of the population seems to have finally gotten the picture. We are of course still plagued by our own impatience and the unfortunate mix of politics and the disagreement about how personal freedom and the common good can coexist.

A year ago, while we were still on the steep part of the learning curve and the specter of the unknown hung over us like a dark cloud, schools and colleges faced a myriad of challenges as they considered how to safely educate their students. Faced with a relative vacuum in leadership from the federal government, school boards and college administrators were left to interpret the trickle of information that filtered down from the media. Many turned for help to hired consultants and a variety of state and local health departments, all of whom were relying on the same information sources that were available to all of us – sources that often were neither peer reviewed nor based on hard facts. In this land that prides itself on free speech, we were all college administrators, local school board members, and parents basing our decision on the same smorgasbord of information that was frequently self-contradictory.

As I look around at the school systems and colleges with which I have some familiarity it has been interesting to observe how their responses to this hodgepodge of opinion and guesstimates have fallen into two basic categories. Some institutions seem to have been primarily motivated by risk avoidance and others appeared to have struggled to maintain their focus on how best to carry out their primary mission of educating their students.

This dichotomy is not surprising. Institutions are composed of people and people naturally self-sort themselves into pessimists and optimists. When a study is published without peer review suggesting that within schools transmission of the virus between children is unusual the optimist may use the scrap of information to support her decision to craft a hybrid system that includes an abundance of in-class experience. The pessimist will probably observe that it was only one study and instead be more concerned about the number of multi-system-inflammatory syndrome cases reported among children in New York City. He will be far less likely to abandon his all-remote learning system.

There is risk inherent in any decision-making process, including incurring a greater risk by failing to make any decision. The person whose primary focus is on avoiding any risk often shuts off the process of creative thinking and problem solving. At the end of the day, the risk avoider may have achieved his goal with a policy that includes aggressive closings but has fallen far short of his primary mission of educating students.

Here in New England there are several examples of small colleges that have managed to create more normal on-campus educational environments. To my knowledge, their experience with case numbers is no worse and may even be better than that of schools of similar size and geographic siting that chose more restrictive policies. You could argue that the less restrictive schools were just lucky. But my hunch is that the institutions that were able to put risk in perspective and remain focused on their mission were able to navigate the uncharted waters more creatively. The bottom line is that we aren’t talking about right or wrong decisions but grouped together they should provide a foundation to build on for the next turmoil.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

The risk of severe outcomes with COVID-19 increases with excess weight in a linear manner beginning in normal body mass index ranges, with the effect apparently independent of obesity-related diseases such as diabetes, and stronger among younger people and Black persons, new research shows.

“Even a small increase in body mass index above 23 kg/m² is a risk factor for adverse outcomes after infection with SARS-CoV-2,” the authors reported.

“Excess weight is a modifiable risk factor and investment in the treatment of overweight and obesity, and long-term preventive strategies could help reduce the severity of COVID-19 disease,” they wrote.

The findings shed important new light in the ongoing efforts to understand COVID-19 effects, Krishnan Bhaskaran, PhD, said in an interview.

“These results confirm and add detail to the established links between overweight and obesity and COVID-19, and also add new information on risks among people with low BMI levels,” said Dr. Bhaskaran, an epidemiologist at the London School of Hygiene & Tropical Medicine, who authored an accompanying editorial (Lancet Diabetes Endocrinol 2021 Apr 29; doi: 10.1016/S2213-8587[21]00109-1).

Obesity has been well established as a major risk factor for poor outcomes among people with COVID-19; however, less is known about the risk of severe outcomes over the broader spectrum of excess weight, and its relationship with other factors.

For the prospective, community-based study, Carmen Piernas, PhD, of the University of Oxford (England) and colleagues evaluated data on nearly 7 million individuals registered in the U.K. QResearch database during Jan. 24–April 30, 2020.

Overall, patients had a mean BMI of 27 kg/m². Among them, 13,503 (.20%) were admitted to the hospital during the study period, 1,601 (.02%) were admitted to an ICU and 5,479 (.08%) died after testing positive for SARS-CoV-2.


 

Risk rises from BMI of 23 kg/m²

In looking at the risk of hospital admission with COVID-19, the authors found a J-shaped relationship with BMI, with the risk increased with a BMI of 20 kg/m² or lower, as well as an increased risk beginning with a BMI of 23 kg/m² – considered normal weight – or higher (hazard ratio, 1.05).

The risk of death from COVID-19 was also J-shaped, however the association with increases in BMI started higher – at 28 kg/m² (adjusted HR 1.04).

In terms of the risk of ICU admission with COVID-19, the curve was not J-shaped, with just a linear association of admission with increasing BMI beginning at 23 kg/m² (adjusted HR 1.10).

“It was surprising to see that the lowest risk of severe COVID-19 was found at a BMI of 23, and each extra BMI unit was associated with significantly higher risk, but we don’t really know yet what the reason is for this,” Dr. Piernas said in an interview.

The association between increasing BMI and risk of hospital admission for COVID-19 beginning at a BMI of 23 kg/m² was more significant among younger people aged 20-39 years than in those aged 80-100 years, with an adjusted HR for hospital admission per BMI unit above 23 kg/m² of 1.09 versus 1.01 (P < .0001).

In addition, the risk associated with BMI and hospital admission was stronger in people who were Black, compared with those who were White (1.07 vs. 1.04), as was the risk of death due to COVID-19 (1.08 vs. 1.04; P < .0001 for both).

“For the risk of death, Blacks have an 8% higher risk with each extra BMI unit, whereas Whites have a 4% increase, which is half the risk,” Dr. Piernas said.

Notably, the increased risks of hospital admission and ICU due to COVID-19 seen with increases in BMI were slightly lower among people with type 2 diabetes, hypertension, and cardiovascular disease compared with patients who did not have those comorbidities, suggesting the association with BMI is not explained by those risk factors.

Dr. Piernas speculated that the effect could reflect that people with diabetes or cardiovascular disease already have a preexisting condition which makes them more susceptible to SARS-CoV-2.

Hence, “the association with BMI in this group may not be as strong as the association found among those without those conditions, in which BMI explains a higher proportion of this increased risk, given the absence of these preexisting conditions.”

Similarly, the effect of BMI on COVID-19 outcomes in younger patients may appear stronger because their rates of other comorbidities are much lower than in older patients.

“Among older people, preexisting conditions and perhaps a weaker immune system may explain their much higher rates of severe COVID outcomes,” Dr. Piernas noted.

Furthermore, older patients may have frailty and high comorbidities that could explain their lower rates of ICU admission with COVID-19, Dr. Bhaskaran added in further comments.

The findings overall underscore that excess weight can represent a risk in COVID-19 outcomes that is, importantly, modifiable, and “suggest that supporting people to reach and maintain a healthy weight is likely to help people reduce their risk of experiencing severe outcomes from this disease, now or in any future waves,” he concluded.

Dr. Piernas and Dr. Bhaskaran had no disclosures to report. Coauthors’ disclosures are detailed in the published study.

The risk of severe outcomes with COVID-19 increases with excess weight in a linear manner beginning in normal body mass index ranges, with the effect apparently independent of obesity-related diseases such as diabetes, and stronger among younger people and Black persons, new research shows.

“Even a small increase in body mass index above 23 kg/m² is a risk factor for adverse outcomes after infection with SARS-CoV-2,” the authors reported.

“Excess weight is a modifiable risk factor and investment in the treatment of overweight and obesity, and long-term preventive strategies could help reduce the severity of COVID-19 disease,” they wrote.

The findings shed important new light in the ongoing efforts to understand COVID-19 effects, Krishnan Bhaskaran, PhD, said in an interview.

“These results confirm and add detail to the established links between overweight and obesity and COVID-19, and also add new information on risks among people with low BMI levels,” said Dr. Bhaskaran, an epidemiologist at the London School of Hygiene & Tropical Medicine, who authored an accompanying editorial (Lancet Diabetes Endocrinol 2021 Apr 29; doi: 10.1016/S2213-8587[21]00109-1).

Obesity has been well established as a major risk factor for poor outcomes among people with COVID-19; however, less is known about the risk of severe outcomes over the broader spectrum of excess weight, and its relationship with other factors.

For the prospective, community-based study, Carmen Piernas, PhD, of the University of Oxford (England) and colleagues evaluated data on nearly 7 million individuals registered in the U.K. QResearch database during Jan. 24–April 30, 2020.

Overall, patients had a mean BMI of 27 kg/m². Among them, 13,503 (.20%) were admitted to the hospital during the study period, 1,601 (.02%) were admitted to an ICU and 5,479 (.08%) died after testing positive for SARS-CoV-2.


 

Risk rises from BMI of 23 kg/m²

In looking at the risk of hospital admission with COVID-19, the authors found a J-shaped relationship with BMI, with the risk increased with a BMI of 20 kg/m² or lower, as well as an increased risk beginning with a BMI of 23 kg/m² – considered normal weight – or higher (hazard ratio, 1.05).

The risk of death from COVID-19 was also J-shaped, however the association with increases in BMI started higher – at 28 kg/m² (adjusted HR 1.04).

In terms of the risk of ICU admission with COVID-19, the curve was not J-shaped, with just a linear association of admission with increasing BMI beginning at 23 kg/m² (adjusted HR 1.10).

“It was surprising to see that the lowest risk of severe COVID-19 was found at a BMI of 23, and each extra BMI unit was associated with significantly higher risk, but we don’t really know yet what the reason is for this,” Dr. Piernas said in an interview.

The association between increasing BMI and risk of hospital admission for COVID-19 beginning at a BMI of 23 kg/m² was more significant among younger people aged 20-39 years than in those aged 80-100 years, with an adjusted HR for hospital admission per BMI unit above 23 kg/m² of 1.09 versus 1.01 (P < .0001).

In addition, the risk associated with BMI and hospital admission was stronger in people who were Black, compared with those who were White (1.07 vs. 1.04), as was the risk of death due to COVID-19 (1.08 vs. 1.04; P < .0001 for both).

“For the risk of death, Blacks have an 8% higher risk with each extra BMI unit, whereas Whites have a 4% increase, which is half the risk,” Dr. Piernas said.

Notably, the increased risks of hospital admission and ICU due to COVID-19 seen with increases in BMI were slightly lower among people with type 2 diabetes, hypertension, and cardiovascular disease compared with patients who did not have those comorbidities, suggesting the association with BMI is not explained by those risk factors.

Dr. Piernas speculated that the effect could reflect that people with diabetes or cardiovascular disease already have a preexisting condition which makes them more susceptible to SARS-CoV-2.

Hence, “the association with BMI in this group may not be as strong as the association found among those without those conditions, in which BMI explains a higher proportion of this increased risk, given the absence of these preexisting conditions.”

Similarly, the effect of BMI on COVID-19 outcomes in younger patients may appear stronger because their rates of other comorbidities are much lower than in older patients.

“Among older people, preexisting conditions and perhaps a weaker immune system may explain their much higher rates of severe COVID outcomes,” Dr. Piernas noted.

Furthermore, older patients may have frailty and high comorbidities that could explain their lower rates of ICU admission with COVID-19, Dr. Bhaskaran added in further comments.

The findings overall underscore that excess weight can represent a risk in COVID-19 outcomes that is, importantly, modifiable, and “suggest that supporting people to reach and maintain a healthy weight is likely to help people reduce their risk of experiencing severe outcomes from this disease, now or in any future waves,” he concluded.

Dr. Piernas and Dr. Bhaskaran had no disclosures to report. Coauthors’ disclosures are detailed in the published study.

The risk of severe outcomes with COVID-19 increases with excess weight in a linear manner beginning in normal body mass index ranges, with the effect apparently independent of obesity-related diseases such as diabetes, and stronger among younger people and Black persons, new research shows.

“Even a small increase in body mass index above 23 kg/m² is a risk factor for adverse outcomes after infection with SARS-CoV-2,” the authors reported.

“Excess weight is a modifiable risk factor and investment in the treatment of overweight and obesity, and long-term preventive strategies could help reduce the severity of COVID-19 disease,” they wrote.

The findings shed important new light in the ongoing efforts to understand COVID-19 effects, Krishnan Bhaskaran, PhD, said in an interview.

“These results confirm and add detail to the established links between overweight and obesity and COVID-19, and also add new information on risks among people with low BMI levels,” said Dr. Bhaskaran, an epidemiologist at the London School of Hygiene & Tropical Medicine, who authored an accompanying editorial (Lancet Diabetes Endocrinol 2021 Apr 29; doi: 10.1016/S2213-8587[21]00109-1).

Obesity has been well established as a major risk factor for poor outcomes among people with COVID-19; however, less is known about the risk of severe outcomes over the broader spectrum of excess weight, and its relationship with other factors.

For the prospective, community-based study, Carmen Piernas, PhD, of the University of Oxford (England) and colleagues evaluated data on nearly 7 million individuals registered in the U.K. QResearch database during Jan. 24–April 30, 2020.

Overall, patients had a mean BMI of 27 kg/m². Among them, 13,503 (.20%) were admitted to the hospital during the study period, 1,601 (.02%) were admitted to an ICU and 5,479 (.08%) died after testing positive for SARS-CoV-2.


 

Risk rises from BMI of 23 kg/m²

In looking at the risk of hospital admission with COVID-19, the authors found a J-shaped relationship with BMI, with the risk increased with a BMI of 20 kg/m² or lower, as well as an increased risk beginning with a BMI of 23 kg/m² – considered normal weight – or higher (hazard ratio, 1.05).

The risk of death from COVID-19 was also J-shaped, however the association with increases in BMI started higher – at 28 kg/m² (adjusted HR 1.04).

In terms of the risk of ICU admission with COVID-19, the curve was not J-shaped, with just a linear association of admission with increasing BMI beginning at 23 kg/m² (adjusted HR 1.10).

“It was surprising to see that the lowest risk of severe COVID-19 was found at a BMI of 23, and each extra BMI unit was associated with significantly higher risk, but we don’t really know yet what the reason is for this,” Dr. Piernas said in an interview.

The association between increasing BMI and risk of hospital admission for COVID-19 beginning at a BMI of 23 kg/m² was more significant among younger people aged 20-39 years than in those aged 80-100 years, with an adjusted HR for hospital admission per BMI unit above 23 kg/m² of 1.09 versus 1.01 (P < .0001).

In addition, the risk associated with BMI and hospital admission was stronger in people who were Black, compared with those who were White (1.07 vs. 1.04), as was the risk of death due to COVID-19 (1.08 vs. 1.04; P < .0001 for both).

“For the risk of death, Blacks have an 8% higher risk with each extra BMI unit, whereas Whites have a 4% increase, which is half the risk,” Dr. Piernas said.

Notably, the increased risks of hospital admission and ICU due to COVID-19 seen with increases in BMI were slightly lower among people with type 2 diabetes, hypertension, and cardiovascular disease compared with patients who did not have those comorbidities, suggesting the association with BMI is not explained by those risk factors.

Dr. Piernas speculated that the effect could reflect that people with diabetes or cardiovascular disease already have a preexisting condition which makes them more susceptible to SARS-CoV-2.

Hence, “the association with BMI in this group may not be as strong as the association found among those without those conditions, in which BMI explains a higher proportion of this increased risk, given the absence of these preexisting conditions.”

Similarly, the effect of BMI on COVID-19 outcomes in younger patients may appear stronger because their rates of other comorbidities are much lower than in older patients.

“Among older people, preexisting conditions and perhaps a weaker immune system may explain their much higher rates of severe COVID outcomes,” Dr. Piernas noted.

Furthermore, older patients may have frailty and high comorbidities that could explain their lower rates of ICU admission with COVID-19, Dr. Bhaskaran added in further comments.

The findings overall underscore that excess weight can represent a risk in COVID-19 outcomes that is, importantly, modifiable, and “suggest that supporting people to reach and maintain a healthy weight is likely to help people reduce their risk of experiencing severe outcomes from this disease, now or in any future waves,” he concluded.

Dr. Piernas and Dr. Bhaskaran had no disclosures to report. Coauthors’ disclosures are detailed in the published study.

New cases of COVID-19 in children are trending downward again after dropping for a second consecutive week, according to a report from the American Academy of Pediatrics and the Children’s Hospital Association.

Despite that drop, however, children made up a larger share (22.4%) of all cases reported during the week of April 23-29, compared with the previous week, when the proportion reached what was then a pandemic high of 20.8%, based on data in the weekly AAP/CHA report.

New cases totaled 71,649 for the week of April 23-29, down by 10.3% from the week before and by 19.0% over this most recent 2-week decline, but still a ways to go before reaching the low point of the year (52,695) recorded during the second week of March, the report shows.

Since the beginning of the pandemic, just over 3.78 million children have been infected by SARS-CoV-2, which is 13.8% of all cases reported in 49 states (excluding New York), the District of Columbia, New York City, Puerto Rico, and Guam.

The overall rate of COVID-19 has reached 5,026 cases per 100,000 children, or 5% of the total pediatric population, although there is considerable variation among the states regarding age ranges used to define child cases. Most states use a range of 0-17 or 0-19 years, but Florida and Utah use a range of 0-14 years and South Carolina and Tennessee go with 0-20, the AAP and CHA noted.

There is also much variation between the states when it comes to cumulative child COVID-19 rates, with the lowest rate reported in Hawaii (1,264 per 100,000) and the highest in North Dakota (9,416 per 100,000). The lowest proportion of child cases to all cases is found in Florida (8.7%) and the highest in Vermont (22.2%), the AAP and CHA said.

The number of COVID-19–related deaths was 303 as of April 29, up by 7 from the previous week in the 43 states, along with New York City, Puerto Rico, and Guam, that are reporting mortality data by age. The proportion of child deaths to child cases remains at 0.01%, and children represent just 0.06% of all COVID-19 deaths, according to the AAP/CHA report.

[email protected]

New cases of COVID-19 in children are trending downward again after dropping for a second consecutive week, according to a report from the American Academy of Pediatrics and the Children’s Hospital Association.

Despite that drop, however, children made up a larger share (22.4%) of all cases reported during the week of April 23-29, compared with the previous week, when the proportion reached what was then a pandemic high of 20.8%, based on data in the weekly AAP/CHA report.

New cases totaled 71,649 for the week of April 23-29, down by 10.3% from the week before and by 19.0% over this most recent 2-week decline, but still a ways to go before reaching the low point of the year (52,695) recorded during the second week of March, the report shows.

Since the beginning of the pandemic, just over 3.78 million children have been infected by SARS-CoV-2, which is 13.8% of all cases reported in 49 states (excluding New York), the District of Columbia, New York City, Puerto Rico, and Guam.

The overall rate of COVID-19 has reached 5,026 cases per 100,000 children, or 5% of the total pediatric population, although there is considerable variation among the states regarding age ranges used to define child cases. Most states use a range of 0-17 or 0-19 years, but Florida and Utah use a range of 0-14 years and South Carolina and Tennessee go with 0-20, the AAP and CHA noted.

There is also much variation between the states when it comes to cumulative child COVID-19 rates, with the lowest rate reported in Hawaii (1,264 per 100,000) and the highest in North Dakota (9,416 per 100,000). The lowest proportion of child cases to all cases is found in Florida (8.7%) and the highest in Vermont (22.2%), the AAP and CHA said.

The number of COVID-19–related deaths was 303 as of April 29, up by 7 from the previous week in the 43 states, along with New York City, Puerto Rico, and Guam, that are reporting mortality data by age. The proportion of child deaths to child cases remains at 0.01%, and children represent just 0.06% of all COVID-19 deaths, according to the AAP/CHA report.

[email protected]

New cases of COVID-19 in children are trending downward again after dropping for a second consecutive week, according to a report from the American Academy of Pediatrics and the Children’s Hospital Association.

Despite that drop, however, children made up a larger share (22.4%) of all cases reported during the week of April 23-29, compared with the previous week, when the proportion reached what was then a pandemic high of 20.8%, based on data in the weekly AAP/CHA report.

New cases totaled 71,649 for the week of April 23-29, down by 10.3% from the week before and by 19.0% over this most recent 2-week decline, but still a ways to go before reaching the low point of the year (52,695) recorded during the second week of March, the report shows.

Since the beginning of the pandemic, just over 3.78 million children have been infected by SARS-CoV-2, which is 13.8% of all cases reported in 49 states (excluding New York), the District of Columbia, New York City, Puerto Rico, and Guam.

The overall rate of COVID-19 has reached 5,026 cases per 100,000 children, or 5% of the total pediatric population, although there is considerable variation among the states regarding age ranges used to define child cases. Most states use a range of 0-17 or 0-19 years, but Florida and Utah use a range of 0-14 years and South Carolina and Tennessee go with 0-20, the AAP and CHA noted.

There is also much variation between the states when it comes to cumulative child COVID-19 rates, with the lowest rate reported in Hawaii (1,264 per 100,000) and the highest in North Dakota (9,416 per 100,000). The lowest proportion of child cases to all cases is found in Florida (8.7%) and the highest in Vermont (22.2%), the AAP and CHA said.

The number of COVID-19–related deaths was 303 as of April 29, up by 7 from the previous week in the 43 states, along with New York City, Puerto Rico, and Guam, that are reporting mortality data by age. The proportion of child deaths to child cases remains at 0.01%, and children represent just 0.06% of all COVID-19 deaths, according to the AAP/CHA report.

[email protected]

Before COVID-19 pandemic, suicide rates were already increasing among adolescents.¹ Loneliness, because of social isolation and loss of in-person community contacts, was recognized as one factor perhaps contributing to increasing adolescent suicide.² Now, with the physical distancing measures vital to curbing the spread, the loneliness epidemic that preceded COVID-19 has only worsened, and suicidal thoughts in adolescents remain on the rise.³

Given the crucial role of interpersonal interactions and community in healthy adolescent development, these troubling trends provide insight not only into the psychosocial health of our teenagers but also into the psychosocial health of our society as a whole.

Over the past 8 months, our psychiatric crisis stabilization unit has experienced a surge in admissions for adolescents with suicidal ideation, often with accompanying attempts. Even more concerning, a significant percentage of these patients do not have additional symptoms of depression or premorbid risk factors for suicide. In many cases, there are no warning signs to alert parents of their adolescent’s imminent suicidal behavior.

Prior to COVID-19, most of our patients with suicidal ideations arrived withdrawn, irritable, and isolative. Interactions with these patients evoked poignant feelings of empathy and sadness, and these patients endorsed multiple additional symptoms consistent with criteria for a specified depressive disorder.

More recently, since COVID-19, we have observed patients who, mere hours earlier, were in an ED receiving medical interventions for a suicide attempt, now present on our unit smiling, laughing, and interacting contentedly with their peers. Upon integration into our milieu, they often report complete resolution of their suicidal thoughts. Interactions with these patients do not conjure feelings of sadness or despair. In fact, we often struggle with diagnostic specificity, because many of these patients do not meet criteria for a specified depressive disorder.

As observed in real time on our unit, meaningful interpersonal interactions are especially crucial to our adolescents’ psychosocial and emotional well-being. As their independence grows, their holding environment expands to incorporate the community. Nonparent family members, teachers, mentors, coaches, peers, parents, and most importantly, same-aged peers play a vital role in creating the environment necessary for healthy adolescent development.

The larger community is essential for adolescents to develop the skills and confidence to move into adulthood. When adolescents are lonely, with less contact with the community outside of their family, they lose the milieu in which they develop. Their fundamental psychological need of belonging becomes compromised; they fail to experience fidelity or a sense of self; and sometimes they no longer have the desire to live.

So what might the increasing suicide rate in adolescents indicate about the status of the psychosocial health of our society as a whole? Based on the vital necessity of community to support their development, adolescents are the demographic that is perhaps most susceptible to loneliness, isolation, and loss of community. Like the canary in the coal mines, this increase in suicidal ideations in our adolescent population may be a warning that our current lack of psychosocial supports have become toxic. If we cannot restore our relatedness and reconstruct our sense of community, societal psychosocial health may continue to decline.
 

References

1. National Center for Health Statistics Data Brief. 2019 Oct (352). https://www.cdc.gov/nchs/data/databriefs/db352-h.pdf

2. J Soc Pers Relationships. 2019 Mar 19. doi: 10.1177/0265407519836170.

3. Medscape.com. 2020 Sep 25. https://www.medscape.com/viewarticle/938065.
 

Dr. Loper is the team leader for inpatient psychiatric services at Prisma Health–Midlands in Columbia, S.C. He is an assistant professor in the department of neuropsychiatry and behavioral science at the University of South Carolina, Columbia. He has no conflicts of interest. Dr. Kaminstein is an adjunct assistant professor at the graduate school of education and affiliated faculty in the organizational dynamics program, School of Arts and Sciences, at the University of Pennsylvania, Philadelphia. He is a social psychologist who has been studying groups and organizations for more than 40 years. He has no conflicts of interest.


 

Before COVID-19 pandemic, suicide rates were already increasing among adolescents.¹ Loneliness, because of social isolation and loss of in-person community contacts, was recognized as one factor perhaps contributing to increasing adolescent suicide.² Now, with the physical distancing measures vital to curbing the spread, the loneliness epidemic that preceded COVID-19 has only worsened, and suicidal thoughts in adolescents remain on the rise.³

Given the crucial role of interpersonal interactions and community in healthy adolescent development, these troubling trends provide insight not only into the psychosocial health of our teenagers but also into the psychosocial health of our society as a whole.

Over the past 8 months, our psychiatric crisis stabilization unit has experienced a surge in admissions for adolescents with suicidal ideation, often with accompanying attempts. Even more concerning, a significant percentage of these patients do not have additional symptoms of depression or premorbid risk factors for suicide. In many cases, there are no warning signs to alert parents of their adolescent’s imminent suicidal behavior.

Prior to COVID-19, most of our patients with suicidal ideations arrived withdrawn, irritable, and isolative. Interactions with these patients evoked poignant feelings of empathy and sadness, and these patients endorsed multiple additional symptoms consistent with criteria for a specified depressive disorder.

More recently, since COVID-19, we have observed patients who, mere hours earlier, were in an ED receiving medical interventions for a suicide attempt, now present on our unit smiling, laughing, and interacting contentedly with their peers. Upon integration into our milieu, they often report complete resolution of their suicidal thoughts. Interactions with these patients do not conjure feelings of sadness or despair. In fact, we often struggle with diagnostic specificity, because many of these patients do not meet criteria for a specified depressive disorder.

As observed in real time on our unit, meaningful interpersonal interactions are especially crucial to our adolescents’ psychosocial and emotional well-being. As their independence grows, their holding environment expands to incorporate the community. Nonparent family members, teachers, mentors, coaches, peers, parents, and most importantly, same-aged peers play a vital role in creating the environment necessary for healthy adolescent development.

The larger community is essential for adolescents to develop the skills and confidence to move into adulthood. When adolescents are lonely, with less contact with the community outside of their family, they lose the milieu in which they develop. Their fundamental psychological need of belonging becomes compromised; they fail to experience fidelity or a sense of self; and sometimes they no longer have the desire to live.

So what might the increasing suicide rate in adolescents indicate about the status of the psychosocial health of our society as a whole? Based on the vital necessity of community to support their development, adolescents are the demographic that is perhaps most susceptible to loneliness, isolation, and loss of community. Like the canary in the coal mines, this increase in suicidal ideations in our adolescent population may be a warning that our current lack of psychosocial supports have become toxic. If we cannot restore our relatedness and reconstruct our sense of community, societal psychosocial health may continue to decline.
 

References

1. National Center for Health Statistics Data Brief. 2019 Oct (352). https://www.cdc.gov/nchs/data/databriefs/db352-h.pdf

2. J Soc Pers Relationships. 2019 Mar 19. doi: 10.1177/0265407519836170.

3. Medscape.com. 2020 Sep 25. https://www.medscape.com/viewarticle/938065.
 

Dr. Loper is the team leader for inpatient psychiatric services at Prisma Health–Midlands in Columbia, S.C. He is an assistant professor in the department of neuropsychiatry and behavioral science at the University of South Carolina, Columbia. He has no conflicts of interest. Dr. Kaminstein is an adjunct assistant professor at the graduate school of education and affiliated faculty in the organizational dynamics program, School of Arts and Sciences, at the University of Pennsylvania, Philadelphia. He is a social psychologist who has been studying groups and organizations for more than 40 years. He has no conflicts of interest.


 

Before COVID-19 pandemic, suicide rates were already increasing among adolescents.¹ Loneliness, because of social isolation and loss of in-person community contacts, was recognized as one factor perhaps contributing to increasing adolescent suicide.² Now, with the physical distancing measures vital to curbing the spread, the loneliness epidemic that preceded COVID-19 has only worsened, and suicidal thoughts in adolescents remain on the rise.³

Given the crucial role of interpersonal interactions and community in healthy adolescent development, these troubling trends provide insight not only into the psychosocial health of our teenagers but also into the psychosocial health of our society as a whole.

Over the past 8 months, our psychiatric crisis stabilization unit has experienced a surge in admissions for adolescents with suicidal ideation, often with accompanying attempts. Even more concerning, a significant percentage of these patients do not have additional symptoms of depression or premorbid risk factors for suicide. In many cases, there are no warning signs to alert parents of their adolescent’s imminent suicidal behavior.

Prior to COVID-19, most of our patients with suicidal ideations arrived withdrawn, irritable, and isolative. Interactions with these patients evoked poignant feelings of empathy and sadness, and these patients endorsed multiple additional symptoms consistent with criteria for a specified depressive disorder.

More recently, since COVID-19, we have observed patients who, mere hours earlier, were in an ED receiving medical interventions for a suicide attempt, now present on our unit smiling, laughing, and interacting contentedly with their peers. Upon integration into our milieu, they often report complete resolution of their suicidal thoughts. Interactions with these patients do not conjure feelings of sadness or despair. In fact, we often struggle with diagnostic specificity, because many of these patients do not meet criteria for a specified depressive disorder.

As observed in real time on our unit, meaningful interpersonal interactions are especially crucial to our adolescents’ psychosocial and emotional well-being. As their independence grows, their holding environment expands to incorporate the community. Nonparent family members, teachers, mentors, coaches, peers, parents, and most importantly, same-aged peers play a vital role in creating the environment necessary for healthy adolescent development.

The larger community is essential for adolescents to develop the skills and confidence to move into adulthood. When adolescents are lonely, with less contact with the community outside of their family, they lose the milieu in which they develop. Their fundamental psychological need of belonging becomes compromised; they fail to experience fidelity or a sense of self; and sometimes they no longer have the desire to live.

So what might the increasing suicide rate in adolescents indicate about the status of the psychosocial health of our society as a whole? Based on the vital necessity of community to support their development, adolescents are the demographic that is perhaps most susceptible to loneliness, isolation, and loss of community. Like the canary in the coal mines, this increase in suicidal ideations in our adolescent population may be a warning that our current lack of psychosocial supports have become toxic. If we cannot restore our relatedness and reconstruct our sense of community, societal psychosocial health may continue to decline.
 

References

1. National Center for Health Statistics Data Brief. 2019 Oct (352). https://www.cdc.gov/nchs/data/databriefs/db352-h.pdf

2. J Soc Pers Relationships. 2019 Mar 19. doi: 10.1177/0265407519836170.

3. Medscape.com. 2020 Sep 25. https://www.medscape.com/viewarticle/938065.
 

Dr. Loper is the team leader for inpatient psychiatric services at Prisma Health–Midlands in Columbia, S.C. He is an assistant professor in the department of neuropsychiatry and behavioral science at the University of South Carolina, Columbia. He has no conflicts of interest. Dr. Kaminstein is an adjunct assistant professor at the graduate school of education and affiliated faculty in the organizational dynamics program, School of Arts and Sciences, at the University of Pennsylvania, Philadelphia. He is a social psychologist who has been studying groups and organizations for more than 40 years. He has no conflicts of interest.


 

The Food and Drug Administration could expand the use of the Pfizer COVID-19 vaccine to teens early next week, The New York Times and CNN reported, both citing unnamed officials familiar with the agency’s plans.

In late March, Pfizer submitted data to the FDA showing its mRNA vaccine was 100% effective at preventing COVID-19 infection in children ages 12 to 15. Their vaccine  is already authorized for use teens and adults ages 16 and older.

The move would make about 17 million more Americans eligible for vaccination and would be a major step toward getting both adolescents and teens back into classrooms full time by next fall.

“Across the globe, we are longing for a normal life. This is especially true for our children. The initial results we have seen in the adolescent studies suggest that children are particularly well protected by vaccination, which is very encouraging given the trends we have seen in recent weeks regarding the spread of the B.1.1.7 U.K. variant,” Ugur Sahin, CEO and co-founder of Pfizer partner BioNTech, said in a March 31 press release.

Getting schools fully reopened for in-person learning has been a goal of both the Trump and Biden administrations, but it has been tricky to pull off, as some parents and teachers have been reluctant to return to classrooms with so much uncertainty about the risk and the role of children in spreading the virus.

A recent study of roughly 150,000 school-aged children in Israel found that while kids under age 10 were unlikely to catch or spread the virus as they reentered classrooms. Older children, though, were a different story. The study found that children ages 10-19 had risks of catching the virus that were as high as adults ages 20-60.

The risk for severe illness and death from COVID-19 rises with age.

Children and teens are at relatively low risk from severe outcomes after a COVID-19 infection compared to adults, but they can catch it and some will get really sick with it, especially if they have an underlying health condition, like obesity or asthma that makes them more vulnerable.

Beyond the initial infection, children can get a rare late complication called MIS-C, that while treatable, can be severe and requires hospitalization. Emerging reports also suggest there are some kids that become long haulers in much the same way adults do, dealing with lingering problems for months after they first get sick.

As new variants of the coronavirus circulate in the United States, some states have seen big increases in the number of children and teens with COVID. In Michigan, for example, which recently dealt with a spring surge of cases dominated by the B.1.1.7 variant, cases in children and teens quadrupled in April compared to February.

Beyond individual protection, vaccinating children and teens has been seen as important to achieving strong community protection, or herd immunity, against the new coronavirus.

If the FDA expands the authorization for the Pfizer vaccine, the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices will likely meet to review data on the safety and efficacy of the vaccine. The committee may then vote on new recommendations for use of the vaccine in the United States.

Not everyone agrees with the idea that American adolescents, who are at relatively low risk of bad outcomes, could get access to COVID vaccines ahead of vulnerable essential workers and seniors in other parts of the world that are still fighting the pandemic with little access to vaccines.

A version of this article first appeared on WebMD.com.

The Food and Drug Administration could expand the use of the Pfizer COVID-19 vaccine to teens early next week, The New York Times and CNN reported, both citing unnamed officials familiar with the agency’s plans.

In late March, Pfizer submitted data to the FDA showing its mRNA vaccine was 100% effective at preventing COVID-19 infection in children ages 12 to 15. Their vaccine  is already authorized for use teens and adults ages 16 and older.

The move would make about 17 million more Americans eligible for vaccination and would be a major step toward getting both adolescents and teens back into classrooms full time by next fall.

“Across the globe, we are longing for a normal life. This is especially true for our children. The initial results we have seen in the adolescent studies suggest that children are particularly well protected by vaccination, which is very encouraging given the trends we have seen in recent weeks regarding the spread of the B.1.1.7 U.K. variant,” Ugur Sahin, CEO and co-founder of Pfizer partner BioNTech, said in a March 31 press release.

Getting schools fully reopened for in-person learning has been a goal of both the Trump and Biden administrations, but it has been tricky to pull off, as some parents and teachers have been reluctant to return to classrooms with so much uncertainty about the risk and the role of children in spreading the virus.

A recent study of roughly 150,000 school-aged children in Israel found that while kids under age 10 were unlikely to catch or spread the virus as they reentered classrooms. Older children, though, were a different story. The study found that children ages 10-19 had risks of catching the virus that were as high as adults ages 20-60.

The risk for severe illness and death from COVID-19 rises with age.

Children and teens are at relatively low risk from severe outcomes after a COVID-19 infection compared to adults, but they can catch it and some will get really sick with it, especially if they have an underlying health condition, like obesity or asthma that makes them more vulnerable.

Beyond the initial infection, children can get a rare late complication called MIS-C, that while treatable, can be severe and requires hospitalization. Emerging reports also suggest there are some kids that become long haulers in much the same way adults do, dealing with lingering problems for months after they first get sick.

As new variants of the coronavirus circulate in the United States, some states have seen big increases in the number of children and teens with COVID. In Michigan, for example, which recently dealt with a spring surge of cases dominated by the B.1.1.7 variant, cases in children and teens quadrupled in April compared to February.

Beyond individual protection, vaccinating children and teens has been seen as important to achieving strong community protection, or herd immunity, against the new coronavirus.

If the FDA expands the authorization for the Pfizer vaccine, the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices will likely meet to review data on the safety and efficacy of the vaccine. The committee may then vote on new recommendations for use of the vaccine in the United States.

Not everyone agrees with the idea that American adolescents, who are at relatively low risk of bad outcomes, could get access to COVID vaccines ahead of vulnerable essential workers and seniors in other parts of the world that are still fighting the pandemic with little access to vaccines.

A version of this article first appeared on WebMD.com.

The Food and Drug Administration could expand the use of the Pfizer COVID-19 vaccine to teens early next week, The New York Times and CNN reported, both citing unnamed officials familiar with the agency’s plans.

In late March, Pfizer submitted data to the FDA showing its mRNA vaccine was 100% effective at preventing COVID-19 infection in children ages 12 to 15. Their vaccine  is already authorized for use teens and adults ages 16 and older.

The move would make about 17 million more Americans eligible for vaccination and would be a major step toward getting both adolescents and teens back into classrooms full time by next fall.

“Across the globe, we are longing for a normal life. This is especially true for our children. The initial results we have seen in the adolescent studies suggest that children are particularly well protected by vaccination, which is very encouraging given the trends we have seen in recent weeks regarding the spread of the B.1.1.7 U.K. variant,” Ugur Sahin, CEO and co-founder of Pfizer partner BioNTech, said in a March 31 press release.

Getting schools fully reopened for in-person learning has been a goal of both the Trump and Biden administrations, but it has been tricky to pull off, as some parents and teachers have been reluctant to return to classrooms with so much uncertainty about the risk and the role of children in spreading the virus.

A recent study of roughly 150,000 school-aged children in Israel found that while kids under age 10 were unlikely to catch or spread the virus as they reentered classrooms. Older children, though, were a different story. The study found that children ages 10-19 had risks of catching the virus that were as high as adults ages 20-60.

The risk for severe illness and death from COVID-19 rises with age.

Children and teens are at relatively low risk from severe outcomes after a COVID-19 infection compared to adults, but they can catch it and some will get really sick with it, especially if they have an underlying health condition, like obesity or asthma that makes them more vulnerable.

Beyond the initial infection, children can get a rare late complication called MIS-C, that while treatable, can be severe and requires hospitalization. Emerging reports also suggest there are some kids that become long haulers in much the same way adults do, dealing with lingering problems for months after they first get sick.

As new variants of the coronavirus circulate in the United States, some states have seen big increases in the number of children and teens with COVID. In Michigan, for example, which recently dealt with a spring surge of cases dominated by the B.1.1.7 variant, cases in children and teens quadrupled in April compared to February.

Beyond individual protection, vaccinating children and teens has been seen as important to achieving strong community protection, or herd immunity, against the new coronavirus.

If the FDA expands the authorization for the Pfizer vaccine, the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices will likely meet to review data on the safety and efficacy of the vaccine. The committee may then vote on new recommendations for use of the vaccine in the United States.

Not everyone agrees with the idea that American adolescents, who are at relatively low risk of bad outcomes, could get access to COVID vaccines ahead of vulnerable essential workers and seniors in other parts of the world that are still fighting the pandemic with little access to vaccines.

A version of this article first appeared on WebMD.com.

Concern and anxiety around COVID-19 remains high among Americans, with more people reporting mental health effects from the pandemic this year than last, and parents concerned about the mental health of their children, results of a new poll by the American Psychiatric Association show. Although the overall level of anxiety has decreased from last year’s APA poll, “the degree to which anxiety still reigns is concerning,” APA President Jeffrey Geller, MD, MPH, told this news organization.

The results of the latest poll were presented at the American Psychiatric Association 2021 annual meeting and based on an online survey conducted March 26 to April 5 among a sample of 1,000 adults aged 18 years or older.

Serious mental health hit

In the new poll, about 4 in 10 Americans (41%) report they are more anxious than last year, down from just over 60%.

Young adults aged 18-29 years (49%) and Hispanic/Latinos (50%) are more likely to report being more anxious now than a year ago. Those 65 or older (30%) are less apt to say they feel more anxious than last year.

The latest poll also shows that Americans are more anxious about family and loved ones getting COVID-19 (64%) than about catching the virus themselves (49%). 

Concern about family and loved ones contracting COVID-19 has increased since last year’s poll (conducted September 2020), rising from 56% then to 64% now. Hispanic/Latinx individuals (73%) and African American/Black individuals (76%) are more anxious about COVID-19 than White people (59%).

In the new poll, 43% of adults report the pandemic has had a serious impact on their mental health, up from 37% in 2020. Younger adults are more apt than older adults to report serious mental health effects.

Slightly fewer Americans report the pandemic is affecting their day-to-day life now as compared to a year ago, in ways such as problems sleeping (19% down from 22%), difficulty concentrating (18% down from 20%), and fighting more with loved ones (16% down from 17%).

The percentage of adults consuming more alcohol or other substances/drugs than normal increased slightly since last year (14%-17%). Additionally, 33% of adults (40% of women) report gaining weight during the pandemic.

Call to action

More than half of adults (53%) with children report they are concerned about the mental state of their children and almost half (48%) report the pandemic has caused mental health problems for one or more of their children, including minor problems for 29% and major problems for 19%.

More than a quarter (26%) of parents have sought professional mental health help for their children because of the pandemic.

Nearly half (49%) of parents of children younger than 18 years say their child received help from a mental health professional since the start of the pandemic; 23% received help from a primary care professional, 18% from a psychiatrist, 15% from a psychologist, 13% from a therapist, 10% from a social worker, and 10% from a school counselor or school psychologist.

More than 1 in 5 parents reported difficulty scheduling appointments for their child with a mental health professional.

“This poll shows that, even as vaccines become more widespread, Americans are still worried about the mental state of their children,” Dr. Geller said in a news release.

“This is a call to action for policymakers, who need to remember that, in our COVID-19 recovery, there’s no health without mental health,” he added.

Just over three-quarters (76%) of those surveyed say they have been or intend to get vaccinated; 22% say they don’t intend to get vaccinated; and 2% didn’t know.

For those who do not intend to get vaccinated, the primary concern (53%) is about side effects of the vaccine. Other reasons for not getting vaccinated include believing the vaccine is not effective (31%), believing the makers of the vaccine aren’t being honest about what’s in it (27%), and fear/anxiety about needles (12%).

Resiliency a finite resource

Reached for comment, Samoon Ahmad, MD, professor in the department of psychiatry, New York University, said it’s not surprising that Americans are still suffering more anxiety than normal.

“The Census Bureau’s Household Pulse Survey has shown that anxiety and depression levels have remained higher than normal since the pandemic began. That 43% of adults now say that the pandemic has had a serious impact on their mental health seems in line with what that survey has been reporting for over a year,” Dr. Ahmad, who serves as unit chief of inpatient psychiatry at Bellevue Hospital Center in New York, said in an interview.

He believes there are several reasons why anxiety levels remain high. One reason is something he’s noticed among his patients for years. “Most people struggle with anxiety especially at night when the noise and distractions of contemporary life fade away. This is the time of introspection,” he explained.

“Quarantine has been kind of like a protracted night because the distractions that are common in the so-called ‘rat race’ have been relatively muted for the past 14 months. I believe this has caused what you might call ‘forced introspection,’ and that this is giving rise to feelings of anxiety as people use their time alone to reassess their careers and their social lives and really begin to fret about some of the decisions that have led them to this point in their lives,” said Dr. Ahmad.

The other finding in the APA survey – that people are more concerned about their loved ones catching the virus than they were a year ago – is also not surprising, Dr. Ahmad said.

“Even though we seem to have turned a corner in the United States and the worst of the pandemic is behind us, the surge that went from roughly November through March of this year was more wide-reaching geographically than previous waves, and I think this made the severity of the virus far more real to people who lived in communities that had been spared severe outbreaks during the surges that we saw in the spring and summer of 2020,” Dr. Ahmad told this news organization.

“There’s also heightened concern over variants and the efficacy of the vaccine in treating these variants. Those who have families in other countries where the virus is surging, such as India or parts of Latin America, are likely experiencing additional stress and anxiety too,” he noted.

While the new APA poll findings are not surprising, they still are “deeply concerning,” Dr. Ahmad said.

“Resiliency is a finite resource, and people can only take so much stress before their mental health begins to suffer. For most people, this is not going to lead to some kind of overdramatic nervous breakdown. Instead, one may notice that they are more irritable than they once were, that they’re not sleeping particularly well, or that they have a nagging sense of discomfort and stress when doing activities that they used to think of as normal,” like taking a trip to the grocery store, meeting up with friends, or going to work, Dr. Ahmad said.

“Overcoming this kind of anxiety and reacclimating ourselves to social situations is going to take more time for some people than others, and that is perfectly natural,” said Dr. Ahmad, founder of the Integrative Center for Wellness in New York.

“I don’t think it’s wise to try to put a limit on what constitutes a normal amount of time to readjust, and I think everyone in the field of mental health needs to avoid pathologizing any lingering sense of unease. No one needs to be medicated or diagnosed with a mental illness because they are nervous about going into public spaces in the immediate aftermath of a pandemic. We need to show a lot of patience and encourage people to readjust at their own pace for the foreseeable future,” Dr. Ahmad said.

Dr. Geller and Dr. Ahmad have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Concern and anxiety around COVID-19 remains high among Americans, with more people reporting mental health effects from the pandemic this year than last, and parents concerned about the mental health of their children, results of a new poll by the American Psychiatric Association show. Although the overall level of anxiety has decreased from last year’s APA poll, “the degree to which anxiety still reigns is concerning,” APA President Jeffrey Geller, MD, MPH, told this news organization.

The results of the latest poll were presented at the American Psychiatric Association 2021 annual meeting and based on an online survey conducted March 26 to April 5 among a sample of 1,000 adults aged 18 years or older.

Serious mental health hit

In the new poll, about 4 in 10 Americans (41%) report they are more anxious than last year, down from just over 60%.

Young adults aged 18-29 years (49%) and Hispanic/Latinos (50%) are more likely to report being more anxious now than a year ago. Those 65 or older (30%) are less apt to say they feel more anxious than last year.

The latest poll also shows that Americans are more anxious about family and loved ones getting COVID-19 (64%) than about catching the virus themselves (49%). 

Concern about family and loved ones contracting COVID-19 has increased since last year’s poll (conducted September 2020), rising from 56% then to 64% now. Hispanic/Latinx individuals (73%) and African American/Black individuals (76%) are more anxious about COVID-19 than White people (59%).

In the new poll, 43% of adults report the pandemic has had a serious impact on their mental health, up from 37% in 2020. Younger adults are more apt than older adults to report serious mental health effects.

Slightly fewer Americans report the pandemic is affecting their day-to-day life now as compared to a year ago, in ways such as problems sleeping (19% down from 22%), difficulty concentrating (18% down from 20%), and fighting more with loved ones (16% down from 17%).

The percentage of adults consuming more alcohol or other substances/drugs than normal increased slightly since last year (14%-17%). Additionally, 33% of adults (40% of women) report gaining weight during the pandemic.

Call to action

More than half of adults (53%) with children report they are concerned about the mental state of their children and almost half (48%) report the pandemic has caused mental health problems for one or more of their children, including minor problems for 29% and major problems for 19%.

More than a quarter (26%) of parents have sought professional mental health help for their children because of the pandemic.

Nearly half (49%) of parents of children younger than 18 years say their child received help from a mental health professional since the start of the pandemic; 23% received help from a primary care professional, 18% from a psychiatrist, 15% from a psychologist, 13% from a therapist, 10% from a social worker, and 10% from a school counselor or school psychologist.

More than 1 in 5 parents reported difficulty scheduling appointments for their child with a mental health professional.

“This poll shows that, even as vaccines become more widespread, Americans are still worried about the mental state of their children,” Dr. Geller said in a news release.

“This is a call to action for policymakers, who need to remember that, in our COVID-19 recovery, there’s no health without mental health,” he added.

Just over three-quarters (76%) of those surveyed say they have been or intend to get vaccinated; 22% say they don’t intend to get vaccinated; and 2% didn’t know.

For those who do not intend to get vaccinated, the primary concern (53%) is about side effects of the vaccine. Other reasons for not getting vaccinated include believing the vaccine is not effective (31%), believing the makers of the vaccine aren’t being honest about what’s in it (27%), and fear/anxiety about needles (12%).

Resiliency a finite resource

Reached for comment, Samoon Ahmad, MD, professor in the department of psychiatry, New York University, said it’s not surprising that Americans are still suffering more anxiety than normal.

“The Census Bureau’s Household Pulse Survey has shown that anxiety and depression levels have remained higher than normal since the pandemic began. That 43% of adults now say that the pandemic has had a serious impact on their mental health seems in line with what that survey has been reporting for over a year,” Dr. Ahmad, who serves as unit chief of inpatient psychiatry at Bellevue Hospital Center in New York, said in an interview.

He believes there are several reasons why anxiety levels remain high. One reason is something he’s noticed among his patients for years. “Most people struggle with anxiety especially at night when the noise and distractions of contemporary life fade away. This is the time of introspection,” he explained.

“Quarantine has been kind of like a protracted night because the distractions that are common in the so-called ‘rat race’ have been relatively muted for the past 14 months. I believe this has caused what you might call ‘forced introspection,’ and that this is giving rise to feelings of anxiety as people use their time alone to reassess their careers and their social lives and really begin to fret about some of the decisions that have led them to this point in their lives,” said Dr. Ahmad.

The other finding in the APA survey – that people are more concerned about their loved ones catching the virus than they were a year ago – is also not surprising, Dr. Ahmad said.

“Even though we seem to have turned a corner in the United States and the worst of the pandemic is behind us, the surge that went from roughly November through March of this year was more wide-reaching geographically than previous waves, and I think this made the severity of the virus far more real to people who lived in communities that had been spared severe outbreaks during the surges that we saw in the spring and summer of 2020,” Dr. Ahmad told this news organization.

“There’s also heightened concern over variants and the efficacy of the vaccine in treating these variants. Those who have families in other countries where the virus is surging, such as India or parts of Latin America, are likely experiencing additional stress and anxiety too,” he noted.

While the new APA poll findings are not surprising, they still are “deeply concerning,” Dr. Ahmad said.

“Resiliency is a finite resource, and people can only take so much stress before their mental health begins to suffer. For most people, this is not going to lead to some kind of overdramatic nervous breakdown. Instead, one may notice that they are more irritable than they once were, that they’re not sleeping particularly well, or that they have a nagging sense of discomfort and stress when doing activities that they used to think of as normal,” like taking a trip to the grocery store, meeting up with friends, or going to work, Dr. Ahmad said.

“Overcoming this kind of anxiety and reacclimating ourselves to social situations is going to take more time for some people than others, and that is perfectly natural,” said Dr. Ahmad, founder of the Integrative Center for Wellness in New York.

“I don’t think it’s wise to try to put a limit on what constitutes a normal amount of time to readjust, and I think everyone in the field of mental health needs to avoid pathologizing any lingering sense of unease. No one needs to be medicated or diagnosed with a mental illness because they are nervous about going into public spaces in the immediate aftermath of a pandemic. We need to show a lot of patience and encourage people to readjust at their own pace for the foreseeable future,” Dr. Ahmad said.

Dr. Geller and Dr. Ahmad have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Concern and anxiety around COVID-19 remains high among Americans, with more people reporting mental health effects from the pandemic this year than last, and parents concerned about the mental health of their children, results of a new poll by the American Psychiatric Association show. Although the overall level of anxiety has decreased from last year’s APA poll, “the degree to which anxiety still reigns is concerning,” APA President Jeffrey Geller, MD, MPH, told this news organization.

The results of the latest poll were presented at the American Psychiatric Association 2021 annual meeting and based on an online survey conducted March 26 to April 5 among a sample of 1,000 adults aged 18 years or older.

Serious mental health hit

In the new poll, about 4 in 10 Americans (41%) report they are more anxious than last year, down from just over 60%.

Young adults aged 18-29 years (49%) and Hispanic/Latinos (50%) are more likely to report being more anxious now than a year ago. Those 65 or older (30%) are less apt to say they feel more anxious than last year.

The latest poll also shows that Americans are more anxious about family and loved ones getting COVID-19 (64%) than about catching the virus themselves (49%). 

Concern about family and loved ones contracting COVID-19 has increased since last year’s poll (conducted September 2020), rising from 56% then to 64% now. Hispanic/Latinx individuals (73%) and African American/Black individuals (76%) are more anxious about COVID-19 than White people (59%).

In the new poll, 43% of adults report the pandemic has had a serious impact on their mental health, up from 37% in 2020. Younger adults are more apt than older adults to report serious mental health effects.

Slightly fewer Americans report the pandemic is affecting their day-to-day life now as compared to a year ago, in ways such as problems sleeping (19% down from 22%), difficulty concentrating (18% down from 20%), and fighting more with loved ones (16% down from 17%).

The percentage of adults consuming more alcohol or other substances/drugs than normal increased slightly since last year (14%-17%). Additionally, 33% of adults (40% of women) report gaining weight during the pandemic.

Call to action

More than half of adults (53%) with children report they are concerned about the mental state of their children and almost half (48%) report the pandemic has caused mental health problems for one or more of their children, including minor problems for 29% and major problems for 19%.

More than a quarter (26%) of parents have sought professional mental health help for their children because of the pandemic.

Nearly half (49%) of parents of children younger than 18 years say their child received help from a mental health professional since the start of the pandemic; 23% received help from a primary care professional, 18% from a psychiatrist, 15% from a psychologist, 13% from a therapist, 10% from a social worker, and 10% from a school counselor or school psychologist.

More than 1 in 5 parents reported difficulty scheduling appointments for their child with a mental health professional.

“This poll shows that, even as vaccines become more widespread, Americans are still worried about the mental state of their children,” Dr. Geller said in a news release.

“This is a call to action for policymakers, who need to remember that, in our COVID-19 recovery, there’s no health without mental health,” he added.

Just over three-quarters (76%) of those surveyed say they have been or intend to get vaccinated; 22% say they don’t intend to get vaccinated; and 2% didn’t know.

For those who do not intend to get vaccinated, the primary concern (53%) is about side effects of the vaccine. Other reasons for not getting vaccinated include believing the vaccine is not effective (31%), believing the makers of the vaccine aren’t being honest about what’s in it (27%), and fear/anxiety about needles (12%).

Resiliency a finite resource

Reached for comment, Samoon Ahmad, MD, professor in the department of psychiatry, New York University, said it’s not surprising that Americans are still suffering more anxiety than normal.

“The Census Bureau’s Household Pulse Survey has shown that anxiety and depression levels have remained higher than normal since the pandemic began. That 43% of adults now say that the pandemic has had a serious impact on their mental health seems in line with what that survey has been reporting for over a year,” Dr. Ahmad, who serves as unit chief of inpatient psychiatry at Bellevue Hospital Center in New York, said in an interview.

He believes there are several reasons why anxiety levels remain high. One reason is something he’s noticed among his patients for years. “Most people struggle with anxiety especially at night when the noise and distractions of contemporary life fade away. This is the time of introspection,” he explained.

“Quarantine has been kind of like a protracted night because the distractions that are common in the so-called ‘rat race’ have been relatively muted for the past 14 months. I believe this has caused what you might call ‘forced introspection,’ and that this is giving rise to feelings of anxiety as people use their time alone to reassess their careers and their social lives and really begin to fret about some of the decisions that have led them to this point in their lives,” said Dr. Ahmad.

The other finding in the APA survey – that people are more concerned about their loved ones catching the virus than they were a year ago – is also not surprising, Dr. Ahmad said.

“Even though we seem to have turned a corner in the United States and the worst of the pandemic is behind us, the surge that went from roughly November through March of this year was more wide-reaching geographically than previous waves, and I think this made the severity of the virus far more real to people who lived in communities that had been spared severe outbreaks during the surges that we saw in the spring and summer of 2020,” Dr. Ahmad told this news organization.

“There’s also heightened concern over variants and the efficacy of the vaccine in treating these variants. Those who have families in other countries where the virus is surging, such as India or parts of Latin America, are likely experiencing additional stress and anxiety too,” he noted.

While the new APA poll findings are not surprising, they still are “deeply concerning,” Dr. Ahmad said.

“Resiliency is a finite resource, and people can only take so much stress before their mental health begins to suffer. For most people, this is not going to lead to some kind of overdramatic nervous breakdown. Instead, one may notice that they are more irritable than they once were, that they’re not sleeping particularly well, or that they have a nagging sense of discomfort and stress when doing activities that they used to think of as normal,” like taking a trip to the grocery store, meeting up with friends, or going to work, Dr. Ahmad said.

“Overcoming this kind of anxiety and reacclimating ourselves to social situations is going to take more time for some people than others, and that is perfectly natural,” said Dr. Ahmad, founder of the Integrative Center for Wellness in New York.

“I don’t think it’s wise to try to put a limit on what constitutes a normal amount of time to readjust, and I think everyone in the field of mental health needs to avoid pathologizing any lingering sense of unease. No one needs to be medicated or diagnosed with a mental illness because they are nervous about going into public spaces in the immediate aftermath of a pandemic. We need to show a lot of patience and encourage people to readjust at their own pace for the foreseeable future,” Dr. Ahmad said.

Dr. Geller and Dr. Ahmad have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Moral distress can result when health professionals like doctors and nurses feel prevented from doing what they know is right and ethically correct – reflecting the values of their profession and their own sense of professional integrity – because of unmanageable caseload demands, lack of resources, coverage limitations, or institutional policies.

Hospitalists are not exempt from moral distress, which is associated with soul-searching, burnout, and even PTSD. It is also associated with a higher likelihood for professionals to report an intention to leave their jobs. But the COVID-19 pandemic has superimposed a whole new layer of challenges, constraints, and frustrations, creating a potent mix of trauma and exhaustion, cumulative unease, depleted job satisfaction, and difficult ethical choices.

These challenges include seeing so many patients die and working with short supplies of personal protective equipment (PPE) – with resulting fears that they could catch the virus or pass it on to others, including loved ones. Also, not having enough ventilators or even beds for patients in hospitals hit hard by COVID surges raises fears that decisions for rationing medical care might become necessary.

In a commentary published in the Journal of General Internal Medicine in October 2019 – shortly before the COVID pandemic burst onto the scene – hospitalist and medical sociologist Elizabeth Dzeng, MD, PhD, MPH, and hospital medicine pioneer Robert Wachter, MD, MHM, both from the University of California, San Francisco, described “moral distress and professional ethical dissonance as root causes of burnout.”¹ They characterized moral distress by its emotional exhaustion, depersonalization, reduced sense of accomplishment, and moral apathy, and they called for renewed attention to social and ethical dimensions of practice and threats to physician professionalism.

Prevailing explanations for documented high rates of burnout in doctors have tended to focus on work hours and struggles with electronic medical records and the like, Dr. Dzeng and Dr. Wachter wrote. “We see evidence of an insidious moral distress resulting from physicians’ inability to act in accord with their individual and professional ethical values due to institutional and social constraints.”

COVID has intensified these issues surrounding moral distress. “In a short period of time it created more situations that raise issues of moral distress than I have seen since the early days of HIV,” Dr. Wachter said. “Those of us who work in hospitals often find ourselves in complex circumstances with limited resources. What was so striking about COVID was finding ourselves caring for large volumes of patients who had a condition that was new to us.”

And the fact that constraints imposed by COVID, such as having to don unwieldy PPE and not allowing families to be present with hospitalized loved ones, are explainable and rational only helps a little with the clinician’s distress.

People talk about the need for doctors to be more resilient, Dr. Dzeng added, but that’s too narrow of an approach to these very real challenges. There are huge issues of workforce retention and costs, major mental health issues, suicide – and implications for patient care, because burned-out doctors can be bad doctors.
 

What is moral distress?

Moral distress is a term from the nursing ethics literature, attributed to philosopher Andrew Jameton in 1984.² Contributors to moral distress imposed by COVID include having to make difficult medical decisions under stressful circumstances – especially early on, when effective treatment options were few. Doctors felt the demands of the pandemic were putting care quality and patient safety at risk. Poor working conditions overall, being pushed to work beyond their normal physical limits for days at a time, and feelings of not being valued added to this stress. But some say the pandemic has only highlighted and amplified existing inequities and disparities in the health care system.

Experts say moral distress is about feeling powerless, especially in a system driven by market values, and feeling let down by a society that has put them in harm’s way. They work all day under physically and emotionally exhausting conditions and then go home to hear specious conspiracy theories about the pandemic and see other people unwilling to wear masks.

Moral distress is complicated, said Lucia Wocial, PhD, RN, a nurse ethicist and cochair of the ethics consultation subcommittee at Indiana University Health in Indianapolis. “If you say you have moral distress, my first response is: tell me more. It helps to peel back the layers of this complexity. Emotion is only part of moral distress. It’s about the professional’s sense of responsibility and obligation – and the inability to honor that.”

Dr. Wocial, whose research specialty is moral distress, is corresponding author of a study published in the Journal of General Internal Medicine in February 2020, which identified moral distress in 4 out of 10 surveyed physicians who cared for older hospitalized adults and found themselves needing to work with their surrogate decision-makers.³ “We know physician moral distress is higher when people haven’t had the chance to hold conversations about their end-of-life care preferences,” she said, such as whether to continue life support.

“We have also learned that communication is key to diminishing physician moral distress. Our responsibility as clinicians is to guide patients and families through these decisions. If the family feels a high level of support from me, then my moral distress is lower,” she added. “If you think about how COVID has evolved, at first people were dying so quickly. Some patients were going to the ICU on ventilators without ever having a goals-of-care conversation.”

COVID has shifted the usual standard of care in U.S. hospitals in the face of patient surges. “How can you feel okay in accepting a level of care that in the prepandemic world would not have been acceptable?” Dr. Wocial posed. “What if you know the standard of care has shifted, of necessity, but you haven’t had time to prepare for it and nobody’s talking about what that means? Who is going to help you accept that good enough under these circumstances is enough – at least for today?”
 

What to call it

Michael J. Asken, PhD, director of provider well-being at UPMC Pinnacle Harrisburg (Pa.), has questioned in print the use of the military and wartime term “moral injury” when applied to a variety of less serious physician stressors.⁴ More recently, however, he observed, “The pandemic has muted or erased many of the distinctions between medical care and military conflict. ... The onslaught and volume of critical patients and resulting deaths is beyond what most providers have ever contemplated as part of care.”⁵

In a recent interview with the Hospitalist, he said: “While I initially resisted using the term moral injury, especially pre-COVID, because it was not equivalent to the moral injury created by war, I have relented a bit.” The volume of deaths and the apparent dangers to providers themselves reflect some of the critical aspects of war, and repetitive, intense, and/or incessant ethical challenges may have longer term negative psychological or emotional effects.

“Feeling emotional pain in situations of multiple deaths is to be expected and, perhaps, should even be welcomed as a sign of retained humanity and a buffer against burnout and cynicism in these times of unabating stress,” Dr. Asken said. “This is only true, however, if the emotional impact is tolerable and not experienced in repetitive extremes.”

Courtesy Avera Health

“These things are real,” said Clarissa Barnes, MD, a physician adviser, hospitalist at Avera McKennan Hospital in Sioux Falls, S.D., and former medical director of Avera’s LIGHT Program, a wellness-oriented service for clinicians. Dr. Barnes herself caught the virus on the job but has since recovered.

“Physicians don’t see their work as an occupation. It’s their core identity: I am a doctor; I practice medicine. If things are being done in ways I don’t think are right, that’s fundamentally a breach,” she said. “As internists, we have an opportunity to forestall death whenever we can and, if not, promote a peaceful death. That’s what made me choose this specialty. I think there’s value in allowing a person to end well. But when that doesn’t happen because of social or administrative reasons, that’s hard.”
 

Where is the leadership?

“A lot of moral injury comes down to the individual health system and its leaders. Some have done well; others you hear saying things that make you question whether these are the people you want leading the organization. Hospitalists need to have a clear value framework and an idea of how to negotiate things when decisions don’t match that framework,” Dr. Barnes said.

“Sometimes administrators have additional information that they’re not sharing,” she added. “They’re caught between a rock and a hard place regarding the decisions they have to make, but they need to be more transparent and not hold things so close to their vest while thinking they are helping clinicians [by doing so]. Physicians need to understand why they are being asked to do things counter to what they believe is appropriate.”

David Oliver, MD, a geriatrics and internal medicine consultant at Royal Berkshire Hospital in Reading, England, also practices as a hospital physician, a role similar to the hospitalist in the United States. “In any system, in any environment, the job of being a doctor, nurse, or other health professional carries a lot of responsibility. That is a timeless, inherent stress of medical practice. With COVID, we’ve seen a lot of emotional burdens – a whole separate set of problems outside of your control, where you are responsible for care but don’t have accountability,” he said.

“People like me, hospital doctors, are used to chronic workforce issues in the National Health Service. But we didn’t sign up to come and get COVID and be hospitalized ourselves.” More than 850 frontline health care providers in the U.K. have so far died from the virus, Dr. Oliver said. “I saw five patients die in 90 minutes one day in April. That’s above and beyond normal human capacity.”

In England specifically, he said, it has exposed underlying structural issues and serious workforce gaps, unfilled vacancies, and a much lower number of ICU beds per 100,000 population than the United States or Europe. And there is consistent pressure to send patients home in order to empty beds for new patients.

But a range of supportive services is offered in U.K. hospitals, such as making senior clinicians available to speak to frontline clinicians, providing mentorship and a sounding board. The Point of Care Foundation has helped to disseminate the practice of Schwartz Rounds, a group reflective practice forum for health care teams developed by the Schwartz Center for Compassionate Healthcare in Boston.

“We don’t need this clap-for-the-NHS heroes stuff,” Dr. Oliver said. “We need an adequate workforce and [better] working conditions. What happened on the front lines of the pandemic was heroic – all done by local clinical teams. But where was the government – the centralized NHS? A lot of frontline clinicians aren’t feeling valued, supported, or listened to.”
 

What can be done?

What are some things that hospitalists can do, individually and collectively, to try to prevent moral distress from turning into full-scale burnout? Dr. Wocial emphasized the importance of unit-based ethics conversations. “At IU Health we have someone who is available to sit down with frontline clinicians and help unpack what they are experiencing,” she said. Clinicians need to be able to process this terrible experience in order to sort out the feelings of sadness from questions of whether they are doing something wrong.

Hospital chaplains are exquisitely skilled at supporting people and debriefing hospital teams, Dr. Wocial added. Palliative care professionals are also skilled at facilitating goals of care conversations with patients and families and can support hospitalists through coaching and joint family meetings.

“It’s about raising your sense of agency in your job – what in your practice you can control. People need to be able to talk frankly about it. Some managers say to clinicians: ‘Just buck up,’ while others are doing a fabulous job of offering support to their staff,” Dr. Wocial said. Hospitalists have to be willing to say when they’ve had too much. “You may not get help when you first ask for it. Be persistent. Asking for help doesn’t make you weak.”

Most doctors have their own strategies for managing stress on the job, Dr. Wachter noted. “What makes it a little easier is not having to do it alone. Many find solace in community, but community has been constrained by this pandemic. You can’t just go out for a beer after work anymore. So what are other ways to let off steam?”

The people leading hospitalist programs need to work harder at creating community and empathy when the tools allowing people to get together are somewhat limited. “Everybody is tired of Zoom,” he said. “One thing I learned as a manager was to just send messages to people acknowledging that I know this is hard. Try to think from the lens of other people and what they would find useful.”

The pandemic has been terribly unpredictable, Dr. Wachter added, but it won’t go on forever. For some doctors, yoga or mindfulness meditation may be very comforting. “For me, that’s not what I do. Golf or a good Seinfeld episode works for me.”

SHM’s Wellbeing Taskforce has created a “Hospital Medicine COVID Check-in Guide for Self & Peers” to promote both sharing and support for one another. It can be found at SHM’s Wellbeing webpage [www.hospitalmedicine.org/practice-management/wellbeing/]. The Taskforce believes that sharing common stressors as hospitalists can be healing, said its chair, Sarah Richards, MD, assistant professor of medicine at the University of Nebraska, Omaha. “This is especially true in situations where we feel we can’t provide the type of care we know our patients deserve.”
 

Respect, advocacy, self-care

Dr. Asken encouraged clinicians to focus on the efforts they are making on the job, not just the outcomes. “If someone has done their absolute best in a given circumstance, satisfaction and solace needs to be taken from that,” he said.

“Ongoing support group meetings, which we have called frontline support groups, should occur on a regular basis. Designated for physicians on the medical floors and in critical care units who are directly involved with COVID patients, these provide a brief respite but also engagement, sharing, and strengthening of mutual support.”

A lot of these issues have a fundamental thread, which comes down to respect, Dr. Barnes said. “Hospitalists need to hear their hospital administrators say: ‘I hear what you’re saying [about a problem]. Let’s think together about how to solve it.’ We need to work on being clear, and we need to speak up for what’s right. If you aren’t comfortable doing things you are being asked to do in the hospital, maybe you’re not working in the right place.”

Some efforts in the area of wellness and self-care really are helpful, Dr. Barnes said. “But you can’t exercise you way through a health system that doesn’t respect you. You need to get out of the mindset that you have no ability to make things different. We are not powerless as doctors. We can do a lot, actually. Physicians need to take ownership. If you are a hospitalist and you’re not part of any local or state or national organization that advocates for physicians, you should be.”
 

References

1. Dzeng L and Wachter RM. Ethics in conflict: Moral distress as a root cause of burnout. J Gen Intern Med. 2020 Feb;35(2):409-11. doi: 10.1007/s11606-019-05505-6.

2. Jameton A, Nursing Practice: The ethical issues. Prentice Hall Series in the Philosophy of Medicine. 1984, Englewood Cliffs, N.J.: Prentice Hall.

3. Wocial LD et al. Factors associated with physician moral distress caring for hospitalized elderly patients needing a surrogate decision-maker: A prospective study. J Gen Intern Med. 2020 May;35(5):1405-12. doi: 10.1007/s11606-020-05652-1.

4. Asken MJ. It’s not moral injury: It’s burnout (or something else). Medical Economics; June 7, 2019.

5. Asken MJ. Now it is moral injury: The COVID-19 pandemic and moral distress. Medical Economics; April 29, 2020.

Moral distress can result when health professionals like doctors and nurses feel prevented from doing what they know is right and ethically correct – reflecting the values of their profession and their own sense of professional integrity – because of unmanageable caseload demands, lack of resources, coverage limitations, or institutional policies.

Hospitalists are not exempt from moral distress, which is associated with soul-searching, burnout, and even PTSD. It is also associated with a higher likelihood for professionals to report an intention to leave their jobs. But the COVID-19 pandemic has superimposed a whole new layer of challenges, constraints, and frustrations, creating a potent mix of trauma and exhaustion, cumulative unease, depleted job satisfaction, and difficult ethical choices.

These challenges include seeing so many patients die and working with short supplies of personal protective equipment (PPE) – with resulting fears that they could catch the virus or pass it on to others, including loved ones. Also, not having enough ventilators or even beds for patients in hospitals hit hard by COVID surges raises fears that decisions for rationing medical care might become necessary.

In a commentary published in the Journal of General Internal Medicine in October 2019 – shortly before the COVID pandemic burst onto the scene – hospitalist and medical sociologist Elizabeth Dzeng, MD, PhD, MPH, and hospital medicine pioneer Robert Wachter, MD, MHM, both from the University of California, San Francisco, described “moral distress and professional ethical dissonance as root causes of burnout.”¹ They characterized moral distress by its emotional exhaustion, depersonalization, reduced sense of accomplishment, and moral apathy, and they called for renewed attention to social and ethical dimensions of practice and threats to physician professionalism.

Prevailing explanations for documented high rates of burnout in doctors have tended to focus on work hours and struggles with electronic medical records and the like, Dr. Dzeng and Dr. Wachter wrote. “We see evidence of an insidious moral distress resulting from physicians’ inability to act in accord with their individual and professional ethical values due to institutional and social constraints.”

COVID has intensified these issues surrounding moral distress. “In a short period of time it created more situations that raise issues of moral distress than I have seen since the early days of HIV,” Dr. Wachter said. “Those of us who work in hospitals often find ourselves in complex circumstances with limited resources. What was so striking about COVID was finding ourselves caring for large volumes of patients who had a condition that was new to us.”

And the fact that constraints imposed by COVID, such as having to don unwieldy PPE and not allowing families to be present with hospitalized loved ones, are explainable and rational only helps a little with the clinician’s distress.

People talk about the need for doctors to be more resilient, Dr. Dzeng added, but that’s too narrow of an approach to these very real challenges. There are huge issues of workforce retention and costs, major mental health issues, suicide – and implications for patient care, because burned-out doctors can be bad doctors.
 

What is moral distress?

Moral distress is a term from the nursing ethics literature, attributed to philosopher Andrew Jameton in 1984.² Contributors to moral distress imposed by COVID include having to make difficult medical decisions under stressful circumstances – especially early on, when effective treatment options were few. Doctors felt the demands of the pandemic were putting care quality and patient safety at risk. Poor working conditions overall, being pushed to work beyond their normal physical limits for days at a time, and feelings of not being valued added to this stress. But some say the pandemic has only highlighted and amplified existing inequities and disparities in the health care system.

Experts say moral distress is about feeling powerless, especially in a system driven by market values, and feeling let down by a society that has put them in harm’s way. They work all day under physically and emotionally exhausting conditions and then go home to hear specious conspiracy theories about the pandemic and see other people unwilling to wear masks.

Moral distress is complicated, said Lucia Wocial, PhD, RN, a nurse ethicist and cochair of the ethics consultation subcommittee at Indiana University Health in Indianapolis. “If you say you have moral distress, my first response is: tell me more. It helps to peel back the layers of this complexity. Emotion is only part of moral distress. It’s about the professional’s sense of responsibility and obligation – and the inability to honor that.”

Dr. Wocial, whose research specialty is moral distress, is corresponding author of a study published in the Journal of General Internal Medicine in February 2020, which identified moral distress in 4 out of 10 surveyed physicians who cared for older hospitalized adults and found themselves needing to work with their surrogate decision-makers.³ “We know physician moral distress is higher when people haven’t had the chance to hold conversations about their end-of-life care preferences,” she said, such as whether to continue life support.

“We have also learned that communication is key to diminishing physician moral distress. Our responsibility as clinicians is to guide patients and families through these decisions. If the family feels a high level of support from me, then my moral distress is lower,” she added. “If you think about how COVID has evolved, at first people were dying so quickly. Some patients were going to the ICU on ventilators without ever having a goals-of-care conversation.”

COVID has shifted the usual standard of care in U.S. hospitals in the face of patient surges. “How can you feel okay in accepting a level of care that in the prepandemic world would not have been acceptable?” Dr. Wocial posed. “What if you know the standard of care has shifted, of necessity, but you haven’t had time to prepare for it and nobody’s talking about what that means? Who is going to help you accept that good enough under these circumstances is enough – at least for today?”
 

What to call it

Michael J. Asken, PhD, director of provider well-being at UPMC Pinnacle Harrisburg (Pa.), has questioned in print the use of the military and wartime term “moral injury” when applied to a variety of less serious physician stressors.⁴ More recently, however, he observed, “The pandemic has muted or erased many of the distinctions between medical care and military conflict. ... The onslaught and volume of critical patients and resulting deaths is beyond what most providers have ever contemplated as part of care.”⁵

In a recent interview with the Hospitalist, he said: “While I initially resisted using the term moral injury, especially pre-COVID, because it was not equivalent to the moral injury created by war, I have relented a bit.” The volume of deaths and the apparent dangers to providers themselves reflect some of the critical aspects of war, and repetitive, intense, and/or incessant ethical challenges may have longer term negative psychological or emotional effects.

“Feeling emotional pain in situations of multiple deaths is to be expected and, perhaps, should even be welcomed as a sign of retained humanity and a buffer against burnout and cynicism in these times of unabating stress,” Dr. Asken said. “This is only true, however, if the emotional impact is tolerable and not experienced in repetitive extremes.”

Courtesy Avera Health

“These things are real,” said Clarissa Barnes, MD, a physician adviser, hospitalist at Avera McKennan Hospital in Sioux Falls, S.D., and former medical director of Avera’s LIGHT Program, a wellness-oriented service for clinicians. Dr. Barnes herself caught the virus on the job but has since recovered.

“Physicians don’t see their work as an occupation. It’s their core identity: I am a doctor; I practice medicine. If things are being done in ways I don’t think are right, that’s fundamentally a breach,” she said. “As internists, we have an opportunity to forestall death whenever we can and, if not, promote a peaceful death. That’s what made me choose this specialty. I think there’s value in allowing a person to end well. But when that doesn’t happen because of social or administrative reasons, that’s hard.”
 

Where is the leadership?

“A lot of moral injury comes down to the individual health system and its leaders. Some have done well; others you hear saying things that make you question whether these are the people you want leading the organization. Hospitalists need to have a clear value framework and an idea of how to negotiate things when decisions don’t match that framework,” Dr. Barnes said.

“Sometimes administrators have additional information that they’re not sharing,” she added. “They’re caught between a rock and a hard place regarding the decisions they have to make, but they need to be more transparent and not hold things so close to their vest while thinking they are helping clinicians [by doing so]. Physicians need to understand why they are being asked to do things counter to what they believe is appropriate.”

David Oliver, MD, a geriatrics and internal medicine consultant at Royal Berkshire Hospital in Reading, England, also practices as a hospital physician, a role similar to the hospitalist in the United States. “In any system, in any environment, the job of being a doctor, nurse, or other health professional carries a lot of responsibility. That is a timeless, inherent stress of medical practice. With COVID, we’ve seen a lot of emotional burdens – a whole separate set of problems outside of your control, where you are responsible for care but don’t have accountability,” he said.

“People like me, hospital doctors, are used to chronic workforce issues in the National Health Service. But we didn’t sign up to come and get COVID and be hospitalized ourselves.” More than 850 frontline health care providers in the U.K. have so far died from the virus, Dr. Oliver said. “I saw five patients die in 90 minutes one day in April. That’s above and beyond normal human capacity.”

In England specifically, he said, it has exposed underlying structural issues and serious workforce gaps, unfilled vacancies, and a much lower number of ICU beds per 100,000 population than the United States or Europe. And there is consistent pressure to send patients home in order to empty beds for new patients.

But a range of supportive services is offered in U.K. hospitals, such as making senior clinicians available to speak to frontline clinicians, providing mentorship and a sounding board. The Point of Care Foundation has helped to disseminate the practice of Schwartz Rounds, a group reflective practice forum for health care teams developed by the Schwartz Center for Compassionate Healthcare in Boston.

“We don’t need this clap-for-the-NHS heroes stuff,” Dr. Oliver said. “We need an adequate workforce and [better] working conditions. What happened on the front lines of the pandemic was heroic – all done by local clinical teams. But where was the government – the centralized NHS? A lot of frontline clinicians aren’t feeling valued, supported, or listened to.”
 

What can be done?

What are some things that hospitalists can do, individually and collectively, to try to prevent moral distress from turning into full-scale burnout? Dr. Wocial emphasized the importance of unit-based ethics conversations. “At IU Health we have someone who is available to sit down with frontline clinicians and help unpack what they are experiencing,” she said. Clinicians need to be able to process this terrible experience in order to sort out the feelings of sadness from questions of whether they are doing something wrong.

Hospital chaplains are exquisitely skilled at supporting people and debriefing hospital teams, Dr. Wocial added. Palliative care professionals are also skilled at facilitating goals of care conversations with patients and families and can support hospitalists through coaching and joint family meetings.

“It’s about raising your sense of agency in your job – what in your practice you can control. People need to be able to talk frankly about it. Some managers say to clinicians: ‘Just buck up,’ while others are doing a fabulous job of offering support to their staff,” Dr. Wocial said. Hospitalists have to be willing to say when they’ve had too much. “You may not get help when you first ask for it. Be persistent. Asking for help doesn’t make you weak.”

Most doctors have their own strategies for managing stress on the job, Dr. Wachter noted. “What makes it a little easier is not having to do it alone. Many find solace in community, but community has been constrained by this pandemic. You can’t just go out for a beer after work anymore. So what are other ways to let off steam?”

The people leading hospitalist programs need to work harder at creating community and empathy when the tools allowing people to get together are somewhat limited. “Everybody is tired of Zoom,” he said. “One thing I learned as a manager was to just send messages to people acknowledging that I know this is hard. Try to think from the lens of other people and what they would find useful.”

The pandemic has been terribly unpredictable, Dr. Wachter added, but it won’t go on forever. For some doctors, yoga or mindfulness meditation may be very comforting. “For me, that’s not what I do. Golf or a good Seinfeld episode works for me.”

SHM’s Wellbeing Taskforce has created a “Hospital Medicine COVID Check-in Guide for Self & Peers” to promote both sharing and support for one another. It can be found at SHM’s Wellbeing webpage [www.hospitalmedicine.org/practice-management/wellbeing/]. The Taskforce believes that sharing common stressors as hospitalists can be healing, said its chair, Sarah Richards, MD, assistant professor of medicine at the University of Nebraska, Omaha. “This is especially true in situations where we feel we can’t provide the type of care we know our patients deserve.”
 

Respect, advocacy, self-care

Dr. Asken encouraged clinicians to focus on the efforts they are making on the job, not just the outcomes. “If someone has done their absolute best in a given circumstance, satisfaction and solace needs to be taken from that,” he said.

“Ongoing support group meetings, which we have called frontline support groups, should occur on a regular basis. Designated for physicians on the medical floors and in critical care units who are directly involved with COVID patients, these provide a brief respite but also engagement, sharing, and strengthening of mutual support.”

A lot of these issues have a fundamental thread, which comes down to respect, Dr. Barnes said. “Hospitalists need to hear their hospital administrators say: ‘I hear what you’re saying [about a problem]. Let’s think together about how to solve it.’ We need to work on being clear, and we need to speak up for what’s right. If you aren’t comfortable doing things you are being asked to do in the hospital, maybe you’re not working in the right place.”

Some efforts in the area of wellness and self-care really are helpful, Dr. Barnes said. “But you can’t exercise you way through a health system that doesn’t respect you. You need to get out of the mindset that you have no ability to make things different. We are not powerless as doctors. We can do a lot, actually. Physicians need to take ownership. If you are a hospitalist and you’re not part of any local or state or national organization that advocates for physicians, you should be.”
 

References

1. Dzeng L and Wachter RM. Ethics in conflict: Moral distress as a root cause of burnout. J Gen Intern Med. 2020 Feb;35(2):409-11. doi: 10.1007/s11606-019-05505-6.

2. Jameton A, Nursing Practice: The ethical issues. Prentice Hall Series in the Philosophy of Medicine. 1984, Englewood Cliffs, N.J.: Prentice Hall.

3. Wocial LD et al. Factors associated with physician moral distress caring for hospitalized elderly patients needing a surrogate decision-maker: A prospective study. J Gen Intern Med. 2020 May;35(5):1405-12. doi: 10.1007/s11606-020-05652-1.

4. Asken MJ. It’s not moral injury: It’s burnout (or something else). Medical Economics; June 7, 2019.

5. Asken MJ. Now it is moral injury: The COVID-19 pandemic and moral distress. Medical Economics; April 29, 2020.

Moral distress can result when health professionals like doctors and nurses feel prevented from doing what they know is right and ethically correct – reflecting the values of their profession and their own sense of professional integrity – because of unmanageable caseload demands, lack of resources, coverage limitations, or institutional policies.

Hospitalists are not exempt from moral distress, which is associated with soul-searching, burnout, and even PTSD. It is also associated with a higher likelihood for professionals to report an intention to leave their jobs. But the COVID-19 pandemic has superimposed a whole new layer of challenges, constraints, and frustrations, creating a potent mix of trauma and exhaustion, cumulative unease, depleted job satisfaction, and difficult ethical choices.

These challenges include seeing so many patients die and working with short supplies of personal protective equipment (PPE) – with resulting fears that they could catch the virus or pass it on to others, including loved ones. Also, not having enough ventilators or even beds for patients in hospitals hit hard by COVID surges raises fears that decisions for rationing medical care might become necessary.

In a commentary published in the Journal of General Internal Medicine in October 2019 – shortly before the COVID pandemic burst onto the scene – hospitalist and medical sociologist Elizabeth Dzeng, MD, PhD, MPH, and hospital medicine pioneer Robert Wachter, MD, MHM, both from the University of California, San Francisco, described “moral distress and professional ethical dissonance as root causes of burnout.”¹ They characterized moral distress by its emotional exhaustion, depersonalization, reduced sense of accomplishment, and moral apathy, and they called for renewed attention to social and ethical dimensions of practice and threats to physician professionalism.

Prevailing explanations for documented high rates of burnout in doctors have tended to focus on work hours and struggles with electronic medical records and the like, Dr. Dzeng and Dr. Wachter wrote. “We see evidence of an insidious moral distress resulting from physicians’ inability to act in accord with their individual and professional ethical values due to institutional and social constraints.”

COVID has intensified these issues surrounding moral distress. “In a short period of time it created more situations that raise issues of moral distress than I have seen since the early days of HIV,” Dr. Wachter said. “Those of us who work in hospitals often find ourselves in complex circumstances with limited resources. What was so striking about COVID was finding ourselves caring for large volumes of patients who had a condition that was new to us.”

And the fact that constraints imposed by COVID, such as having to don unwieldy PPE and not allowing families to be present with hospitalized loved ones, are explainable and rational only helps a little with the clinician’s distress.

People talk about the need for doctors to be more resilient, Dr. Dzeng added, but that’s too narrow of an approach to these very real challenges. There are huge issues of workforce retention and costs, major mental health issues, suicide – and implications for patient care, because burned-out doctors can be bad doctors.
 

What is moral distress?

Moral distress is a term from the nursing ethics literature, attributed to philosopher Andrew Jameton in 1984.² Contributors to moral distress imposed by COVID include having to make difficult medical decisions under stressful circumstances – especially early on, when effective treatment options were few. Doctors felt the demands of the pandemic were putting care quality and patient safety at risk. Poor working conditions overall, being pushed to work beyond their normal physical limits for days at a time, and feelings of not being valued added to this stress. But some say the pandemic has only highlighted and amplified existing inequities and disparities in the health care system.

Experts say moral distress is about feeling powerless, especially in a system driven by market values, and feeling let down by a society that has put them in harm’s way. They work all day under physically and emotionally exhausting conditions and then go home to hear specious conspiracy theories about the pandemic and see other people unwilling to wear masks.

Moral distress is complicated, said Lucia Wocial, PhD, RN, a nurse ethicist and cochair of the ethics consultation subcommittee at Indiana University Health in Indianapolis. “If you say you have moral distress, my first response is: tell me more. It helps to peel back the layers of this complexity. Emotion is only part of moral distress. It’s about the professional’s sense of responsibility and obligation – and the inability to honor that.”

Dr. Wocial, whose research specialty is moral distress, is corresponding author of a study published in the Journal of General Internal Medicine in February 2020, which identified moral distress in 4 out of 10 surveyed physicians who cared for older hospitalized adults and found themselves needing to work with their surrogate decision-makers.³ “We know physician moral distress is higher when people haven’t had the chance to hold conversations about their end-of-life care preferences,” she said, such as whether to continue life support.

“We have also learned that communication is key to diminishing physician moral distress. Our responsibility as clinicians is to guide patients and families through these decisions. If the family feels a high level of support from me, then my moral distress is lower,” she added. “If you think about how COVID has evolved, at first people were dying so quickly. Some patients were going to the ICU on ventilators without ever having a goals-of-care conversation.”

COVID has shifted the usual standard of care in U.S. hospitals in the face of patient surges. “How can you feel okay in accepting a level of care that in the prepandemic world would not have been acceptable?” Dr. Wocial posed. “What if you know the standard of care has shifted, of necessity, but you haven’t had time to prepare for it and nobody’s talking about what that means? Who is going to help you accept that good enough under these circumstances is enough – at least for today?”
 

What to call it

Michael J. Asken, PhD, director of provider well-being at UPMC Pinnacle Harrisburg (Pa.), has questioned in print the use of the military and wartime term “moral injury” when applied to a variety of less serious physician stressors.⁴ More recently, however, he observed, “The pandemic has muted or erased many of the distinctions between medical care and military conflict. ... The onslaught and volume of critical patients and resulting deaths is beyond what most providers have ever contemplated as part of care.”⁵

In a recent interview with the Hospitalist, he said: “While I initially resisted using the term moral injury, especially pre-COVID, because it was not equivalent to the moral injury created by war, I have relented a bit.” The volume of deaths and the apparent dangers to providers themselves reflect some of the critical aspects of war, and repetitive, intense, and/or incessant ethical challenges may have longer term negative psychological or emotional effects.

“Feeling emotional pain in situations of multiple deaths is to be expected and, perhaps, should even be welcomed as a sign of retained humanity and a buffer against burnout and cynicism in these times of unabating stress,” Dr. Asken said. “This is only true, however, if the emotional impact is tolerable and not experienced in repetitive extremes.”

Courtesy Avera Health

“These things are real,” said Clarissa Barnes, MD, a physician adviser, hospitalist at Avera McKennan Hospital in Sioux Falls, S.D., and former medical director of Avera’s LIGHT Program, a wellness-oriented service for clinicians. Dr. Barnes herself caught the virus on the job but has since recovered.

“Physicians don’t see their work as an occupation. It’s their core identity: I am a doctor; I practice medicine. If things are being done in ways I don’t think are right, that’s fundamentally a breach,” she said. “As internists, we have an opportunity to forestall death whenever we can and, if not, promote a peaceful death. That’s what made me choose this specialty. I think there’s value in allowing a person to end well. But when that doesn’t happen because of social or administrative reasons, that’s hard.”
 

Where is the leadership?

“A lot of moral injury comes down to the individual health system and its leaders. Some have done well; others you hear saying things that make you question whether these are the people you want leading the organization. Hospitalists need to have a clear value framework and an idea of how to negotiate things when decisions don’t match that framework,” Dr. Barnes said.

“Sometimes administrators have additional information that they’re not sharing,” she added. “They’re caught between a rock and a hard place regarding the decisions they have to make, but they need to be more transparent and not hold things so close to their vest while thinking they are helping clinicians [by doing so]. Physicians need to understand why they are being asked to do things counter to what they believe is appropriate.”

David Oliver, MD, a geriatrics and internal medicine consultant at Royal Berkshire Hospital in Reading, England, also practices as a hospital physician, a role similar to the hospitalist in the United States. “In any system, in any environment, the job of being a doctor, nurse, or other health professional carries a lot of responsibility. That is a timeless, inherent stress of medical practice. With COVID, we’ve seen a lot of emotional burdens – a whole separate set of problems outside of your control, where you are responsible for care but don’t have accountability,” he said.

“People like me, hospital doctors, are used to chronic workforce issues in the National Health Service. But we didn’t sign up to come and get COVID and be hospitalized ourselves.” More than 850 frontline health care providers in the U.K. have so far died from the virus, Dr. Oliver said. “I saw five patients die in 90 minutes one day in April. That’s above and beyond normal human capacity.”

In England specifically, he said, it has exposed underlying structural issues and serious workforce gaps, unfilled vacancies, and a much lower number of ICU beds per 100,000 population than the United States or Europe. And there is consistent pressure to send patients home in order to empty beds for new patients.

But a range of supportive services is offered in U.K. hospitals, such as making senior clinicians available to speak to frontline clinicians, providing mentorship and a sounding board. The Point of Care Foundation has helped to disseminate the practice of Schwartz Rounds, a group reflective practice forum for health care teams developed by the Schwartz Center for Compassionate Healthcare in Boston.

“We don’t need this clap-for-the-NHS heroes stuff,” Dr. Oliver said. “We need an adequate workforce and [better] working conditions. What happened on the front lines of the pandemic was heroic – all done by local clinical teams. But where was the government – the centralized NHS? A lot of frontline clinicians aren’t feeling valued, supported, or listened to.”
 

What can be done?

What are some things that hospitalists can do, individually and collectively, to try to prevent moral distress from turning into full-scale burnout? Dr. Wocial emphasized the importance of unit-based ethics conversations. “At IU Health we have someone who is available to sit down with frontline clinicians and help unpack what they are experiencing,” she said. Clinicians need to be able to process this terrible experience in order to sort out the feelings of sadness from questions of whether they are doing something wrong.

Hospital chaplains are exquisitely skilled at supporting people and debriefing hospital teams, Dr. Wocial added. Palliative care professionals are also skilled at facilitating goals of care conversations with patients and families and can support hospitalists through coaching and joint family meetings.

“It’s about raising your sense of agency in your job – what in your practice you can control. People need to be able to talk frankly about it. Some managers say to clinicians: ‘Just buck up,’ while others are doing a fabulous job of offering support to their staff,” Dr. Wocial said. Hospitalists have to be willing to say when they’ve had too much. “You may not get help when you first ask for it. Be persistent. Asking for help doesn’t make you weak.”

Most doctors have their own strategies for managing stress on the job, Dr. Wachter noted. “What makes it a little easier is not having to do it alone. Many find solace in community, but community has been constrained by this pandemic. You can’t just go out for a beer after work anymore. So what are other ways to let off steam?”

The people leading hospitalist programs need to work harder at creating community and empathy when the tools allowing people to get together are somewhat limited. “Everybody is tired of Zoom,” he said. “One thing I learned as a manager was to just send messages to people acknowledging that I know this is hard. Try to think from the lens of other people and what they would find useful.”

The pandemic has been terribly unpredictable, Dr. Wachter added, but it won’t go on forever. For some doctors, yoga or mindfulness meditation may be very comforting. “For me, that’s not what I do. Golf or a good Seinfeld episode works for me.”

SHM’s Wellbeing Taskforce has created a “Hospital Medicine COVID Check-in Guide for Self & Peers” to promote both sharing and support for one another. It can be found at SHM’s Wellbeing webpage [www.hospitalmedicine.org/practice-management/wellbeing/]. The Taskforce believes that sharing common stressors as hospitalists can be healing, said its chair, Sarah Richards, MD, assistant professor of medicine at the University of Nebraska, Omaha. “This is especially true in situations where we feel we can’t provide the type of care we know our patients deserve.”
 

Respect, advocacy, self-care

Dr. Asken encouraged clinicians to focus on the efforts they are making on the job, not just the outcomes. “If someone has done their absolute best in a given circumstance, satisfaction and solace needs to be taken from that,” he said.

“Ongoing support group meetings, which we have called frontline support groups, should occur on a regular basis. Designated for physicians on the medical floors and in critical care units who are directly involved with COVID patients, these provide a brief respite but also engagement, sharing, and strengthening of mutual support.”

A lot of these issues have a fundamental thread, which comes down to respect, Dr. Barnes said. “Hospitalists need to hear their hospital administrators say: ‘I hear what you’re saying [about a problem]. Let’s think together about how to solve it.’ We need to work on being clear, and we need to speak up for what’s right. If you aren’t comfortable doing things you are being asked to do in the hospital, maybe you’re not working in the right place.”

Some efforts in the area of wellness and self-care really are helpful, Dr. Barnes said. “But you can’t exercise you way through a health system that doesn’t respect you. You need to get out of the mindset that you have no ability to make things different. We are not powerless as doctors. We can do a lot, actually. Physicians need to take ownership. If you are a hospitalist and you’re not part of any local or state or national organization that advocates for physicians, you should be.”
 

References

1. Dzeng L and Wachter RM. Ethics in conflict: Moral distress as a root cause of burnout. J Gen Intern Med. 2020 Feb;35(2):409-11. doi: 10.1007/s11606-019-05505-6.

2. Jameton A, Nursing Practice: The ethical issues. Prentice Hall Series in the Philosophy of Medicine. 1984, Englewood Cliffs, N.J.: Prentice Hall.

3. Wocial LD et al. Factors associated with physician moral distress caring for hospitalized elderly patients needing a surrogate decision-maker: A prospective study. J Gen Intern Med. 2020 May;35(5):1405-12. doi: 10.1007/s11606-020-05652-1.

4. Asken MJ. It’s not moral injury: It’s burnout (or something else). Medical Economics; June 7, 2019.

5. Asken MJ. Now it is moral injury: The COVID-19 pandemic and moral distress. Medical Economics; April 29, 2020.

The majority of children with type 1 diabetes who tested positive for SARS-CoV-2 were cared for at home and did well, according to the first report of outcomes of pediatric patients with type 1 diabetes and COVID-19 from the United States.

Most children who were hospitalized had diabetic ketoacidosis (DKA) and high hemoglobin A1c levels, the new report from the T1D Exchange Quality Improvement Collaborative indicates. Fewer than 2% required respiratory support, and no deaths were recorded.

The greatest risk for adverse COVID-19 outcomes was among children with A1c levels >9%. In addition, children of certain ethnic minority groups and those with public health insurance were more likely to be hospitalized.

The study, conducted by G. Todd Alonso, MD, of the University of Colorado, Barbara Davis Center, Aurora, and colleagues, was published online April 14 in the Journal of Diabetes..

“As early reports identified diabetes as a risk factor for increased morbidity and mortality with COVID-19, the findings from this surveillance study should provide measured reassurance for families of children with type 1 diabetes as well as pediatric endocrinologists and their care teams,” say Dr. Alonso and colleagues.
 

Disproportionate rate of hospitalization, DKA among Black patients

Initiated in April 2020, the T1D Exchange Quality Improvement Collaborative comprises 56 diabetes centers, of which 52 submitted a total of 266 cases involving patients younger than 19 years who had type 1 diabetes and who tested positive for SARS-CoV-2 infection. Those with new-onset type 1 diabetes were excluded from this analysis and were reported separately. The data were collected between April 9, 2020, and Jan. 15, 2021.

Of the 266 patients, 23% (61) were hospitalized, and 205 were not. There were no differences by age, gender, or diabetes duration.

However, those hospitalized were more likely to be Black (34% vs. 13% among White patients; P < .001) and to have public health insurance (64% vs. 41%; P < .001). They also had higher A1c levels than patients who were not hospitalized (11% vs. 8.2%; P < .001), and fewer used insulin pumps (26% vs. 54%; P < .001) and continuous glucose monitors (39% vs. 75%; P < .001).

Those hospitalized were also more likely to have hyperglycemia (48% vs. 28%; P = .007), nausea (33% vs. 6%; P < .001), and vomiting (49% vs. 3%; P < .001). Rates of dry cough, excess fatigue, and body aches/headaches did not differ between those hospitalized and those who remained at home.

The most common adverse outcome was DKA, which occurred in 72% (44) of those hospitalized.

The most recent A1c level was less than 9% in 82% of those hospitalized vs. 31% of those who weren’t (P < .001) and in 38 of the 44 (86%) who had DKA.

“Our data reveal a disproportionate rate of hospitalization and DKA among racial and ethnic minority groups, children who were publicly insured, and those with higher A1c. It is essential to find pathways for the most vulnerable patients to have adequate, equitable access to medical care via in person and telehealth services, to obtain and successfully use diabetes technology, and to optimize sick day management,” say Dr. Alonso and colleagues.

One child, a 15-year-old White boy, underwent intubation and was placed on a ventilator. His most recent A1c was 8.9%. Another child, a 13-year-old boy whose most recent A1c level was 11.1%, developed multisystem inflammatory syndrome of childhood.

The registry remains open.

The T1D Exchange QI Collaborative is funded by the Helmsley Charitable Trust. The T1D Exchange received partial financial support for this study from Abbott Diabetes, Dexcom, Medtronic, Insulet Corporation, JDRF, Eli Lilly, and Tandem Diabetes Care. None of the sponsors were involved in initiating, designing, or preparing the manuscript for this study.

A version of this article first appeared on Medscape.com.

The majority of children with type 1 diabetes who tested positive for SARS-CoV-2 were cared for at home and did well, according to the first report of outcomes of pediatric patients with type 1 diabetes and COVID-19 from the United States.

Most children who were hospitalized had diabetic ketoacidosis (DKA) and high hemoglobin A1c levels, the new report from the T1D Exchange Quality Improvement Collaborative indicates. Fewer than 2% required respiratory support, and no deaths were recorded.

The greatest risk for adverse COVID-19 outcomes was among children with A1c levels >9%. In addition, children of certain ethnic minority groups and those with public health insurance were more likely to be hospitalized.

The study, conducted by G. Todd Alonso, MD, of the University of Colorado, Barbara Davis Center, Aurora, and colleagues, was published online April 14 in the Journal of Diabetes..

“As early reports identified diabetes as a risk factor for increased morbidity and mortality with COVID-19, the findings from this surveillance study should provide measured reassurance for families of children with type 1 diabetes as well as pediatric endocrinologists and their care teams,” say Dr. Alonso and colleagues.
 

Disproportionate rate of hospitalization, DKA among Black patients

Initiated in April 2020, the T1D Exchange Quality Improvement Collaborative comprises 56 diabetes centers, of which 52 submitted a total of 266 cases involving patients younger than 19 years who had type 1 diabetes and who tested positive for SARS-CoV-2 infection. Those with new-onset type 1 diabetes were excluded from this analysis and were reported separately. The data were collected between April 9, 2020, and Jan. 15, 2021.

Of the 266 patients, 23% (61) were hospitalized, and 205 were not. There were no differences by age, gender, or diabetes duration.

However, those hospitalized were more likely to be Black (34% vs. 13% among White patients; P < .001) and to have public health insurance (64% vs. 41%; P < .001). They also had higher A1c levels than patients who were not hospitalized (11% vs. 8.2%; P < .001), and fewer used insulin pumps (26% vs. 54%; P < .001) and continuous glucose monitors (39% vs. 75%; P < .001).

Those hospitalized were also more likely to have hyperglycemia (48% vs. 28%; P = .007), nausea (33% vs. 6%; P < .001), and vomiting (49% vs. 3%; P < .001). Rates of dry cough, excess fatigue, and body aches/headaches did not differ between those hospitalized and those who remained at home.

The most common adverse outcome was DKA, which occurred in 72% (44) of those hospitalized.

The most recent A1c level was less than 9% in 82% of those hospitalized vs. 31% of those who weren’t (P < .001) and in 38 of the 44 (86%) who had DKA.

“Our data reveal a disproportionate rate of hospitalization and DKA among racial and ethnic minority groups, children who were publicly insured, and those with higher A1c. It is essential to find pathways for the most vulnerable patients to have adequate, equitable access to medical care via in person and telehealth services, to obtain and successfully use diabetes technology, and to optimize sick day management,” say Dr. Alonso and colleagues.

One child, a 15-year-old White boy, underwent intubation and was placed on a ventilator. His most recent A1c was 8.9%. Another child, a 13-year-old boy whose most recent A1c level was 11.1%, developed multisystem inflammatory syndrome of childhood.

The registry remains open.

The T1D Exchange QI Collaborative is funded by the Helmsley Charitable Trust. The T1D Exchange received partial financial support for this study from Abbott Diabetes, Dexcom, Medtronic, Insulet Corporation, JDRF, Eli Lilly, and Tandem Diabetes Care. None of the sponsors were involved in initiating, designing, or preparing the manuscript for this study.

A version of this article first appeared on Medscape.com.

The majority of children with type 1 diabetes who tested positive for SARS-CoV-2 were cared for at home and did well, according to the first report of outcomes of pediatric patients with type 1 diabetes and COVID-19 from the United States.

Most children who were hospitalized had diabetic ketoacidosis (DKA) and high hemoglobin A1c levels, the new report from the T1D Exchange Quality Improvement Collaborative indicates. Fewer than 2% required respiratory support, and no deaths were recorded.

The greatest risk for adverse COVID-19 outcomes was among children with A1c levels >9%. In addition, children of certain ethnic minority groups and those with public health insurance were more likely to be hospitalized.

The study, conducted by G. Todd Alonso, MD, of the University of Colorado, Barbara Davis Center, Aurora, and colleagues, was published online April 14 in the Journal of Diabetes..

“As early reports identified diabetes as a risk factor for increased morbidity and mortality with COVID-19, the findings from this surveillance study should provide measured reassurance for families of children with type 1 diabetes as well as pediatric endocrinologists and their care teams,” say Dr. Alonso and colleagues.
 

Disproportionate rate of hospitalization, DKA among Black patients

Initiated in April 2020, the T1D Exchange Quality Improvement Collaborative comprises 56 diabetes centers, of which 52 submitted a total of 266 cases involving patients younger than 19 years who had type 1 diabetes and who tested positive for SARS-CoV-2 infection. Those with new-onset type 1 diabetes were excluded from this analysis and were reported separately. The data were collected between April 9, 2020, and Jan. 15, 2021.

Of the 266 patients, 23% (61) were hospitalized, and 205 were not. There were no differences by age, gender, or diabetes duration.

However, those hospitalized were more likely to be Black (34% vs. 13% among White patients; P < .001) and to have public health insurance (64% vs. 41%; P < .001). They also had higher A1c levels than patients who were not hospitalized (11% vs. 8.2%; P < .001), and fewer used insulin pumps (26% vs. 54%; P < .001) and continuous glucose monitors (39% vs. 75%; P < .001).

Those hospitalized were also more likely to have hyperglycemia (48% vs. 28%; P = .007), nausea (33% vs. 6%; P < .001), and vomiting (49% vs. 3%; P < .001). Rates of dry cough, excess fatigue, and body aches/headaches did not differ between those hospitalized and those who remained at home.

The most common adverse outcome was DKA, which occurred in 72% (44) of those hospitalized.

The most recent A1c level was less than 9% in 82% of those hospitalized vs. 31% of those who weren’t (P < .001) and in 38 of the 44 (86%) who had DKA.

“Our data reveal a disproportionate rate of hospitalization and DKA among racial and ethnic minority groups, children who were publicly insured, and those with higher A1c. It is essential to find pathways for the most vulnerable patients to have adequate, equitable access to medical care via in person and telehealth services, to obtain and successfully use diabetes technology, and to optimize sick day management,” say Dr. Alonso and colleagues.

One child, a 15-year-old White boy, underwent intubation and was placed on a ventilator. His most recent A1c was 8.9%. Another child, a 13-year-old boy whose most recent A1c level was 11.1%, developed multisystem inflammatory syndrome of childhood.

The registry remains open.

The T1D Exchange QI Collaborative is funded by the Helmsley Charitable Trust. The T1D Exchange received partial financial support for this study from Abbott Diabetes, Dexcom, Medtronic, Insulet Corporation, JDRF, Eli Lilly, and Tandem Diabetes Care. None of the sponsors were involved in initiating, designing, or preparing the manuscript for this study.

A version of this article first appeared on Medscape.com.

COVID-19 and its resulting lockdowns are linked to posttraumatic stress disorder symptoms and other adverse outcomes among patients with eating disorders (EDs), two new studies show.

Courtesy Bill Branson/National Cancer Institute

Results of the first study show that patients with EDs had more stress, anxiety, depression, and PTSD-related symptoms during the lockdowns than their mentally healthy peers.

In the second study, treatment-related symptom improvement among patients with bulimia nervosa (BN) slowed following lockdown. In addition, patients with BN or anorexia nervosa (AN) experienced significant worsening of disorder-specific behaviors, including binge eating and overexercising.

Because of the strict lockdown measures introduced by the Italian government to contain the COVID-19 pandemic, “everyday life of all citizens was disrupted,” Veronica Nisticò, MS, Università Degli Studi Di Milano, who led the first study, told delegates attending the virtual European Psychiatric Association 2021 Congress.

In addition to difficulties in accessing health care, “it became difficult to go to the supermarket, to the gym, and to have the social support we were all used to,” all of which had a well-documented impact on mental health, added Ms. Nisticò, who is also affiliated with Aldo Ravelli Research Center for Neurotechnology and Experimental Brain Therapeutics.
 

Loss of control

Previous research suggests that individuals with EDs experience high levels of anxiety and an increase in binge eating, exercise, and purging behaviors, said Ms. Nisticò.

To investigate further, the researchers conducted a longitudinal study of the changes in prevalence of adverse outcomes. In the study, two assessments were conducted.

In the first assessment, conducted in April 2020, the researchers assessed 59 outpatients with EDs and 43 unaffected hospital staff and their acquaintances. The second group served as the control group.

Participants completed an online survey that included several standardized depression and anxiety scales, as well as an ad hoc survey adapted from the Eating Disorder Examination Questionnaire. This assessed changes in restrictive dieting, control over food, body image, and psychological well-being in comparison with prepandemic levels.

The results, which were also recently published online in Eating and Weight Disorders – Studies on Anorexia, Bulimia and Obesity, showed that patients with EDs experienced significantly more stress, anxiety, depression, and PTSD-related symptoms in comparison with control persons (P < .05 for all).

In addition, the investigators found that those with EDs were more fearful of losing control over their eating behavior, spent more time thinking about food and their body, and became more uncomfortable seeing their body than before the lockdown in comparison with those without EDs (P < .05).
 

Clinical implications

A second assessment, which occurred in June 2020, after lockdown restrictions were lifted, included 40 patients with EDs who had taken part in the first assessment. This time, participants were asked to compare their current eating behavior with their eating behavior during the lockdown.

Although the lifting of lockdown restrictions was associated with significant improvement in PTSD-related symptoms, the impact on stress, anxiety, and depression persisted.

These findings, said Ms. Nisticó, support the hypothesis that specific conditions that occurred during the lockdown had a direct effect on specific ED symptoms.

These findings, she added, should be considered when developing interventions for EDs in the context of individual psychotherapy and when designing large, preventive interventions.

In the second study, Eleonora Rossi, MD, psychiatric unit, department of health sciences, University of Florence (Italy), and colleagues examined the longitudinal impact of the pandemic on individuals with EDs.

They examined 74 patients with AN or BN who had undergone baseline assessments and had completed a number of questionnaires in the first months of 2019 in conjunction with being enrolled in another study.

Participants were treated with enhanced cognitive-behavioral therapy and were reevaluated between November 2019 and January 2020. They were then compared with 97 healthy individuals.
 

Bulimia patients more vulnerable

After the outbreak of the pandemic, most treatment was administered online, so patients were able to continue therapy, Dr. Rossi said during her presentation.

All participants were assessed again in April 2020, 6 weeks after the start of Italy’s lockdown.

The results, which were published in the International Journal of Eating Disorders, show that the patients with EDs “underwent a significant improvement in terms of general and eating disorder specific psychopathology” during the first treatment period, Dr. Rossi reported. In addition, among those with AN, body mass index increased significantly (P < .05 for all).

Patients with AN continued to improve during the lockdown when therapy was administered online. However, improvements that had occurred among those with BN slowed, Dr. Rossi noted.

In addition, both groups of patients with EDs experienced a worsening of their pathological eating behaviors during the lockdown, in particular, objective binge eating and compensatory physical exercise (P < .05).

“Indeed, the positive trajectory of improvement observed before lockdown was clearly interrupted during the pandemic period,” Dr. Rossi said. This could “represent a possible hint of an imminent exacerbation of the disease.”

The results also suggest that the occurrence of arguments within the household and fear regarding the safety of loved ones predicted an increase in symptoms during the lockdown, she added.

In addition, patients with BN reported more severe COVID-related PTSD symptoms than did those with AN and the control group. This increase in severity of symptoms was more prevalent among patients who had a history of childhood trauma and among those with insecure attachment, suggesting that such patients may be more vulnerable.
 

Evidence of recovery

Commenting on the studies, David Spiegel, MD, associate chair of psychiatry, Stanford (Calif.) University, noted that EDs commonly occur after physical or sexual trauma earlier in life.

“It’s a standard thing with trauma-related disorders that any other, even relatively minor, traumatic experience can exacerbate PTSD symptoms,” said Dr. Spiegel, who was not involved in the studies. In addition, the trauma of the COVID pandemic “was not minor.

“The relative isolation and the lack of outside contact may focus many people with eating disorders even more on their struggles with how they are taking care of their bodies,” said Dr. Spiegel.

“It struck me that the anorexia nervosa group were more impervious than the bulimia nervosa group, but I think that’s the case with the disorder. In some ways it’s more severe, obviously a more life-threatening disorder,” he added.

The “hopeful thing is that there seemed to be some evidence of recovery and improvement, particularly with the posttraumatic stress exacerbation, as time went on,” Dr. Spiegel said, “and that’s a good thing.”

The study authors and Dr. Spiegel reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

COVID-19 and its resulting lockdowns are linked to posttraumatic stress disorder symptoms and other adverse outcomes among patients with eating disorders (EDs), two new studies show.

Courtesy Bill Branson/National Cancer Institute

Results of the first study show that patients with EDs had more stress, anxiety, depression, and PTSD-related symptoms during the lockdowns than their mentally healthy peers.

In the second study, treatment-related symptom improvement among patients with bulimia nervosa (BN) slowed following lockdown. In addition, patients with BN or anorexia nervosa (AN) experienced significant worsening of disorder-specific behaviors, including binge eating and overexercising.

Because of the strict lockdown measures introduced by the Italian government to contain the COVID-19 pandemic, “everyday life of all citizens was disrupted,” Veronica Nisticò, MS, Università Degli Studi Di Milano, who led the first study, told delegates attending the virtual European Psychiatric Association 2021 Congress.

In addition to difficulties in accessing health care, “it became difficult to go to the supermarket, to the gym, and to have the social support we were all used to,” all of which had a well-documented impact on mental health, added Ms. Nisticò, who is also affiliated with Aldo Ravelli Research Center for Neurotechnology and Experimental Brain Therapeutics.
 

Loss of control

Previous research suggests that individuals with EDs experience high levels of anxiety and an increase in binge eating, exercise, and purging behaviors, said Ms. Nisticò.

To investigate further, the researchers conducted a longitudinal study of the changes in prevalence of adverse outcomes. In the study, two assessments were conducted.

In the first assessment, conducted in April 2020, the researchers assessed 59 outpatients with EDs and 43 unaffected hospital staff and their acquaintances. The second group served as the control group.

Participants completed an online survey that included several standardized depression and anxiety scales, as well as an ad hoc survey adapted from the Eating Disorder Examination Questionnaire. This assessed changes in restrictive dieting, control over food, body image, and psychological well-being in comparison with prepandemic levels.

The results, which were also recently published online in Eating and Weight Disorders – Studies on Anorexia, Bulimia and Obesity, showed that patients with EDs experienced significantly more stress, anxiety, depression, and PTSD-related symptoms in comparison with control persons (P < .05 for all).

In addition, the investigators found that those with EDs were more fearful of losing control over their eating behavior, spent more time thinking about food and their body, and became more uncomfortable seeing their body than before the lockdown in comparison with those without EDs (P < .05).
 

Clinical implications

A second assessment, which occurred in June 2020, after lockdown restrictions were lifted, included 40 patients with EDs who had taken part in the first assessment. This time, participants were asked to compare their current eating behavior with their eating behavior during the lockdown.

Although the lifting of lockdown restrictions was associated with significant improvement in PTSD-related symptoms, the impact on stress, anxiety, and depression persisted.

These findings, said Ms. Nisticó, support the hypothesis that specific conditions that occurred during the lockdown had a direct effect on specific ED symptoms.

These findings, she added, should be considered when developing interventions for EDs in the context of individual psychotherapy and when designing large, preventive interventions.

In the second study, Eleonora Rossi, MD, psychiatric unit, department of health sciences, University of Florence (Italy), and colleagues examined the longitudinal impact of the pandemic on individuals with EDs.

They examined 74 patients with AN or BN who had undergone baseline assessments and had completed a number of questionnaires in the first months of 2019 in conjunction with being enrolled in another study.

Participants were treated with enhanced cognitive-behavioral therapy and were reevaluated between November 2019 and January 2020. They were then compared with 97 healthy individuals.
 

Bulimia patients more vulnerable

After the outbreak of the pandemic, most treatment was administered online, so patients were able to continue therapy, Dr. Rossi said during her presentation.

All participants were assessed again in April 2020, 6 weeks after the start of Italy’s lockdown.

The results, which were published in the International Journal of Eating Disorders, show that the patients with EDs “underwent a significant improvement in terms of general and eating disorder specific psychopathology” during the first treatment period, Dr. Rossi reported. In addition, among those with AN, body mass index increased significantly (P < .05 for all).

Patients with AN continued to improve during the lockdown when therapy was administered online. However, improvements that had occurred among those with BN slowed, Dr. Rossi noted.

In addition, both groups of patients with EDs experienced a worsening of their pathological eating behaviors during the lockdown, in particular, objective binge eating and compensatory physical exercise (P < .05).

“Indeed, the positive trajectory of improvement observed before lockdown was clearly interrupted during the pandemic period,” Dr. Rossi said. This could “represent a possible hint of an imminent exacerbation of the disease.”

The results also suggest that the occurrence of arguments within the household and fear regarding the safety of loved ones predicted an increase in symptoms during the lockdown, she added.

In addition, patients with BN reported more severe COVID-related PTSD symptoms than did those with AN and the control group. This increase in severity of symptoms was more prevalent among patients who had a history of childhood trauma and among those with insecure attachment, suggesting that such patients may be more vulnerable.
 

Evidence of recovery

Commenting on the studies, David Spiegel, MD, associate chair of psychiatry, Stanford (Calif.) University, noted that EDs commonly occur after physical or sexual trauma earlier in life.

“It’s a standard thing with trauma-related disorders that any other, even relatively minor, traumatic experience can exacerbate PTSD symptoms,” said Dr. Spiegel, who was not involved in the studies. In addition, the trauma of the COVID pandemic “was not minor.

“The relative isolation and the lack of outside contact may focus many people with eating disorders even more on their struggles with how they are taking care of their bodies,” said Dr. Spiegel.

“It struck me that the anorexia nervosa group were more impervious than the bulimia nervosa group, but I think that’s the case with the disorder. In some ways it’s more severe, obviously a more life-threatening disorder,” he added.

The “hopeful thing is that there seemed to be some evidence of recovery and improvement, particularly with the posttraumatic stress exacerbation, as time went on,” Dr. Spiegel said, “and that’s a good thing.”

The study authors and Dr. Spiegel reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

COVID-19 and its resulting lockdowns are linked to posttraumatic stress disorder symptoms and other adverse outcomes among patients with eating disorders (EDs), two new studies show.

Courtesy Bill Branson/National Cancer Institute

Results of the first study show that patients with EDs had more stress, anxiety, depression, and PTSD-related symptoms during the lockdowns than their mentally healthy peers.

In the second study, treatment-related symptom improvement among patients with bulimia nervosa (BN) slowed following lockdown. In addition, patients with BN or anorexia nervosa (AN) experienced significant worsening of disorder-specific behaviors, including binge eating and overexercising.

Because of the strict lockdown measures introduced by the Italian government to contain the COVID-19 pandemic, “everyday life of all citizens was disrupted,” Veronica Nisticò, MS, Università Degli Studi Di Milano, who led the first study, told delegates attending the virtual European Psychiatric Association 2021 Congress.

In addition to difficulties in accessing health care, “it became difficult to go to the supermarket, to the gym, and to have the social support we were all used to,” all of which had a well-documented impact on mental health, added Ms. Nisticò, who is also affiliated with Aldo Ravelli Research Center for Neurotechnology and Experimental Brain Therapeutics.
 

Loss of control

Previous research suggests that individuals with EDs experience high levels of anxiety and an increase in binge eating, exercise, and purging behaviors, said Ms. Nisticò.

To investigate further, the researchers conducted a longitudinal study of the changes in prevalence of adverse outcomes. In the study, two assessments were conducted.

In the first assessment, conducted in April 2020, the researchers assessed 59 outpatients with EDs and 43 unaffected hospital staff and their acquaintances. The second group served as the control group.

Participants completed an online survey that included several standardized depression and anxiety scales, as well as an ad hoc survey adapted from the Eating Disorder Examination Questionnaire. This assessed changes in restrictive dieting, control over food, body image, and psychological well-being in comparison with prepandemic levels.

The results, which were also recently published online in Eating and Weight Disorders – Studies on Anorexia, Bulimia and Obesity, showed that patients with EDs experienced significantly more stress, anxiety, depression, and PTSD-related symptoms in comparison with control persons (P < .05 for all).

In addition, the investigators found that those with EDs were more fearful of losing control over their eating behavior, spent more time thinking about food and their body, and became more uncomfortable seeing their body than before the lockdown in comparison with those without EDs (P < .05).
 

Clinical implications

A second assessment, which occurred in June 2020, after lockdown restrictions were lifted, included 40 patients with EDs who had taken part in the first assessment. This time, participants were asked to compare their current eating behavior with their eating behavior during the lockdown.

Although the lifting of lockdown restrictions was associated with significant improvement in PTSD-related symptoms, the impact on stress, anxiety, and depression persisted.

These findings, said Ms. Nisticó, support the hypothesis that specific conditions that occurred during the lockdown had a direct effect on specific ED symptoms.

These findings, she added, should be considered when developing interventions for EDs in the context of individual psychotherapy and when designing large, preventive interventions.

In the second study, Eleonora Rossi, MD, psychiatric unit, department of health sciences, University of Florence (Italy), and colleagues examined the longitudinal impact of the pandemic on individuals with EDs.

They examined 74 patients with AN or BN who had undergone baseline assessments and had completed a number of questionnaires in the first months of 2019 in conjunction with being enrolled in another study.

Participants were treated with enhanced cognitive-behavioral therapy and were reevaluated between November 2019 and January 2020. They were then compared with 97 healthy individuals.
 

Bulimia patients more vulnerable

After the outbreak of the pandemic, most treatment was administered online, so patients were able to continue therapy, Dr. Rossi said during her presentation.

All participants were assessed again in April 2020, 6 weeks after the start of Italy’s lockdown.

The results, which were published in the International Journal of Eating Disorders, show that the patients with EDs “underwent a significant improvement in terms of general and eating disorder specific psychopathology” during the first treatment period, Dr. Rossi reported. In addition, among those with AN, body mass index increased significantly (P < .05 for all).

Patients with AN continued to improve during the lockdown when therapy was administered online. However, improvements that had occurred among those with BN slowed, Dr. Rossi noted.

In addition, both groups of patients with EDs experienced a worsening of their pathological eating behaviors during the lockdown, in particular, objective binge eating and compensatory physical exercise (P < .05).

“Indeed, the positive trajectory of improvement observed before lockdown was clearly interrupted during the pandemic period,” Dr. Rossi said. This could “represent a possible hint of an imminent exacerbation of the disease.”

The results also suggest that the occurrence of arguments within the household and fear regarding the safety of loved ones predicted an increase in symptoms during the lockdown, she added.

In addition, patients with BN reported more severe COVID-related PTSD symptoms than did those with AN and the control group. This increase in severity of symptoms was more prevalent among patients who had a history of childhood trauma and among those with insecure attachment, suggesting that such patients may be more vulnerable.
 

Evidence of recovery

Commenting on the studies, David Spiegel, MD, associate chair of psychiatry, Stanford (Calif.) University, noted that EDs commonly occur after physical or sexual trauma earlier in life.

“It’s a standard thing with trauma-related disorders that any other, even relatively minor, traumatic experience can exacerbate PTSD symptoms,” said Dr. Spiegel, who was not involved in the studies. In addition, the trauma of the COVID pandemic “was not minor.

“The relative isolation and the lack of outside contact may focus many people with eating disorders even more on their struggles with how they are taking care of their bodies,” said Dr. Spiegel.

“It struck me that the anorexia nervosa group were more impervious than the bulimia nervosa group, but I think that’s the case with the disorder. In some ways it’s more severe, obviously a more life-threatening disorder,” he added.

The “hopeful thing is that there seemed to be some evidence of recovery and improvement, particularly with the posttraumatic stress exacerbation, as time went on,” Dr. Spiegel said, “and that’s a good thing.”

The study authors and Dr. Spiegel reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.