MDedge Psychiatry

The American Academy of Pediatrics (AAP), the American Academy of Child and Adolescent Psychiatry (AACAP) and Children’s Hospital Association have declared a national emergency in children’s mental health.

COVID-19 has taken a serious toll, the organizations say, on top of already mounting challenges. Policy changes are urgently needed, they say.

“Today’s declaration is an urgent call to policymakers at all levels of government – we must treat this mental health crisis like the emergency it is,” AAP President Lee Savio Beers, MD, said in a statement.

The Centers for Disease Control and Prevention found that between March and October 2020, emergency department visits for mental health emergencies rose by 24% for children ages 5-11 years and 31% for children ages 12-17 years. ED visits for suspected suicide attempts increased nearly 51% among girls ages 12-17 years of age in early 2021 compared to the same period in 2019.

Recent data in Pediatrics also show a marked increase in loss of a caregiver and sharp disparities by race and ethnicity.

“We found that from April 1, 2020, through June 30, 2021, over 140,000 children in the U.S. experienced the death of a parent or grandparent caregiver. The risk of such loss was 1.1 to 4.5 times higher among children of racial and ethnic minorities, compared to non-Hispanic White children,” researchers wrote.

“We are caring for young people with soaring rates of depression, anxiety, trauma, loneliness, and suicidality that will have lasting impacts on them, their families, their communities, and all of our futures,” said AACAP President Gabrielle A. Carlson, MD.

Among the actions the groups are calling for are the following:

• Increase federal funding to ensure all families can access mental health services.
• Improve access to telemedicine.
• Accelerate integration of mental health care in pediatric primary care.
• Fully fund community-based systems of care that connect families to evidence-based interventions.
• Promote and pay for trauma-informed care services.
• Address workforce challenges so that children can access mental health services wherever they live.

The organizations represent more than 77,000 physician members and more than 200 children’s hospitals.

Jenna Triana, MD, a child and adolescent psychiatrist at the University of Minnesota, Minneapolis, said in an interview that while specific institutions such as the University of Colorado have declared emergencies in pediatric mental health, declaring a national emergency is important.

She said the timing is important because fall is typically a heavy time for pediatric psychiatry with children and adolescents returning to school, and it is especially pronounced with the pandemic.

The usual diagnoses providers are seeing “are all worse,” she said.

“The bar for getting admission to the hospital has been raised because we’re such a limited resource. We’ve had to be so thoughtful about who truly, truly needs admission and who can come up with some kind of safe plan for outside of the hospital,” Dr. Triana said.

“The patients I’m seeing in the hospital – the level of illness I’m seeing is much higher than it was a couple of years ago,” she said.

Now, Dr. Triana said, patients who are depressed and suicidal are seeking help outside the hospital in day-treatment programs or intensive outpatient therapy.

At the hospital, she said, “our wait list is usually around 20 kids sitting in the ER waiting for a patient bed. Kids wait either in the ER or a medical bed sometimes a week or more waiting for inpatient psychiatry.”

She said while she thinks all of the proposed recommendations are good, “I think what’s difficult is the speed at which any of this can happen."

“We’re in crisis now and we’ve been in crisis for months,” she added.

She said the key will be using what’s already in place – telehealth options to ease the burdens and training more primary care providers in mental health triage.

Joanna Quigley, MD, a child and adolescent psychiatrist at the University of Michigan in Ann Arbor, said in an interview, “It’s very powerful that these three groups came together and made a joint effort and statement to really highlight how serious this problem is across the country.”

She said she sees all of the challenges the leaders of the organizations describe.

At Michigan, she said, as elsewhere, specialists are seeing a large increase in the number of children presenting to the children’s psychiatric ED and the children’s ED and increased demand for outpatient services.

Children in need are waiting “several months” to see either therapists or psychiatrists, she said.

Dr. Quigley said primary care offices are seeing more children and children with higher levels of anxiety and depression as well as self-harm and suicidal thoughts in the pandemic.

She noted that it’s challenging to find providers who are accepting new patients and hard to find providers who take certain kinds of insurance, particularly Medicaid, she said.

Change will take strengthening all the areas of support the organizations’ leaders are calling for, she said.

“School-based interventions are so vital, especially for these children who have been away from an in-person setting and were without services for the time that schools were shut down,” she said.

Dr. Quigley and Dr. Triana report no relevant financial relationships.

The American Academy of Pediatrics (AAP), the American Academy of Child and Adolescent Psychiatry (AACAP) and Children’s Hospital Association have declared a national emergency in children’s mental health.

COVID-19 has taken a serious toll, the organizations say, on top of already mounting challenges. Policy changes are urgently needed, they say.

“Today’s declaration is an urgent call to policymakers at all levels of government – we must treat this mental health crisis like the emergency it is,” AAP President Lee Savio Beers, MD, said in a statement.

The Centers for Disease Control and Prevention found that between March and October 2020, emergency department visits for mental health emergencies rose by 24% for children ages 5-11 years and 31% for children ages 12-17 years. ED visits for suspected suicide attempts increased nearly 51% among girls ages 12-17 years of age in early 2021 compared to the same period in 2019.

Recent data in Pediatrics also show a marked increase in loss of a caregiver and sharp disparities by race and ethnicity.

“We found that from April 1, 2020, through June 30, 2021, over 140,000 children in the U.S. experienced the death of a parent or grandparent caregiver. The risk of such loss was 1.1 to 4.5 times higher among children of racial and ethnic minorities, compared to non-Hispanic White children,” researchers wrote.

“We are caring for young people with soaring rates of depression, anxiety, trauma, loneliness, and suicidality that will have lasting impacts on them, their families, their communities, and all of our futures,” said AACAP President Gabrielle A. Carlson, MD.

Among the actions the groups are calling for are the following:

• Increase federal funding to ensure all families can access mental health services.
• Improve access to telemedicine.
• Accelerate integration of mental health care in pediatric primary care.
• Fully fund community-based systems of care that connect families to evidence-based interventions.
• Promote and pay for trauma-informed care services.
• Address workforce challenges so that children can access mental health services wherever they live.

The organizations represent more than 77,000 physician members and more than 200 children’s hospitals.

Jenna Triana, MD, a child and adolescent psychiatrist at the University of Minnesota, Minneapolis, said in an interview that while specific institutions such as the University of Colorado have declared emergencies in pediatric mental health, declaring a national emergency is important.

She said the timing is important because fall is typically a heavy time for pediatric psychiatry with children and adolescents returning to school, and it is especially pronounced with the pandemic.

The usual diagnoses providers are seeing “are all worse,” she said.

“The bar for getting admission to the hospital has been raised because we’re such a limited resource. We’ve had to be so thoughtful about who truly, truly needs admission and who can come up with some kind of safe plan for outside of the hospital,” Dr. Triana said.

“The patients I’m seeing in the hospital – the level of illness I’m seeing is much higher than it was a couple of years ago,” she said.

Now, Dr. Triana said, patients who are depressed and suicidal are seeking help outside the hospital in day-treatment programs or intensive outpatient therapy.

At the hospital, she said, “our wait list is usually around 20 kids sitting in the ER waiting for a patient bed. Kids wait either in the ER or a medical bed sometimes a week or more waiting for inpatient psychiatry.”

She said while she thinks all of the proposed recommendations are good, “I think what’s difficult is the speed at which any of this can happen."

“We’re in crisis now and we’ve been in crisis for months,” she added.

She said the key will be using what’s already in place – telehealth options to ease the burdens and training more primary care providers in mental health triage.

Joanna Quigley, MD, a child and adolescent psychiatrist at the University of Michigan in Ann Arbor, said in an interview, “It’s very powerful that these three groups came together and made a joint effort and statement to really highlight how serious this problem is across the country.”

She said she sees all of the challenges the leaders of the organizations describe.

At Michigan, she said, as elsewhere, specialists are seeing a large increase in the number of children presenting to the children’s psychiatric ED and the children’s ED and increased demand for outpatient services.

Children in need are waiting “several months” to see either therapists or psychiatrists, she said.

Dr. Quigley said primary care offices are seeing more children and children with higher levels of anxiety and depression as well as self-harm and suicidal thoughts in the pandemic.

She noted that it’s challenging to find providers who are accepting new patients and hard to find providers who take certain kinds of insurance, particularly Medicaid, she said.

Change will take strengthening all the areas of support the organizations’ leaders are calling for, she said.

“School-based interventions are so vital, especially for these children who have been away from an in-person setting and were without services for the time that schools were shut down,” she said.

Dr. Quigley and Dr. Triana report no relevant financial relationships.

The American Academy of Pediatrics (AAP), the American Academy of Child and Adolescent Psychiatry (AACAP) and Children’s Hospital Association have declared a national emergency in children’s mental health.

COVID-19 has taken a serious toll, the organizations say, on top of already mounting challenges. Policy changes are urgently needed, they say.

“Today’s declaration is an urgent call to policymakers at all levels of government – we must treat this mental health crisis like the emergency it is,” AAP President Lee Savio Beers, MD, said in a statement.

The Centers for Disease Control and Prevention found that between March and October 2020, emergency department visits for mental health emergencies rose by 24% for children ages 5-11 years and 31% for children ages 12-17 years. ED visits for suspected suicide attempts increased nearly 51% among girls ages 12-17 years of age in early 2021 compared to the same period in 2019.

Recent data in Pediatrics also show a marked increase in loss of a caregiver and sharp disparities by race and ethnicity.

“We found that from April 1, 2020, through June 30, 2021, over 140,000 children in the U.S. experienced the death of a parent or grandparent caregiver. The risk of such loss was 1.1 to 4.5 times higher among children of racial and ethnic minorities, compared to non-Hispanic White children,” researchers wrote.

“We are caring for young people with soaring rates of depression, anxiety, trauma, loneliness, and suicidality that will have lasting impacts on them, their families, their communities, and all of our futures,” said AACAP President Gabrielle A. Carlson, MD.

Among the actions the groups are calling for are the following:

• Increase federal funding to ensure all families can access mental health services.
• Improve access to telemedicine.
• Accelerate integration of mental health care in pediatric primary care.
• Fully fund community-based systems of care that connect families to evidence-based interventions.
• Promote and pay for trauma-informed care services.
• Address workforce challenges so that children can access mental health services wherever they live.

The organizations represent more than 77,000 physician members and more than 200 children’s hospitals.

Jenna Triana, MD, a child and adolescent psychiatrist at the University of Minnesota, Minneapolis, said in an interview that while specific institutions such as the University of Colorado have declared emergencies in pediatric mental health, declaring a national emergency is important.

She said the timing is important because fall is typically a heavy time for pediatric psychiatry with children and adolescents returning to school, and it is especially pronounced with the pandemic.

The usual diagnoses providers are seeing “are all worse,” she said.

“The bar for getting admission to the hospital has been raised because we’re such a limited resource. We’ve had to be so thoughtful about who truly, truly needs admission and who can come up with some kind of safe plan for outside of the hospital,” Dr. Triana said.

“The patients I’m seeing in the hospital – the level of illness I’m seeing is much higher than it was a couple of years ago,” she said.

Now, Dr. Triana said, patients who are depressed and suicidal are seeking help outside the hospital in day-treatment programs or intensive outpatient therapy.

At the hospital, she said, “our wait list is usually around 20 kids sitting in the ER waiting for a patient bed. Kids wait either in the ER or a medical bed sometimes a week or more waiting for inpatient psychiatry.”

She said while she thinks all of the proposed recommendations are good, “I think what’s difficult is the speed at which any of this can happen."

“We’re in crisis now and we’ve been in crisis for months,” she added.

She said the key will be using what’s already in place – telehealth options to ease the burdens and training more primary care providers in mental health triage.

Joanna Quigley, MD, a child and adolescent psychiatrist at the University of Michigan in Ann Arbor, said in an interview, “It’s very powerful that these three groups came together and made a joint effort and statement to really highlight how serious this problem is across the country.”

She said she sees all of the challenges the leaders of the organizations describe.

At Michigan, she said, as elsewhere, specialists are seeing a large increase in the number of children presenting to the children’s psychiatric ED and the children’s ED and increased demand for outpatient services.

Children in need are waiting “several months” to see either therapists or psychiatrists, she said.

Dr. Quigley said primary care offices are seeing more children and children with higher levels of anxiety and depression as well as self-harm and suicidal thoughts in the pandemic.

She noted that it’s challenging to find providers who are accepting new patients and hard to find providers who take certain kinds of insurance, particularly Medicaid, she said.

Change will take strengthening all the areas of support the organizations’ leaders are calling for, she said.

“School-based interventions are so vital, especially for these children who have been away from an in-person setting and were without services for the time that schools were shut down,” she said.

Dr. Quigley and Dr. Triana report no relevant financial relationships.

Someday I plan to retire.

Hopefully it’s not coming up anytime soon, but I’m sure it’s sooner than I realize. I’ve been in practice for 23 years, so I’m well past the halfway point of an average medical career.

I will miss a lot. There will be many things I won’t miss, but the job has far more good than bad, even today.

I’ve spent a lot of time at this huge desk, which my dad bought for his solo law practice in 1967. Although I won’t miss the lack of sleep, I will miss the silence of getting to the office before first light, making tea, and getting started for the day. It’s a peaceful daily start in a less-then-predictable job.

I’ll miss my patients. Not all of them, but most. The majority are decent people, and it’s an honor to be able to help them. Doing that has been the driving force that started me on this path a long time ago and still keeps me moving forward.

In some respects I’ll feel bad about retiring and leaving them. Some have been with me since residency. It will bother me that they’ll have to start over with a new neurologist. Hopefully that person will give them care as good, if not better, than I have.

I’ll really miss my staff. I’ve been lucky. They’re awesome, and have stayed with me for this crazy ride. My MA has been here since 1999, my secretary since 2004. At work they’re my family. Away from work they’re a part of my family. The three of us have survived my hospital call, good economic times, bad economic times, moving the office, my MA moving to the boondocks, the antics and events of our kids, and, as of now, a pandemic. They make the day fun. I’ll feel bad that they’ll need to change jobs if they’re still working then.

What I won’t miss are more concrete things – the endless forms, time spent on the phone and online to get medications and tests approved, the difficult (personality wise) patients who think being nasty and mean is going to get them better care, and having to practice CYA defensive medicine.

Medicine is a far from perfect job. But, in the overall balance of my life, it continues to be what I enjoy getting up and doing every day. It’s good to look back after 23 years, and still have, overall, no regrets about choosing this ride.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Someday I plan to retire.

Hopefully it’s not coming up anytime soon, but I’m sure it’s sooner than I realize. I’ve been in practice for 23 years, so I’m well past the halfway point of an average medical career.

I will miss a lot. There will be many things I won’t miss, but the job has far more good than bad, even today.

I’ve spent a lot of time at this huge desk, which my dad bought for his solo law practice in 1967. Although I won’t miss the lack of sleep, I will miss the silence of getting to the office before first light, making tea, and getting started for the day. It’s a peaceful daily start in a less-then-predictable job.

I’ll miss my patients. Not all of them, but most. The majority are decent people, and it’s an honor to be able to help them. Doing that has been the driving force that started me on this path a long time ago and still keeps me moving forward.

In some respects I’ll feel bad about retiring and leaving them. Some have been with me since residency. It will bother me that they’ll have to start over with a new neurologist. Hopefully that person will give them care as good, if not better, than I have.

I’ll really miss my staff. I’ve been lucky. They’re awesome, and have stayed with me for this crazy ride. My MA has been here since 1999, my secretary since 2004. At work they’re my family. Away from work they’re a part of my family. The three of us have survived my hospital call, good economic times, bad economic times, moving the office, my MA moving to the boondocks, the antics and events of our kids, and, as of now, a pandemic. They make the day fun. I’ll feel bad that they’ll need to change jobs if they’re still working then.

What I won’t miss are more concrete things – the endless forms, time spent on the phone and online to get medications and tests approved, the difficult (personality wise) patients who think being nasty and mean is going to get them better care, and having to practice CYA defensive medicine.

Medicine is a far from perfect job. But, in the overall balance of my life, it continues to be what I enjoy getting up and doing every day. It’s good to look back after 23 years, and still have, overall, no regrets about choosing this ride.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Someday I plan to retire.

Hopefully it’s not coming up anytime soon, but I’m sure it’s sooner than I realize. I’ve been in practice for 23 years, so I’m well past the halfway point of an average medical career.

I will miss a lot. There will be many things I won’t miss, but the job has far more good than bad, even today.

I’ve spent a lot of time at this huge desk, which my dad bought for his solo law practice in 1967. Although I won’t miss the lack of sleep, I will miss the silence of getting to the office before first light, making tea, and getting started for the day. It’s a peaceful daily start in a less-then-predictable job.

I’ll miss my patients. Not all of them, but most. The majority are decent people, and it’s an honor to be able to help them. Doing that has been the driving force that started me on this path a long time ago and still keeps me moving forward.

In some respects I’ll feel bad about retiring and leaving them. Some have been with me since residency. It will bother me that they’ll have to start over with a new neurologist. Hopefully that person will give them care as good, if not better, than I have.

I’ll really miss my staff. I’ve been lucky. They’re awesome, and have stayed with me for this crazy ride. My MA has been here since 1999, my secretary since 2004. At work they’re my family. Away from work they’re a part of my family. The three of us have survived my hospital call, good economic times, bad economic times, moving the office, my MA moving to the boondocks, the antics and events of our kids, and, as of now, a pandemic. They make the day fun. I’ll feel bad that they’ll need to change jobs if they’re still working then.

What I won’t miss are more concrete things – the endless forms, time spent on the phone and online to get medications and tests approved, the difficult (personality wise) patients who think being nasty and mean is going to get them better care, and having to practice CYA defensive medicine.

Medicine is a far from perfect job. But, in the overall balance of my life, it continues to be what I enjoy getting up and doing every day. It’s good to look back after 23 years, and still have, overall, no regrets about choosing this ride.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

How did toilet paper become the unofficial symbol of anxiety during the pandemic? Empty store shelves are a stark reminder of how COVID-19 has taken a toll on people.

gmcoop/E+

At the beginning of the pandemic, stay-at-home orders drove people to buy large amounts of household goods, especially toilet paper. Demand grew to unforeseen heights in March 2020, with $1.45 billion in toilet paper sales in the 4-week period ending March 29, up 112% from the year before, according to IRI, a Chicago-based market research firm.

As the Delta variant drove a COVID-19 resurgence this summer, market research suggests that almost one in two Americans started stockpiling toilet paper again over fears that supply would run out. The higher demand causes ripples through the retail chain, and a growing number of stores are again facing challenges in stocking toilet paper.

Yet there is plenty for everyone if people don’t stockpile too much, according to paper industry market analyst Ronalds Gonzalez, PhD, an associate professor of conversion economics and sustainability at North Carolina State University, Raleigh.

“As long as people buy what they actually need and don’t get into a panic, there won’t be any issue with the supply of hygienic tissue,” he says, adding that “too much” would equate to stockpiling 6-8 months’ worth of toilet paper, as some people did early in the pandemic.

But retailers are worried that history will repeat itself. In late September 2021, warehouse retail giant Costco told Wall Street analysts that it decided to limit customer purchases of essential items like toilet paper and water. Another retailer, Sam’s Club, began limiting customer purchases of supplies like toilet paper at the end of July.

“We are wired to run with the herd,” says Bradley Klontz, PsyD, an associate professor of practice at Creighton University Heider College of Business, Omaha, N.E., who specializes in financial psychology.

“Quite literally, the last person to get to Costco doesn’t get the toilet paper, so when the herd is running in a certain direction, we feel a biological imperative to not be that last person. That fear of scarcity actually creates the experience of scarcity,” he explains.
 

The science behind the stockpile

People are collectively alerted by photos shared on social media showing store shelves stripped of toilet paper. Those images triggered consumers to rush out and buy bathroom tissue, even if they didn’t need it – and that herd behavior created toilet paper shortages.

Now, a year and half into the pandemic, people are hypervigilant to danger. Any hint of a possible toilet paper shortage can provoke anxiety and the desire to stockpile.

“It’s an adaptive response to having just gone through the experience” of seeing empty store shelves, says Dr. Klontz. He advises people to take a deep breath before buying extra toilet paper and then assess whether it is truly needed.

Deep in our brains is the limbic system, a group of structures that rules over emotions, motivation, reward, learning, memory, and the fight-or-flight response to stress and danger. When a person senses danger, the brain activates hormones to raise blood pressure and heart rate, increase blood flow, and boost the breath rate, making the body ready to fight or flee under threat.

Once everything settles, the body activates chemicals like dopamine that bring on positive feelings of well-being, rewarding that flight-or-fight response. In this way, the brain powerfully reinforces a key survival instinct.

This sequence of experiences and the brain chemistry behind them may explain why people panic-buy toilet paper.

“With toilet paper, my limbic system starts thinking about a perceived threat to safety,” says Julie Pike, PhD, a psychologist in Chapel Hill, N.C., who specializes in anxiety, hoarding, and posttraumatic stress disorder.

She notes that, in stockpiling toilet paper, “we avoid a perceived threat and then we are chemically rewarded” with dopamine. A storage closet full of toilet paper after a perceived threat of scarcity – no matter how unfounded – brings on that satisfied feeling.
 

When the market shifted

Paper producers make hygiene paper for two markets: the commercial (think: those big rolls of thin paper used in offices, schools, and restaurants) and the consumer (the soft paper you likely use at home). In the spring of 2020, the commercial market plummeted, and the consumer market skyrocketed.

Generally, the consumer toilet paper market is steady. The average American uses about 57 toilet sheets a day and about 50 pounds annually. Grocery stores and other retailers keep just enough toilet paper on hand to meet this steady demand, meaning panic buying at the start of the pandemic quickly depleted stocks. Paper makers had to change production to meet higher consumer demand and fewer commercial buyers.

By the end of the summer of 2020, toilet paper makers had adjusted for the market shift and caught up with demand, as consumers worked through their stockpiles of paper. But retail inventories remain lean because toilet paper doesn’t carry huge profit margins. For this reason, even healthy stocks remain sensitive to sudden shifts in consumer demand, Dr. Gonzalez says.

“If people buy more than they should, then they are just buying from other people,” creating an unnecessary scarcity of toilet paper, he says.
 

The supply chain

It is true that the supply chain is under unprecedented strain, leading to higher prices for many goods, says Katie Denis, vice president of research and industry narrative at the Consumer Brands Association, Washington, which represents toilet paper makers Georgia-Pacific and Procter & Gamble. Consumers should expect toilet paper to be available, but there may be fewer options for product sizes, she says.

Still, Dr. Gonzalez says consumers should not worry too much about the global supply chain affecting the domestic toilet paper supply. The raw material for toilet paper production is available domestically, and more than 97% of the supply on U.S. retailer shelves is made in the United States, he says.

In modern society, toilet paper is a primary link to civilization, health, and hygiene. While there is no easy substitute, alternatives do exist A bidet, for example, is a device that can spray water on the genital area. Other options are reusable cloths, sponges, baby wipes, napkins, towels, and washcloths.
 

Human health and hygiene

“Compared to many other items, toilet paper can’t really be replaced,” says Frank H. Farley, PhD, a professor of psychological studies in education at Temple University, who studies human motivation. “It is a unique consumer item that is perceived to be extremely necessary. In that way, it plays into that survivor mentality, that having it is necessary for survival.”

Being without it can truly seem like an existential threat.

New York City emergency planner Ira Tannenbaum advises families to assess their usage of essential household supplies like toilet paper (you can do so through this toilet paper calculator) and keep at least a 1-week supply on hand in case of emergency. New York City has posted recommendations to families for emergency planning, including the guidance to “avoid panic buying.”

Dr. Pike says she would stockpile a bit more, something that could be done gradually, before there’s a panic. She says that if people are tempted to buy more out of anxiety, they should remind themselves that shortages arise because of panicky purchasing.

“Leave some for other families – other people have children and partners and siblings just like us,” she says.

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

How did toilet paper become the unofficial symbol of anxiety during the pandemic? Empty store shelves are a stark reminder of how COVID-19 has taken a toll on people.

gmcoop/E+

At the beginning of the pandemic, stay-at-home orders drove people to buy large amounts of household goods, especially toilet paper. Demand grew to unforeseen heights in March 2020, with $1.45 billion in toilet paper sales in the 4-week period ending March 29, up 112% from the year before, according to IRI, a Chicago-based market research firm.

As the Delta variant drove a COVID-19 resurgence this summer, market research suggests that almost one in two Americans started stockpiling toilet paper again over fears that supply would run out. The higher demand causes ripples through the retail chain, and a growing number of stores are again facing challenges in stocking toilet paper.

Yet there is plenty for everyone if people don’t stockpile too much, according to paper industry market analyst Ronalds Gonzalez, PhD, an associate professor of conversion economics and sustainability at North Carolina State University, Raleigh.

“As long as people buy what they actually need and don’t get into a panic, there won’t be any issue with the supply of hygienic tissue,” he says, adding that “too much” would equate to stockpiling 6-8 months’ worth of toilet paper, as some people did early in the pandemic.

But retailers are worried that history will repeat itself. In late September 2021, warehouse retail giant Costco told Wall Street analysts that it decided to limit customer purchases of essential items like toilet paper and water. Another retailer, Sam’s Club, began limiting customer purchases of supplies like toilet paper at the end of July.

“We are wired to run with the herd,” says Bradley Klontz, PsyD, an associate professor of practice at Creighton University Heider College of Business, Omaha, N.E., who specializes in financial psychology.

“Quite literally, the last person to get to Costco doesn’t get the toilet paper, so when the herd is running in a certain direction, we feel a biological imperative to not be that last person. That fear of scarcity actually creates the experience of scarcity,” he explains.
 

The science behind the stockpile

People are collectively alerted by photos shared on social media showing store shelves stripped of toilet paper. Those images triggered consumers to rush out and buy bathroom tissue, even if they didn’t need it – and that herd behavior created toilet paper shortages.

Now, a year and half into the pandemic, people are hypervigilant to danger. Any hint of a possible toilet paper shortage can provoke anxiety and the desire to stockpile.

“It’s an adaptive response to having just gone through the experience” of seeing empty store shelves, says Dr. Klontz. He advises people to take a deep breath before buying extra toilet paper and then assess whether it is truly needed.

Deep in our brains is the limbic system, a group of structures that rules over emotions, motivation, reward, learning, memory, and the fight-or-flight response to stress and danger. When a person senses danger, the brain activates hormones to raise blood pressure and heart rate, increase blood flow, and boost the breath rate, making the body ready to fight or flee under threat.

Once everything settles, the body activates chemicals like dopamine that bring on positive feelings of well-being, rewarding that flight-or-fight response. In this way, the brain powerfully reinforces a key survival instinct.

This sequence of experiences and the brain chemistry behind them may explain why people panic-buy toilet paper.

“With toilet paper, my limbic system starts thinking about a perceived threat to safety,” says Julie Pike, PhD, a psychologist in Chapel Hill, N.C., who specializes in anxiety, hoarding, and posttraumatic stress disorder.

She notes that, in stockpiling toilet paper, “we avoid a perceived threat and then we are chemically rewarded” with dopamine. A storage closet full of toilet paper after a perceived threat of scarcity – no matter how unfounded – brings on that satisfied feeling.
 

When the market shifted

Paper producers make hygiene paper for two markets: the commercial (think: those big rolls of thin paper used in offices, schools, and restaurants) and the consumer (the soft paper you likely use at home). In the spring of 2020, the commercial market plummeted, and the consumer market skyrocketed.

Generally, the consumer toilet paper market is steady. The average American uses about 57 toilet sheets a day and about 50 pounds annually. Grocery stores and other retailers keep just enough toilet paper on hand to meet this steady demand, meaning panic buying at the start of the pandemic quickly depleted stocks. Paper makers had to change production to meet higher consumer demand and fewer commercial buyers.

By the end of the summer of 2020, toilet paper makers had adjusted for the market shift and caught up with demand, as consumers worked through their stockpiles of paper. But retail inventories remain lean because toilet paper doesn’t carry huge profit margins. For this reason, even healthy stocks remain sensitive to sudden shifts in consumer demand, Dr. Gonzalez says.

“If people buy more than they should, then they are just buying from other people,” creating an unnecessary scarcity of toilet paper, he says.
 

The supply chain

It is true that the supply chain is under unprecedented strain, leading to higher prices for many goods, says Katie Denis, vice president of research and industry narrative at the Consumer Brands Association, Washington, which represents toilet paper makers Georgia-Pacific and Procter & Gamble. Consumers should expect toilet paper to be available, but there may be fewer options for product sizes, she says.

Still, Dr. Gonzalez says consumers should not worry too much about the global supply chain affecting the domestic toilet paper supply. The raw material for toilet paper production is available domestically, and more than 97% of the supply on U.S. retailer shelves is made in the United States, he says.

In modern society, toilet paper is a primary link to civilization, health, and hygiene. While there is no easy substitute, alternatives do exist A bidet, for example, is a device that can spray water on the genital area. Other options are reusable cloths, sponges, baby wipes, napkins, towels, and washcloths.
 

Human health and hygiene

“Compared to many other items, toilet paper can’t really be replaced,” says Frank H. Farley, PhD, a professor of psychological studies in education at Temple University, who studies human motivation. “It is a unique consumer item that is perceived to be extremely necessary. In that way, it plays into that survivor mentality, that having it is necessary for survival.”

Being without it can truly seem like an existential threat.

New York City emergency planner Ira Tannenbaum advises families to assess their usage of essential household supplies like toilet paper (you can do so through this toilet paper calculator) and keep at least a 1-week supply on hand in case of emergency. New York City has posted recommendations to families for emergency planning, including the guidance to “avoid panic buying.”

Dr. Pike says she would stockpile a bit more, something that could be done gradually, before there’s a panic. She says that if people are tempted to buy more out of anxiety, they should remind themselves that shortages arise because of panicky purchasing.

“Leave some for other families – other people have children and partners and siblings just like us,” she says.

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

How did toilet paper become the unofficial symbol of anxiety during the pandemic? Empty store shelves are a stark reminder of how COVID-19 has taken a toll on people.

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At the beginning of the pandemic, stay-at-home orders drove people to buy large amounts of household goods, especially toilet paper. Demand grew to unforeseen heights in March 2020, with $1.45 billion in toilet paper sales in the 4-week period ending March 29, up 112% from the year before, according to IRI, a Chicago-based market research firm.

As the Delta variant drove a COVID-19 resurgence this summer, market research suggests that almost one in two Americans started stockpiling toilet paper again over fears that supply would run out. The higher demand causes ripples through the retail chain, and a growing number of stores are again facing challenges in stocking toilet paper.

Yet there is plenty for everyone if people don’t stockpile too much, according to paper industry market analyst Ronalds Gonzalez, PhD, an associate professor of conversion economics and sustainability at North Carolina State University, Raleigh.

“As long as people buy what they actually need and don’t get into a panic, there won’t be any issue with the supply of hygienic tissue,” he says, adding that “too much” would equate to stockpiling 6-8 months’ worth of toilet paper, as some people did early in the pandemic.

But retailers are worried that history will repeat itself. In late September 2021, warehouse retail giant Costco told Wall Street analysts that it decided to limit customer purchases of essential items like toilet paper and water. Another retailer, Sam’s Club, began limiting customer purchases of supplies like toilet paper at the end of July.

“We are wired to run with the herd,” says Bradley Klontz, PsyD, an associate professor of practice at Creighton University Heider College of Business, Omaha, N.E., who specializes in financial psychology.

“Quite literally, the last person to get to Costco doesn’t get the toilet paper, so when the herd is running in a certain direction, we feel a biological imperative to not be that last person. That fear of scarcity actually creates the experience of scarcity,” he explains.
 

The science behind the stockpile

People are collectively alerted by photos shared on social media showing store shelves stripped of toilet paper. Those images triggered consumers to rush out and buy bathroom tissue, even if they didn’t need it – and that herd behavior created toilet paper shortages.

Now, a year and half into the pandemic, people are hypervigilant to danger. Any hint of a possible toilet paper shortage can provoke anxiety and the desire to stockpile.

“It’s an adaptive response to having just gone through the experience” of seeing empty store shelves, says Dr. Klontz. He advises people to take a deep breath before buying extra toilet paper and then assess whether it is truly needed.

Deep in our brains is the limbic system, a group of structures that rules over emotions, motivation, reward, learning, memory, and the fight-or-flight response to stress and danger. When a person senses danger, the brain activates hormones to raise blood pressure and heart rate, increase blood flow, and boost the breath rate, making the body ready to fight or flee under threat.

Once everything settles, the body activates chemicals like dopamine that bring on positive feelings of well-being, rewarding that flight-or-fight response. In this way, the brain powerfully reinforces a key survival instinct.

This sequence of experiences and the brain chemistry behind them may explain why people panic-buy toilet paper.

“With toilet paper, my limbic system starts thinking about a perceived threat to safety,” says Julie Pike, PhD, a psychologist in Chapel Hill, N.C., who specializes in anxiety, hoarding, and posttraumatic stress disorder.

She notes that, in stockpiling toilet paper, “we avoid a perceived threat and then we are chemically rewarded” with dopamine. A storage closet full of toilet paper after a perceived threat of scarcity – no matter how unfounded – brings on that satisfied feeling.
 

When the market shifted

Paper producers make hygiene paper for two markets: the commercial (think: those big rolls of thin paper used in offices, schools, and restaurants) and the consumer (the soft paper you likely use at home). In the spring of 2020, the commercial market plummeted, and the consumer market skyrocketed.

Generally, the consumer toilet paper market is steady. The average American uses about 57 toilet sheets a day and about 50 pounds annually. Grocery stores and other retailers keep just enough toilet paper on hand to meet this steady demand, meaning panic buying at the start of the pandemic quickly depleted stocks. Paper makers had to change production to meet higher consumer demand and fewer commercial buyers.

By the end of the summer of 2020, toilet paper makers had adjusted for the market shift and caught up with demand, as consumers worked through their stockpiles of paper. But retail inventories remain lean because toilet paper doesn’t carry huge profit margins. For this reason, even healthy stocks remain sensitive to sudden shifts in consumer demand, Dr. Gonzalez says.

“If people buy more than they should, then they are just buying from other people,” creating an unnecessary scarcity of toilet paper, he says.
 

The supply chain

It is true that the supply chain is under unprecedented strain, leading to higher prices for many goods, says Katie Denis, vice president of research and industry narrative at the Consumer Brands Association, Washington, which represents toilet paper makers Georgia-Pacific and Procter & Gamble. Consumers should expect toilet paper to be available, but there may be fewer options for product sizes, she says.

Still, Dr. Gonzalez says consumers should not worry too much about the global supply chain affecting the domestic toilet paper supply. The raw material for toilet paper production is available domestically, and more than 97% of the supply on U.S. retailer shelves is made in the United States, he says.

In modern society, toilet paper is a primary link to civilization, health, and hygiene. While there is no easy substitute, alternatives do exist A bidet, for example, is a device that can spray water on the genital area. Other options are reusable cloths, sponges, baby wipes, napkins, towels, and washcloths.
 

Human health and hygiene

“Compared to many other items, toilet paper can’t really be replaced,” says Frank H. Farley, PhD, a professor of psychological studies in education at Temple University, who studies human motivation. “It is a unique consumer item that is perceived to be extremely necessary. In that way, it plays into that survivor mentality, that having it is necessary for survival.”

Being without it can truly seem like an existential threat.

New York City emergency planner Ira Tannenbaum advises families to assess their usage of essential household supplies like toilet paper (you can do so through this toilet paper calculator) and keep at least a 1-week supply on hand in case of emergency. New York City has posted recommendations to families for emergency planning, including the guidance to “avoid panic buying.”

Dr. Pike says she would stockpile a bit more, something that could be done gradually, before there’s a panic. She says that if people are tempted to buy more out of anxiety, they should remind themselves that shortages arise because of panicky purchasing.

“Leave some for other families – other people have children and partners and siblings just like us,” she says.

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

The catastrophic collapse of the Surfside, Fla., Champlain Towers South left ambiguous loss, trauma, grief, and other psychiatric and psychological sequelae in its wake.

Now that a few months have passed since the tragedy, which took the lives of 98 residents, it is helpful to examine the psychiatric and psychological support efforts that emerged.

We can think of those support efforts as operating on two tracks: one was pursued by mental health professionals representing numerous organizations; the other was pursued by local, regional, and international first responders – specifically, by Israeli Defense Force (IDF) members who came to our community at the request of Surfside families.

Those efforts were guided by existing frameworks for crisis response designed to provide containment amid the naturally disorganizing effects of the trauma and ambiguous loss. In retrospect, it was clear that the mechanisms by which those frameworks coalesced and functioned were more implicit and organically synchronous than explicitly coordinated and agreed upon. As the rescue and support efforts proceeded, and a unique “Surfside collapse community” formed; key themes emerged and revealed intrinsic links between the first-responder/search and rescue and psychological strategies.

In this article, we discuss relevant themes and parallels between the psychological intervention/strategies and the first-responder disaster response and the practical utility of implementing an integrated strategy. Our hope is that a better understanding of these strategies will help future therapists and responders who respond to crises.
 

Setting the frame

The importance of setting a psychotherapeutic frame is indisputable regardless of theoretical orientation or therapeutic modality. Predictable, consistent conditions under which therapy takes place support a patient’s capacity to tolerate the ambiguous and unpredictable aspects of the process. Those “rules of engagement” provide a structure where subjective experiences can be formulated, organized, understood, and integrated. Twice-daily briefs held in a centralized location (dubbed the Surfside “family center”) paralleled this frame and served that same containing function by offering structure, order, and predictability amid the palpable chaos of ambiguous loss and traumatic grief. Those briefs provided key information on the status of the operation and described the rescue strategy. These were led by the Miami-Dade assistant fire chief and IDF colonel (E.E.), who presented a unified front and consistent presence.

It is essential that briefings such as these be coordinated (and unified) with clear expectations about ground rules, much like what is involved in therapeutic informed consent. In this context, rules included permissions related to documentation of meetings, information sharing, and rules of communication with the media in an effort to protect the vulnerable.

The centralized meeting location served as an important center of gravity and unified place of waiting and information receipt. It provided a dedicated space to meet with humanitarian aid organizations and government officials, and symbolized continuity, consistency, ease of information transmission, and a place where practical needs could be addressed. Meals, toiletries, and other supplies were provided to simplify and maintain daily routines. Those are otherwise unremarkable practices that seemed impossible to manage amid a crisis, yet can be inherently grounding and emotionally organizing when facing deep psychological fragmentation.

Meeting in person allowed the IDF to offer operational visuals to allow those affected to feel less helpless and cultivate a sense of purpose by being part of the strategy/mission. Their strategy included “population intelligence,” which was aimed at both information gathering to practically facilitate the rescue/recovery process (for example, locating victims, property, and recreating a visual of how the building fell), and inspiring people to participate. This engagement helped many transition from a place of denial/repression to acknowledging loss/grief, and from a passive to active part of the effort, in a way that was safe and realistic – as opposed to going to the site and aiding themselves, as some had requested.

Naturally, a central location made it possible to offer immediate psychological assistance and support. Clinicians responding to crisis should be carefully selected in light of the immense suffering, emotional vulnerability, and heightened reactivity of those affected. People were overwhelmed by deep sorrow, fear, anger, and uncertainty, vacillating between hope and despair, and mobilized by a desire to help. Those providing support need to be interpersonally skilled and able to regulate their own emotions. They must be able to formulate – in real time – an understanding of what is needed, and implement a strategic plan. Like first responders, it is also key for providers to be easily accessible and identifiable in uniform so that people in the grip of a survival response can easily identify and elicit support.

The power of strategy

The Israeli delegation and mental health approaches were aligned with respect to cultivating a team identity and keeping the team spirit elevated. The delegation’s approach was to deemphasize rank during the mission in that everyone was responsible for anything that was needed and no task was below anyone’s rank. The same was true for the mental health support response: Early interventions were focused on addressing practical needs – providing blankets, water, chargers, food, and a calming presence to counter the initial chaos. No task was too small, regardless of title or role. As more structure and order ensued, it was possible to offer more traditional crisis-related interventions aimed at grounding those affected.

Both teams worked to ensure 24-hour coverage, which was crucial given the need for consistency and continuity. Our commitment was to support the victims’ families and survivors by fully embracing the chaos and the situational demands, offering attunement and support, and satisfying both basic and higher-level needs. We divided and conquered work, observed signals of need, offered immediate support where necessary, and coordinated longer-term care plans when possible. The importance of ongoing self-care, consultation, and debriefing while doing this work cannot be overstated. Time to address basic needs and the impact of vicarious trauma as a team must be built in.
 

Importance of flexibility

This tragedy came with unique complexities and sensitivities that needed to be identified expediently and addressed with a concrete, comprehensive plan. This was true for both the rescue and psychological support efforts, and flexibility was key. There was nothing traditional about our work from a therapeutic perspective – we found quiet corners and empty offices, went for walks, met in lobbies, and checked in by phone. The interventions were brief.

Roles shifted often between aiding in addressing practical needs, advocating for victims and connecting them to appropriate resources, supporting the police in making death notifications, providing support and space for processing during and after briefings, and more.

Similarly, the rescue team constantly reevaluated their strategy because of what they discovered as they dismantled the collapsed building, in addition to managing external impacting factors (heat, rain, lightning, and the threat of the remaining structure falling).
 

Language matters

The iteration of commitment to the families/victims/mission and to work speedily and efficiently was important for both rescuers and therapists. It was key during the briefings for the chief and colonel (E.E.) to share information in a manner that was professional, discreet, honest and explicit. Their willingness and ability to be vulnerable and to share their personal feelings as active rescuers humanized them. Their approach was matter of fact, yet warm, loving, and containing, all of which conveyed dignity and respect.

Word choice mattered, and the IDF’s intentional choice to refer to recovered victims as “souls,” rather than “bodies,” conveyed their sensitivity to the intensity of anguish, depth of loss, and gravity of the situation. From a psychological perspective, the transition between “rescue” efforts signifying the potential saving of lives to “recovery” of bodies or remains was significant and demarcated a dramatic shift. The weeks-long efforts, once painfully slow, then felt too abrupt to process.

One extraordinary moment was the chief’s response to the families’ discomfort at the news of the switch from rescue to recovery. The families were anxious about losing the structure that the briefings provided and were apprehensive about the handoff from fire to the police department. With great compassion and attunement, he assured them that he would stay with them, and they together, as a family, would decide when to conclude the in-person briefings. The colonel (E.E.), too, provided assurance that neither procedure nor the urgency of the recovery would change. It was both heart-warming and containing that information related to the operation was shared in a clear manner, and that the thought process and rationale behind major decisions (e.g., demolishing the remaining building, decision to pause operations, switch from rescue to recovery) was shared. It was useful for the clinicians to be aware of this rationale in helping individuals metabolize the information and process the associated trauma and grief.
 

Unification is key

Surfside has left an indelible impact on us. We saw and experienced unity in many respects – clinicians from various backgrounds collaborating, families bonding and caring for one another, community support and solidarity, and the cooperation and coordination of the search and rescue teams. The diverse groups providing support came to feel like a family, and the importance of inter- and intrateam integration cannot be overstated. We were transformed both by our professional collaborations and authentic connections with those affected, and will forever cherish the experience, one another, the families, and the souls lost.

Dr. Feldman is a licensed clinical psychologist in private practice in Miami. She is an adjunct professor in the college of psychology at Nova Southeastern University, Fort Lauderdale, Fla., where she teaches clinical psychology doctoral students. She also serves on the board of directors of The Southeast Florida Association for Psychoanalytic Psychology. Dr. Feldman has no disclosures. Col. Edri is the Israeli Defense Forces District Commander of the Home Front Command Haifa District. He served as the deputy commander for the Israeli Defense Forces Search and Rescue Delegation, which was brought in to provide international aid to the local and domestic forces responding to the Surfside, Fla., building collapse. Col. Edri has no disclosures. Dr. Davidtz is a licensed psychologist and associate professor in the College of Psychology at Nova Southeastern University, Fort Lauderdale, Fla., where she is director of internship training for the Psychology Services Center and director of psychological services for the emotionally distressed, a specialty clinic that serves people with serious mental illness and personality disorders. She also maintains a part-time private practice specializing in the treatment of complex posttraumatic conditions and personality disorders. Dr. Davidtz has no disclosures.

The catastrophic collapse of the Surfside, Fla., Champlain Towers South left ambiguous loss, trauma, grief, and other psychiatric and psychological sequelae in its wake.

Now that a few months have passed since the tragedy, which took the lives of 98 residents, it is helpful to examine the psychiatric and psychological support efforts that emerged.

We can think of those support efforts as operating on two tracks: one was pursued by mental health professionals representing numerous organizations; the other was pursued by local, regional, and international first responders – specifically, by Israeli Defense Force (IDF) members who came to our community at the request of Surfside families.

Those efforts were guided by existing frameworks for crisis response designed to provide containment amid the naturally disorganizing effects of the trauma and ambiguous loss. In retrospect, it was clear that the mechanisms by which those frameworks coalesced and functioned were more implicit and organically synchronous than explicitly coordinated and agreed upon. As the rescue and support efforts proceeded, and a unique “Surfside collapse community” formed; key themes emerged and revealed intrinsic links between the first-responder/search and rescue and psychological strategies.

In this article, we discuss relevant themes and parallels between the psychological intervention/strategies and the first-responder disaster response and the practical utility of implementing an integrated strategy. Our hope is that a better understanding of these strategies will help future therapists and responders who respond to crises.
 

Setting the frame

The importance of setting a psychotherapeutic frame is indisputable regardless of theoretical orientation or therapeutic modality. Predictable, consistent conditions under which therapy takes place support a patient’s capacity to tolerate the ambiguous and unpredictable aspects of the process. Those “rules of engagement” provide a structure where subjective experiences can be formulated, organized, understood, and integrated. Twice-daily briefs held in a centralized location (dubbed the Surfside “family center”) paralleled this frame and served that same containing function by offering structure, order, and predictability amid the palpable chaos of ambiguous loss and traumatic grief. Those briefs provided key information on the status of the operation and described the rescue strategy. These were led by the Miami-Dade assistant fire chief and IDF colonel (E.E.), who presented a unified front and consistent presence.

It is essential that briefings such as these be coordinated (and unified) with clear expectations about ground rules, much like what is involved in therapeutic informed consent. In this context, rules included permissions related to documentation of meetings, information sharing, and rules of communication with the media in an effort to protect the vulnerable.

The centralized meeting location served as an important center of gravity and unified place of waiting and information receipt. It provided a dedicated space to meet with humanitarian aid organizations and government officials, and symbolized continuity, consistency, ease of information transmission, and a place where practical needs could be addressed. Meals, toiletries, and other supplies were provided to simplify and maintain daily routines. Those are otherwise unremarkable practices that seemed impossible to manage amid a crisis, yet can be inherently grounding and emotionally organizing when facing deep psychological fragmentation.

Meeting in person allowed the IDF to offer operational visuals to allow those affected to feel less helpless and cultivate a sense of purpose by being part of the strategy/mission. Their strategy included “population intelligence,” which was aimed at both information gathering to practically facilitate the rescue/recovery process (for example, locating victims, property, and recreating a visual of how the building fell), and inspiring people to participate. This engagement helped many transition from a place of denial/repression to acknowledging loss/grief, and from a passive to active part of the effort, in a way that was safe and realistic – as opposed to going to the site and aiding themselves, as some had requested.

Naturally, a central location made it possible to offer immediate psychological assistance and support. Clinicians responding to crisis should be carefully selected in light of the immense suffering, emotional vulnerability, and heightened reactivity of those affected. People were overwhelmed by deep sorrow, fear, anger, and uncertainty, vacillating between hope and despair, and mobilized by a desire to help. Those providing support need to be interpersonally skilled and able to regulate their own emotions. They must be able to formulate – in real time – an understanding of what is needed, and implement a strategic plan. Like first responders, it is also key for providers to be easily accessible and identifiable in uniform so that people in the grip of a survival response can easily identify and elicit support.

The power of strategy

The Israeli delegation and mental health approaches were aligned with respect to cultivating a team identity and keeping the team spirit elevated. The delegation’s approach was to deemphasize rank during the mission in that everyone was responsible for anything that was needed and no task was below anyone’s rank. The same was true for the mental health support response: Early interventions were focused on addressing practical needs – providing blankets, water, chargers, food, and a calming presence to counter the initial chaos. No task was too small, regardless of title or role. As more structure and order ensued, it was possible to offer more traditional crisis-related interventions aimed at grounding those affected.

Both teams worked to ensure 24-hour coverage, which was crucial given the need for consistency and continuity. Our commitment was to support the victims’ families and survivors by fully embracing the chaos and the situational demands, offering attunement and support, and satisfying both basic and higher-level needs. We divided and conquered work, observed signals of need, offered immediate support where necessary, and coordinated longer-term care plans when possible. The importance of ongoing self-care, consultation, and debriefing while doing this work cannot be overstated. Time to address basic needs and the impact of vicarious trauma as a team must be built in.
 

Importance of flexibility

This tragedy came with unique complexities and sensitivities that needed to be identified expediently and addressed with a concrete, comprehensive plan. This was true for both the rescue and psychological support efforts, and flexibility was key. There was nothing traditional about our work from a therapeutic perspective – we found quiet corners and empty offices, went for walks, met in lobbies, and checked in by phone. The interventions were brief.

Roles shifted often between aiding in addressing practical needs, advocating for victims and connecting them to appropriate resources, supporting the police in making death notifications, providing support and space for processing during and after briefings, and more.

Similarly, the rescue team constantly reevaluated their strategy because of what they discovered as they dismantled the collapsed building, in addition to managing external impacting factors (heat, rain, lightning, and the threat of the remaining structure falling).
 

Language matters

The iteration of commitment to the families/victims/mission and to work speedily and efficiently was important for both rescuers and therapists. It was key during the briefings for the chief and colonel (E.E.) to share information in a manner that was professional, discreet, honest and explicit. Their willingness and ability to be vulnerable and to share their personal feelings as active rescuers humanized them. Their approach was matter of fact, yet warm, loving, and containing, all of which conveyed dignity and respect.

Word choice mattered, and the IDF’s intentional choice to refer to recovered victims as “souls,” rather than “bodies,” conveyed their sensitivity to the intensity of anguish, depth of loss, and gravity of the situation. From a psychological perspective, the transition between “rescue” efforts signifying the potential saving of lives to “recovery” of bodies or remains was significant and demarcated a dramatic shift. The weeks-long efforts, once painfully slow, then felt too abrupt to process.

One extraordinary moment was the chief’s response to the families’ discomfort at the news of the switch from rescue to recovery. The families were anxious about losing the structure that the briefings provided and were apprehensive about the handoff from fire to the police department. With great compassion and attunement, he assured them that he would stay with them, and they together, as a family, would decide when to conclude the in-person briefings. The colonel (E.E.), too, provided assurance that neither procedure nor the urgency of the recovery would change. It was both heart-warming and containing that information related to the operation was shared in a clear manner, and that the thought process and rationale behind major decisions (e.g., demolishing the remaining building, decision to pause operations, switch from rescue to recovery) was shared. It was useful for the clinicians to be aware of this rationale in helping individuals metabolize the information and process the associated trauma and grief.
 

Unification is key

Surfside has left an indelible impact on us. We saw and experienced unity in many respects – clinicians from various backgrounds collaborating, families bonding and caring for one another, community support and solidarity, and the cooperation and coordination of the search and rescue teams. The diverse groups providing support came to feel like a family, and the importance of inter- and intrateam integration cannot be overstated. We were transformed both by our professional collaborations and authentic connections with those affected, and will forever cherish the experience, one another, the families, and the souls lost.

Dr. Feldman is a licensed clinical psychologist in private practice in Miami. She is an adjunct professor in the college of psychology at Nova Southeastern University, Fort Lauderdale, Fla., where she teaches clinical psychology doctoral students. She also serves on the board of directors of The Southeast Florida Association for Psychoanalytic Psychology. Dr. Feldman has no disclosures. Col. Edri is the Israeli Defense Forces District Commander of the Home Front Command Haifa District. He served as the deputy commander for the Israeli Defense Forces Search and Rescue Delegation, which was brought in to provide international aid to the local and domestic forces responding to the Surfside, Fla., building collapse. Col. Edri has no disclosures. Dr. Davidtz is a licensed psychologist and associate professor in the College of Psychology at Nova Southeastern University, Fort Lauderdale, Fla., where she is director of internship training for the Psychology Services Center and director of psychological services for the emotionally distressed, a specialty clinic that serves people with serious mental illness and personality disorders. She also maintains a part-time private practice specializing in the treatment of complex posttraumatic conditions and personality disorders. Dr. Davidtz has no disclosures.

The catastrophic collapse of the Surfside, Fla., Champlain Towers South left ambiguous loss, trauma, grief, and other psychiatric and psychological sequelae in its wake.

Now that a few months have passed since the tragedy, which took the lives of 98 residents, it is helpful to examine the psychiatric and psychological support efforts that emerged.

We can think of those support efforts as operating on two tracks: one was pursued by mental health professionals representing numerous organizations; the other was pursued by local, regional, and international first responders – specifically, by Israeli Defense Force (IDF) members who came to our community at the request of Surfside families.

Those efforts were guided by existing frameworks for crisis response designed to provide containment amid the naturally disorganizing effects of the trauma and ambiguous loss. In retrospect, it was clear that the mechanisms by which those frameworks coalesced and functioned were more implicit and organically synchronous than explicitly coordinated and agreed upon. As the rescue and support efforts proceeded, and a unique “Surfside collapse community” formed; key themes emerged and revealed intrinsic links between the first-responder/search and rescue and psychological strategies.

In this article, we discuss relevant themes and parallels between the psychological intervention/strategies and the first-responder disaster response and the practical utility of implementing an integrated strategy. Our hope is that a better understanding of these strategies will help future therapists and responders who respond to crises.
 

Setting the frame

The importance of setting a psychotherapeutic frame is indisputable regardless of theoretical orientation or therapeutic modality. Predictable, consistent conditions under which therapy takes place support a patient’s capacity to tolerate the ambiguous and unpredictable aspects of the process. Those “rules of engagement” provide a structure where subjective experiences can be formulated, organized, understood, and integrated. Twice-daily briefs held in a centralized location (dubbed the Surfside “family center”) paralleled this frame and served that same containing function by offering structure, order, and predictability amid the palpable chaos of ambiguous loss and traumatic grief. Those briefs provided key information on the status of the operation and described the rescue strategy. These were led by the Miami-Dade assistant fire chief and IDF colonel (E.E.), who presented a unified front and consistent presence.

It is essential that briefings such as these be coordinated (and unified) with clear expectations about ground rules, much like what is involved in therapeutic informed consent. In this context, rules included permissions related to documentation of meetings, information sharing, and rules of communication with the media in an effort to protect the vulnerable.

The centralized meeting location served as an important center of gravity and unified place of waiting and information receipt. It provided a dedicated space to meet with humanitarian aid organizations and government officials, and symbolized continuity, consistency, ease of information transmission, and a place where practical needs could be addressed. Meals, toiletries, and other supplies were provided to simplify and maintain daily routines. Those are otherwise unremarkable practices that seemed impossible to manage amid a crisis, yet can be inherently grounding and emotionally organizing when facing deep psychological fragmentation.

Meeting in person allowed the IDF to offer operational visuals to allow those affected to feel less helpless and cultivate a sense of purpose by being part of the strategy/mission. Their strategy included “population intelligence,” which was aimed at both information gathering to practically facilitate the rescue/recovery process (for example, locating victims, property, and recreating a visual of how the building fell), and inspiring people to participate. This engagement helped many transition from a place of denial/repression to acknowledging loss/grief, and from a passive to active part of the effort, in a way that was safe and realistic – as opposed to going to the site and aiding themselves, as some had requested.

Naturally, a central location made it possible to offer immediate psychological assistance and support. Clinicians responding to crisis should be carefully selected in light of the immense suffering, emotional vulnerability, and heightened reactivity of those affected. People were overwhelmed by deep sorrow, fear, anger, and uncertainty, vacillating between hope and despair, and mobilized by a desire to help. Those providing support need to be interpersonally skilled and able to regulate their own emotions. They must be able to formulate – in real time – an understanding of what is needed, and implement a strategic plan. Like first responders, it is also key for providers to be easily accessible and identifiable in uniform so that people in the grip of a survival response can easily identify and elicit support.

The power of strategy

The Israeli delegation and mental health approaches were aligned with respect to cultivating a team identity and keeping the team spirit elevated. The delegation’s approach was to deemphasize rank during the mission in that everyone was responsible for anything that was needed and no task was below anyone’s rank. The same was true for the mental health support response: Early interventions were focused on addressing practical needs – providing blankets, water, chargers, food, and a calming presence to counter the initial chaos. No task was too small, regardless of title or role. As more structure and order ensued, it was possible to offer more traditional crisis-related interventions aimed at grounding those affected.

Both teams worked to ensure 24-hour coverage, which was crucial given the need for consistency and continuity. Our commitment was to support the victims’ families and survivors by fully embracing the chaos and the situational demands, offering attunement and support, and satisfying both basic and higher-level needs. We divided and conquered work, observed signals of need, offered immediate support where necessary, and coordinated longer-term care plans when possible. The importance of ongoing self-care, consultation, and debriefing while doing this work cannot be overstated. Time to address basic needs and the impact of vicarious trauma as a team must be built in.
 

Importance of flexibility

This tragedy came with unique complexities and sensitivities that needed to be identified expediently and addressed with a concrete, comprehensive plan. This was true for both the rescue and psychological support efforts, and flexibility was key. There was nothing traditional about our work from a therapeutic perspective – we found quiet corners and empty offices, went for walks, met in lobbies, and checked in by phone. The interventions were brief.

Roles shifted often between aiding in addressing practical needs, advocating for victims and connecting them to appropriate resources, supporting the police in making death notifications, providing support and space for processing during and after briefings, and more.

Similarly, the rescue team constantly reevaluated their strategy because of what they discovered as they dismantled the collapsed building, in addition to managing external impacting factors (heat, rain, lightning, and the threat of the remaining structure falling).
 

Language matters

The iteration of commitment to the families/victims/mission and to work speedily and efficiently was important for both rescuers and therapists. It was key during the briefings for the chief and colonel (E.E.) to share information in a manner that was professional, discreet, honest and explicit. Their willingness and ability to be vulnerable and to share their personal feelings as active rescuers humanized them. Their approach was matter of fact, yet warm, loving, and containing, all of which conveyed dignity and respect.

Word choice mattered, and the IDF’s intentional choice to refer to recovered victims as “souls,” rather than “bodies,” conveyed their sensitivity to the intensity of anguish, depth of loss, and gravity of the situation. From a psychological perspective, the transition between “rescue” efforts signifying the potential saving of lives to “recovery” of bodies or remains was significant and demarcated a dramatic shift. The weeks-long efforts, once painfully slow, then felt too abrupt to process.

One extraordinary moment was the chief’s response to the families’ discomfort at the news of the switch from rescue to recovery. The families were anxious about losing the structure that the briefings provided and were apprehensive about the handoff from fire to the police department. With great compassion and attunement, he assured them that he would stay with them, and they together, as a family, would decide when to conclude the in-person briefings. The colonel (E.E.), too, provided assurance that neither procedure nor the urgency of the recovery would change. It was both heart-warming and containing that information related to the operation was shared in a clear manner, and that the thought process and rationale behind major decisions (e.g., demolishing the remaining building, decision to pause operations, switch from rescue to recovery) was shared. It was useful for the clinicians to be aware of this rationale in helping individuals metabolize the information and process the associated trauma and grief.
 

Unification is key

Surfside has left an indelible impact on us. We saw and experienced unity in many respects – clinicians from various backgrounds collaborating, families bonding and caring for one another, community support and solidarity, and the cooperation and coordination of the search and rescue teams. The diverse groups providing support came to feel like a family, and the importance of inter- and intrateam integration cannot be overstated. We were transformed both by our professional collaborations and authentic connections with those affected, and will forever cherish the experience, one another, the families, and the souls lost.

Dr. Feldman is a licensed clinical psychologist in private practice in Miami. She is an adjunct professor in the college of psychology at Nova Southeastern University, Fort Lauderdale, Fla., where she teaches clinical psychology doctoral students. She also serves on the board of directors of The Southeast Florida Association for Psychoanalytic Psychology. Dr. Feldman has no disclosures. Col. Edri is the Israeli Defense Forces District Commander of the Home Front Command Haifa District. He served as the deputy commander for the Israeli Defense Forces Search and Rescue Delegation, which was brought in to provide international aid to the local and domestic forces responding to the Surfside, Fla., building collapse. Col. Edri has no disclosures. Dr. Davidtz is a licensed psychologist and associate professor in the College of Psychology at Nova Southeastern University, Fort Lauderdale, Fla., where she is director of internship training for the Psychology Services Center and director of psychological services for the emotionally distressed, a specialty clinic that serves people with serious mental illness and personality disorders. She also maintains a part-time private practice specializing in the treatment of complex posttraumatic conditions and personality disorders. Dr. Davidtz has no disclosures.

In patients with breast cancer, an impaired white-matter microstructure, identified by neuroimaging before chemotherapy, may be a risk factor for cognitive decline after chemotherapy.

“Cognitive decline is frequently observed after chemotherapy,” according to Michiel B. de Ruiter, PhD, a research scientist with the Netherlands Cancer Institute in Amsterdam. He specializes in cognitive neuroscience and was the lead author of a study published online Sept. 30, 2021, in the Journal of Clinical Oncology. Dr. de Ruiter and colleagues found that fractional anisotropy may demonstrate a low brain white-matter reserve which could be a risk factor for cognitive decline after chemotherapy for breast cancer treatment.

Cognitive decline after chemotherapy has been reported in 20%-40% of patients with cancer affecting quality of life and daily living skills. Studies have suggested that genetic makeup, advanced age, fatigue, and premorbid intelligence quotient are risk factors for chemotherapy-associated cognitive decline. Changes in the microstructure of brain white matter, known as brain reserve, have been reported after exposure to chemotherapy, but its link to cognitive decline is understudied. Several studies outside of oncology have used MRI to derive fractional anisotropy as a measure for brain reserve.

In the new JCO study, researchers examined fractional anisotropy, as measured by MRI, before chemotherapy. The analysis included 49 patients who underwent neuropsychological tests before treatment with anthracycline-based chemotherapy, then again at 6 months and 2 years after chemotherapy.

The results were compared with those of patients with breast cancer who did not receive systemic therapy and then with a control group consisting of patients without cancer.

A low fractional anisotropy score suggested cognitive decline more than 3 years after receiving chemotherapy treatment. The finding was independent of age, premorbid intelligence quotient, baseline fatigue and baseline cognitive complaints. And, having low premorbid intelligence quotient was an independent risk factor for chemotherapy-associated cognitive decline, which the authors said is in line with previous findings.

Fractional anisotropy did not predict cognitive decline in patients who did not receive systemic therapy, as well as patients in the control group.

The findings could possibly lead to the development a pretreatment assessment to screen for patients who may at risk for cognitive decline, the authors wrote. “Clinically validated assessments of white-matter reserve as assessed with an MRI scan may be part of a pretreatment screening. This could also aid in early identification of cognitive decline after chemotherapy, allowing targeted and early interventions to improve cognitive problems,” such as psychoeducation and cognitive rehabilitation.

No potential conflicts of interest were reported.

In patients with breast cancer, an impaired white-matter microstructure, identified by neuroimaging before chemotherapy, may be a risk factor for cognitive decline after chemotherapy.

“Cognitive decline is frequently observed after chemotherapy,” according to Michiel B. de Ruiter, PhD, a research scientist with the Netherlands Cancer Institute in Amsterdam. He specializes in cognitive neuroscience and was the lead author of a study published online Sept. 30, 2021, in the Journal of Clinical Oncology. Dr. de Ruiter and colleagues found that fractional anisotropy may demonstrate a low brain white-matter reserve which could be a risk factor for cognitive decline after chemotherapy for breast cancer treatment.

Cognitive decline after chemotherapy has been reported in 20%-40% of patients with cancer affecting quality of life and daily living skills. Studies have suggested that genetic makeup, advanced age, fatigue, and premorbid intelligence quotient are risk factors for chemotherapy-associated cognitive decline. Changes in the microstructure of brain white matter, known as brain reserve, have been reported after exposure to chemotherapy, but its link to cognitive decline is understudied. Several studies outside of oncology have used MRI to derive fractional anisotropy as a measure for brain reserve.

In the new JCO study, researchers examined fractional anisotropy, as measured by MRI, before chemotherapy. The analysis included 49 patients who underwent neuropsychological tests before treatment with anthracycline-based chemotherapy, then again at 6 months and 2 years after chemotherapy.

The results were compared with those of patients with breast cancer who did not receive systemic therapy and then with a control group consisting of patients without cancer.

A low fractional anisotropy score suggested cognitive decline more than 3 years after receiving chemotherapy treatment. The finding was independent of age, premorbid intelligence quotient, baseline fatigue and baseline cognitive complaints. And, having low premorbid intelligence quotient was an independent risk factor for chemotherapy-associated cognitive decline, which the authors said is in line with previous findings.

Fractional anisotropy did not predict cognitive decline in patients who did not receive systemic therapy, as well as patients in the control group.

The findings could possibly lead to the development a pretreatment assessment to screen for patients who may at risk for cognitive decline, the authors wrote. “Clinically validated assessments of white-matter reserve as assessed with an MRI scan may be part of a pretreatment screening. This could also aid in early identification of cognitive decline after chemotherapy, allowing targeted and early interventions to improve cognitive problems,” such as psychoeducation and cognitive rehabilitation.

No potential conflicts of interest were reported.

In patients with breast cancer, an impaired white-matter microstructure, identified by neuroimaging before chemotherapy, may be a risk factor for cognitive decline after chemotherapy.

“Cognitive decline is frequently observed after chemotherapy,” according to Michiel B. de Ruiter, PhD, a research scientist with the Netherlands Cancer Institute in Amsterdam. He specializes in cognitive neuroscience and was the lead author of a study published online Sept. 30, 2021, in the Journal of Clinical Oncology. Dr. de Ruiter and colleagues found that fractional anisotropy may demonstrate a low brain white-matter reserve which could be a risk factor for cognitive decline after chemotherapy for breast cancer treatment.

Cognitive decline after chemotherapy has been reported in 20%-40% of patients with cancer affecting quality of life and daily living skills. Studies have suggested that genetic makeup, advanced age, fatigue, and premorbid intelligence quotient are risk factors for chemotherapy-associated cognitive decline. Changes in the microstructure of brain white matter, known as brain reserve, have been reported after exposure to chemotherapy, but its link to cognitive decline is understudied. Several studies outside of oncology have used MRI to derive fractional anisotropy as a measure for brain reserve.

In the new JCO study, researchers examined fractional anisotropy, as measured by MRI, before chemotherapy. The analysis included 49 patients who underwent neuropsychological tests before treatment with anthracycline-based chemotherapy, then again at 6 months and 2 years after chemotherapy.

The results were compared with those of patients with breast cancer who did not receive systemic therapy and then with a control group consisting of patients without cancer.

A low fractional anisotropy score suggested cognitive decline more than 3 years after receiving chemotherapy treatment. The finding was independent of age, premorbid intelligence quotient, baseline fatigue and baseline cognitive complaints. And, having low premorbid intelligence quotient was an independent risk factor for chemotherapy-associated cognitive decline, which the authors said is in line with previous findings.

Fractional anisotropy did not predict cognitive decline in patients who did not receive systemic therapy, as well as patients in the control group.

The findings could possibly lead to the development a pretreatment assessment to screen for patients who may at risk for cognitive decline, the authors wrote. “Clinically validated assessments of white-matter reserve as assessed with an MRI scan may be part of a pretreatment screening. This could also aid in early identification of cognitive decline after chemotherapy, allowing targeted and early interventions to improve cognitive problems,” such as psychoeducation and cognitive rehabilitation.

No potential conflicts of interest were reported.

An inpatient psychiatric diagnosis at some point over a lifetime is significantly associated with a range of sleep problems, results from the largest study of its kind show.

A prior diagnosis of major depression, schizophrenia, anxiety, or bipolar disorder was associated with a later bedtime, earlier waking time, and significantly poorer sleep quality that included frequent awakenings during the night and shorter sleep bouts.

“We were struck by the pervasiveness of sleep problems across all the diagnoses of mental illness and sleep parameters we looked at,” study investigator Michael Wainberg, PhD, a postdoctoral fellow at the Krembil Centre for Neuroinformatics at the Center for Addiction and Mental Health (CAMH), Toronto, told this news organization. “This suggests there may need to be even more of an emphasis on sleep in these patients than there already is.”

The study, which includes data from nearly 90,000 adults in the United Kingdom, was published online October 12 in PLoS Medicine.

Wavebreak Media/Thinkstockphotos

Trove of data

Data for the analysis comes from the UK Biobank, a large-scale biomedical database launched in 2006 that has collected biological and medical data on more than 500,000 individuals who consented to provide blood, urine, and saliva samples and detailed lifestyle information that is matched to their medical records.

Between 2013 and 2015, more than 103,000 of these participants agreed to wear accelerometers on their wrists for 24 hours a day for 7 days, collecting a trove of data for researchers to mine.

“This allows us to get at objectively derived sleep measures and to measure them in greater numbers of people who have experienced mental illness,” said senior author Shreejoy Tripathy, PhD, assistant professor at the University of Toronto and independent scientist for CAMH. “You can study multiple disorders at once and the influence of other variables that might not be possible in the context of other studies.”

The research is the first known large-scale transdiagnostic study of objectively measured sleep and mental health. Insomnia and other sleep disorders are common among people with mental illness, as shown in prior research, including at least one study that used the same dataset the team employed for this project.

The new findings add to that body of work, Dr. Wainberg said, and look beyond just how long a person sleeps to the quality of the sleep they get.

“We found that the metrics of sleep quality seem to be affected more than mere sleep duration,” he said.
 

Unexpected finding

After excluding participants with faulty accelerometers and those who didn’t wear them for the entire 7-day study period, data from 89,205 participants (aged 43-79, 56% female, 97% self-reported White) was included. Lifetime inpatient psychiatric diagnoses were reported in 2.5% of the entire cohort.

Researchers looked at 10 sleep measures: bedtime, wake-up time, sleep duration, wake after sleep onset, sleep efficiency, number of awakenings, duration of longest sleep bout, number of naps, and variability in bedtime and sleep duration.

Although the effect sizes were small, having any psychiatric diagnosis was associated with significantly lower scores on every sleep measure except sleep duration.

Compared with those with no inpatient psychiatric diagnosis, those with any psychiatric diagnosis were significantly more likely to:

• have a later bedtime (beta = 0.07; 95% confidence interval, 0.06-0.09)
• have later wake-up time (beta = 0.10; 95% CI, 0.09-0.11)
• wake after sleep onset (beta = 0.10; 95% CI, 0.09-0.12)
• have poorer sleep efficiency (beta = –0.12; 95% CI, −0.14 to −0.11)
• have more awakenings (beta = 0.10; 95% CI, 0.09-0.11)
• have shorter duration of their longest sleep bout (beta = –0.09; 95% CI, −0.11 to −0.08)
• take more naps (beta = 0.11; 95% CI, 0.09-0.12)
• have greater variability in their bedtime (beta = 0.08; 95% CI, 0.06-0.09)
• have greater variability in their sleep duration (beta = 0.10; 95% CI, 0.09-0.12)

The only significant differences in sleep duration were found in those with lifetime major depressive disorder, who slept significantly less (beta = −0.02; P = .003), and in those with lifetime schizophrenia, who slept significantly longer (beta = 0.02; P = .0008).

Researchers found similar results when they examined patient-reported sleep measures collected when participants enrolled in the biobank, long before they agreed to wear an accelerometer.

“Everyone with a lifetime mental illness diagnosis trended toward worse sleep quality, regardless of their diagnosis,” Dr. Tripathy said. “We didn’t expect to see that.”

Limitations of the biobank data prohibited analysis by age and past or current use of psychiatric medications. In addition, investigators were unable to determine whether mental illness was active or controlled at the time of the study. Information on these, and other factors, is needed to truly begin to understand the real-world status of sleep patterns in people with mental illness, the researchers note.

However, the biobank data demonstrates how this type of information can be collected, helping Dr. Tripathy and others to design a new study that will launch next year with patients at CAMH. This effort is part of the BrainHealth Databank, a project that aims to develop a patient data bank similar to the one in the UK that was used for this study.

“We’ve shown that you can use wearable devices to measure correlates of sleep and derive insights about the objective measurements of sleep and associate them with mental illness diagnosis,” Dr. Tripathy said.

The study received no outside funding. Dr. Wainberg and Dr. Tripathy report receiving funding from Kavli Foundation, Krembil Foundation, CAMH Discovery Fund, the McLaughlin Foundation, NSERC, and CIHR. Disclosures for other authors are fully listed in the original article.

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

An inpatient psychiatric diagnosis at some point over a lifetime is significantly associated with a range of sleep problems, results from the largest study of its kind show.

A prior diagnosis of major depression, schizophrenia, anxiety, or bipolar disorder was associated with a later bedtime, earlier waking time, and significantly poorer sleep quality that included frequent awakenings during the night and shorter sleep bouts.

“We were struck by the pervasiveness of sleep problems across all the diagnoses of mental illness and sleep parameters we looked at,” study investigator Michael Wainberg, PhD, a postdoctoral fellow at the Krembil Centre for Neuroinformatics at the Center for Addiction and Mental Health (CAMH), Toronto, told this news organization. “This suggests there may need to be even more of an emphasis on sleep in these patients than there already is.”

The study, which includes data from nearly 90,000 adults in the United Kingdom, was published online October 12 in PLoS Medicine.

Wavebreak Media/Thinkstockphotos

Trove of data

Data for the analysis comes from the UK Biobank, a large-scale biomedical database launched in 2006 that has collected biological and medical data on more than 500,000 individuals who consented to provide blood, urine, and saliva samples and detailed lifestyle information that is matched to their medical records.

Between 2013 and 2015, more than 103,000 of these participants agreed to wear accelerometers on their wrists for 24 hours a day for 7 days, collecting a trove of data for researchers to mine.

“This allows us to get at objectively derived sleep measures and to measure them in greater numbers of people who have experienced mental illness,” said senior author Shreejoy Tripathy, PhD, assistant professor at the University of Toronto and independent scientist for CAMH. “You can study multiple disorders at once and the influence of other variables that might not be possible in the context of other studies.”

The research is the first known large-scale transdiagnostic study of objectively measured sleep and mental health. Insomnia and other sleep disorders are common among people with mental illness, as shown in prior research, including at least one study that used the same dataset the team employed for this project.

The new findings add to that body of work, Dr. Wainberg said, and look beyond just how long a person sleeps to the quality of the sleep they get.

“We found that the metrics of sleep quality seem to be affected more than mere sleep duration,” he said.
 

Unexpected finding

After excluding participants with faulty accelerometers and those who didn’t wear them for the entire 7-day study period, data from 89,205 participants (aged 43-79, 56% female, 97% self-reported White) was included. Lifetime inpatient psychiatric diagnoses were reported in 2.5% of the entire cohort.

Researchers looked at 10 sleep measures: bedtime, wake-up time, sleep duration, wake after sleep onset, sleep efficiency, number of awakenings, duration of longest sleep bout, number of naps, and variability in bedtime and sleep duration.

Although the effect sizes were small, having any psychiatric diagnosis was associated with significantly lower scores on every sleep measure except sleep duration.

Compared with those with no inpatient psychiatric diagnosis, those with any psychiatric diagnosis were significantly more likely to:

• have a later bedtime (beta = 0.07; 95% confidence interval, 0.06-0.09)
• have later wake-up time (beta = 0.10; 95% CI, 0.09-0.11)
• wake after sleep onset (beta = 0.10; 95% CI, 0.09-0.12)
• have poorer sleep efficiency (beta = –0.12; 95% CI, −0.14 to −0.11)
• have more awakenings (beta = 0.10; 95% CI, 0.09-0.11)
• have shorter duration of their longest sleep bout (beta = –0.09; 95% CI, −0.11 to −0.08)
• take more naps (beta = 0.11; 95% CI, 0.09-0.12)
• have greater variability in their bedtime (beta = 0.08; 95% CI, 0.06-0.09)
• have greater variability in their sleep duration (beta = 0.10; 95% CI, 0.09-0.12)

The only significant differences in sleep duration were found in those with lifetime major depressive disorder, who slept significantly less (beta = −0.02; P = .003), and in those with lifetime schizophrenia, who slept significantly longer (beta = 0.02; P = .0008).

Researchers found similar results when they examined patient-reported sleep measures collected when participants enrolled in the biobank, long before they agreed to wear an accelerometer.

“Everyone with a lifetime mental illness diagnosis trended toward worse sleep quality, regardless of their diagnosis,” Dr. Tripathy said. “We didn’t expect to see that.”

Limitations of the biobank data prohibited analysis by age and past or current use of psychiatric medications. In addition, investigators were unable to determine whether mental illness was active or controlled at the time of the study. Information on these, and other factors, is needed to truly begin to understand the real-world status of sleep patterns in people with mental illness, the researchers note.

However, the biobank data demonstrates how this type of information can be collected, helping Dr. Tripathy and others to design a new study that will launch next year with patients at CAMH. This effort is part of the BrainHealth Databank, a project that aims to develop a patient data bank similar to the one in the UK that was used for this study.

“We’ve shown that you can use wearable devices to measure correlates of sleep and derive insights about the objective measurements of sleep and associate them with mental illness diagnosis,” Dr. Tripathy said.

The study received no outside funding. Dr. Wainberg and Dr. Tripathy report receiving funding from Kavli Foundation, Krembil Foundation, CAMH Discovery Fund, the McLaughlin Foundation, NSERC, and CIHR. Disclosures for other authors are fully listed in the original article.

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

An inpatient psychiatric diagnosis at some point over a lifetime is significantly associated with a range of sleep problems, results from the largest study of its kind show.

A prior diagnosis of major depression, schizophrenia, anxiety, or bipolar disorder was associated with a later bedtime, earlier waking time, and significantly poorer sleep quality that included frequent awakenings during the night and shorter sleep bouts.

“We were struck by the pervasiveness of sleep problems across all the diagnoses of mental illness and sleep parameters we looked at,” study investigator Michael Wainberg, PhD, a postdoctoral fellow at the Krembil Centre for Neuroinformatics at the Center for Addiction and Mental Health (CAMH), Toronto, told this news organization. “This suggests there may need to be even more of an emphasis on sleep in these patients than there already is.”

The study, which includes data from nearly 90,000 adults in the United Kingdom, was published online October 12 in PLoS Medicine.

Wavebreak Media/Thinkstockphotos

Trove of data

Data for the analysis comes from the UK Biobank, a large-scale biomedical database launched in 2006 that has collected biological and medical data on more than 500,000 individuals who consented to provide blood, urine, and saliva samples and detailed lifestyle information that is matched to their medical records.

Between 2013 and 2015, more than 103,000 of these participants agreed to wear accelerometers on their wrists for 24 hours a day for 7 days, collecting a trove of data for researchers to mine.

“This allows us to get at objectively derived sleep measures and to measure them in greater numbers of people who have experienced mental illness,” said senior author Shreejoy Tripathy, PhD, assistant professor at the University of Toronto and independent scientist for CAMH. “You can study multiple disorders at once and the influence of other variables that might not be possible in the context of other studies.”

The research is the first known large-scale transdiagnostic study of objectively measured sleep and mental health. Insomnia and other sleep disorders are common among people with mental illness, as shown in prior research, including at least one study that used the same dataset the team employed for this project.

The new findings add to that body of work, Dr. Wainberg said, and look beyond just how long a person sleeps to the quality of the sleep they get.

“We found that the metrics of sleep quality seem to be affected more than mere sleep duration,” he said.
 

Unexpected finding

After excluding participants with faulty accelerometers and those who didn’t wear them for the entire 7-day study period, data from 89,205 participants (aged 43-79, 56% female, 97% self-reported White) was included. Lifetime inpatient psychiatric diagnoses were reported in 2.5% of the entire cohort.

Researchers looked at 10 sleep measures: bedtime, wake-up time, sleep duration, wake after sleep onset, sleep efficiency, number of awakenings, duration of longest sleep bout, number of naps, and variability in bedtime and sleep duration.

Although the effect sizes were small, having any psychiatric diagnosis was associated with significantly lower scores on every sleep measure except sleep duration.

Compared with those with no inpatient psychiatric diagnosis, those with any psychiatric diagnosis were significantly more likely to:

• have a later bedtime (beta = 0.07; 95% confidence interval, 0.06-0.09)
• have later wake-up time (beta = 0.10; 95% CI, 0.09-0.11)
• wake after sleep onset (beta = 0.10; 95% CI, 0.09-0.12)
• have poorer sleep efficiency (beta = –0.12; 95% CI, −0.14 to −0.11)
• have more awakenings (beta = 0.10; 95% CI, 0.09-0.11)
• have shorter duration of their longest sleep bout (beta = –0.09; 95% CI, −0.11 to −0.08)
• take more naps (beta = 0.11; 95% CI, 0.09-0.12)
• have greater variability in their bedtime (beta = 0.08; 95% CI, 0.06-0.09)
• have greater variability in their sleep duration (beta = 0.10; 95% CI, 0.09-0.12)

The only significant differences in sleep duration were found in those with lifetime major depressive disorder, who slept significantly less (beta = −0.02; P = .003), and in those with lifetime schizophrenia, who slept significantly longer (beta = 0.02; P = .0008).

Researchers found similar results when they examined patient-reported sleep measures collected when participants enrolled in the biobank, long before they agreed to wear an accelerometer.

“Everyone with a lifetime mental illness diagnosis trended toward worse sleep quality, regardless of their diagnosis,” Dr. Tripathy said. “We didn’t expect to see that.”

Limitations of the biobank data prohibited analysis by age and past or current use of psychiatric medications. In addition, investigators were unable to determine whether mental illness was active or controlled at the time of the study. Information on these, and other factors, is needed to truly begin to understand the real-world status of sleep patterns in people with mental illness, the researchers note.

However, the biobank data demonstrates how this type of information can be collected, helping Dr. Tripathy and others to design a new study that will launch next year with patients at CAMH. This effort is part of the BrainHealth Databank, a project that aims to develop a patient data bank similar to the one in the UK that was used for this study.

“We’ve shown that you can use wearable devices to measure correlates of sleep and derive insights about the objective measurements of sleep and associate them with mental illness diagnosis,” Dr. Tripathy said.

The study received no outside funding. Dr. Wainberg and Dr. Tripathy report receiving funding from Kavli Foundation, Krembil Foundation, CAMH Discovery Fund, the McLaughlin Foundation, NSERC, and CIHR. Disclosures for other authors are fully listed in the original article.

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

Adding art therapy to standard drug treatment in Parkinson’s disease (PD) not only improves severity of both motor and nonmotor symptoms, but also slows rates of disease progression, new research suggests.

TimothyOLeary/Thinkstock

Fifty PD patients were randomly assigned to receive either art therapy, including sculpting and drawing, plus drug therapy or drug therapy alone, and followed up over 12 months.

Patients receiving combined therapy experienced improvements in symptoms, depression, and cognitive scores, and had reduced tremor and daytime sleepiness. They were also substantially less likely to experience disease progression.

“The use of art therapy can reduce the severity of motor and nonmotor manifestations of Parkinson’s disease,” said study investigator Iryna Khubetova, MD, PhD, head of the neurology department, Odessa (Ukraine) Regional Clinical Hospital.

Crucially, the positive effects “persisted throughout the observation period,” she added.

The findings were presented at the virtual congress of the European College of Neuropsychopharmacology.
 

A promising approach

Dr. Khubetova told this news organization that offering art therapy to PD patients was “very affordable,” especially as professional artists “provided materials for painting and other art supplies free of charge.”

“We hope this approach is very promising and would be widely adopted.”

She suggested the positive effect of art therapy could be related to “activating the brain’s reward neural network.”

This may be via improved visual attention acting on visuospatial mechanisms and emotional drive, with “activation of the medial orbitofrontal cortex, ventral striatum, and other structures.”

The researchers note PD, a “multisystem progressive neurodegenerative disease,” is among the three most common neurological disorders, with an incidence of 100-150 cases per 100,000 people.

They also note that nonpharmacologic approaches are “widely used” as an adjunct to drug therapy and as part of an “integrated approach” to disease management.

To examine the clinical efficacy of art therapy, the team recruited patients with PD who had preserved facility for independent movement, defined as stages 1-2.5 on the Hoehn and Yahr scale.

Patients were randomly assigned to art therapy sessions alongside standard drug therapy or to standard drug therapy alone. The art therapy included sculpting, free drawing, and coloring patterns.
 

Multiple benefits

Participants were assessed at baseline and at 6 and 12 months with the Unified Parkinson Disease Rating Scale (UPDRS), the Beck Depression Inventory, the Montreal Cognitive Assessment, and the Pegboard Test of finger dexterity.

Fifty patients were included in the study, with 30 assigned to standard drug therapy alone and 20 to the combined intervention. Participants had a mean age of 57.8 years, and 46% were women.

Over the study period, investigators found patients assigned to art therapy plus drug treatment had improved mood, as well as decreased daytime sleeping, reduced tremor, and a decrease in anxiety and fear intensity.

Between baseline and the 6- and 12-month assessments, patients in the combined therapy group showed improvements in scores on all of the questionnaires, and on the Pegboard Test. In contrast, scores were either stable or worsened in the standard drug therapy–alone group.

The team notes that there was also a marked difference in rates of disease progression, defined as a change on the Hoehn and Yahr scale of at least 0.5 points, between the two groups.

Only two (10%) patients in the combined drug and art therapy progressed over the study period, compared with 10 (33%) in the control group (P = .05).

The findings complement those of a recent study conducted by Alberto Cucca, MD, of the Fresco Institute for Parkinson’s and Movement Disorders, New York University, and colleagues.

Eighteen patients took part in the prospective, open-label trial. They were assessed before and after 20 sessions of art therapy on a range of measures.

Results revealed that following the art therapy, patients had improvements in the Navon Test (which assesses visual neglect, eye tracking, and UPDRS scores), as well as significantly increased functional connectivity levels in the visual cortex on resting-state functional MRI.
 

Many benefits, no side effects

Rebecca Gilbert, MD, PhD, vice president and chief scientific officer of the American Parkinson Disease Association, who was not involved in either study, told this news organization that the idea of art therapy for patients with Parkinson’s is “very reasonable.”

She highlighted that “people with Parkinson’s have many issues with their visuospatial abilities,” as well as their depth and distance perception, and so “enhancing that aspect could potentially be very beneficial.”

“So I’m hopeful that it’s a really good avenue to explore, and the preliminary data are very exciting.”

Dr. Gilbert also highlighted that the “wonderful” aspect of art therapy is that there are “so many benefits and not really any side effects.” Patients can “take the meds … and then enhance that with various therapies, and this would be an additional option.”

Another notable aspect of art therapy is the “social element” and the sense of “camaraderie,” although that has “to be teased out from the benefits you would get from the actual art therapy.”

Finally, Dr. Gilbert pointed out that the difference between the current trial and Dr. Cucca’s trial is the presence of a control group.

“Of course, it’s not blinded, because you know whether you got therapy or not … but that extra element of being able to compare with a group that didn’t get the treatment gives it a little more weight in terms of the field.”

No funding was declared. The authors have disclosed no relevant financial relationships.

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

Adding art therapy to standard drug treatment in Parkinson’s disease (PD) not only improves severity of both motor and nonmotor symptoms, but also slows rates of disease progression, new research suggests.

TimothyOLeary/Thinkstock

Fifty PD patients were randomly assigned to receive either art therapy, including sculpting and drawing, plus drug therapy or drug therapy alone, and followed up over 12 months.

Patients receiving combined therapy experienced improvements in symptoms, depression, and cognitive scores, and had reduced tremor and daytime sleepiness. They were also substantially less likely to experience disease progression.

“The use of art therapy can reduce the severity of motor and nonmotor manifestations of Parkinson’s disease,” said study investigator Iryna Khubetova, MD, PhD, head of the neurology department, Odessa (Ukraine) Regional Clinical Hospital.

Crucially, the positive effects “persisted throughout the observation period,” she added.

The findings were presented at the virtual congress of the European College of Neuropsychopharmacology.
 

A promising approach

Dr. Khubetova told this news organization that offering art therapy to PD patients was “very affordable,” especially as professional artists “provided materials for painting and other art supplies free of charge.”

“We hope this approach is very promising and would be widely adopted.”

She suggested the positive effect of art therapy could be related to “activating the brain’s reward neural network.”

This may be via improved visual attention acting on visuospatial mechanisms and emotional drive, with “activation of the medial orbitofrontal cortex, ventral striatum, and other structures.”

The researchers note PD, a “multisystem progressive neurodegenerative disease,” is among the three most common neurological disorders, with an incidence of 100-150 cases per 100,000 people.

They also note that nonpharmacologic approaches are “widely used” as an adjunct to drug therapy and as part of an “integrated approach” to disease management.

To examine the clinical efficacy of art therapy, the team recruited patients with PD who had preserved facility for independent movement, defined as stages 1-2.5 on the Hoehn and Yahr scale.

Patients were randomly assigned to art therapy sessions alongside standard drug therapy or to standard drug therapy alone. The art therapy included sculpting, free drawing, and coloring patterns.
 

Multiple benefits

Participants were assessed at baseline and at 6 and 12 months with the Unified Parkinson Disease Rating Scale (UPDRS), the Beck Depression Inventory, the Montreal Cognitive Assessment, and the Pegboard Test of finger dexterity.

Fifty patients were included in the study, with 30 assigned to standard drug therapy alone and 20 to the combined intervention. Participants had a mean age of 57.8 years, and 46% were women.

Over the study period, investigators found patients assigned to art therapy plus drug treatment had improved mood, as well as decreased daytime sleeping, reduced tremor, and a decrease in anxiety and fear intensity.

Between baseline and the 6- and 12-month assessments, patients in the combined therapy group showed improvements in scores on all of the questionnaires, and on the Pegboard Test. In contrast, scores were either stable or worsened in the standard drug therapy–alone group.

The team notes that there was also a marked difference in rates of disease progression, defined as a change on the Hoehn and Yahr scale of at least 0.5 points, between the two groups.

Only two (10%) patients in the combined drug and art therapy progressed over the study period, compared with 10 (33%) in the control group (P = .05).

The findings complement those of a recent study conducted by Alberto Cucca, MD, of the Fresco Institute for Parkinson’s and Movement Disorders, New York University, and colleagues.

Eighteen patients took part in the prospective, open-label trial. They were assessed before and after 20 sessions of art therapy on a range of measures.

Results revealed that following the art therapy, patients had improvements in the Navon Test (which assesses visual neglect, eye tracking, and UPDRS scores), as well as significantly increased functional connectivity levels in the visual cortex on resting-state functional MRI.
 

Many benefits, no side effects

Rebecca Gilbert, MD, PhD, vice president and chief scientific officer of the American Parkinson Disease Association, who was not involved in either study, told this news organization that the idea of art therapy for patients with Parkinson’s is “very reasonable.”

She highlighted that “people with Parkinson’s have many issues with their visuospatial abilities,” as well as their depth and distance perception, and so “enhancing that aspect could potentially be very beneficial.”

“So I’m hopeful that it’s a really good avenue to explore, and the preliminary data are very exciting.”

Dr. Gilbert also highlighted that the “wonderful” aspect of art therapy is that there are “so many benefits and not really any side effects.” Patients can “take the meds … and then enhance that with various therapies, and this would be an additional option.”

Another notable aspect of art therapy is the “social element” and the sense of “camaraderie,” although that has “to be teased out from the benefits you would get from the actual art therapy.”

Finally, Dr. Gilbert pointed out that the difference between the current trial and Dr. Cucca’s trial is the presence of a control group.

“Of course, it’s not blinded, because you know whether you got therapy or not … but that extra element of being able to compare with a group that didn’t get the treatment gives it a little more weight in terms of the field.”

No funding was declared. The authors have disclosed no relevant financial relationships.

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

Adding art therapy to standard drug treatment in Parkinson’s disease (PD) not only improves severity of both motor and nonmotor symptoms, but also slows rates of disease progression, new research suggests.

TimothyOLeary/Thinkstock

Fifty PD patients were randomly assigned to receive either art therapy, including sculpting and drawing, plus drug therapy or drug therapy alone, and followed up over 12 months.

Patients receiving combined therapy experienced improvements in symptoms, depression, and cognitive scores, and had reduced tremor and daytime sleepiness. They were also substantially less likely to experience disease progression.

“The use of art therapy can reduce the severity of motor and nonmotor manifestations of Parkinson’s disease,” said study investigator Iryna Khubetova, MD, PhD, head of the neurology department, Odessa (Ukraine) Regional Clinical Hospital.

Crucially, the positive effects “persisted throughout the observation period,” she added.

The findings were presented at the virtual congress of the European College of Neuropsychopharmacology.
 

A promising approach

Dr. Khubetova told this news organization that offering art therapy to PD patients was “very affordable,” especially as professional artists “provided materials for painting and other art supplies free of charge.”

“We hope this approach is very promising and would be widely adopted.”

She suggested the positive effect of art therapy could be related to “activating the brain’s reward neural network.”

This may be via improved visual attention acting on visuospatial mechanisms and emotional drive, with “activation of the medial orbitofrontal cortex, ventral striatum, and other structures.”

The researchers note PD, a “multisystem progressive neurodegenerative disease,” is among the three most common neurological disorders, with an incidence of 100-150 cases per 100,000 people.

They also note that nonpharmacologic approaches are “widely used” as an adjunct to drug therapy and as part of an “integrated approach” to disease management.

To examine the clinical efficacy of art therapy, the team recruited patients with PD who had preserved facility for independent movement, defined as stages 1-2.5 on the Hoehn and Yahr scale.

Patients were randomly assigned to art therapy sessions alongside standard drug therapy or to standard drug therapy alone. The art therapy included sculpting, free drawing, and coloring patterns.
 

Multiple benefits

Participants were assessed at baseline and at 6 and 12 months with the Unified Parkinson Disease Rating Scale (UPDRS), the Beck Depression Inventory, the Montreal Cognitive Assessment, and the Pegboard Test of finger dexterity.

Fifty patients were included in the study, with 30 assigned to standard drug therapy alone and 20 to the combined intervention. Participants had a mean age of 57.8 years, and 46% were women.

Over the study period, investigators found patients assigned to art therapy plus drug treatment had improved mood, as well as decreased daytime sleeping, reduced tremor, and a decrease in anxiety and fear intensity.

Between baseline and the 6- and 12-month assessments, patients in the combined therapy group showed improvements in scores on all of the questionnaires, and on the Pegboard Test. In contrast, scores were either stable or worsened in the standard drug therapy–alone group.

The team notes that there was also a marked difference in rates of disease progression, defined as a change on the Hoehn and Yahr scale of at least 0.5 points, between the two groups.

Only two (10%) patients in the combined drug and art therapy progressed over the study period, compared with 10 (33%) in the control group (P = .05).

The findings complement those of a recent study conducted by Alberto Cucca, MD, of the Fresco Institute for Parkinson’s and Movement Disorders, New York University, and colleagues.

Eighteen patients took part in the prospective, open-label trial. They were assessed before and after 20 sessions of art therapy on a range of measures.

Results revealed that following the art therapy, patients had improvements in the Navon Test (which assesses visual neglect, eye tracking, and UPDRS scores), as well as significantly increased functional connectivity levels in the visual cortex on resting-state functional MRI.
 

Many benefits, no side effects

Rebecca Gilbert, MD, PhD, vice president and chief scientific officer of the American Parkinson Disease Association, who was not involved in either study, told this news organization that the idea of art therapy for patients with Parkinson’s is “very reasonable.”

She highlighted that “people with Parkinson’s have many issues with their visuospatial abilities,” as well as their depth and distance perception, and so “enhancing that aspect could potentially be very beneficial.”

“So I’m hopeful that it’s a really good avenue to explore, and the preliminary data are very exciting.”

Dr. Gilbert also highlighted that the “wonderful” aspect of art therapy is that there are “so many benefits and not really any side effects.” Patients can “take the meds … and then enhance that with various therapies, and this would be an additional option.”

Another notable aspect of art therapy is the “social element” and the sense of “camaraderie,” although that has “to be teased out from the benefits you would get from the actual art therapy.”

Finally, Dr. Gilbert pointed out that the difference between the current trial and Dr. Cucca’s trial is the presence of a control group.

“Of course, it’s not blinded, because you know whether you got therapy or not … but that extra element of being able to compare with a group that didn’t get the treatment gives it a little more weight in terms of the field.”

No funding was declared. The authors have disclosed no relevant financial relationships.

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

Substance use disorders can be a thorny topic in residency because of our role as gatekeepers of mental hospitals during our training. Intoxicated patients often get dismissed as a burden and distraction, malingering their way into a comfortable place to regain sobriety. This is extremely prevalent, often constituting the majority of patients seen during an emergency department call.

A typical interview may elicit any or all symptoms in the DSM yet be best explained by substance use intoxication or withdrawal. Alcohol and other CNS depressants commonly cause feelings of sadness and/or suicidality. Methamphetamine and other CNS stimulants commonly cause symptoms of psychosis or mania, followed by feelings of sadness and/or suicidality.

Different EDs have different degrees of patience for individuals in the process of becoming sober. Some departments will pressure clinicians into quickly discarding those patients and often frown upon any attempt at providing solace by raising the concern of reinforcing maladaptive behavior. A mystery-meat sandwich of admirable blandness may be the extent of help offered. Some more fortunate patients also receive a juice box or even a taxi voucher in an especially generous ED. This is always against our better judgment, of course, as we are told those gestures encourage abuse.

Other EDs will permit patients to remain until sober, allowing for another evaluation without the influence of controlled substances. We are reminded of many conversations with patients with substance use disorders, where topics discussed included: 1. Recommendation to seek substance use services, which are often nonexistent or with wait lists spanning months; 2. Education on the role of mental health hospitals and how patients’ despair in the context of intoxication does not meet some scriptural criteria; 3. Pep talks aided by such previously described sandwiches and juice boxes to encourage a sobering patient to leave the facility of their own will.

Methamphetamine, heroin, and alcohol are rarely one-and-done endeavors. We sparingly see our patients for their very first ED visit while intoxicated or crashing. They know how the system runs and which ED will more readily allow them an overnight stay. The number of times they have been recommended for substance use treatment is beyond counting – they may have been on a wait list a handful of times. They are aware of our reluctance to provide inpatient psychiatric treatment for substance use, but it is worth a shot trying, anyway – sometimes they get lucky. Usually it is the pep talk, relief from hunger pangs, and daylight that get them out the doors – until next time.

It is under this context that many trainees become psychiatrists, a process that solidifies the separation between drug use and mental illness. Many graduate from residency practically equating substance use disorder with malingering or futility. This can take on a surreal quality as many localities have recently adopted particular forms or requirements like the dispensation of naloxone syringes to all patients with substance use disorders. While the desire and effort are noble, it may suggest to a patient presenting for help that society’s main interest is to avoid seeing them die rather than help with available resources for maintaining sobriety.

Therein lies the conundrum, a conundrum that spans psychiatry to society. The conundrum is our ambivalence between punishing the choice of drug use or healing the substance use disorder. Should we discharge the intoxicated patient as soon as they are safe to walk out, or should we make every effort possible to find long-term solutions? Where someone decides to draw the line often seems quite arbitrary.
 

The calculation becomes more complex

A defining moment appears to have been society’s reconsideration of its stance on substance use disorders when affluent White teenagers started dying in the suburbs from pain pills overdoses. Suddenly, those children needed and deserved treatment, not punishment. We find ourselves far away from a time when the loudest societal commentary on substance use entailed mothers advocating for harsher sentences against drunk drivers.

More recently, as psychiatry and large contingents of society have decided to take up the mantle of equity and social justice, we have begun to make progress in decriminalizing substance use in an effort to reverse systemic discrimination toward minority groups. This has taken many shapes, including drug legalization, criminal justice reform, and even the provision of clean substance use paraphernalia for safer use of IV drugs. Police reform has led to reluctance to arrest or press charges for nonviolent crimes and reduced police presence in minority neighborhoods. The “rich White teenager” approach is now recommended in all neighborhoods.

Society’s attempt at decriminalizing drug use has run parallel with psychiatry’s recent attempts at reduced pathologizing of behaviors more prevalent in underprivileged groups and cultures. This runs the gamut, from avoiding the use of the term “agitated” because of its racial connotations, to advocating for reduced rates of schizophrenia diagnoses in Black males.¹ A diagnosis of substance use disorder carries with it similar troublesome societal implications. Decriminalization, legalization, provision of substances to the population, normalization, and other societal reforms will likely have an impact on the prevalence of substance use disorder diagnoses, which involve many criteria dependent on societal context.

It would be expected that criteria such as hazardous use, social problems, and attempts to quit will decrease as social acceptance increases. How might this affect access to substance use treatment, an already extremely limited resource?

Now, as forensic psychiatrists, we find ourselves adjudicating on the role of drugs at a time when society is wrestling with its attitude on the breadth of responsibility possessed by people who use drugs. In California, as in many other states, insanity laws exclude those who were insane as a result of drug use, as a testament to or possibly a remnant of how society feels about the role of choice and responsibility in the use of drugs. Yet another defendant who admits to drug use may on the contrary receive a much more lenient plea deal if willing to commit to sobriety. But in a never-ending maze of differing judgments and opinions, a less understanding district attorney may argue that the additional risk posed by the use of drugs and resulting impulsivity may actually warrant a heavier sentence.

In a recent attempt at atonement for our past punitive stance on drug users, we have found a desire to protect those who use drugs by punishing those who sell, at times forgetting that these populations are deeply intertwined. A recent law permits the federal charge of distribution of fentanyl resulting in death, which carries the mandatory minimum of 20 years in prison. Yet, if the user whom we are trying to protect by this law is also the one selling, what are we left with?

Fentanyl has been a particularly tragic development in the history of mankind and drug use. Substance use has rarely been so easily linked to accidental death. While many physicians can easily explain the safety of fentanyl when used as prescribed and in controlled settings, this is certainly not the case in the community. Measuring micrograms of fentanyl is outside the knowledge and capabilities of most drug dealers, who are not equipped with pharmacy-grade scales. Yet, as a result, they sell and customers buy quantities of fentanyl that range from homeopathically low to lethally high because of a mixture of negligence and deliberate indifference.

Another effort at atonement has been attempts at decriminalizing drug use and releasing many nonviolent offenders. This can, however, encourage bystanders to report more acts as crime rather than public intoxication, to ensure a police response when confronted by intoxicated people. Whereas previously an inebriated person who is homeless may have been called for and asked to seek shelter, they now get called on, and subsequently charged for, allegedly mumbling a threat by a frustrated bystander.

The release of offenders has its limits. Many placements on probation require sobriety and result in longer sentences for the use of substances that are otherwise decriminalized. The decriminalization and reexamination of substance use by society should widen the scope from simply considering crime to examining the use of drugs throughout the legal system and even beyond.

The DSM and psychiatry are not intended or equipped to adjudicate disputes on where the lines should be drawn between determinism and free will. We are knowledgeable of patients with substance use disorders, the effect of intoxicating substances, and the capacity of patients with substance use disorders to act in law-abiding ways. Our field can inform without simply advocating whether our patients should be punished. While society is currently struggling with how to apportion blame, psychiatry should resist the urge to impose medical solutions to social problems. Our solutions would almost certainly be grossly limited as we are still struggling to repent for lobotomizing “uppity” young women² and using electroshock therapy to disrupt perverse impulses in homosexual males.³ Social norms and political zeitgeists change over time while the psychological and physiological principles underlying our understanding of mental illness should, in theory, stay relatively constant. Psychiatry’s answers for societal ills do not usually improve with time but rather have a tendency to be humbling.
 

Dr. Badre is a clinical and forensic psychiatrist in San Diego. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre can be reached at his website, BadreMD.com.

Dr. Compton is a psychiatry resident at University of California, San Diego. His background includes medical education, mental health advocacy, work with underserved populations, and brain cancer research.

References

1.Medlock MM et al., eds. “Racism and Psychiatry: Contemporary Issues and Interventions” (New York: Springer, 2018).

2. Tone A and Koziol M. CMAJ. 2018:190(20):e624-5.

3. McGuire RJ and Vallance M. BMJ. 1964;1(5376):151-3.

Substance use disorders can be a thorny topic in residency because of our role as gatekeepers of mental hospitals during our training. Intoxicated patients often get dismissed as a burden and distraction, malingering their way into a comfortable place to regain sobriety. This is extremely prevalent, often constituting the majority of patients seen during an emergency department call.

A typical interview may elicit any or all symptoms in the DSM yet be best explained by substance use intoxication or withdrawal. Alcohol and other CNS depressants commonly cause feelings of sadness and/or suicidality. Methamphetamine and other CNS stimulants commonly cause symptoms of psychosis or mania, followed by feelings of sadness and/or suicidality.

Different EDs have different degrees of patience for individuals in the process of becoming sober. Some departments will pressure clinicians into quickly discarding those patients and often frown upon any attempt at providing solace by raising the concern of reinforcing maladaptive behavior. A mystery-meat sandwich of admirable blandness may be the extent of help offered. Some more fortunate patients also receive a juice box or even a taxi voucher in an especially generous ED. This is always against our better judgment, of course, as we are told those gestures encourage abuse.

Other EDs will permit patients to remain until sober, allowing for another evaluation without the influence of controlled substances. We are reminded of many conversations with patients with substance use disorders, where topics discussed included: 1. Recommendation to seek substance use services, which are often nonexistent or with wait lists spanning months; 2. Education on the role of mental health hospitals and how patients’ despair in the context of intoxication does not meet some scriptural criteria; 3. Pep talks aided by such previously described sandwiches and juice boxes to encourage a sobering patient to leave the facility of their own will.

Methamphetamine, heroin, and alcohol are rarely one-and-done endeavors. We sparingly see our patients for their very first ED visit while intoxicated or crashing. They know how the system runs and which ED will more readily allow them an overnight stay. The number of times they have been recommended for substance use treatment is beyond counting – they may have been on a wait list a handful of times. They are aware of our reluctance to provide inpatient psychiatric treatment for substance use, but it is worth a shot trying, anyway – sometimes they get lucky. Usually it is the pep talk, relief from hunger pangs, and daylight that get them out the doors – until next time.

It is under this context that many trainees become psychiatrists, a process that solidifies the separation between drug use and mental illness. Many graduate from residency practically equating substance use disorder with malingering or futility. This can take on a surreal quality as many localities have recently adopted particular forms or requirements like the dispensation of naloxone syringes to all patients with substance use disorders. While the desire and effort are noble, it may suggest to a patient presenting for help that society’s main interest is to avoid seeing them die rather than help with available resources for maintaining sobriety.

Therein lies the conundrum, a conundrum that spans psychiatry to society. The conundrum is our ambivalence between punishing the choice of drug use or healing the substance use disorder. Should we discharge the intoxicated patient as soon as they are safe to walk out, or should we make every effort possible to find long-term solutions? Where someone decides to draw the line often seems quite arbitrary.
 

The calculation becomes more complex

A defining moment appears to have been society’s reconsideration of its stance on substance use disorders when affluent White teenagers started dying in the suburbs from pain pills overdoses. Suddenly, those children needed and deserved treatment, not punishment. We find ourselves far away from a time when the loudest societal commentary on substance use entailed mothers advocating for harsher sentences against drunk drivers.

More recently, as psychiatry and large contingents of society have decided to take up the mantle of equity and social justice, we have begun to make progress in decriminalizing substance use in an effort to reverse systemic discrimination toward minority groups. This has taken many shapes, including drug legalization, criminal justice reform, and even the provision of clean substance use paraphernalia for safer use of IV drugs. Police reform has led to reluctance to arrest or press charges for nonviolent crimes and reduced police presence in minority neighborhoods. The “rich White teenager” approach is now recommended in all neighborhoods.

Society’s attempt at decriminalizing drug use has run parallel with psychiatry’s recent attempts at reduced pathologizing of behaviors more prevalent in underprivileged groups and cultures. This runs the gamut, from avoiding the use of the term “agitated” because of its racial connotations, to advocating for reduced rates of schizophrenia diagnoses in Black males.¹ A diagnosis of substance use disorder carries with it similar troublesome societal implications. Decriminalization, legalization, provision of substances to the population, normalization, and other societal reforms will likely have an impact on the prevalence of substance use disorder diagnoses, which involve many criteria dependent on societal context.

It would be expected that criteria such as hazardous use, social problems, and attempts to quit will decrease as social acceptance increases. How might this affect access to substance use treatment, an already extremely limited resource?

Now, as forensic psychiatrists, we find ourselves adjudicating on the role of drugs at a time when society is wrestling with its attitude on the breadth of responsibility possessed by people who use drugs. In California, as in many other states, insanity laws exclude those who were insane as a result of drug use, as a testament to or possibly a remnant of how society feels about the role of choice and responsibility in the use of drugs. Yet another defendant who admits to drug use may on the contrary receive a much more lenient plea deal if willing to commit to sobriety. But in a never-ending maze of differing judgments and opinions, a less understanding district attorney may argue that the additional risk posed by the use of drugs and resulting impulsivity may actually warrant a heavier sentence.

In a recent attempt at atonement for our past punitive stance on drug users, we have found a desire to protect those who use drugs by punishing those who sell, at times forgetting that these populations are deeply intertwined. A recent law permits the federal charge of distribution of fentanyl resulting in death, which carries the mandatory minimum of 20 years in prison. Yet, if the user whom we are trying to protect by this law is also the one selling, what are we left with?

Fentanyl has been a particularly tragic development in the history of mankind and drug use. Substance use has rarely been so easily linked to accidental death. While many physicians can easily explain the safety of fentanyl when used as prescribed and in controlled settings, this is certainly not the case in the community. Measuring micrograms of fentanyl is outside the knowledge and capabilities of most drug dealers, who are not equipped with pharmacy-grade scales. Yet, as a result, they sell and customers buy quantities of fentanyl that range from homeopathically low to lethally high because of a mixture of negligence and deliberate indifference.

Another effort at atonement has been attempts at decriminalizing drug use and releasing many nonviolent offenders. This can, however, encourage bystanders to report more acts as crime rather than public intoxication, to ensure a police response when confronted by intoxicated people. Whereas previously an inebriated person who is homeless may have been called for and asked to seek shelter, they now get called on, and subsequently charged for, allegedly mumbling a threat by a frustrated bystander.

The release of offenders has its limits. Many placements on probation require sobriety and result in longer sentences for the use of substances that are otherwise decriminalized. The decriminalization and reexamination of substance use by society should widen the scope from simply considering crime to examining the use of drugs throughout the legal system and even beyond.

The DSM and psychiatry are not intended or equipped to adjudicate disputes on where the lines should be drawn between determinism and free will. We are knowledgeable of patients with substance use disorders, the effect of intoxicating substances, and the capacity of patients with substance use disorders to act in law-abiding ways. Our field can inform without simply advocating whether our patients should be punished. While society is currently struggling with how to apportion blame, psychiatry should resist the urge to impose medical solutions to social problems. Our solutions would almost certainly be grossly limited as we are still struggling to repent for lobotomizing “uppity” young women² and using electroshock therapy to disrupt perverse impulses in homosexual males.³ Social norms and political zeitgeists change over time while the psychological and physiological principles underlying our understanding of mental illness should, in theory, stay relatively constant. Psychiatry’s answers for societal ills do not usually improve with time but rather have a tendency to be humbling.
 

Dr. Badre is a clinical and forensic psychiatrist in San Diego. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre can be reached at his website, BadreMD.com.

Dr. Compton is a psychiatry resident at University of California, San Diego. His background includes medical education, mental health advocacy, work with underserved populations, and brain cancer research.

References

1.Medlock MM et al., eds. “Racism and Psychiatry: Contemporary Issues and Interventions” (New York: Springer, 2018).

2. Tone A and Koziol M. CMAJ. 2018:190(20):e624-5.

3. McGuire RJ and Vallance M. BMJ. 1964;1(5376):151-3.

Substance use disorders can be a thorny topic in residency because of our role as gatekeepers of mental hospitals during our training. Intoxicated patients often get dismissed as a burden and distraction, malingering their way into a comfortable place to regain sobriety. This is extremely prevalent, often constituting the majority of patients seen during an emergency department call.

A typical interview may elicit any or all symptoms in the DSM yet be best explained by substance use intoxication or withdrawal. Alcohol and other CNS depressants commonly cause feelings of sadness and/or suicidality. Methamphetamine and other CNS stimulants commonly cause symptoms of psychosis or mania, followed by feelings of sadness and/or suicidality.

Different EDs have different degrees of patience for individuals in the process of becoming sober. Some departments will pressure clinicians into quickly discarding those patients and often frown upon any attempt at providing solace by raising the concern of reinforcing maladaptive behavior. A mystery-meat sandwich of admirable blandness may be the extent of help offered. Some more fortunate patients also receive a juice box or even a taxi voucher in an especially generous ED. This is always against our better judgment, of course, as we are told those gestures encourage abuse.

Other EDs will permit patients to remain until sober, allowing for another evaluation without the influence of controlled substances. We are reminded of many conversations with patients with substance use disorders, where topics discussed included: 1. Recommendation to seek substance use services, which are often nonexistent or with wait lists spanning months; 2. Education on the role of mental health hospitals and how patients’ despair in the context of intoxication does not meet some scriptural criteria; 3. Pep talks aided by such previously described sandwiches and juice boxes to encourage a sobering patient to leave the facility of their own will.

Methamphetamine, heroin, and alcohol are rarely one-and-done endeavors. We sparingly see our patients for their very first ED visit while intoxicated or crashing. They know how the system runs and which ED will more readily allow them an overnight stay. The number of times they have been recommended for substance use treatment is beyond counting – they may have been on a wait list a handful of times. They are aware of our reluctance to provide inpatient psychiatric treatment for substance use, but it is worth a shot trying, anyway – sometimes they get lucky. Usually it is the pep talk, relief from hunger pangs, and daylight that get them out the doors – until next time.

It is under this context that many trainees become psychiatrists, a process that solidifies the separation between drug use and mental illness. Many graduate from residency practically equating substance use disorder with malingering or futility. This can take on a surreal quality as many localities have recently adopted particular forms or requirements like the dispensation of naloxone syringes to all patients with substance use disorders. While the desire and effort are noble, it may suggest to a patient presenting for help that society’s main interest is to avoid seeing them die rather than help with available resources for maintaining sobriety.

Therein lies the conundrum, a conundrum that spans psychiatry to society. The conundrum is our ambivalence between punishing the choice of drug use or healing the substance use disorder. Should we discharge the intoxicated patient as soon as they are safe to walk out, or should we make every effort possible to find long-term solutions? Where someone decides to draw the line often seems quite arbitrary.
 

The calculation becomes more complex

A defining moment appears to have been society’s reconsideration of its stance on substance use disorders when affluent White teenagers started dying in the suburbs from pain pills overdoses. Suddenly, those children needed and deserved treatment, not punishment. We find ourselves far away from a time when the loudest societal commentary on substance use entailed mothers advocating for harsher sentences against drunk drivers.

More recently, as psychiatry and large contingents of society have decided to take up the mantle of equity and social justice, we have begun to make progress in decriminalizing substance use in an effort to reverse systemic discrimination toward minority groups. This has taken many shapes, including drug legalization, criminal justice reform, and even the provision of clean substance use paraphernalia for safer use of IV drugs. Police reform has led to reluctance to arrest or press charges for nonviolent crimes and reduced police presence in minority neighborhoods. The “rich White teenager” approach is now recommended in all neighborhoods.

Society’s attempt at decriminalizing drug use has run parallel with psychiatry’s recent attempts at reduced pathologizing of behaviors more prevalent in underprivileged groups and cultures. This runs the gamut, from avoiding the use of the term “agitated” because of its racial connotations, to advocating for reduced rates of schizophrenia diagnoses in Black males.¹ A diagnosis of substance use disorder carries with it similar troublesome societal implications. Decriminalization, legalization, provision of substances to the population, normalization, and other societal reforms will likely have an impact on the prevalence of substance use disorder diagnoses, which involve many criteria dependent on societal context.

It would be expected that criteria such as hazardous use, social problems, and attempts to quit will decrease as social acceptance increases. How might this affect access to substance use treatment, an already extremely limited resource?

Now, as forensic psychiatrists, we find ourselves adjudicating on the role of drugs at a time when society is wrestling with its attitude on the breadth of responsibility possessed by people who use drugs. In California, as in many other states, insanity laws exclude those who were insane as a result of drug use, as a testament to or possibly a remnant of how society feels about the role of choice and responsibility in the use of drugs. Yet another defendant who admits to drug use may on the contrary receive a much more lenient plea deal if willing to commit to sobriety. But in a never-ending maze of differing judgments and opinions, a less understanding district attorney may argue that the additional risk posed by the use of drugs and resulting impulsivity may actually warrant a heavier sentence.

In a recent attempt at atonement for our past punitive stance on drug users, we have found a desire to protect those who use drugs by punishing those who sell, at times forgetting that these populations are deeply intertwined. A recent law permits the federal charge of distribution of fentanyl resulting in death, which carries the mandatory minimum of 20 years in prison. Yet, if the user whom we are trying to protect by this law is also the one selling, what are we left with?

Fentanyl has been a particularly tragic development in the history of mankind and drug use. Substance use has rarely been so easily linked to accidental death. While many physicians can easily explain the safety of fentanyl when used as prescribed and in controlled settings, this is certainly not the case in the community. Measuring micrograms of fentanyl is outside the knowledge and capabilities of most drug dealers, who are not equipped with pharmacy-grade scales. Yet, as a result, they sell and customers buy quantities of fentanyl that range from homeopathically low to lethally high because of a mixture of negligence and deliberate indifference.

Another effort at atonement has been attempts at decriminalizing drug use and releasing many nonviolent offenders. This can, however, encourage bystanders to report more acts as crime rather than public intoxication, to ensure a police response when confronted by intoxicated people. Whereas previously an inebriated person who is homeless may have been called for and asked to seek shelter, they now get called on, and subsequently charged for, allegedly mumbling a threat by a frustrated bystander.

The release of offenders has its limits. Many placements on probation require sobriety and result in longer sentences for the use of substances that are otherwise decriminalized. The decriminalization and reexamination of substance use by society should widen the scope from simply considering crime to examining the use of drugs throughout the legal system and even beyond.

The DSM and psychiatry are not intended or equipped to adjudicate disputes on where the lines should be drawn between determinism and free will. We are knowledgeable of patients with substance use disorders, the effect of intoxicating substances, and the capacity of patients with substance use disorders to act in law-abiding ways. Our field can inform without simply advocating whether our patients should be punished. While society is currently struggling with how to apportion blame, psychiatry should resist the urge to impose medical solutions to social problems. Our solutions would almost certainly be grossly limited as we are still struggling to repent for lobotomizing “uppity” young women² and using electroshock therapy to disrupt perverse impulses in homosexual males.³ Social norms and political zeitgeists change over time while the psychological and physiological principles underlying our understanding of mental illness should, in theory, stay relatively constant. Psychiatry’s answers for societal ills do not usually improve with time but rather have a tendency to be humbling.
 

Dr. Badre is a clinical and forensic psychiatrist in San Diego. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre can be reached at his website, BadreMD.com.

Dr. Compton is a psychiatry resident at University of California, San Diego. His background includes medical education, mental health advocacy, work with underserved populations, and brain cancer research.

References

1.Medlock MM et al., eds. “Racism and Psychiatry: Contemporary Issues and Interventions” (New York: Springer, 2018).

2. Tone A and Koziol M. CMAJ. 2018:190(20):e624-5.

3. McGuire RJ and Vallance M. BMJ. 1964;1(5376):151-3.

The U.S. Food and Drug Administration (FDA) has approved a high-dose naloxone injection product for the emergency treatment of opioid overdose.

ZIMHI from Adamis Pharmaceuticals is administered using a single-dose, prefilled syringe that delivers 5 mg of naloxone hydrochloride solution through intramuscular or subcutaneous injection.

Naloxone is an opioid antagonist that works by blocking or reversing the effects of the opioid, including extreme drowsiness, slowed breathing, or loss of consciousness.

Opioid-related overdose deaths — driven partly by prescription drug overdoses — remain a leading cause of death in the United States.

ZIMHI “provides an additional option in the treatment of opioid overdoses,” the FDA said in a statement announcing approval.

In a statement from Adamis Pharmaceuticals, Jeffrey Galinkin, MD, an anesthesiologist and former member of the FDA advisory committee for analgesics and addiction products, said he is “pleased to see this much-needed, high-dose naloxone product will become part of the treatment tool kit as a countermeasure to the continued surge in fentanyl related deaths.”

“The higher intramuscular doses of naloxone in ZIMHI should result in more rapid and higher levels of naloxone in the systemic circulation, which in turn, should result in more successful resuscitations,” Dr. Galinkin said.

Last spring the FDA approved a higher-dose naloxone hydrochloride nasal spray (Kloxxado) for the emergency treatment of opioid overdose.

Kloxxado delivers 8 mg of naloxone into the nasal cavity, which is twice as much as the 4 mg of naloxone contained in Narcan nasal spray.

The FDA approved ZIMHI (and Kloxxado) through the 505(b)(2) regulatory pathway, which allows the agency to refer to previous findings of safety and efficacy for an already-approved product, as well as to review findings from further studies of the product.

The company plans to launch ZIMHI in the first quarter of 2022.

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

The U.S. Food and Drug Administration (FDA) has approved a high-dose naloxone injection product for the emergency treatment of opioid overdose.

ZIMHI from Adamis Pharmaceuticals is administered using a single-dose, prefilled syringe that delivers 5 mg of naloxone hydrochloride solution through intramuscular or subcutaneous injection.

Naloxone is an opioid antagonist that works by blocking or reversing the effects of the opioid, including extreme drowsiness, slowed breathing, or loss of consciousness.

Opioid-related overdose deaths — driven partly by prescription drug overdoses — remain a leading cause of death in the United States.

ZIMHI “provides an additional option in the treatment of opioid overdoses,” the FDA said in a statement announcing approval.

In a statement from Adamis Pharmaceuticals, Jeffrey Galinkin, MD, an anesthesiologist and former member of the FDA advisory committee for analgesics and addiction products, said he is “pleased to see this much-needed, high-dose naloxone product will become part of the treatment tool kit as a countermeasure to the continued surge in fentanyl related deaths.”

“The higher intramuscular doses of naloxone in ZIMHI should result in more rapid and higher levels of naloxone in the systemic circulation, which in turn, should result in more successful resuscitations,” Dr. Galinkin said.

Last spring the FDA approved a higher-dose naloxone hydrochloride nasal spray (Kloxxado) for the emergency treatment of opioid overdose.

Kloxxado delivers 8 mg of naloxone into the nasal cavity, which is twice as much as the 4 mg of naloxone contained in Narcan nasal spray.

The FDA approved ZIMHI (and Kloxxado) through the 505(b)(2) regulatory pathway, which allows the agency to refer to previous findings of safety and efficacy for an already-approved product, as well as to review findings from further studies of the product.

The company plans to launch ZIMHI in the first quarter of 2022.

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

The U.S. Food and Drug Administration (FDA) has approved a high-dose naloxone injection product for the emergency treatment of opioid overdose.

ZIMHI from Adamis Pharmaceuticals is administered using a single-dose, prefilled syringe that delivers 5 mg of naloxone hydrochloride solution through intramuscular or subcutaneous injection.

Naloxone is an opioid antagonist that works by blocking or reversing the effects of the opioid, including extreme drowsiness, slowed breathing, or loss of consciousness.

Opioid-related overdose deaths — driven partly by prescription drug overdoses — remain a leading cause of death in the United States.

ZIMHI “provides an additional option in the treatment of opioid overdoses,” the FDA said in a statement announcing approval.

In a statement from Adamis Pharmaceuticals, Jeffrey Galinkin, MD, an anesthesiologist and former member of the FDA advisory committee for analgesics and addiction products, said he is “pleased to see this much-needed, high-dose naloxone product will become part of the treatment tool kit as a countermeasure to the continued surge in fentanyl related deaths.”

“The higher intramuscular doses of naloxone in ZIMHI should result in more rapid and higher levels of naloxone in the systemic circulation, which in turn, should result in more successful resuscitations,” Dr. Galinkin said.

Last spring the FDA approved a higher-dose naloxone hydrochloride nasal spray (Kloxxado) for the emergency treatment of opioid overdose.

Kloxxado delivers 8 mg of naloxone into the nasal cavity, which is twice as much as the 4 mg of naloxone contained in Narcan nasal spray.

The FDA approved ZIMHI (and Kloxxado) through the 505(b)(2) regulatory pathway, which allows the agency to refer to previous findings of safety and efficacy for an already-approved product, as well as to review findings from further studies of the product.

The company plans to launch ZIMHI in the first quarter of 2022.

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

Physician employment contracts include some new dangers. This includes physicians taking a new job, but it also includes already-employed doctors who are being asked to resign a new contract that contains new conditions. A number of these new clauses have arisen because of COVID-19. When the pandemic dramatically reduced patient flow, many employers didn’t have enough money to pay doctors and didn’t always have physicians in the right location or practice setting.

Vowing this would never happen again, some employers have rewritten their physician contracts to make it easier to reassign and terminate physicians.

Here are 12 potential land mines in a physician employment contract, some of which were added as a result of the pandemic.
 

You could be immediately terminated without notice

One outcome of the pandemic is the growing use of “force majeure” clauses, which give the employer the right to reduce your compensation or even terminate you due to a natural disaster, which could include COVID.

“COVID made employers aware of the potential impact of disasters on their operations,” said Dan Shay, a health law attorney at Alice Gosfield & Associates in Philadelphia. “Therefore, even as the threat of COVID abates in many places, employers are continuing to put this provision in the contract.”

What can you do? “One way to get some protection is to rule out a termination without cause in the first year,” said Michael A. Cassidy, a physician contract attorney at Tucker Arensberg in Pittsburgh.

The force majeure clause is less likely to affect salary, but could impact bonus and incentive tied to performance. It’s wise to try to specifically limit how much the force majeure could reduce pay tied to performance, and to be prepared to negotiate that aspect of your contract.
 

No protections if you’re let go through no fault of your own

You could lose your job if your employer could not generate enough business and has to let some doctors go. This happened quite often in the early days of the COVID pandemic.

In these situations, the doctor has not done anything wrong to prompt the termination, but the restrictive covenant may still apply, meaning that the doctor would have to leave the area to find work.

What can you do? You’re in a good position to get this changed, said Christopher L. Nuland, a solo physician contract attorney in Jacksonville, Fla. “Many employers recognize that it would be draconian to require a restrictive covenant in this case, and they will agree to modify this provision.”

Similarly, the employer may not cover your tail insurance even if you were let go from your work through no fault of your own. Most malpractice policies for employer physicians require buying an extra policy, called a tail, if you leave. In some cases, the employer won’t provide a tail and will make the departing doctor buy it.

In these cases, “try for a compromise, such as stipulating that the party that caused the termination should pay for the tail,” Mr. Nuland said. “The employer may not agree to anything more than that because they want to set up a disincentive against you leaving.”
 

Employer could unilaterally alter your compensation

Many recent contracts give the employer the option to unilaterally modify compensation, such as changing the base salary or raising the target required for meeting the productivity bonus, said Ericka L. Adler, a physician contract attorney at Roetzel & Andress in Chicago.

Ms. Adler thought this change could have been prompted by employers’ financial problems during the pandemic. In the early months of COVID, many physicians were not making much money for the employer but still had to be paid. So employers added a clause saying they could reduce compensation at any time, she said.

What can you do? Harsh provisions like this often come up in contracts with private equity firms, Mr. Cassidy said. “The contract might say the employer can adjust compensation or even terminate physicians based on productivity or their profitability. And it may say that if they reassign you to a new location and you refuse, they can terminate you.”

“If you can’t get these clauses removed, try to reduce the impact of a termination by providing longer notice periods or by inserting a severance agreement,” Mr. Cassidy said.
 

Accelerating notice for without-cause terminations

Physicians who are convicted of a felony or other moral issue can usually be terminated immediately. But if you are terminated for other reasons – that is, “without cause” – you are given notice at a certain number of days before you have to leave (typically 60-90 days), so that you have time to find a new job.

Some recent contracts, however, allow for very little notice in without-cause terminations, which allows the employer to fire you in as little as 0 days after providing notice, Ms. Adler said.

“This means that, even if 90 days’ notice is provided in the contract, the employer can decide that your last day will be an earlier date,” she said.

Why is this happening? Ms. Adler said employers want to begin reallocating resources and patients as soon as possible. The problem came to employers’ attention during the COVID pandemic, when they were contractually forced to pay doctors for doing little or nothing during the notice period.

What can you do? Possibly not much, other than attempt to negotiate. “Large employers typically don’t want to drop this provision, but at the least, the doctor needs to understand the risk it creates for them,” she said.
 

You could be assigned to far-off locations

As patient care needs changed dramatically during the pandemic, employers needed to reassign doctors to new locations.

Some new contracts allow employers to simply inform the doctor that they are changing the work location. However, “you don’t want to be assigned to a new work location that is 50 miles away,” Mr. Nuland said.

What can you do? Mr. Nuland recommended adding new language saying that, if the new assignment is more than 20 miles away, both parties would have to approve it.

You could end up working too many off-hours

“Most employers won’t issue a specific work schedule,” Mr. Nuland said. “They want the flexibility to assign evening or weekend work, and it would be difficult for a young doctor to change this.”

What can you do? Mr. Nuland recommended trying to set some limits. “You can try to limit off-hours work to two times a month or something like that,” she said. And if you need to have a special schedule, such as not working on Fridays, Adler advises that this should be put into the contract.

If you can’t get anything changed in the contract, Mr. Nuland said the next-best thing is to ask employers to tell you specifically what they plan to do with you. “Most employers will give you an informal idea of what’s expected – maybe not an exact schedule, but it’s quite likely they will honor it.”
 

You wouldn’t be able to work nearby if you left the job

Most contracts have a noncompete clause, also known as a “restrictive covenant,” which prevents employed physicians from working in the area if they left the job.

“Almost every doctor I represent has told me that they’re not concerned about the noncompete clause because, they believe, it is not enforceable anyway,” Ms. Adler said. “This is incorrect.”

Mr. Nuland said the faster pace of job-changing during the pandemic makes it all the more likely that doctors have to deal with a restrictive covenant. At the same time, some employers have been expanding the restriction – either by enlarging the radius where the restriction applies or by making the restriction apply to each of their sites, so that each one has a restricted radius around it.

For example, one contract Mr. Nuland is currently reviewing has a 20-mile radius that in effect becomes a 120-mile radius because the employer is counting four offices.

What can you do? Mr. Nuland advised trying to reduce the impact of the noncompete – for instance, making it apply only to the offices where you worked, or trading more time for less distance. “If you have a 2-year, 20-mile restriction, ask for a 3-year, 10-mile restriction, where the radius could be easier to deal with,” he said.
 

You might end up with too much call

Contracts rarely detail your call schedule because employers want flexibility to expand call as patient care needs change, but you can try adding some specificity, said Sanja Ord, a physician contract attorney at Greensfelder, Hemker & Gale in St. Louis.

Contracts often use wide-open language to describe call, such as simply making it “subject to the house call policies,” Mr. Cassidy said. Language that is more beneficial to the physician would say that call must be “equal” among “similarly situated” physicians.

But Ms. Ord said even provisions for equal call can turn out to be onerous if there are too few doctors in the call roster, so it’s a good idea to find out just how many doctors will be participating in call.

Still, Adler said even that strategy can’t remove all risk. What happens, she asked, if several physicians participating in call decide to leave? Then you might end up with call every other night.

What can you do? Mr. Cassidy recommends specifying a maximum amount of call – for example, no more frequent than one in four nights.
 

Physician must pay for reimbursement claw-backs by payers

When auditors for Medicare or other payers find overpayments after the fact, called a ‘claw-back,’ the provider must pay them back. But which provider has to do that – you or your employer?

In many cases, your employer’s billing office may have introduced the error, but there may be a clause in the contract stating that the physician is solely responsible for all claw-backs. That could be costly.

What can you do? Mr. Shay said the clause should state that you have to pay only when it is the result of your own error or omission, and also not when it was made at the direction of the employer.
 

Some work may be outside of your subspecialty

In some cases, the employer may assign subspecialized doctors to work outside their subspecialty, Mr. Nuland said.

For example, he said he represented an endocrinologist who expected to see only diabetes patients but was assigned to some general internal medicine work as well, and an otolaryngologist client of his who completed a fellowship on facial plastic surgery was expected to do liposuction in a cosmetic surgery group.

What can you do? To prevent this from happening, Mr. Nuland recommends a clause stating that your work will be restricted to your subspecialty.

What the employer promised isn’t in the contract

“Beware of promises that are not in the contract,” Mr. Shay said. “You might feel you can really trust your new boss and what he tells you, but what if that person resigns, or the organization gets a new owner who doesn’t honor unwritten agreements?”

Many contracts have an integration clause, which specifies that the contract constitutes the complete agreement between the two parties, and it nullifies any other oral or written promises made to the physician.

For example, the employer might have promised a relocation bonus and a sign-on bonus, but for some reason it didn’t get into the contract, Ms. Ord said. In those cases, the employer is under no obligation to honor the promise.

What can you do? Mr. Cassidy said it is possible to hold the employer to a commitment made outside the contract. The alternative document, such as an offer letter, has to specifically state that the commitment is protected from the integration clause in the contract, he said, adding: “It is still better to have the commitment put into the contract.”
 

Contract is simply accepted as is

“Generally, the bigger the employer, the less likely they will alter an agreement just to make you happy,” Mr. Shay said.

But even in these contracts, he said there is still opportunity to fix errors and ambiguities that could harm you later – or even alter a provision if you can’t remove it outright.

The back-and-forth is important, Ms. Adler said. “Negotiation means trying to have some control over your job and your life.”

Mr. Cassidy said a big part of contract review is facing up to the possibility that you may have to resign or be let go.

“Many physicians don’t like to think about leaving when they’re just starting a job, but they need to,” he said. “You need to begin with the end in mind. Think about what would happen if this job didn’t work out.”

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

Physician employment contracts include some new dangers. This includes physicians taking a new job, but it also includes already-employed doctors who are being asked to resign a new contract that contains new conditions. A number of these new clauses have arisen because of COVID-19. When the pandemic dramatically reduced patient flow, many employers didn’t have enough money to pay doctors and didn’t always have physicians in the right location or practice setting.

Vowing this would never happen again, some employers have rewritten their physician contracts to make it easier to reassign and terminate physicians.

Here are 12 potential land mines in a physician employment contract, some of which were added as a result of the pandemic.
 

You could be immediately terminated without notice

One outcome of the pandemic is the growing use of “force majeure” clauses, which give the employer the right to reduce your compensation or even terminate you due to a natural disaster, which could include COVID.

“COVID made employers aware of the potential impact of disasters on their operations,” said Dan Shay, a health law attorney at Alice Gosfield & Associates in Philadelphia. “Therefore, even as the threat of COVID abates in many places, employers are continuing to put this provision in the contract.”

What can you do? “One way to get some protection is to rule out a termination without cause in the first year,” said Michael A. Cassidy, a physician contract attorney at Tucker Arensberg in Pittsburgh.

The force majeure clause is less likely to affect salary, but could impact bonus and incentive tied to performance. It’s wise to try to specifically limit how much the force majeure could reduce pay tied to performance, and to be prepared to negotiate that aspect of your contract.
 

No protections if you’re let go through no fault of your own

You could lose your job if your employer could not generate enough business and has to let some doctors go. This happened quite often in the early days of the COVID pandemic.

In these situations, the doctor has not done anything wrong to prompt the termination, but the restrictive covenant may still apply, meaning that the doctor would have to leave the area to find work.

What can you do? You’re in a good position to get this changed, said Christopher L. Nuland, a solo physician contract attorney in Jacksonville, Fla. “Many employers recognize that it would be draconian to require a restrictive covenant in this case, and they will agree to modify this provision.”

Similarly, the employer may not cover your tail insurance even if you were let go from your work through no fault of your own. Most malpractice policies for employer physicians require buying an extra policy, called a tail, if you leave. In some cases, the employer won’t provide a tail and will make the departing doctor buy it.

In these cases, “try for a compromise, such as stipulating that the party that caused the termination should pay for the tail,” Mr. Nuland said. “The employer may not agree to anything more than that because they want to set up a disincentive against you leaving.”
 

Employer could unilaterally alter your compensation

Many recent contracts give the employer the option to unilaterally modify compensation, such as changing the base salary or raising the target required for meeting the productivity bonus, said Ericka L. Adler, a physician contract attorney at Roetzel & Andress in Chicago.

Ms. Adler thought this change could have been prompted by employers’ financial problems during the pandemic. In the early months of COVID, many physicians were not making much money for the employer but still had to be paid. So employers added a clause saying they could reduce compensation at any time, she said.

What can you do? Harsh provisions like this often come up in contracts with private equity firms, Mr. Cassidy said. “The contract might say the employer can adjust compensation or even terminate physicians based on productivity or their profitability. And it may say that if they reassign you to a new location and you refuse, they can terminate you.”

“If you can’t get these clauses removed, try to reduce the impact of a termination by providing longer notice periods or by inserting a severance agreement,” Mr. Cassidy said.
 

Accelerating notice for without-cause terminations

Physicians who are convicted of a felony or other moral issue can usually be terminated immediately. But if you are terminated for other reasons – that is, “without cause” – you are given notice at a certain number of days before you have to leave (typically 60-90 days), so that you have time to find a new job.

Some recent contracts, however, allow for very little notice in without-cause terminations, which allows the employer to fire you in as little as 0 days after providing notice, Ms. Adler said.

“This means that, even if 90 days’ notice is provided in the contract, the employer can decide that your last day will be an earlier date,” she said.

Why is this happening? Ms. Adler said employers want to begin reallocating resources and patients as soon as possible. The problem came to employers’ attention during the COVID pandemic, when they were contractually forced to pay doctors for doing little or nothing during the notice period.

What can you do? Possibly not much, other than attempt to negotiate. “Large employers typically don’t want to drop this provision, but at the least, the doctor needs to understand the risk it creates for them,” she said.
 

You could be assigned to far-off locations

As patient care needs changed dramatically during the pandemic, employers needed to reassign doctors to new locations.

Some new contracts allow employers to simply inform the doctor that they are changing the work location. However, “you don’t want to be assigned to a new work location that is 50 miles away,” Mr. Nuland said.

What can you do? Mr. Nuland recommended adding new language saying that, if the new assignment is more than 20 miles away, both parties would have to approve it.

You could end up working too many off-hours

“Most employers won’t issue a specific work schedule,” Mr. Nuland said. “They want the flexibility to assign evening or weekend work, and it would be difficult for a young doctor to change this.”

What can you do? Mr. Nuland recommended trying to set some limits. “You can try to limit off-hours work to two times a month or something like that,” she said. And if you need to have a special schedule, such as not working on Fridays, Adler advises that this should be put into the contract.

If you can’t get anything changed in the contract, Mr. Nuland said the next-best thing is to ask employers to tell you specifically what they plan to do with you. “Most employers will give you an informal idea of what’s expected – maybe not an exact schedule, but it’s quite likely they will honor it.”
 

You wouldn’t be able to work nearby if you left the job

Most contracts have a noncompete clause, also known as a “restrictive covenant,” which prevents employed physicians from working in the area if they left the job.

“Almost every doctor I represent has told me that they’re not concerned about the noncompete clause because, they believe, it is not enforceable anyway,” Ms. Adler said. “This is incorrect.”

Mr. Nuland said the faster pace of job-changing during the pandemic makes it all the more likely that doctors have to deal with a restrictive covenant. At the same time, some employers have been expanding the restriction – either by enlarging the radius where the restriction applies or by making the restriction apply to each of their sites, so that each one has a restricted radius around it.

For example, one contract Mr. Nuland is currently reviewing has a 20-mile radius that in effect becomes a 120-mile radius because the employer is counting four offices.

What can you do? Mr. Nuland advised trying to reduce the impact of the noncompete – for instance, making it apply only to the offices where you worked, or trading more time for less distance. “If you have a 2-year, 20-mile restriction, ask for a 3-year, 10-mile restriction, where the radius could be easier to deal with,” he said.
 

You might end up with too much call

Contracts rarely detail your call schedule because employers want flexibility to expand call as patient care needs change, but you can try adding some specificity, said Sanja Ord, a physician contract attorney at Greensfelder, Hemker & Gale in St. Louis.

Contracts often use wide-open language to describe call, such as simply making it “subject to the house call policies,” Mr. Cassidy said. Language that is more beneficial to the physician would say that call must be “equal” among “similarly situated” physicians.

But Ms. Ord said even provisions for equal call can turn out to be onerous if there are too few doctors in the call roster, so it’s a good idea to find out just how many doctors will be participating in call.

Still, Adler said even that strategy can’t remove all risk. What happens, she asked, if several physicians participating in call decide to leave? Then you might end up with call every other night.

What can you do? Mr. Cassidy recommends specifying a maximum amount of call – for example, no more frequent than one in four nights.
 

Physician must pay for reimbursement claw-backs by payers

When auditors for Medicare or other payers find overpayments after the fact, called a ‘claw-back,’ the provider must pay them back. But which provider has to do that – you or your employer?

In many cases, your employer’s billing office may have introduced the error, but there may be a clause in the contract stating that the physician is solely responsible for all claw-backs. That could be costly.

What can you do? Mr. Shay said the clause should state that you have to pay only when it is the result of your own error or omission, and also not when it was made at the direction of the employer.
 

Some work may be outside of your subspecialty

In some cases, the employer may assign subspecialized doctors to work outside their subspecialty, Mr. Nuland said.

For example, he said he represented an endocrinologist who expected to see only diabetes patients but was assigned to some general internal medicine work as well, and an otolaryngologist client of his who completed a fellowship on facial plastic surgery was expected to do liposuction in a cosmetic surgery group.

What can you do? To prevent this from happening, Mr. Nuland recommends a clause stating that your work will be restricted to your subspecialty.

What the employer promised isn’t in the contract

“Beware of promises that are not in the contract,” Mr. Shay said. “You might feel you can really trust your new boss and what he tells you, but what if that person resigns, or the organization gets a new owner who doesn’t honor unwritten agreements?”

Many contracts have an integration clause, which specifies that the contract constitutes the complete agreement between the two parties, and it nullifies any other oral or written promises made to the physician.

For example, the employer might have promised a relocation bonus and a sign-on bonus, but for some reason it didn’t get into the contract, Ms. Ord said. In those cases, the employer is under no obligation to honor the promise.

What can you do? Mr. Cassidy said it is possible to hold the employer to a commitment made outside the contract. The alternative document, such as an offer letter, has to specifically state that the commitment is protected from the integration clause in the contract, he said, adding: “It is still better to have the commitment put into the contract.”
 

Contract is simply accepted as is

“Generally, the bigger the employer, the less likely they will alter an agreement just to make you happy,” Mr. Shay said.

But even in these contracts, he said there is still opportunity to fix errors and ambiguities that could harm you later – or even alter a provision if you can’t remove it outright.

The back-and-forth is important, Ms. Adler said. “Negotiation means trying to have some control over your job and your life.”

Mr. Cassidy said a big part of contract review is facing up to the possibility that you may have to resign or be let go.

“Many physicians don’t like to think about leaving when they’re just starting a job, but they need to,” he said. “You need to begin with the end in mind. Think about what would happen if this job didn’t work out.”

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

Physician employment contracts include some new dangers. This includes physicians taking a new job, but it also includes already-employed doctors who are being asked to resign a new contract that contains new conditions. A number of these new clauses have arisen because of COVID-19. When the pandemic dramatically reduced patient flow, many employers didn’t have enough money to pay doctors and didn’t always have physicians in the right location or practice setting.

Vowing this would never happen again, some employers have rewritten their physician contracts to make it easier to reassign and terminate physicians.

Here are 12 potential land mines in a physician employment contract, some of which were added as a result of the pandemic.
 

You could be immediately terminated without notice

One outcome of the pandemic is the growing use of “force majeure” clauses, which give the employer the right to reduce your compensation or even terminate you due to a natural disaster, which could include COVID.

“COVID made employers aware of the potential impact of disasters on their operations,” said Dan Shay, a health law attorney at Alice Gosfield & Associates in Philadelphia. “Therefore, even as the threat of COVID abates in many places, employers are continuing to put this provision in the contract.”

What can you do? “One way to get some protection is to rule out a termination without cause in the first year,” said Michael A. Cassidy, a physician contract attorney at Tucker Arensberg in Pittsburgh.

The force majeure clause is less likely to affect salary, but could impact bonus and incentive tied to performance. It’s wise to try to specifically limit how much the force majeure could reduce pay tied to performance, and to be prepared to negotiate that aspect of your contract.
 

No protections if you’re let go through no fault of your own

You could lose your job if your employer could not generate enough business and has to let some doctors go. This happened quite often in the early days of the COVID pandemic.

In these situations, the doctor has not done anything wrong to prompt the termination, but the restrictive covenant may still apply, meaning that the doctor would have to leave the area to find work.

What can you do? You’re in a good position to get this changed, said Christopher L. Nuland, a solo physician contract attorney in Jacksonville, Fla. “Many employers recognize that it would be draconian to require a restrictive covenant in this case, and they will agree to modify this provision.”

Similarly, the employer may not cover your tail insurance even if you were let go from your work through no fault of your own. Most malpractice policies for employer physicians require buying an extra policy, called a tail, if you leave. In some cases, the employer won’t provide a tail and will make the departing doctor buy it.

In these cases, “try for a compromise, such as stipulating that the party that caused the termination should pay for the tail,” Mr. Nuland said. “The employer may not agree to anything more than that because they want to set up a disincentive against you leaving.”
 

Employer could unilaterally alter your compensation

Many recent contracts give the employer the option to unilaterally modify compensation, such as changing the base salary or raising the target required for meeting the productivity bonus, said Ericka L. Adler, a physician contract attorney at Roetzel & Andress in Chicago.

Ms. Adler thought this change could have been prompted by employers’ financial problems during the pandemic. In the early months of COVID, many physicians were not making much money for the employer but still had to be paid. So employers added a clause saying they could reduce compensation at any time, she said.

What can you do? Harsh provisions like this often come up in contracts with private equity firms, Mr. Cassidy said. “The contract might say the employer can adjust compensation or even terminate physicians based on productivity or their profitability. And it may say that if they reassign you to a new location and you refuse, they can terminate you.”

“If you can’t get these clauses removed, try to reduce the impact of a termination by providing longer notice periods or by inserting a severance agreement,” Mr. Cassidy said.
 

Accelerating notice for without-cause terminations

Physicians who are convicted of a felony or other moral issue can usually be terminated immediately. But if you are terminated for other reasons – that is, “without cause” – you are given notice at a certain number of days before you have to leave (typically 60-90 days), so that you have time to find a new job.

Some recent contracts, however, allow for very little notice in without-cause terminations, which allows the employer to fire you in as little as 0 days after providing notice, Ms. Adler said.

“This means that, even if 90 days’ notice is provided in the contract, the employer can decide that your last day will be an earlier date,” she said.

Why is this happening? Ms. Adler said employers want to begin reallocating resources and patients as soon as possible. The problem came to employers’ attention during the COVID pandemic, when they were contractually forced to pay doctors for doing little or nothing during the notice period.

What can you do? Possibly not much, other than attempt to negotiate. “Large employers typically don’t want to drop this provision, but at the least, the doctor needs to understand the risk it creates for them,” she said.
 

You could be assigned to far-off locations

As patient care needs changed dramatically during the pandemic, employers needed to reassign doctors to new locations.

Some new contracts allow employers to simply inform the doctor that they are changing the work location. However, “you don’t want to be assigned to a new work location that is 50 miles away,” Mr. Nuland said.

What can you do? Mr. Nuland recommended adding new language saying that, if the new assignment is more than 20 miles away, both parties would have to approve it.

You could end up working too many off-hours

“Most employers won’t issue a specific work schedule,” Mr. Nuland said. “They want the flexibility to assign evening or weekend work, and it would be difficult for a young doctor to change this.”

What can you do? Mr. Nuland recommended trying to set some limits. “You can try to limit off-hours work to two times a month or something like that,” she said. And if you need to have a special schedule, such as not working on Fridays, Adler advises that this should be put into the contract.

If you can’t get anything changed in the contract, Mr. Nuland said the next-best thing is to ask employers to tell you specifically what they plan to do with you. “Most employers will give you an informal idea of what’s expected – maybe not an exact schedule, but it’s quite likely they will honor it.”
 

You wouldn’t be able to work nearby if you left the job

Most contracts have a noncompete clause, also known as a “restrictive covenant,” which prevents employed physicians from working in the area if they left the job.

“Almost every doctor I represent has told me that they’re not concerned about the noncompete clause because, they believe, it is not enforceable anyway,” Ms. Adler said. “This is incorrect.”

Mr. Nuland said the faster pace of job-changing during the pandemic makes it all the more likely that doctors have to deal with a restrictive covenant. At the same time, some employers have been expanding the restriction – either by enlarging the radius where the restriction applies or by making the restriction apply to each of their sites, so that each one has a restricted radius around it.

For example, one contract Mr. Nuland is currently reviewing has a 20-mile radius that in effect becomes a 120-mile radius because the employer is counting four offices.

What can you do? Mr. Nuland advised trying to reduce the impact of the noncompete – for instance, making it apply only to the offices where you worked, or trading more time for less distance. “If you have a 2-year, 20-mile restriction, ask for a 3-year, 10-mile restriction, where the radius could be easier to deal with,” he said.
 

You might end up with too much call

Contracts rarely detail your call schedule because employers want flexibility to expand call as patient care needs change, but you can try adding some specificity, said Sanja Ord, a physician contract attorney at Greensfelder, Hemker & Gale in St. Louis.

Contracts often use wide-open language to describe call, such as simply making it “subject to the house call policies,” Mr. Cassidy said. Language that is more beneficial to the physician would say that call must be “equal” among “similarly situated” physicians.

But Ms. Ord said even provisions for equal call can turn out to be onerous if there are too few doctors in the call roster, so it’s a good idea to find out just how many doctors will be participating in call.

Still, Adler said even that strategy can’t remove all risk. What happens, she asked, if several physicians participating in call decide to leave? Then you might end up with call every other night.

What can you do? Mr. Cassidy recommends specifying a maximum amount of call – for example, no more frequent than one in four nights.
 

Physician must pay for reimbursement claw-backs by payers

When auditors for Medicare or other payers find overpayments after the fact, called a ‘claw-back,’ the provider must pay them back. But which provider has to do that – you or your employer?

In many cases, your employer’s billing office may have introduced the error, but there may be a clause in the contract stating that the physician is solely responsible for all claw-backs. That could be costly.

What can you do? Mr. Shay said the clause should state that you have to pay only when it is the result of your own error or omission, and also not when it was made at the direction of the employer.
 

Some work may be outside of your subspecialty

In some cases, the employer may assign subspecialized doctors to work outside their subspecialty, Mr. Nuland said.

For example, he said he represented an endocrinologist who expected to see only diabetes patients but was assigned to some general internal medicine work as well, and an otolaryngologist client of his who completed a fellowship on facial plastic surgery was expected to do liposuction in a cosmetic surgery group.

What can you do? To prevent this from happening, Mr. Nuland recommends a clause stating that your work will be restricted to your subspecialty.

What the employer promised isn’t in the contract

“Beware of promises that are not in the contract,” Mr. Shay said. “You might feel you can really trust your new boss and what he tells you, but what if that person resigns, or the organization gets a new owner who doesn’t honor unwritten agreements?”

Many contracts have an integration clause, which specifies that the contract constitutes the complete agreement between the two parties, and it nullifies any other oral or written promises made to the physician.

For example, the employer might have promised a relocation bonus and a sign-on bonus, but for some reason it didn’t get into the contract, Ms. Ord said. In those cases, the employer is under no obligation to honor the promise.

What can you do? Mr. Cassidy said it is possible to hold the employer to a commitment made outside the contract. The alternative document, such as an offer letter, has to specifically state that the commitment is protected from the integration clause in the contract, he said, adding: “It is still better to have the commitment put into the contract.”
 

Contract is simply accepted as is

“Generally, the bigger the employer, the less likely they will alter an agreement just to make you happy,” Mr. Shay said.

But even in these contracts, he said there is still opportunity to fix errors and ambiguities that could harm you later – or even alter a provision if you can’t remove it outright.

The back-and-forth is important, Ms. Adler said. “Negotiation means trying to have some control over your job and your life.”

Mr. Cassidy said a big part of contract review is facing up to the possibility that you may have to resign or be let go.

“Many physicians don’t like to think about leaving when they’re just starting a job, but they need to,” he said. “You need to begin with the end in mind. Think about what would happen if this job didn’t work out.”

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