MDedge Psychiatry

The U.S. Food and Drug Administration has approved an updated label for the controversial Alzheimer’s drug aducanumab (Aduhelm), emphasizing that the drug should only be used in patients with the earliest stages of disease – the group studied in the clinical trials.

The FDA approved aducanumab in early June amid significant controversy and disregarding the recommendation by its own advisory panel not to approve the drug. The original prescribing information implied that the drug – which is administered intravenously and costs around $56,000 a year – could be used for treatment of any patient with Alzheimer’s disease.

The updated label now states that aducanumab should be initiated only in patients with mild cognitive impairment (MCI) or mild dementia stage of disease – the population in which treatment was initiated in the clinical trials leading to approval of the anti-amyloid drug.

The FDA granted accelerated approval of the drug based on data from clinical trials showing a reduction in amyloid beta plaques observed in patients with MCI or mild dementia stage of disease.

“Continued approval for the indication may be contingent upon verification of clinical benefit in confirmatory trial(s),” the label states. It emphasizes that there are no safety or effectiveness data on starting aducanumab treatment at earlier or later stages of the disease than were studied.

“Based on our ongoing conversations with prescribing physicians, FDA, and patient advocates, we submitted this label update with the goal to further clarify the patient population that was studied across the three Aduhelm clinical trials that supported approval,” Alfred Sandrock Jr., MD, PhD, Biogen’s head of research and development, said in a statement announcing the label update.   

“We are committed to continue to listen to the community’s needs as clinical practice adapts to this important, first-in-class treatment option,” said Dr. Sandrock.

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

The U.S. Food and Drug Administration has approved an updated label for the controversial Alzheimer’s drug aducanumab (Aduhelm), emphasizing that the drug should only be used in patients with the earliest stages of disease – the group studied in the clinical trials.

The FDA approved aducanumab in early June amid significant controversy and disregarding the recommendation by its own advisory panel not to approve the drug. The original prescribing information implied that the drug – which is administered intravenously and costs around $56,000 a year – could be used for treatment of any patient with Alzheimer’s disease.

The updated label now states that aducanumab should be initiated only in patients with mild cognitive impairment (MCI) or mild dementia stage of disease – the population in which treatment was initiated in the clinical trials leading to approval of the anti-amyloid drug.

The FDA granted accelerated approval of the drug based on data from clinical trials showing a reduction in amyloid beta plaques observed in patients with MCI or mild dementia stage of disease.

“Continued approval for the indication may be contingent upon verification of clinical benefit in confirmatory trial(s),” the label states. It emphasizes that there are no safety or effectiveness data on starting aducanumab treatment at earlier or later stages of the disease than were studied.

“Based on our ongoing conversations with prescribing physicians, FDA, and patient advocates, we submitted this label update with the goal to further clarify the patient population that was studied across the three Aduhelm clinical trials that supported approval,” Alfred Sandrock Jr., MD, PhD, Biogen’s head of research and development, said in a statement announcing the label update.   

“We are committed to continue to listen to the community’s needs as clinical practice adapts to this important, first-in-class treatment option,” said Dr. Sandrock.

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

The U.S. Food and Drug Administration has approved an updated label for the controversial Alzheimer’s drug aducanumab (Aduhelm), emphasizing that the drug should only be used in patients with the earliest stages of disease – the group studied in the clinical trials.

The FDA approved aducanumab in early June amid significant controversy and disregarding the recommendation by its own advisory panel not to approve the drug. The original prescribing information implied that the drug – which is administered intravenously and costs around $56,000 a year – could be used for treatment of any patient with Alzheimer’s disease.

The updated label now states that aducanumab should be initiated only in patients with mild cognitive impairment (MCI) or mild dementia stage of disease – the population in which treatment was initiated in the clinical trials leading to approval of the anti-amyloid drug.

The FDA granted accelerated approval of the drug based on data from clinical trials showing a reduction in amyloid beta plaques observed in patients with MCI or mild dementia stage of disease.

“Continued approval for the indication may be contingent upon verification of clinical benefit in confirmatory trial(s),” the label states. It emphasizes that there are no safety or effectiveness data on starting aducanumab treatment at earlier or later stages of the disease than were studied.

“Based on our ongoing conversations with prescribing physicians, FDA, and patient advocates, we submitted this label update with the goal to further clarify the patient population that was studied across the three Aduhelm clinical trials that supported approval,” Alfred Sandrock Jr., MD, PhD, Biogen’s head of research and development, said in a statement announcing the label update.   

“We are committed to continue to listen to the community’s needs as clinical practice adapts to this important, first-in-class treatment option,” said Dr. Sandrock.

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

Insert clove A into nostril B

Just when you start wondering what crazy and potentially dangerous thing people can do to themselves next, comes a crazy and potentially dangerous new trend. The good folks at TikTok have provided patients a new treatment for stuffed up sinuses.

Dangerous? Well, that’s what doctors say, anyway.

“We typically do not recommend putting anything into the nostril for the obvious fact that it could get dislodged or lodged up into the nasal cavity,” Anthony Del Signore, MD, of Mount Sinai Union Square, New York, told TODAY.

“Not only does it have the potential to rot or cause a nasal obstruction, it can induce an episode of sinusitis,” Omid Mehdizadeh, MD, of Providence Saint John’s Health Center, Santa Monica, Calif., explained to Shape.

But who doesn't want to breathe easier and keep blood-sucking vampires at bay?

Max Pixel

Seeing faces in random places?

Ever look up at the clouds, at a fast-moving train, or into your morning bowl of cereal and see two eyes, a nose, and a mouth looking back at you? You may shake it off and think you’re imagining something, but it's actually your brain doing what it’s built to do and researchers know why.

The phenomenon is called face pareidolia, and it’s technically an error function of the human brain. Evolution has molded our brains to rapidly identify faces, according to David Alais, PhD, of the University of Sydney, Australia, lead author of the study.

“But the system plays ‘fast and loose’ by applying a crude template of two eyes over a nose and mouth. Lots of things can satisfy that template and thus trigger a face detection response,” he said in a separate statement. But not only are we seeing faces, our brains go one step further and seemingly give those faces feelings.

University of Sydney

Corporate dream manipulation

Advertisements are quite literally everywhere. On billboards, in commercials, in videos, in movies; the list goes on and on. Still, at least you can shut your eyes and be mercifully free of corporate interference inside your own head, right? Right?

Early in 2021, Coors launched an ad campaign that seemed to be a b bit of a gimmick, if not a joke. Coors claimed that if people watched an ad before bed, and played an 8-hour soundscape while sleeping, their dreams would be filled with crisp mountains and cold, thirst-quenching beverages. While, the Coors campaign didn’t go viral, someone was paying attention. A group of 35 leading researchers published an open letter on the subject of corporate dream manipulation, in the journal Dream Engineering.

"Multiple marketing studies are openly testing new ways to alter and motivate purchasing behavior through dream and sleep hacking. The commercial, for-profit use of dream incubation is rapidly becoming a reality," wrote the investigators. "As sleep and dream researchers, we are deeply concerned about marketing plans aimed at generating profits at the cost of interfering with our natural nocturnal memory processing."

People have tried to manipulate their dreams for countless years, but only in recent years have scientists attempted to target or manipulate behavior through dreams. In a 2014 study, smokers exposed to tobacco smoke and rotten egg smell while sleeping reduced their cigarette consumption by 30%.

Free-Photos/Pixabay

Got breast milk?

As we know, breast milk has endless benefits for newbords and babies, but many things can stand in the way of a mother’s ability to breastfeed. Baby formula has served as a good enough substitute. But now, there might be something that’s even better.

A start-up company called BIOMILQ created a product that could be groundbreaking. Using “breakthrough mammary biotechnology,” BIOMILQ created cell-cultured breast milk.

Focus_on_Nature/Getty Images

Insert clove A into nostril B

Just when you start wondering what crazy and potentially dangerous thing people can do to themselves next, comes a crazy and potentially dangerous new trend. The good folks at TikTok have provided patients a new treatment for stuffed up sinuses.

Dangerous? Well, that’s what doctors say, anyway.

“We typically do not recommend putting anything into the nostril for the obvious fact that it could get dislodged or lodged up into the nasal cavity,” Anthony Del Signore, MD, of Mount Sinai Union Square, New York, told TODAY.

“Not only does it have the potential to rot or cause a nasal obstruction, it can induce an episode of sinusitis,” Omid Mehdizadeh, MD, of Providence Saint John’s Health Center, Santa Monica, Calif., explained to Shape.

But who doesn't want to breathe easier and keep blood-sucking vampires at bay?

Max Pixel

Seeing faces in random places?

Ever look up at the clouds, at a fast-moving train, or into your morning bowl of cereal and see two eyes, a nose, and a mouth looking back at you? You may shake it off and think you’re imagining something, but it's actually your brain doing what it’s built to do and researchers know why.

The phenomenon is called face pareidolia, and it’s technically an error function of the human brain. Evolution has molded our brains to rapidly identify faces, according to David Alais, PhD, of the University of Sydney, Australia, lead author of the study.

“But the system plays ‘fast and loose’ by applying a crude template of two eyes over a nose and mouth. Lots of things can satisfy that template and thus trigger a face detection response,” he said in a separate statement. But not only are we seeing faces, our brains go one step further and seemingly give those faces feelings.

University of Sydney

Corporate dream manipulation

Advertisements are quite literally everywhere. On billboards, in commercials, in videos, in movies; the list goes on and on. Still, at least you can shut your eyes and be mercifully free of corporate interference inside your own head, right? Right?

Early in 2021, Coors launched an ad campaign that seemed to be a b bit of a gimmick, if not a joke. Coors claimed that if people watched an ad before bed, and played an 8-hour soundscape while sleeping, their dreams would be filled with crisp mountains and cold, thirst-quenching beverages. While, the Coors campaign didn’t go viral, someone was paying attention. A group of 35 leading researchers published an open letter on the subject of corporate dream manipulation, in the journal Dream Engineering.

"Multiple marketing studies are openly testing new ways to alter and motivate purchasing behavior through dream and sleep hacking. The commercial, for-profit use of dream incubation is rapidly becoming a reality," wrote the investigators. "As sleep and dream researchers, we are deeply concerned about marketing plans aimed at generating profits at the cost of interfering with our natural nocturnal memory processing."

People have tried to manipulate their dreams for countless years, but only in recent years have scientists attempted to target or manipulate behavior through dreams. In a 2014 study, smokers exposed to tobacco smoke and rotten egg smell while sleeping reduced their cigarette consumption by 30%.

Free-Photos/Pixabay

Got breast milk?

As we know, breast milk has endless benefits for newbords and babies, but many things can stand in the way of a mother’s ability to breastfeed. Baby formula has served as a good enough substitute. But now, there might be something that’s even better.

A start-up company called BIOMILQ created a product that could be groundbreaking. Using “breakthrough mammary biotechnology,” BIOMILQ created cell-cultured breast milk.

Focus_on_Nature/Getty Images

Insert clove A into nostril B

Just when you start wondering what crazy and potentially dangerous thing people can do to themselves next, comes a crazy and potentially dangerous new trend. The good folks at TikTok have provided patients a new treatment for stuffed up sinuses.

Dangerous? Well, that’s what doctors say, anyway.

“We typically do not recommend putting anything into the nostril for the obvious fact that it could get dislodged or lodged up into the nasal cavity,” Anthony Del Signore, MD, of Mount Sinai Union Square, New York, told TODAY.

“Not only does it have the potential to rot or cause a nasal obstruction, it can induce an episode of sinusitis,” Omid Mehdizadeh, MD, of Providence Saint John’s Health Center, Santa Monica, Calif., explained to Shape.

But who doesn't want to breathe easier and keep blood-sucking vampires at bay?

Max Pixel

Seeing faces in random places?

Ever look up at the clouds, at a fast-moving train, or into your morning bowl of cereal and see two eyes, a nose, and a mouth looking back at you? You may shake it off and think you’re imagining something, but it's actually your brain doing what it’s built to do and researchers know why.

The phenomenon is called face pareidolia, and it’s technically an error function of the human brain. Evolution has molded our brains to rapidly identify faces, according to David Alais, PhD, of the University of Sydney, Australia, lead author of the study.

“But the system plays ‘fast and loose’ by applying a crude template of two eyes over a nose and mouth. Lots of things can satisfy that template and thus trigger a face detection response,” he said in a separate statement. But not only are we seeing faces, our brains go one step further and seemingly give those faces feelings.

University of Sydney

Corporate dream manipulation

Advertisements are quite literally everywhere. On billboards, in commercials, in videos, in movies; the list goes on and on. Still, at least you can shut your eyes and be mercifully free of corporate interference inside your own head, right? Right?

Early in 2021, Coors launched an ad campaign that seemed to be a b bit of a gimmick, if not a joke. Coors claimed that if people watched an ad before bed, and played an 8-hour soundscape while sleeping, their dreams would be filled with crisp mountains and cold, thirst-quenching beverages. While, the Coors campaign didn’t go viral, someone was paying attention. A group of 35 leading researchers published an open letter on the subject of corporate dream manipulation, in the journal Dream Engineering.

"Multiple marketing studies are openly testing new ways to alter and motivate purchasing behavior through dream and sleep hacking. The commercial, for-profit use of dream incubation is rapidly becoming a reality," wrote the investigators. "As sleep and dream researchers, we are deeply concerned about marketing plans aimed at generating profits at the cost of interfering with our natural nocturnal memory processing."

People have tried to manipulate their dreams for countless years, but only in recent years have scientists attempted to target or manipulate behavior through dreams. In a 2014 study, smokers exposed to tobacco smoke and rotten egg smell while sleeping reduced their cigarette consumption by 30%.

Free-Photos/Pixabay

Got breast milk?

As we know, breast milk has endless benefits for newbords and babies, but many things can stand in the way of a mother’s ability to breastfeed. Baby formula has served as a good enough substitute. But now, there might be something that’s even better.

A start-up company called BIOMILQ created a product that could be groundbreaking. Using “breakthrough mammary biotechnology,” BIOMILQ created cell-cultured breast milk.

Focus_on_Nature/Getty Images

The contagious Delta variant has become the dominant form of the coronavirus in the United States, now accounting for more than 51% of COVID-19 cases in the country, according to new CDC data to updated on July 6.

The variant, also known as B.1.617.2 and first detected in India, makes up more than 80% of new cases in some Midwestern states, including Iowa, Kansas, and Missouri. Delta also accounts for 74% of cases in Western states such as Colorado and Utah and 59% of cases in Southern states such as Louisiana and Texas.

Communities with low vaccination rates are bearing the brunt of new Delta cases. Public health experts are urging those who are unvaccinated to get a shot to protect themselves and their communities against future surges.

“Right now we have two Americas: the vaccinated and the unvaccinated,” Paul Offit, MD, an infectious disease specialist at Children’s Hospital of Philadelphia, told NPR.

“We’re feeling pretty good right now because it’s the summer,” he said. “But come winter, if we still have a significant percentage of the population that is unvaccinated, we’re going to see this virus surge again.”

So far, COVID-19 vaccines appear to protect people against the Delta variant. But health officials are watching other variants that could evade vaccine protection and lead to major outbreaks this year.

For instance, certain mutations in the Epsilon variant may allow it to evade the immunity from past infections and current COVID-19 vaccines, according to a new study published July 1 in the Science. The variant, also known as B.1.427/B.1.429 and first identified in California, has now been reported in 34 countries and could become widespread in the United States.

Researchers from the University of Washington and clinics in Switzerland tested the variant in blood samples from vaccinated people, as well as those who were previously infected with COVID-19. They found that the neutralizing power was reduced by about 2 to 3½ times.

The research team also visualized the variant and found that three mutations on Epsilon’s spike protein allow the virus to escape certain antibodies and lower the strength of vaccines.

Epsilon “relies on an indirect and unusual neutralization-escape strategy,” they wrote, saying that understanding these escape routes could help scientists track new variants, curb the pandemic, and create booster shots.

In Australia, for instance, public health officials have detected the Lambda variant, which could be more infectious than the Delta variant and resistant to vaccines, according to Sky News.

A hotel quarantine program in New South Wales identified the variant in someone who had returned from travel, the news outlet reported. Also known as C.37, Lambda was named a “variant of interest” by the World Health Organization in June.

Lambda was first identified in Peru in December and now accounts for more than 80% of the country’s cases, according to the Financial Times. It has since been found in 27 countries, including the U.S., U.K., and Germany.

The variant has seven mutations on the spike protein that allow the virus to infect human cells, the news outlet reported. One mutation is like another mutation on the Delta variant, which could make it more contagious.

In a preprint study published July 1, researchers at the University of Chile at Santiago found that Lambda is better able to escape antibodies created by the CoronaVac vaccine made by Sinovac in China. In the paper, which hasn’t yet been peer-reviewed, researchers tested blood samples from local health care workers in Santiago who had received two doses of the vaccine.

“Our data revealed that the spike protein ... carries mutations conferring increased infectivity and the ability to escape from neutralizing antibodies,” they wrote.

The research team urged countries to continue testing for contagious variants, even in areas with high vaccination rates, so scientists can identify mutations quickly and analyze whether new variants can escape vaccines.

“The world has to get its act together,” Saad Omer, PhD, director of the Yale Institute for Global Health, told NPR. “Otherwise yet another, potentially more dangerous, variant could emerge.”

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

The contagious Delta variant has become the dominant form of the coronavirus in the United States, now accounting for more than 51% of COVID-19 cases in the country, according to new CDC data to updated on July 6.

The variant, also known as B.1.617.2 and first detected in India, makes up more than 80% of new cases in some Midwestern states, including Iowa, Kansas, and Missouri. Delta also accounts for 74% of cases in Western states such as Colorado and Utah and 59% of cases in Southern states such as Louisiana and Texas.

Communities with low vaccination rates are bearing the brunt of new Delta cases. Public health experts are urging those who are unvaccinated to get a shot to protect themselves and their communities against future surges.

“Right now we have two Americas: the vaccinated and the unvaccinated,” Paul Offit, MD, an infectious disease specialist at Children’s Hospital of Philadelphia, told NPR.

“We’re feeling pretty good right now because it’s the summer,” he said. “But come winter, if we still have a significant percentage of the population that is unvaccinated, we’re going to see this virus surge again.”

So far, COVID-19 vaccines appear to protect people against the Delta variant. But health officials are watching other variants that could evade vaccine protection and lead to major outbreaks this year.

For instance, certain mutations in the Epsilon variant may allow it to evade the immunity from past infections and current COVID-19 vaccines, according to a new study published July 1 in the Science. The variant, also known as B.1.427/B.1.429 and first identified in California, has now been reported in 34 countries and could become widespread in the United States.

Researchers from the University of Washington and clinics in Switzerland tested the variant in blood samples from vaccinated people, as well as those who were previously infected with COVID-19. They found that the neutralizing power was reduced by about 2 to 3½ times.

The research team also visualized the variant and found that three mutations on Epsilon’s spike protein allow the virus to escape certain antibodies and lower the strength of vaccines.

Epsilon “relies on an indirect and unusual neutralization-escape strategy,” they wrote, saying that understanding these escape routes could help scientists track new variants, curb the pandemic, and create booster shots.

In Australia, for instance, public health officials have detected the Lambda variant, which could be more infectious than the Delta variant and resistant to vaccines, according to Sky News.

A hotel quarantine program in New South Wales identified the variant in someone who had returned from travel, the news outlet reported. Also known as C.37, Lambda was named a “variant of interest” by the World Health Organization in June.

Lambda was first identified in Peru in December and now accounts for more than 80% of the country’s cases, according to the Financial Times. It has since been found in 27 countries, including the U.S., U.K., and Germany.

The variant has seven mutations on the spike protein that allow the virus to infect human cells, the news outlet reported. One mutation is like another mutation on the Delta variant, which could make it more contagious.

In a preprint study published July 1, researchers at the University of Chile at Santiago found that Lambda is better able to escape antibodies created by the CoronaVac vaccine made by Sinovac in China. In the paper, which hasn’t yet been peer-reviewed, researchers tested blood samples from local health care workers in Santiago who had received two doses of the vaccine.

“Our data revealed that the spike protein ... carries mutations conferring increased infectivity and the ability to escape from neutralizing antibodies,” they wrote.

The research team urged countries to continue testing for contagious variants, even in areas with high vaccination rates, so scientists can identify mutations quickly and analyze whether new variants can escape vaccines.

“The world has to get its act together,” Saad Omer, PhD, director of the Yale Institute for Global Health, told NPR. “Otherwise yet another, potentially more dangerous, variant could emerge.”

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

The contagious Delta variant has become the dominant form of the coronavirus in the United States, now accounting for more than 51% of COVID-19 cases in the country, according to new CDC data to updated on July 6.

The variant, also known as B.1.617.2 and first detected in India, makes up more than 80% of new cases in some Midwestern states, including Iowa, Kansas, and Missouri. Delta also accounts for 74% of cases in Western states such as Colorado and Utah and 59% of cases in Southern states such as Louisiana and Texas.

Communities with low vaccination rates are bearing the brunt of new Delta cases. Public health experts are urging those who are unvaccinated to get a shot to protect themselves and their communities against future surges.

“Right now we have two Americas: the vaccinated and the unvaccinated,” Paul Offit, MD, an infectious disease specialist at Children’s Hospital of Philadelphia, told NPR.

“We’re feeling pretty good right now because it’s the summer,” he said. “But come winter, if we still have a significant percentage of the population that is unvaccinated, we’re going to see this virus surge again.”

So far, COVID-19 vaccines appear to protect people against the Delta variant. But health officials are watching other variants that could evade vaccine protection and lead to major outbreaks this year.

For instance, certain mutations in the Epsilon variant may allow it to evade the immunity from past infections and current COVID-19 vaccines, according to a new study published July 1 in the Science. The variant, also known as B.1.427/B.1.429 and first identified in California, has now been reported in 34 countries and could become widespread in the United States.

Researchers from the University of Washington and clinics in Switzerland tested the variant in blood samples from vaccinated people, as well as those who were previously infected with COVID-19. They found that the neutralizing power was reduced by about 2 to 3½ times.

The research team also visualized the variant and found that three mutations on Epsilon’s spike protein allow the virus to escape certain antibodies and lower the strength of vaccines.

Epsilon “relies on an indirect and unusual neutralization-escape strategy,” they wrote, saying that understanding these escape routes could help scientists track new variants, curb the pandemic, and create booster shots.

In Australia, for instance, public health officials have detected the Lambda variant, which could be more infectious than the Delta variant and resistant to vaccines, according to Sky News.

A hotel quarantine program in New South Wales identified the variant in someone who had returned from travel, the news outlet reported. Also known as C.37, Lambda was named a “variant of interest” by the World Health Organization in June.

Lambda was first identified in Peru in December and now accounts for more than 80% of the country’s cases, according to the Financial Times. It has since been found in 27 countries, including the U.S., U.K., and Germany.

The variant has seven mutations on the spike protein that allow the virus to infect human cells, the news outlet reported. One mutation is like another mutation on the Delta variant, which could make it more contagious.

In a preprint study published July 1, researchers at the University of Chile at Santiago found that Lambda is better able to escape antibodies created by the CoronaVac vaccine made by Sinovac in China. In the paper, which hasn’t yet been peer-reviewed, researchers tested blood samples from local health care workers in Santiago who had received two doses of the vaccine.

“Our data revealed that the spike protein ... carries mutations conferring increased infectivity and the ability to escape from neutralizing antibodies,” they wrote.

The research team urged countries to continue testing for contagious variants, even in areas with high vaccination rates, so scientists can identify mutations quickly and analyze whether new variants can escape vaccines.

“The world has to get its act together,” Saad Omer, PhD, director of the Yale Institute for Global Health, told NPR. “Otherwise yet another, potentially more dangerous, variant could emerge.”

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

All over the country, high numbers of youth experiencing a mental health crisis are presenting to emergency departments, where they are assessed to need an inpatient psychiatric hospitalization but then wait for days and sometimes weeks with nowhere to go. In Colorado, one of the largest children’s hospitals in the state declared their own state of emergency to call attention to the problem after facing a 72% increase in volume for mental health emergency visits.¹ This problem is hardly new, but the COVID pandemic has appeared to take the problem to new heights. In Massachusetts, the “boarding” of youth awaiting psychiatric hospitalization has more than doubled since the pandemic, according to a recent report from National Public Radio.² Like many public health problems, there is evidence that the burden falls disproportionately on groups that have faced health inequities in the past.³

What is causing this? The proximal cause is fairly simple: Acute mental health problems in youth are rising while the supply of intensive services is dropping. The number of available inpatient psychiatric beds has steadily been falling over the years even prior to the COVID pandemic, which then took more capacity offline because of staffing shortages and requirements for additional distance between patients (such as eliminating double-occupancy rooms). Meanwhile, levels of anxiety, depression, and suicidality have been rising in youth for reasons still not adequately understood.

The stories of these youth and their families waiting for stabilization and treatment are heartbreaking, and nobody disagrees with the idea that a child being confined to a small ED room for days is not good care. What is debated, however, is how best to fix this problem both in the short and long term. In the eyes of many, the ultimate solution is clear: more inpatient beds. This may indeed be required for some areas, but a closer look at how an entire mental health system operates often reveals both more complex problems and some alternative potential solutions. For example, hospital staff will often acknowledge that they have patients ready for discharge but who need more intensive step-down services like a residential treatment or partial hospital program to be able to do so safely. You can’t have hospital admissions if you don’t have hospital discharges, so without good step-down options patients back up and the regular flow is disrupted. Upstream of the crisis that sends many youth to EDs is another opportunity area, as these tipping points are often seen coming by others, including their pediatricians, but referrals to clinicians or programs that might bring improvement and prevent the need for an ED evaluation are also in short supply.

In the short term, efforts are being directed by some EDs to make the physical space more therapeutic for individuals experiencing mental health problems and to offer more actual treatment when people are there. This can take the form of having a secure space in which to move around, or being offered some supportive psychotherapy sessions and possible medication changes while in the ED. It can also involve simple things like the availability of books, video games, and toys to help pass the time. Such efforts are greatly needed, and many feel that the notion of mental health emergencies somehow being outside the “lane” of emergency medicine training and practice should have been retired long ago.

Medium-term solutions can involve the standing up of more intensive mental health programs that are below the level of inpatient hospitalizations, such as intensive outpatient or partial hospitalization programs, or improved mobile response services that go beyond triage and actually bring supports and techniques directly to families in need. As mentioned, these levels of services can provide both a step-down option that facilitates a hospital discharge and a measure that can prevent the need for some hospitalizations in the first place.

Looking over the long term, health care systems and governments need to evaluate the degree to which more hospital or residential beds may still be needed, despite our best efforts to improve flow and prevent mental health crises from originating. This can often be a contentious topic, however, and securing public dollars to support more beds is often quite difficult even where there seems to be a clear need.

Hovering over nearly all potential solutions, of course, is the challenge of finding the mental health workforce to implement any new programs and initiatives without stealing from services already in place. This dilemma speaks to ongoing issues of parity between resources devoted to mental health versus physical health care. Some mental health care organizations are currently trying to recruit new workers with bonuses or new incentives, but longer-term fixes are likely to require a hard look at the degree to which our actual commitment to mental health care matches the political rhetoric.

Discussions of how to solve the problem of ED boarding can easily deteriorate into a lot of finger pointing of what somebody else should be doing. The truth is, however, that there are many actions that can be taken by those in very different roles.

While many of these steps require efforts from mental health organizations, emergency departments, government agencies, and hospitals, there are things that can be done within the purview of the primary care clinician. First, look for opportunities to increase your collaboration with mental health professionals through initiatives such as integrated care programs. The Health Resources and Services Administration is now using funds from the American Rescue Plan Act to strengthen integrated care programs across the country and new opportunities may well be available soon to get additional mental health supports to primary care offices. Second, get involved and advocate for the mental health of your patients by communicating with other groups to make other potential solutions a reality.

Children and adolescents waiting for days to get the mental health care they need and deserve is an unacceptable situation that we can and must overcome. Quick fixes will be hard to find, but with some collaborative effort, forward thinking, and, yes, financial investments, we can find solutions that reflect the principle of mental health being a foundation for all health.

Dr. Rettew is a child and adolescent psychiatrist and associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Follow him on Twitter @PediPsych. His latest book is “Parenting Made Complicated: What Science Really Knows About the Greatest Debates of Early Childhood.”

References

1. Tabachnik S. Colorado health leaders declare youth mental health state of emergency: “Our kids have run out of resilience.” Denver Post. 2021 May 25. 

2. Bebinger M. Kids in mental health crisis can languish for days inside ERs. National Public Radio. 2021 Jun 23.

3. Nash KA et al. Pediatrics. 2021:147:5. e2020030692.

All over the country, high numbers of youth experiencing a mental health crisis are presenting to emergency departments, where they are assessed to need an inpatient psychiatric hospitalization but then wait for days and sometimes weeks with nowhere to go. In Colorado, one of the largest children’s hospitals in the state declared their own state of emergency to call attention to the problem after facing a 72% increase in volume for mental health emergency visits.¹ This problem is hardly new, but the COVID pandemic has appeared to take the problem to new heights. In Massachusetts, the “boarding” of youth awaiting psychiatric hospitalization has more than doubled since the pandemic, according to a recent report from National Public Radio.² Like many public health problems, there is evidence that the burden falls disproportionately on groups that have faced health inequities in the past.³

What is causing this? The proximal cause is fairly simple: Acute mental health problems in youth are rising while the supply of intensive services is dropping. The number of available inpatient psychiatric beds has steadily been falling over the years even prior to the COVID pandemic, which then took more capacity offline because of staffing shortages and requirements for additional distance between patients (such as eliminating double-occupancy rooms). Meanwhile, levels of anxiety, depression, and suicidality have been rising in youth for reasons still not adequately understood.

The stories of these youth and their families waiting for stabilization and treatment are heartbreaking, and nobody disagrees with the idea that a child being confined to a small ED room for days is not good care. What is debated, however, is how best to fix this problem both in the short and long term. In the eyes of many, the ultimate solution is clear: more inpatient beds. This may indeed be required for some areas, but a closer look at how an entire mental health system operates often reveals both more complex problems and some alternative potential solutions. For example, hospital staff will often acknowledge that they have patients ready for discharge but who need more intensive step-down services like a residential treatment or partial hospital program to be able to do so safely. You can’t have hospital admissions if you don’t have hospital discharges, so without good step-down options patients back up and the regular flow is disrupted. Upstream of the crisis that sends many youth to EDs is another opportunity area, as these tipping points are often seen coming by others, including their pediatricians, but referrals to clinicians or programs that might bring improvement and prevent the need for an ED evaluation are also in short supply.

In the short term, efforts are being directed by some EDs to make the physical space more therapeutic for individuals experiencing mental health problems and to offer more actual treatment when people are there. This can take the form of having a secure space in which to move around, or being offered some supportive psychotherapy sessions and possible medication changes while in the ED. It can also involve simple things like the availability of books, video games, and toys to help pass the time. Such efforts are greatly needed, and many feel that the notion of mental health emergencies somehow being outside the “lane” of emergency medicine training and practice should have been retired long ago.

Medium-term solutions can involve the standing up of more intensive mental health programs that are below the level of inpatient hospitalizations, such as intensive outpatient or partial hospitalization programs, or improved mobile response services that go beyond triage and actually bring supports and techniques directly to families in need. As mentioned, these levels of services can provide both a step-down option that facilitates a hospital discharge and a measure that can prevent the need for some hospitalizations in the first place.

Looking over the long term, health care systems and governments need to evaluate the degree to which more hospital or residential beds may still be needed, despite our best efforts to improve flow and prevent mental health crises from originating. This can often be a contentious topic, however, and securing public dollars to support more beds is often quite difficult even where there seems to be a clear need.

Hovering over nearly all potential solutions, of course, is the challenge of finding the mental health workforce to implement any new programs and initiatives without stealing from services already in place. This dilemma speaks to ongoing issues of parity between resources devoted to mental health versus physical health care. Some mental health care organizations are currently trying to recruit new workers with bonuses or new incentives, but longer-term fixes are likely to require a hard look at the degree to which our actual commitment to mental health care matches the political rhetoric.

Discussions of how to solve the problem of ED boarding can easily deteriorate into a lot of finger pointing of what somebody else should be doing. The truth is, however, that there are many actions that can be taken by those in very different roles.

While many of these steps require efforts from mental health organizations, emergency departments, government agencies, and hospitals, there are things that can be done within the purview of the primary care clinician. First, look for opportunities to increase your collaboration with mental health professionals through initiatives such as integrated care programs. The Health Resources and Services Administration is now using funds from the American Rescue Plan Act to strengthen integrated care programs across the country and new opportunities may well be available soon to get additional mental health supports to primary care offices. Second, get involved and advocate for the mental health of your patients by communicating with other groups to make other potential solutions a reality.

Children and adolescents waiting for days to get the mental health care they need and deserve is an unacceptable situation that we can and must overcome. Quick fixes will be hard to find, but with some collaborative effort, forward thinking, and, yes, financial investments, we can find solutions that reflect the principle of mental health being a foundation for all health.

Dr. Rettew is a child and adolescent psychiatrist and associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Follow him on Twitter @PediPsych. His latest book is “Parenting Made Complicated: What Science Really Knows About the Greatest Debates of Early Childhood.”

References

1. Tabachnik S. Colorado health leaders declare youth mental health state of emergency: “Our kids have run out of resilience.” Denver Post. 2021 May 25. 

2. Bebinger M. Kids in mental health crisis can languish for days inside ERs. National Public Radio. 2021 Jun 23.

3. Nash KA et al. Pediatrics. 2021:147:5. e2020030692.

All over the country, high numbers of youth experiencing a mental health crisis are presenting to emergency departments, where they are assessed to need an inpatient psychiatric hospitalization but then wait for days and sometimes weeks with nowhere to go. In Colorado, one of the largest children’s hospitals in the state declared their own state of emergency to call attention to the problem after facing a 72% increase in volume for mental health emergency visits.¹ This problem is hardly new, but the COVID pandemic has appeared to take the problem to new heights. In Massachusetts, the “boarding” of youth awaiting psychiatric hospitalization has more than doubled since the pandemic, according to a recent report from National Public Radio.² Like many public health problems, there is evidence that the burden falls disproportionately on groups that have faced health inequities in the past.³

What is causing this? The proximal cause is fairly simple: Acute mental health problems in youth are rising while the supply of intensive services is dropping. The number of available inpatient psychiatric beds has steadily been falling over the years even prior to the COVID pandemic, which then took more capacity offline because of staffing shortages and requirements for additional distance between patients (such as eliminating double-occupancy rooms). Meanwhile, levels of anxiety, depression, and suicidality have been rising in youth for reasons still not adequately understood.

The stories of these youth and their families waiting for stabilization and treatment are heartbreaking, and nobody disagrees with the idea that a child being confined to a small ED room for days is not good care. What is debated, however, is how best to fix this problem both in the short and long term. In the eyes of many, the ultimate solution is clear: more inpatient beds. This may indeed be required for some areas, but a closer look at how an entire mental health system operates often reveals both more complex problems and some alternative potential solutions. For example, hospital staff will often acknowledge that they have patients ready for discharge but who need more intensive step-down services like a residential treatment or partial hospital program to be able to do so safely. You can’t have hospital admissions if you don’t have hospital discharges, so without good step-down options patients back up and the regular flow is disrupted. Upstream of the crisis that sends many youth to EDs is another opportunity area, as these tipping points are often seen coming by others, including their pediatricians, but referrals to clinicians or programs that might bring improvement and prevent the need for an ED evaluation are also in short supply.

In the short term, efforts are being directed by some EDs to make the physical space more therapeutic for individuals experiencing mental health problems and to offer more actual treatment when people are there. This can take the form of having a secure space in which to move around, or being offered some supportive psychotherapy sessions and possible medication changes while in the ED. It can also involve simple things like the availability of books, video games, and toys to help pass the time. Such efforts are greatly needed, and many feel that the notion of mental health emergencies somehow being outside the “lane” of emergency medicine training and practice should have been retired long ago.

Medium-term solutions can involve the standing up of more intensive mental health programs that are below the level of inpatient hospitalizations, such as intensive outpatient or partial hospitalization programs, or improved mobile response services that go beyond triage and actually bring supports and techniques directly to families in need. As mentioned, these levels of services can provide both a step-down option that facilitates a hospital discharge and a measure that can prevent the need for some hospitalizations in the first place.

Looking over the long term, health care systems and governments need to evaluate the degree to which more hospital or residential beds may still be needed, despite our best efforts to improve flow and prevent mental health crises from originating. This can often be a contentious topic, however, and securing public dollars to support more beds is often quite difficult even where there seems to be a clear need.

Hovering over nearly all potential solutions, of course, is the challenge of finding the mental health workforce to implement any new programs and initiatives without stealing from services already in place. This dilemma speaks to ongoing issues of parity between resources devoted to mental health versus physical health care. Some mental health care organizations are currently trying to recruit new workers with bonuses or new incentives, but longer-term fixes are likely to require a hard look at the degree to which our actual commitment to mental health care matches the political rhetoric.

Discussions of how to solve the problem of ED boarding can easily deteriorate into a lot of finger pointing of what somebody else should be doing. The truth is, however, that there are many actions that can be taken by those in very different roles.

While many of these steps require efforts from mental health organizations, emergency departments, government agencies, and hospitals, there are things that can be done within the purview of the primary care clinician. First, look for opportunities to increase your collaboration with mental health professionals through initiatives such as integrated care programs. The Health Resources and Services Administration is now using funds from the American Rescue Plan Act to strengthen integrated care programs across the country and new opportunities may well be available soon to get additional mental health supports to primary care offices. Second, get involved and advocate for the mental health of your patients by communicating with other groups to make other potential solutions a reality.

Children and adolescents waiting for days to get the mental health care they need and deserve is an unacceptable situation that we can and must overcome. Quick fixes will be hard to find, but with some collaborative effort, forward thinking, and, yes, financial investments, we can find solutions that reflect the principle of mental health being a foundation for all health.

Dr. Rettew is a child and adolescent psychiatrist and associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Follow him on Twitter @PediPsych. His latest book is “Parenting Made Complicated: What Science Really Knows About the Greatest Debates of Early Childhood.”

References

1. Tabachnik S. Colorado health leaders declare youth mental health state of emergency: “Our kids have run out of resilience.” Denver Post. 2021 May 25. 

2. Bebinger M. Kids in mental health crisis can languish for days inside ERs. National Public Radio. 2021 Jun 23.

3. Nash KA et al. Pediatrics. 2021:147:5. e2020030692.

A review of human and animal epidemiological studies found that long-term stress and genetic factors may act through the hypothalamic-pituitary-adrenal (HPA) axis – a pathway in the brain that mediates stress responses – to contribute to the development of Alzheimer’s disease. The researchers also proposed a mechanism to account for how genetic factors may affect HPA axis reactivity and lead to inflammation, which is a core component of neurodegeneration.

“Chronic stress can impact the way immune cells in the brain function and increase inflammation. Genetic variants within that stress response can further affect the function of immune cells,” lead author Ayeisha Milligan Armstrong, a PhD candidate at Curtin Health Innovation Research Institute in Perth, Australia, said in an interview.

The findings were published online June 22 in Biological Reviews).

Research has found that long-term stress during early and mid-life is increasingly associated with cognitive decline and neurodegeneration. There is already evidence to suggest that chronic stress is a risk factor for the “sporadic” or late-onset subtype of Alzheimer’s disease.
 

A cascade of events

Stress activates the HPA, which in turn regulates bodily levels of cortisol, a glucocorticoid stress hormone. Increased levels of cortisol are frequently observed in patients with Alzheimer’s disease and “make a major contribution to the disease process,” the authors wrote. For example, the hippocampus – a part of the brain involved in processing and forming memories – has numerous glucocorticoid receptors and is “therefore particularly sensitive to the effects of glucocorticoids.” However, the molecular mechanisms involved remain poorly understood.

“There is an intimate interplay between exposure to chronic stress and pathways influencing the body’s reaction to such stress,” senior author David Groth, PhD, said in a statement. Dr. Groth is an associate professor at Curtin University in Perth, Australia.

There is variation between individuals with regard to how sensitive they are to stress and glucocorticoid responses. Environmental factors such as stress are thought to be at least partly responsible, as are genetic factors such as genetic polymorphisms and epigenetics. “Genetic variations within these pathways can influence the way the brain’s immune system behaves, leading to a dysfunctional response. In the brain, this leads to a chronic disruption of normal brain processes, increasing the risk of subsequent neurodegeneration and ultimately dementia,” Dr. Groth said.

The researchers suggested that these variations may prime the immune cells of the brain, the microglia, to cause inflammation in the brain. Normally, microglia are involved in monitoring the brain tissue for and responding to damage and infections to keep the brain healthy. However, in an inflammatory state, the microglia instead contribute to a “more neurotoxic environment through the production of proinflammatory cytokines, altered synaptic pruning, and the reduced production of protective neurotrophic factors,” the authors wrote. Microglia may also promote the accumulation of amyloid beta and tau protein, which damage the brain tissue and can cause neurodegeneration. There are different groups of microglia in the brain, each of which may respond differently to genetic and environmental stressors.

“Genome-wide association studies have found that of the genes identified as being associated with Alzheimer’s disease, 60.5% are expressed in microglia,” the authors noted.

To connect the roles of chronic stress and brain inflammation in Alzheimer’s disease, the researchers proposed a “two-hit” hypothesis: Early or mid-life exposure to stress primes the microglia to enter an inflammatory state in response to a secondary stimulus later in life.
 

Pay attention to stress

For clinicians, this paper highlights the importance of managing stress in patients and their families.

“Clinicians need to be attuned to the effects of stress on patients and their caregivers, and how that [stress] can affect their morbidity and mortality,” Cynthia Munro, PhD, associate professor of psychiatry and behavioral sciences at Johns Hopkins University, Baltimore, said in an interview. She added that attention must be paid to modifiable risk factors such as poor sleep and diet.

Although managing stress is important, that doesn’t mean that everyone who’s experienced chronic stress will develop Alzheimer’s disease. “Chronic stress can alter the HPA axis but it doesn’t necessarily do so in everyone. A cascade of events needs to occur,” said Dr. Munro. “People should always try to reduce the effects of stress to the extent that they can. Stress can lead to a whole host of negative health outcomes, not just Alzheimer’s disease.”
 

Next steps

Moving forward, the researchers plan to further investigate the molecular mechanisms responsible for the role of stress in Alzheimer’s disease and how genetic variants affect neurodegeneration, Ms. Armstrong said. Ultimately, understanding how stress and genetics contribute to Alzheimer’s disease may lead to the identification of possible therapeutic targets.

Ms. Armstrong and Dr. Munro declared no relevant financial relationships. The study was independently funded.

A review of human and animal epidemiological studies found that long-term stress and genetic factors may act through the hypothalamic-pituitary-adrenal (HPA) axis – a pathway in the brain that mediates stress responses – to contribute to the development of Alzheimer’s disease. The researchers also proposed a mechanism to account for how genetic factors may affect HPA axis reactivity and lead to inflammation, which is a core component of neurodegeneration.

“Chronic stress can impact the way immune cells in the brain function and increase inflammation. Genetic variants within that stress response can further affect the function of immune cells,” lead author Ayeisha Milligan Armstrong, a PhD candidate at Curtin Health Innovation Research Institute in Perth, Australia, said in an interview.

The findings were published online June 22 in Biological Reviews).

Research has found that long-term stress during early and mid-life is increasingly associated with cognitive decline and neurodegeneration. There is already evidence to suggest that chronic stress is a risk factor for the “sporadic” or late-onset subtype of Alzheimer’s disease.
 

A cascade of events

Stress activates the HPA, which in turn regulates bodily levels of cortisol, a glucocorticoid stress hormone. Increased levels of cortisol are frequently observed in patients with Alzheimer’s disease and “make a major contribution to the disease process,” the authors wrote. For example, the hippocampus – a part of the brain involved in processing and forming memories – has numerous glucocorticoid receptors and is “therefore particularly sensitive to the effects of glucocorticoids.” However, the molecular mechanisms involved remain poorly understood.

“There is an intimate interplay between exposure to chronic stress and pathways influencing the body’s reaction to such stress,” senior author David Groth, PhD, said in a statement. Dr. Groth is an associate professor at Curtin University in Perth, Australia.

There is variation between individuals with regard to how sensitive they are to stress and glucocorticoid responses. Environmental factors such as stress are thought to be at least partly responsible, as are genetic factors such as genetic polymorphisms and epigenetics. “Genetic variations within these pathways can influence the way the brain’s immune system behaves, leading to a dysfunctional response. In the brain, this leads to a chronic disruption of normal brain processes, increasing the risk of subsequent neurodegeneration and ultimately dementia,” Dr. Groth said.

The researchers suggested that these variations may prime the immune cells of the brain, the microglia, to cause inflammation in the brain. Normally, microglia are involved in monitoring the brain tissue for and responding to damage and infections to keep the brain healthy. However, in an inflammatory state, the microglia instead contribute to a “more neurotoxic environment through the production of proinflammatory cytokines, altered synaptic pruning, and the reduced production of protective neurotrophic factors,” the authors wrote. Microglia may also promote the accumulation of amyloid beta and tau protein, which damage the brain tissue and can cause neurodegeneration. There are different groups of microglia in the brain, each of which may respond differently to genetic and environmental stressors.

“Genome-wide association studies have found that of the genes identified as being associated with Alzheimer’s disease, 60.5% are expressed in microglia,” the authors noted.

To connect the roles of chronic stress and brain inflammation in Alzheimer’s disease, the researchers proposed a “two-hit” hypothesis: Early or mid-life exposure to stress primes the microglia to enter an inflammatory state in response to a secondary stimulus later in life.
 

Pay attention to stress

For clinicians, this paper highlights the importance of managing stress in patients and their families.

“Clinicians need to be attuned to the effects of stress on patients and their caregivers, and how that [stress] can affect their morbidity and mortality,” Cynthia Munro, PhD, associate professor of psychiatry and behavioral sciences at Johns Hopkins University, Baltimore, said in an interview. She added that attention must be paid to modifiable risk factors such as poor sleep and diet.

Although managing stress is important, that doesn’t mean that everyone who’s experienced chronic stress will develop Alzheimer’s disease. “Chronic stress can alter the HPA axis but it doesn’t necessarily do so in everyone. A cascade of events needs to occur,” said Dr. Munro. “People should always try to reduce the effects of stress to the extent that they can. Stress can lead to a whole host of negative health outcomes, not just Alzheimer’s disease.”
 

Next steps

Moving forward, the researchers plan to further investigate the molecular mechanisms responsible for the role of stress in Alzheimer’s disease and how genetic variants affect neurodegeneration, Ms. Armstrong said. Ultimately, understanding how stress and genetics contribute to Alzheimer’s disease may lead to the identification of possible therapeutic targets.

Ms. Armstrong and Dr. Munro declared no relevant financial relationships. The study was independently funded.

A review of human and animal epidemiological studies found that long-term stress and genetic factors may act through the hypothalamic-pituitary-adrenal (HPA) axis – a pathway in the brain that mediates stress responses – to contribute to the development of Alzheimer’s disease. The researchers also proposed a mechanism to account for how genetic factors may affect HPA axis reactivity and lead to inflammation, which is a core component of neurodegeneration.

“Chronic stress can impact the way immune cells in the brain function and increase inflammation. Genetic variants within that stress response can further affect the function of immune cells,” lead author Ayeisha Milligan Armstrong, a PhD candidate at Curtin Health Innovation Research Institute in Perth, Australia, said in an interview.

The findings were published online June 22 in Biological Reviews).

Research has found that long-term stress during early and mid-life is increasingly associated with cognitive decline and neurodegeneration. There is already evidence to suggest that chronic stress is a risk factor for the “sporadic” or late-onset subtype of Alzheimer’s disease.
 

A cascade of events

Stress activates the HPA, which in turn regulates bodily levels of cortisol, a glucocorticoid stress hormone. Increased levels of cortisol are frequently observed in patients with Alzheimer’s disease and “make a major contribution to the disease process,” the authors wrote. For example, the hippocampus – a part of the brain involved in processing and forming memories – has numerous glucocorticoid receptors and is “therefore particularly sensitive to the effects of glucocorticoids.” However, the molecular mechanisms involved remain poorly understood.

“There is an intimate interplay between exposure to chronic stress and pathways influencing the body’s reaction to such stress,” senior author David Groth, PhD, said in a statement. Dr. Groth is an associate professor at Curtin University in Perth, Australia.

There is variation between individuals with regard to how sensitive they are to stress and glucocorticoid responses. Environmental factors such as stress are thought to be at least partly responsible, as are genetic factors such as genetic polymorphisms and epigenetics. “Genetic variations within these pathways can influence the way the brain’s immune system behaves, leading to a dysfunctional response. In the brain, this leads to a chronic disruption of normal brain processes, increasing the risk of subsequent neurodegeneration and ultimately dementia,” Dr. Groth said.

The researchers suggested that these variations may prime the immune cells of the brain, the microglia, to cause inflammation in the brain. Normally, microglia are involved in monitoring the brain tissue for and responding to damage and infections to keep the brain healthy. However, in an inflammatory state, the microglia instead contribute to a “more neurotoxic environment through the production of proinflammatory cytokines, altered synaptic pruning, and the reduced production of protective neurotrophic factors,” the authors wrote. Microglia may also promote the accumulation of amyloid beta and tau protein, which damage the brain tissue and can cause neurodegeneration. There are different groups of microglia in the brain, each of which may respond differently to genetic and environmental stressors.

“Genome-wide association studies have found that of the genes identified as being associated with Alzheimer’s disease, 60.5% are expressed in microglia,” the authors noted.

To connect the roles of chronic stress and brain inflammation in Alzheimer’s disease, the researchers proposed a “two-hit” hypothesis: Early or mid-life exposure to stress primes the microglia to enter an inflammatory state in response to a secondary stimulus later in life.
 

Pay attention to stress

For clinicians, this paper highlights the importance of managing stress in patients and their families.

“Clinicians need to be attuned to the effects of stress on patients and their caregivers, and how that [stress] can affect their morbidity and mortality,” Cynthia Munro, PhD, associate professor of psychiatry and behavioral sciences at Johns Hopkins University, Baltimore, said in an interview. She added that attention must be paid to modifiable risk factors such as poor sleep and diet.

Although managing stress is important, that doesn’t mean that everyone who’s experienced chronic stress will develop Alzheimer’s disease. “Chronic stress can alter the HPA axis but it doesn’t necessarily do so in everyone. A cascade of events needs to occur,” said Dr. Munro. “People should always try to reduce the effects of stress to the extent that they can. Stress can lead to a whole host of negative health outcomes, not just Alzheimer’s disease.”
 

Next steps

Moving forward, the researchers plan to further investigate the molecular mechanisms responsible for the role of stress in Alzheimer’s disease and how genetic variants affect neurodegeneration, Ms. Armstrong said. Ultimately, understanding how stress and genetics contribute to Alzheimer’s disease may lead to the identification of possible therapeutic targets.

Ms. Armstrong and Dr. Munro declared no relevant financial relationships. The study was independently funded.

Postpartum depression isn’t just something new mothers can get. Turns out it can affect new fathers, too, according to a new study.

Michael W., a 38-year-old New Jersey–based attorney, and his wife had been excitedly planning for the birth of their baby and were overjoyed when she was born.

But after that, “I found that parenting a newborn was shockingly exhausting. I felt unprepared for the task, overwhelmed by the burden of the 24-hour-schedule and lack of sleep, and I struggled with feelings of inadequacy,” he said in an interview.

Michael never thought he had postpartum depression (PPD), perhaps because the condition is more commonly associated with women. But a study published in the American Journal of Men’s Health suggests that PPD also affects men.

A team of Danish investigators led by researcher Sarah Pedersen, of the department of public health, Aarhus University, extensively interviewed eight fathers with PPD and found their primary experiences involved feelings of being overwhelmed and powerless or inadequate, which sometimes turned into anger and frustration.

“I think one of the most important take-home messages is that practicing clinicians working with new parents should invite fathers to your consultations and engage the fathers as much as possible,” Ms. Pedersen said in an interview.

The findings also contained a message for parents, she says.

“I hope you will support each other and talk about your feelings and how you experience the transition to parenthood – know that it will take time to adjust to your new role,” she said.
 

Not enough attention

There’s been too little focus on fathers when it comes to PPD, according to Ms. Pedersen.

“During the last decade, several studies have examined the prevalence of PPD in men, and there is rising evidence that paternal PPD is associated with increased risk of long-term adverse behavioral and emotional outcomes in children,” she said.

Nevertheless, only three studies have been based on interviews with fathers who had personal experience with PPD.

“The purpose of our study was, first of all, to explore the lived experience of fathers who had PPD and, secondly, to gain deeper understanding of their help-seeking behavior – barriers to seeking help and facilitators of help-seeking,” Ms. Pedersen said.

The study was based on “semistructured” interviews with eight Danish fathers (ages 29-38 years) who had had PPD, none of whom had a previous history of depression.

All of them had received a formal diagnosis of PPD by a general practitioner or psychologist, and all had sought or received mental health care and considered themselves recovered from depression at the time of the interview.

The researchers used a technique called interpretative phenomenological analysis to analyze the interviews.

This method “aims to produce in-depth examinations of certain phenomena by examining how individuals make meaning of their own life experiences,” the authors wrote.
 

A ‘radical change’

Of the fathers, five described the period of pregnancy as a “time of happiness, full of positive expectations about fatherhood.”

But “the fathers’ great expectations were later replaced by a very different reality of fatherhood,” the authors wrote, noting that the transition to fatherhood was, in the words of one participant, a “radical change that you just can’t imagine.”

Most fathers expressed a feeling of being overwhelmed, and three felt unready for the task, which added to their depression.

“The participants wanted to be emotionally and physically present in their child’s life, but during the time of their depression, these kind-hearted intentions changed into feelings of guilt and inadequacy, as the participants did not feel they had enough energy and mental strength to become the kind of fathers they wanted to be,” the authors wrote.

The fathers mentioned stressors they believed contributed to their PPD, including complications during their partners’ pregnancies, unplanned cesarean birth (three fathers), the partners’ difficulties with breastfeeding (five fathers), and employment-related concerns. Five reported that their partners had postpartum emotional distress.
 

‘Masculine norms’

A second focus of the research was to examine fathers’ help-seeking behaviors, Ms. Pedersen said.

Ultimately, all the men sought formal help, either from their general practitioners or from a health visitor, with two seeking help right after birth.

Although the men were able to recognize changes in mood and behavior in retrospect, many did not regard them as signs of depression before their diagnosis.

Most had heard of PPD, but primarily as it affects women. Three sought information online about paternal PPD but couldn’t find any.

Four participants described experiencing PPD as “taboo,” based on a “combination of false beliefs, stigma, and masculine norms,” the authors stated, since men “are supposed to be big and strong and take care of everything, and suddenly you can’t.”

The authors reported that seven participants were screened for PPD or depression by a health care professional.

“The screening was an important part of the help-seeking process, as this was the first time two of the fathers were introduced to PPD,” the authors noted.

Although the screening “had the potential to spark conversation” about PPD, it was geared toward women, and some participants did not feel it was relevant to them.

“Future research should focus on identification of educational needs about paternal PPD among both parents, health care professionals, and other professionals taking care of new families,” Ms. Pedersen said.

Michael W. says it would have been helpful if someone had prepared him and his wife for what to expect, or if there had been some type of screening. Also, he advises expectant parents to “get some real-life experience by spending time around a newborn to see what’s involved.”
 

Different symptoms

“We often talk about mothers suffering from PPD, so it is more normalized for mothers to bring it up or for loved ones to ask mothers about how they are doing physically and psychologically after the birth,” Craig Garfield, MD, an attending physician and founder/director of Family and Child Health innovations at Ann and Robert H. Lurie Children’s Hospital, Chicago, said in an interview.

For fathers, “it is not discussed as commonly, so friends and families don’t often ask dads, and dads don’t know where to turn,” said Dr. Garfield, professor of pediatrics and medical social sciences at Northwestern University, Chicago. He was not involved with the study.

He noted that symptoms in fathers might differ from those of mothers.

“I have seen fathers who are anxious or more moody than they had been prior, or more angry, and I have seen fathers who throw themselves into work or begin drinking more – all related to changes in mood and depressive symptoms in the postnatal period,” he said.

Symptoms in men may last longer than in women. Dr. Garfield’s group published a study in which they surveyed 400 mothers and fathers of premature infants in the neonatal intensive care unit (NICU) about depressive symptoms around the time of NICU admission, at discharge home, and then after 30 days at home.

Roughly one-third of mothers screened positive for depressive symptoms around NICU admission, as did 17% of fathers. But the mothers’ depression scores improved by discharge and 30 days after being home, while the fathers’ remained “essentially unchanged,” he said.

“Further, we found that if doctors were to screen mothers and fathers during the NICU stay – at admission or even at discharge – that would greatly improve their ability to predict who would still have depressive symptoms 1 month after going home.”

Ms. Pedersen agrees that clinicians should incorporate screening for PPD into their practices and be proactive in encouraging fathers to get help.

“Keep pushing,” she advised, as “men rarely seek help, compared to women, in matters of mental health.”
 

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

Postpartum depression isn’t just something new mothers can get. Turns out it can affect new fathers, too, according to a new study.

Michael W., a 38-year-old New Jersey–based attorney, and his wife had been excitedly planning for the birth of their baby and were overjoyed when she was born.

But after that, “I found that parenting a newborn was shockingly exhausting. I felt unprepared for the task, overwhelmed by the burden of the 24-hour-schedule and lack of sleep, and I struggled with feelings of inadequacy,” he said in an interview.

Michael never thought he had postpartum depression (PPD), perhaps because the condition is more commonly associated with women. But a study published in the American Journal of Men’s Health suggests that PPD also affects men.

A team of Danish investigators led by researcher Sarah Pedersen, of the department of public health, Aarhus University, extensively interviewed eight fathers with PPD and found their primary experiences involved feelings of being overwhelmed and powerless or inadequate, which sometimes turned into anger and frustration.

“I think one of the most important take-home messages is that practicing clinicians working with new parents should invite fathers to your consultations and engage the fathers as much as possible,” Ms. Pedersen said in an interview.

The findings also contained a message for parents, she says.

“I hope you will support each other and talk about your feelings and how you experience the transition to parenthood – know that it will take time to adjust to your new role,” she said.
 

Not enough attention

There’s been too little focus on fathers when it comes to PPD, according to Ms. Pedersen.

“During the last decade, several studies have examined the prevalence of PPD in men, and there is rising evidence that paternal PPD is associated with increased risk of long-term adverse behavioral and emotional outcomes in children,” she said.

Nevertheless, only three studies have been based on interviews with fathers who had personal experience with PPD.

“The purpose of our study was, first of all, to explore the lived experience of fathers who had PPD and, secondly, to gain deeper understanding of their help-seeking behavior – barriers to seeking help and facilitators of help-seeking,” Ms. Pedersen said.

The study was based on “semistructured” interviews with eight Danish fathers (ages 29-38 years) who had had PPD, none of whom had a previous history of depression.

All of them had received a formal diagnosis of PPD by a general practitioner or psychologist, and all had sought or received mental health care and considered themselves recovered from depression at the time of the interview.

The researchers used a technique called interpretative phenomenological analysis to analyze the interviews.

This method “aims to produce in-depth examinations of certain phenomena by examining how individuals make meaning of their own life experiences,” the authors wrote.
 

A ‘radical change’

Of the fathers, five described the period of pregnancy as a “time of happiness, full of positive expectations about fatherhood.”

But “the fathers’ great expectations were later replaced by a very different reality of fatherhood,” the authors wrote, noting that the transition to fatherhood was, in the words of one participant, a “radical change that you just can’t imagine.”

Most fathers expressed a feeling of being overwhelmed, and three felt unready for the task, which added to their depression.

“The participants wanted to be emotionally and physically present in their child’s life, but during the time of their depression, these kind-hearted intentions changed into feelings of guilt and inadequacy, as the participants did not feel they had enough energy and mental strength to become the kind of fathers they wanted to be,” the authors wrote.

The fathers mentioned stressors they believed contributed to their PPD, including complications during their partners’ pregnancies, unplanned cesarean birth (three fathers), the partners’ difficulties with breastfeeding (five fathers), and employment-related concerns. Five reported that their partners had postpartum emotional distress.
 

‘Masculine norms’

A second focus of the research was to examine fathers’ help-seeking behaviors, Ms. Pedersen said.

Ultimately, all the men sought formal help, either from their general practitioners or from a health visitor, with two seeking help right after birth.

Although the men were able to recognize changes in mood and behavior in retrospect, many did not regard them as signs of depression before their diagnosis.

Most had heard of PPD, but primarily as it affects women. Three sought information online about paternal PPD but couldn’t find any.

Four participants described experiencing PPD as “taboo,” based on a “combination of false beliefs, stigma, and masculine norms,” the authors stated, since men “are supposed to be big and strong and take care of everything, and suddenly you can’t.”

The authors reported that seven participants were screened for PPD or depression by a health care professional.

“The screening was an important part of the help-seeking process, as this was the first time two of the fathers were introduced to PPD,” the authors noted.

Although the screening “had the potential to spark conversation” about PPD, it was geared toward women, and some participants did not feel it was relevant to them.

“Future research should focus on identification of educational needs about paternal PPD among both parents, health care professionals, and other professionals taking care of new families,” Ms. Pedersen said.

Michael W. says it would have been helpful if someone had prepared him and his wife for what to expect, or if there had been some type of screening. Also, he advises expectant parents to “get some real-life experience by spending time around a newborn to see what’s involved.”
 

Different symptoms

“We often talk about mothers suffering from PPD, so it is more normalized for mothers to bring it up or for loved ones to ask mothers about how they are doing physically and psychologically after the birth,” Craig Garfield, MD, an attending physician and founder/director of Family and Child Health innovations at Ann and Robert H. Lurie Children’s Hospital, Chicago, said in an interview.

For fathers, “it is not discussed as commonly, so friends and families don’t often ask dads, and dads don’t know where to turn,” said Dr. Garfield, professor of pediatrics and medical social sciences at Northwestern University, Chicago. He was not involved with the study.

He noted that symptoms in fathers might differ from those of mothers.

“I have seen fathers who are anxious or more moody than they had been prior, or more angry, and I have seen fathers who throw themselves into work or begin drinking more – all related to changes in mood and depressive symptoms in the postnatal period,” he said.

Symptoms in men may last longer than in women. Dr. Garfield’s group published a study in which they surveyed 400 mothers and fathers of premature infants in the neonatal intensive care unit (NICU) about depressive symptoms around the time of NICU admission, at discharge home, and then after 30 days at home.

Roughly one-third of mothers screened positive for depressive symptoms around NICU admission, as did 17% of fathers. But the mothers’ depression scores improved by discharge and 30 days after being home, while the fathers’ remained “essentially unchanged,” he said.

“Further, we found that if doctors were to screen mothers and fathers during the NICU stay – at admission or even at discharge – that would greatly improve their ability to predict who would still have depressive symptoms 1 month after going home.”

Ms. Pedersen agrees that clinicians should incorporate screening for PPD into their practices and be proactive in encouraging fathers to get help.

“Keep pushing,” she advised, as “men rarely seek help, compared to women, in matters of mental health.”
 

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

Postpartum depression isn’t just something new mothers can get. Turns out it can affect new fathers, too, according to a new study.

Michael W., a 38-year-old New Jersey–based attorney, and his wife had been excitedly planning for the birth of their baby and were overjoyed when she was born.

But after that, “I found that parenting a newborn was shockingly exhausting. I felt unprepared for the task, overwhelmed by the burden of the 24-hour-schedule and lack of sleep, and I struggled with feelings of inadequacy,” he said in an interview.

Michael never thought he had postpartum depression (PPD), perhaps because the condition is more commonly associated with women. But a study published in the American Journal of Men’s Health suggests that PPD also affects men.

A team of Danish investigators led by researcher Sarah Pedersen, of the department of public health, Aarhus University, extensively interviewed eight fathers with PPD and found their primary experiences involved feelings of being overwhelmed and powerless or inadequate, which sometimes turned into anger and frustration.

“I think one of the most important take-home messages is that practicing clinicians working with new parents should invite fathers to your consultations and engage the fathers as much as possible,” Ms. Pedersen said in an interview.

The findings also contained a message for parents, she says.

“I hope you will support each other and talk about your feelings and how you experience the transition to parenthood – know that it will take time to adjust to your new role,” she said.
 

Not enough attention

There’s been too little focus on fathers when it comes to PPD, according to Ms. Pedersen.

“During the last decade, several studies have examined the prevalence of PPD in men, and there is rising evidence that paternal PPD is associated with increased risk of long-term adverse behavioral and emotional outcomes in children,” she said.

Nevertheless, only three studies have been based on interviews with fathers who had personal experience with PPD.

“The purpose of our study was, first of all, to explore the lived experience of fathers who had PPD and, secondly, to gain deeper understanding of their help-seeking behavior – barriers to seeking help and facilitators of help-seeking,” Ms. Pedersen said.

The study was based on “semistructured” interviews with eight Danish fathers (ages 29-38 years) who had had PPD, none of whom had a previous history of depression.

All of them had received a formal diagnosis of PPD by a general practitioner or psychologist, and all had sought or received mental health care and considered themselves recovered from depression at the time of the interview.

The researchers used a technique called interpretative phenomenological analysis to analyze the interviews.

This method “aims to produce in-depth examinations of certain phenomena by examining how individuals make meaning of their own life experiences,” the authors wrote.
 

A ‘radical change’

Of the fathers, five described the period of pregnancy as a “time of happiness, full of positive expectations about fatherhood.”

But “the fathers’ great expectations were later replaced by a very different reality of fatherhood,” the authors wrote, noting that the transition to fatherhood was, in the words of one participant, a “radical change that you just can’t imagine.”

Most fathers expressed a feeling of being overwhelmed, and three felt unready for the task, which added to their depression.

“The participants wanted to be emotionally and physically present in their child’s life, but during the time of their depression, these kind-hearted intentions changed into feelings of guilt and inadequacy, as the participants did not feel they had enough energy and mental strength to become the kind of fathers they wanted to be,” the authors wrote.

The fathers mentioned stressors they believed contributed to their PPD, including complications during their partners’ pregnancies, unplanned cesarean birth (three fathers), the partners’ difficulties with breastfeeding (five fathers), and employment-related concerns. Five reported that their partners had postpartum emotional distress.
 

‘Masculine norms’

A second focus of the research was to examine fathers’ help-seeking behaviors, Ms. Pedersen said.

Ultimately, all the men sought formal help, either from their general practitioners or from a health visitor, with two seeking help right after birth.

Although the men were able to recognize changes in mood and behavior in retrospect, many did not regard them as signs of depression before their diagnosis.

Most had heard of PPD, but primarily as it affects women. Three sought information online about paternal PPD but couldn’t find any.

Four participants described experiencing PPD as “taboo,” based on a “combination of false beliefs, stigma, and masculine norms,” the authors stated, since men “are supposed to be big and strong and take care of everything, and suddenly you can’t.”

The authors reported that seven participants were screened for PPD or depression by a health care professional.

“The screening was an important part of the help-seeking process, as this was the first time two of the fathers were introduced to PPD,” the authors noted.

Although the screening “had the potential to spark conversation” about PPD, it was geared toward women, and some participants did not feel it was relevant to them.

“Future research should focus on identification of educational needs about paternal PPD among both parents, health care professionals, and other professionals taking care of new families,” Ms. Pedersen said.

Michael W. says it would have been helpful if someone had prepared him and his wife for what to expect, or if there had been some type of screening. Also, he advises expectant parents to “get some real-life experience by spending time around a newborn to see what’s involved.”
 

Different symptoms

“We often talk about mothers suffering from PPD, so it is more normalized for mothers to bring it up or for loved ones to ask mothers about how they are doing physically and psychologically after the birth,” Craig Garfield, MD, an attending physician and founder/director of Family and Child Health innovations at Ann and Robert H. Lurie Children’s Hospital, Chicago, said in an interview.

For fathers, “it is not discussed as commonly, so friends and families don’t often ask dads, and dads don’t know where to turn,” said Dr. Garfield, professor of pediatrics and medical social sciences at Northwestern University, Chicago. He was not involved with the study.

He noted that symptoms in fathers might differ from those of mothers.

“I have seen fathers who are anxious or more moody than they had been prior, or more angry, and I have seen fathers who throw themselves into work or begin drinking more – all related to changes in mood and depressive symptoms in the postnatal period,” he said.

Symptoms in men may last longer than in women. Dr. Garfield’s group published a study in which they surveyed 400 mothers and fathers of premature infants in the neonatal intensive care unit (NICU) about depressive symptoms around the time of NICU admission, at discharge home, and then after 30 days at home.

Roughly one-third of mothers screened positive for depressive symptoms around NICU admission, as did 17% of fathers. But the mothers’ depression scores improved by discharge and 30 days after being home, while the fathers’ remained “essentially unchanged,” he said.

“Further, we found that if doctors were to screen mothers and fathers during the NICU stay – at admission or even at discharge – that would greatly improve their ability to predict who would still have depressive symptoms 1 month after going home.”

Ms. Pedersen agrees that clinicians should incorporate screening for PPD into their practices and be proactive in encouraging fathers to get help.

“Keep pushing,” she advised, as “men rarely seek help, compared to women, in matters of mental health.”
 

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

The public has watched the ongoing drama unfold in the media for the past 13 years. In 2008, pop star Britney Spears was placed on conservatorship – a court process that gave decision-making powers over her personal, legal, and financial decisions to another person.

On June 23, 2021, Ms. Spears announced in open court that she is traumatized by being conserved and wants her rights back, but we know little about what behaviors left her family and a judge to determine that she was not capable of managing her own affairs, and why this would remain the case for so many years. This is an important conversation for those interested in involuntary care.

Adam Nelson, MD, practices psychiatry in Marin County, Calif. He explained in an interview that there are different types of conservatorships. “Probate conservatorship is the traditional path for conservatorship of person, estate, and/or finances based on evidence of incapacity due to any medical condition. This is the type of conservatorship that Britney Spears has had and which she is now contesting.”

Ms. Spears was placed on conservatorship after two involuntary hospitalizations for psychiatric illness and/or substance abuse. Her father, Jamie Spears, was appointed by the court to be her conservator.

In a New York Times article, reporters Liz Day, Samantha Stark, and Joe Coscarelli recently wrote: “But now, confidential court records obtained by the New York Times reveal that Ms. Spears, 39, expressed serious opposition to the conservatorship earlier and more often than had previously been known, and said that it restricted everything from whom she dated to the color of her kitchen cabinets.” The article goes on to say: “The newly obtained court records show that Ms. Spears questioned [her father’s] fitness for the role. As early as 2014, in a hearing closed to the public, Ms. Spears’s court-appointed lawyer, Samuel D. Ingham III, said she wanted to explore removing her father as conservator, citing his drinking, among other objections on a ‘shopping list’ of grievances.

“As the fight drags on, the bills are piling up – and, in a quirk of the conservatorship system, Ms. Spears has to pay for lawyers on both sides, including those arguing against her wishes in court. A recent $890,000 bill from one set of Mr. Spears’s lawyers, covering about 4 months of work, included media strategizing for defending the conservatorship.”

The case heated up at the June 23 hearing, when Ms. Spears had a telephone hearing with Los Angeles probate Judge Brenda Penney. The call was transcribed and published in Variety. The purpose of the hearing was for Ms. Spears to request an expedited release from her conservatorship without a psychiatric evaluation.

Ms. Spears began her 23-minute testimony to the judge by discussing her work and how she felt compelled to perform. “My management said, if I don’t do this tour, I will have to find an attorney, and by contract my own management could sue me if I didn’t follow through with the tour. ... So out of fear, I went ahead and I did the tour.”

She then discussed concerns by her manager that she was not complying with her medication regimen.

“Three days later, after I said no to Vegas,” Ms. Spears continued, “my therapist sat me down in a room and said he had a million phone calls about how I was not cooperating in rehearsals, and I haven’t been taking my medication. All this was false. He immediately, the next day, put me on lithium out of nowhere. He took me off my normal meds I’ve been on for 5 years. ... There were six different nurses in my home and they wouldn’t let me get in my car to go anywhere for a month.”

She spoke about entering rehab at the insistence of the conservatorship, and relayed her distress about this experience. She talked poignantly about her frustration of feeling she was not being heard by the court the last time she spoke and about the financial conflicts of interest created by her conservatorship. Ms. Spears, who has appeared on national television, recorded albums, and gone on performance tours during this period, has a net worth estimated at $60 million.

“It’s been a long time since I’ve owned my money. And it’s my wish and my dream for all of this to end without being tested,” she told the judge. “Again, it makes no sense whatsoever for the state of California to sit back and literally watch me with their own two eyes, make a living for so many people, and pay so many people trucks and buses on the road with me and be told, I’m not good enough. But I’m great at what I do. And I allow these people to control what I do, ma’am. And it’s enough. It makes no sense at all.”

Finally, Ms. Spears expressed a heart-wrenching desire to have another child and she asserted that the conservatorship will not allow her to see a doctor to have her IUD removed. She talked about being required to go to therapy three times a week and contended that she is traumatized by all that has transpired.

Ms. Spears has not filed the necessary paperwork to have her conservatorship ended. In an interview with Vice, attorney Scott Rahn noted that the process to end conservatorship can be a lengthy and difficult path. To do so, she might first need to petition the court to be allowed to hire her own attorney. If uncontested, the conservatorship could possibly be ended within months, but otherwise this could entail a lengthy trial over the course of years. While ending conservatorship may entail discovery, depositions, and hearings over years, a scathing story in the New Yorker detailed how Ms. Spears was placed into this conservatorship in a matter of days, without being present to give her own testimony. In the usual circumstances, California law requires that the person being conserved must be given 5 days’ notice before a conservatorship takes place, but Ms. Spears was deemed to be at risk of substantial harm and the judge allowed for an immediate conservatorship. The article notes that even axe murderers are allowed to hire lawyers, while those placed in conservatorships are not.


 

Reasoning behind such actions

Often, people are appointed guardians, conservators, or payees because of concerns that their psychiatric or substance use disorders, dementia, or impaired intellectual states lead them to poor decisions that endanger their financial stability. Usually the money they may lose is from a government disability benefit, an inheritance, or former accrued wealth. In this unusual celebrity case, Britney Spears has been conserved while she maintained a rigorous work schedule and actively earned the money she is being protected from spending.

Dr. Nelson talked about how people come to be conserved. “The law regarding conservatorship is a state law, but conservatorships in California are done at the county level, and the counties don’t have a vested interest in protecting people from themselves unless a third party or a family member comes forward. I imagine there is another side to this story, I have never seen it used like this for someone who is working. Questions remain about why this conservatorship has gone on for 13 years.”

Dr. Nelson believes that the current California laws leave room for abuse. “If the children of a wealthy parent observes the parent spending their inheritance in a way they don’t approve of, they can claim the parent is impaired and needs to be conserved. Usually it doesn’t work, but it’s possible there are times when the courts are swayed.”

Why does it matter and why should psychiatrists be concerned? The issue of involuntary treatment is a contentious one, and the stakeholders on all sides are vocal when it comes to our country’s sickest and most vulnerable individuals. Any story with a whiff of abuse, or of someone who is not severely impaired being denied basic civil rights – including the right to refuse treatment – dilutes and stains the efforts of those who are trying to protect people who suffer from chronic psychotic disorders. And when society reaches further to say that an individual is not entitled to make their own basic life decisions, this further stigmatizes those with psychiatric illnesses. And people with both mental illnesses and substance use disorders often get better, so why would conservatorships be permanent?

Does our society want the courts to protect people from their own poor judgment? Should there be judges at every casino entrance? Where are the conservators for those who live in the streets? Again, this is a half-told story, one where the potential for abuse of the conserved remains a high risk, and the long-term message about involuntary care is one of taking a way a person’s rights unnecessarily.

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins, both in Baltimore. She has no disclosures.

The public has watched the ongoing drama unfold in the media for the past 13 years. In 2008, pop star Britney Spears was placed on conservatorship – a court process that gave decision-making powers over her personal, legal, and financial decisions to another person.

On June 23, 2021, Ms. Spears announced in open court that she is traumatized by being conserved and wants her rights back, but we know little about what behaviors left her family and a judge to determine that she was not capable of managing her own affairs, and why this would remain the case for so many years. This is an important conversation for those interested in involuntary care.

Adam Nelson, MD, practices psychiatry in Marin County, Calif. He explained in an interview that there are different types of conservatorships. “Probate conservatorship is the traditional path for conservatorship of person, estate, and/or finances based on evidence of incapacity due to any medical condition. This is the type of conservatorship that Britney Spears has had and which she is now contesting.”

Ms. Spears was placed on conservatorship after two involuntary hospitalizations for psychiatric illness and/or substance abuse. Her father, Jamie Spears, was appointed by the court to be her conservator.

In a New York Times article, reporters Liz Day, Samantha Stark, and Joe Coscarelli recently wrote: “But now, confidential court records obtained by the New York Times reveal that Ms. Spears, 39, expressed serious opposition to the conservatorship earlier and more often than had previously been known, and said that it restricted everything from whom she dated to the color of her kitchen cabinets.” The article goes on to say: “The newly obtained court records show that Ms. Spears questioned [her father’s] fitness for the role. As early as 2014, in a hearing closed to the public, Ms. Spears’s court-appointed lawyer, Samuel D. Ingham III, said she wanted to explore removing her father as conservator, citing his drinking, among other objections on a ‘shopping list’ of grievances.

“As the fight drags on, the bills are piling up – and, in a quirk of the conservatorship system, Ms. Spears has to pay for lawyers on both sides, including those arguing against her wishes in court. A recent $890,000 bill from one set of Mr. Spears’s lawyers, covering about 4 months of work, included media strategizing for defending the conservatorship.”

The case heated up at the June 23 hearing, when Ms. Spears had a telephone hearing with Los Angeles probate Judge Brenda Penney. The call was transcribed and published in Variety. The purpose of the hearing was for Ms. Spears to request an expedited release from her conservatorship without a psychiatric evaluation.

Ms. Spears began her 23-minute testimony to the judge by discussing her work and how she felt compelled to perform. “My management said, if I don’t do this tour, I will have to find an attorney, and by contract my own management could sue me if I didn’t follow through with the tour. ... So out of fear, I went ahead and I did the tour.”

She then discussed concerns by her manager that she was not complying with her medication regimen.

“Three days later, after I said no to Vegas,” Ms. Spears continued, “my therapist sat me down in a room and said he had a million phone calls about how I was not cooperating in rehearsals, and I haven’t been taking my medication. All this was false. He immediately, the next day, put me on lithium out of nowhere. He took me off my normal meds I’ve been on for 5 years. ... There were six different nurses in my home and they wouldn’t let me get in my car to go anywhere for a month.”

She spoke about entering rehab at the insistence of the conservatorship, and relayed her distress about this experience. She talked poignantly about her frustration of feeling she was not being heard by the court the last time she spoke and about the financial conflicts of interest created by her conservatorship. Ms. Spears, who has appeared on national television, recorded albums, and gone on performance tours during this period, has a net worth estimated at $60 million.

“It’s been a long time since I’ve owned my money. And it’s my wish and my dream for all of this to end without being tested,” she told the judge. “Again, it makes no sense whatsoever for the state of California to sit back and literally watch me with their own two eyes, make a living for so many people, and pay so many people trucks and buses on the road with me and be told, I’m not good enough. But I’m great at what I do. And I allow these people to control what I do, ma’am. And it’s enough. It makes no sense at all.”

Finally, Ms. Spears expressed a heart-wrenching desire to have another child and she asserted that the conservatorship will not allow her to see a doctor to have her IUD removed. She talked about being required to go to therapy three times a week and contended that she is traumatized by all that has transpired.

Ms. Spears has not filed the necessary paperwork to have her conservatorship ended. In an interview with Vice, attorney Scott Rahn noted that the process to end conservatorship can be a lengthy and difficult path. To do so, she might first need to petition the court to be allowed to hire her own attorney. If uncontested, the conservatorship could possibly be ended within months, but otherwise this could entail a lengthy trial over the course of years. While ending conservatorship may entail discovery, depositions, and hearings over years, a scathing story in the New Yorker detailed how Ms. Spears was placed into this conservatorship in a matter of days, without being present to give her own testimony. In the usual circumstances, California law requires that the person being conserved must be given 5 days’ notice before a conservatorship takes place, but Ms. Spears was deemed to be at risk of substantial harm and the judge allowed for an immediate conservatorship. The article notes that even axe murderers are allowed to hire lawyers, while those placed in conservatorships are not.


 

Reasoning behind such actions

Often, people are appointed guardians, conservators, or payees because of concerns that their psychiatric or substance use disorders, dementia, or impaired intellectual states lead them to poor decisions that endanger their financial stability. Usually the money they may lose is from a government disability benefit, an inheritance, or former accrued wealth. In this unusual celebrity case, Britney Spears has been conserved while she maintained a rigorous work schedule and actively earned the money she is being protected from spending.

Dr. Nelson talked about how people come to be conserved. “The law regarding conservatorship is a state law, but conservatorships in California are done at the county level, and the counties don’t have a vested interest in protecting people from themselves unless a third party or a family member comes forward. I imagine there is another side to this story, I have never seen it used like this for someone who is working. Questions remain about why this conservatorship has gone on for 13 years.”

Dr. Nelson believes that the current California laws leave room for abuse. “If the children of a wealthy parent observes the parent spending their inheritance in a way they don’t approve of, they can claim the parent is impaired and needs to be conserved. Usually it doesn’t work, but it’s possible there are times when the courts are swayed.”

Why does it matter and why should psychiatrists be concerned? The issue of involuntary treatment is a contentious one, and the stakeholders on all sides are vocal when it comes to our country’s sickest and most vulnerable individuals. Any story with a whiff of abuse, or of someone who is not severely impaired being denied basic civil rights – including the right to refuse treatment – dilutes and stains the efforts of those who are trying to protect people who suffer from chronic psychotic disorders. And when society reaches further to say that an individual is not entitled to make their own basic life decisions, this further stigmatizes those with psychiatric illnesses. And people with both mental illnesses and substance use disorders often get better, so why would conservatorships be permanent?

Does our society want the courts to protect people from their own poor judgment? Should there be judges at every casino entrance? Where are the conservators for those who live in the streets? Again, this is a half-told story, one where the potential for abuse of the conserved remains a high risk, and the long-term message about involuntary care is one of taking a way a person’s rights unnecessarily.

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins, both in Baltimore. She has no disclosures.

The public has watched the ongoing drama unfold in the media for the past 13 years. In 2008, pop star Britney Spears was placed on conservatorship – a court process that gave decision-making powers over her personal, legal, and financial decisions to another person.

On June 23, 2021, Ms. Spears announced in open court that she is traumatized by being conserved and wants her rights back, but we know little about what behaviors left her family and a judge to determine that she was not capable of managing her own affairs, and why this would remain the case for so many years. This is an important conversation for those interested in involuntary care.

Adam Nelson, MD, practices psychiatry in Marin County, Calif. He explained in an interview that there are different types of conservatorships. “Probate conservatorship is the traditional path for conservatorship of person, estate, and/or finances based on evidence of incapacity due to any medical condition. This is the type of conservatorship that Britney Spears has had and which she is now contesting.”

Ms. Spears was placed on conservatorship after two involuntary hospitalizations for psychiatric illness and/or substance abuse. Her father, Jamie Spears, was appointed by the court to be her conservator.

In a New York Times article, reporters Liz Day, Samantha Stark, and Joe Coscarelli recently wrote: “But now, confidential court records obtained by the New York Times reveal that Ms. Spears, 39, expressed serious opposition to the conservatorship earlier and more often than had previously been known, and said that it restricted everything from whom she dated to the color of her kitchen cabinets.” The article goes on to say: “The newly obtained court records show that Ms. Spears questioned [her father’s] fitness for the role. As early as 2014, in a hearing closed to the public, Ms. Spears’s court-appointed lawyer, Samuel D. Ingham III, said she wanted to explore removing her father as conservator, citing his drinking, among other objections on a ‘shopping list’ of grievances.

“As the fight drags on, the bills are piling up – and, in a quirk of the conservatorship system, Ms. Spears has to pay for lawyers on both sides, including those arguing against her wishes in court. A recent $890,000 bill from one set of Mr. Spears’s lawyers, covering about 4 months of work, included media strategizing for defending the conservatorship.”

The case heated up at the June 23 hearing, when Ms. Spears had a telephone hearing with Los Angeles probate Judge Brenda Penney. The call was transcribed and published in Variety. The purpose of the hearing was for Ms. Spears to request an expedited release from her conservatorship without a psychiatric evaluation.

Ms. Spears began her 23-minute testimony to the judge by discussing her work and how she felt compelled to perform. “My management said, if I don’t do this tour, I will have to find an attorney, and by contract my own management could sue me if I didn’t follow through with the tour. ... So out of fear, I went ahead and I did the tour.”

She then discussed concerns by her manager that she was not complying with her medication regimen.

“Three days later, after I said no to Vegas,” Ms. Spears continued, “my therapist sat me down in a room and said he had a million phone calls about how I was not cooperating in rehearsals, and I haven’t been taking my medication. All this was false. He immediately, the next day, put me on lithium out of nowhere. He took me off my normal meds I’ve been on for 5 years. ... There were six different nurses in my home and they wouldn’t let me get in my car to go anywhere for a month.”

She spoke about entering rehab at the insistence of the conservatorship, and relayed her distress about this experience. She talked poignantly about her frustration of feeling she was not being heard by the court the last time she spoke and about the financial conflicts of interest created by her conservatorship. Ms. Spears, who has appeared on national television, recorded albums, and gone on performance tours during this period, has a net worth estimated at $60 million.

“It’s been a long time since I’ve owned my money. And it’s my wish and my dream for all of this to end without being tested,” she told the judge. “Again, it makes no sense whatsoever for the state of California to sit back and literally watch me with their own two eyes, make a living for so many people, and pay so many people trucks and buses on the road with me and be told, I’m not good enough. But I’m great at what I do. And I allow these people to control what I do, ma’am. And it’s enough. It makes no sense at all.”

Finally, Ms. Spears expressed a heart-wrenching desire to have another child and she asserted that the conservatorship will not allow her to see a doctor to have her IUD removed. She talked about being required to go to therapy three times a week and contended that she is traumatized by all that has transpired.

Ms. Spears has not filed the necessary paperwork to have her conservatorship ended. In an interview with Vice, attorney Scott Rahn noted that the process to end conservatorship can be a lengthy and difficult path. To do so, she might first need to petition the court to be allowed to hire her own attorney. If uncontested, the conservatorship could possibly be ended within months, but otherwise this could entail a lengthy trial over the course of years. While ending conservatorship may entail discovery, depositions, and hearings over years, a scathing story in the New Yorker detailed how Ms. Spears was placed into this conservatorship in a matter of days, without being present to give her own testimony. In the usual circumstances, California law requires that the person being conserved must be given 5 days’ notice before a conservatorship takes place, but Ms. Spears was deemed to be at risk of substantial harm and the judge allowed for an immediate conservatorship. The article notes that even axe murderers are allowed to hire lawyers, while those placed in conservatorships are not.


 

Reasoning behind such actions

Often, people are appointed guardians, conservators, or payees because of concerns that their psychiatric or substance use disorders, dementia, or impaired intellectual states lead them to poor decisions that endanger their financial stability. Usually the money they may lose is from a government disability benefit, an inheritance, or former accrued wealth. In this unusual celebrity case, Britney Spears has been conserved while she maintained a rigorous work schedule and actively earned the money she is being protected from spending.

Dr. Nelson talked about how people come to be conserved. “The law regarding conservatorship is a state law, but conservatorships in California are done at the county level, and the counties don’t have a vested interest in protecting people from themselves unless a third party or a family member comes forward. I imagine there is another side to this story, I have never seen it used like this for someone who is working. Questions remain about why this conservatorship has gone on for 13 years.”

Dr. Nelson believes that the current California laws leave room for abuse. “If the children of a wealthy parent observes the parent spending their inheritance in a way they don’t approve of, they can claim the parent is impaired and needs to be conserved. Usually it doesn’t work, but it’s possible there are times when the courts are swayed.”

Why does it matter and why should psychiatrists be concerned? The issue of involuntary treatment is a contentious one, and the stakeholders on all sides are vocal when it comes to our country’s sickest and most vulnerable individuals. Any story with a whiff of abuse, or of someone who is not severely impaired being denied basic civil rights – including the right to refuse treatment – dilutes and stains the efforts of those who are trying to protect people who suffer from chronic psychotic disorders. And when society reaches further to say that an individual is not entitled to make their own basic life decisions, this further stigmatizes those with psychiatric illnesses. And people with both mental illnesses and substance use disorders often get better, so why would conservatorships be permanent?

Does our society want the courts to protect people from their own poor judgment? Should there be judges at every casino entrance? Where are the conservators for those who live in the streets? Again, this is a half-told story, one where the potential for abuse of the conserved remains a high risk, and the long-term message about involuntary care is one of taking a way a person’s rights unnecessarily.

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins, both in Baltimore. She has no disclosures.

“What’s my number?” When I hear this from my financial planning clients, I know they mean: “What investment net worth do I need to be financially independent and make practicing medicine optional?” In my 20-year career, this “magic number” is by far the most common thing physicians want to know.

Wiroj Sidhisoradej/EyeEm/Getty Images

If you look online, articles may recommend having a portfolio valued at $2 million, $5 million, and not uncommonly $10 million or more to retire. Really? $10 million? You might be thinking that surely not everyone needs that amount. Luckily, that’s true.

There’s no magic number your portfolio should be – just your number.

It’s human nature to want a simple, clear target to shoot for. But unfortunately, there’s no generic answer when it comes to saving for retirement. Even after a comprehensive hour-long review of a client’s financial plan – including insurance, investments, estate planning, and other items – the most honest answer I can give is: “It depends.” Not satisfying, I know. But there are still too many holes to fill.

By far the most important factor in getting beyond “it depends” is having an accurate estimate of annual retirement expenses. I have clients who live comfortably on $50,000 a year in retirement and others who need $250,000 or more. Knowing how much you need – your personal number – depends on the individual’s unique dream for retirement and calculating what that dream will cost.

Form a guesstimate based on savings and anticipated expenses

The total portfolio value needed to sustain an annual expense of $50,000 a year in retirement spending versus the portfolio size needed for $250,000 or more, blows apart the fiction of a universal “magic number.” It’s just not that simple. While it’s hard to gauge exactly what you will need, the right information can lead to a logical guesstimate about what size portfolio will provide you with financial independence.

In the end, it’s up to you to determine your desired retirement lifestyle. Then, the only way to get there is to calculate how much it will cost and save up for it by following a well-informed financial plan. This plan will be based on strategy that shifts from the middle to the later stages of your medical career and into retirement.

Let’s see how it works.
 

Early to mid-career: Focus on building up retirement savings

We ultimately want to save enough to meet our retirement expenses. But figuring out how much to save when you’re in your 40s and 50s is difficult. A mid-career physician likely has significant family- and child-related expenses. When we become empty-nesters, those expenses will decline. In retirement they may disappear entirely, but new expenses may arise.

With large variations in expenses at different life stages, it’s hard to calculate exactly how much you will need to save. Early on, the most sensible thing is putting aside a “reasonable” percentage of gross income for retirement savings.

What is a ‘reasonable’ savings goal for retirement?

As is often the case with high-income earners, many of our clients don’t have a budget or a clear picture of their current expenses and spending habits. That’s alright as long as they are building up a reasonable nest egg for the future – which begs the question of what is reasonable.

For mid-career docs, a reasonable goal to aim for is putting aside 20% of gross income for retirement. What you spend the rest of your money on is less important than how much you’re saving.

This is quite different from how you’ll handle expenses during retirement, when you no longer have a steady stream of income; rather, you have a pot of money that needs to last you another 20, 30, or even 40 years. At that point, thinking about specific expenses becomes more important (more on this topic later). That said, if you’re a mid-career doctor who is not meeting this 20% savings goal, it’s time to make a plan that will free up cash for retirement savings and investments.
 

Later-career docs: Calculate your spending level in retirement

Financial success means having a portfolio that can support your retirement dreams – with the confidence that your money will last and you won’t need to watch every dollar you spend. As you near retirement, your focus will shift away from accumulating savings to calculating the annual expenses you will have to meet in retirement.

A good place to start is figuring out which expenses will be necessary and which will be more flexible. To do this, separate your anticipated spending into these two categories:

• Fixed expenses: You can confidently forecast your “must-have” fixed expenses – such as property taxes, property/casualty insurance, health care costs, utilities, and groceries – because they remain steady from month to month.
• Discretionary expenses: These “like-to-have” expenses vary from month to month. This makes them harder to predict but easier to control. They might include dining out, travel, and charitable contributions.

As a retiree, understanding your fixed and discretionary expenses can help you prepare for a bear market, when the stock market can decline by 20% or more. Your portfolio won’t consist entirely of stocks, so it shouldn’t drop to that degree. Still, it will decline significantly. You may need to cut back on spending for a year or 2 to allow your portfolio to recover, particularly if the portfolio declines early in retirement.

Are you ready for retirement?

During the long bull market preceding the great recession of 2007 and 2009, many physicians retired –only to return to their practices when their portfolio values plummeted. In the exuberance of the moment, many failed to heed the warnings of many economists and got caught flat-footed.

Right now it’s a bull market, but we’re seeing concerning signs, such as an out-of-control housing market and rumblings about inflation and rising consumer costs. Sound familiar? If you hope to retire soon, take the time to objectively look around the corner so you can plan appropriately – whether your goal is to retire completely, stay in practice part-time, or even take on a new opportunity.

In an “it-depends” world, don’t be lured by a fictitious magic number, no matter what comes up when you Google: “When can I retire?” Instead, save early, imagine your dream retirement, and calculate expenses later to see what’s possible.

Dr. Greenwald is a graduate of the Albert Einstein College of Medicine, New York. Dr. Greenwald completed his internal medicine residency at the University of Minnesota, Minneapolis. He practiced internal medicine in the Twin Cities for 11 years before making the transition to financial planning for physicians, beginning in 1998.

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

“What’s my number?” When I hear this from my financial planning clients, I know they mean: “What investment net worth do I need to be financially independent and make practicing medicine optional?” In my 20-year career, this “magic number” is by far the most common thing physicians want to know.

Wiroj Sidhisoradej/EyeEm/Getty Images

If you look online, articles may recommend having a portfolio valued at $2 million, $5 million, and not uncommonly $10 million or more to retire. Really? $10 million? You might be thinking that surely not everyone needs that amount. Luckily, that’s true.

There’s no magic number your portfolio should be – just your number.

It’s human nature to want a simple, clear target to shoot for. But unfortunately, there’s no generic answer when it comes to saving for retirement. Even after a comprehensive hour-long review of a client’s financial plan – including insurance, investments, estate planning, and other items – the most honest answer I can give is: “It depends.” Not satisfying, I know. But there are still too many holes to fill.

By far the most important factor in getting beyond “it depends” is having an accurate estimate of annual retirement expenses. I have clients who live comfortably on $50,000 a year in retirement and others who need $250,000 or more. Knowing how much you need – your personal number – depends on the individual’s unique dream for retirement and calculating what that dream will cost.

Form a guesstimate based on savings and anticipated expenses

The total portfolio value needed to sustain an annual expense of $50,000 a year in retirement spending versus the portfolio size needed for $250,000 or more, blows apart the fiction of a universal “magic number.” It’s just not that simple. While it’s hard to gauge exactly what you will need, the right information can lead to a logical guesstimate about what size portfolio will provide you with financial independence.

In the end, it’s up to you to determine your desired retirement lifestyle. Then, the only way to get there is to calculate how much it will cost and save up for it by following a well-informed financial plan. This plan will be based on strategy that shifts from the middle to the later stages of your medical career and into retirement.

Let’s see how it works.
 

Early to mid-career: Focus on building up retirement savings

We ultimately want to save enough to meet our retirement expenses. But figuring out how much to save when you’re in your 40s and 50s is difficult. A mid-career physician likely has significant family- and child-related expenses. When we become empty-nesters, those expenses will decline. In retirement they may disappear entirely, but new expenses may arise.

With large variations in expenses at different life stages, it’s hard to calculate exactly how much you will need to save. Early on, the most sensible thing is putting aside a “reasonable” percentage of gross income for retirement savings.

What is a ‘reasonable’ savings goal for retirement?

As is often the case with high-income earners, many of our clients don’t have a budget or a clear picture of their current expenses and spending habits. That’s alright as long as they are building up a reasonable nest egg for the future – which begs the question of what is reasonable.

For mid-career docs, a reasonable goal to aim for is putting aside 20% of gross income for retirement. What you spend the rest of your money on is less important than how much you’re saving.

This is quite different from how you’ll handle expenses during retirement, when you no longer have a steady stream of income; rather, you have a pot of money that needs to last you another 20, 30, or even 40 years. At that point, thinking about specific expenses becomes more important (more on this topic later). That said, if you’re a mid-career doctor who is not meeting this 20% savings goal, it’s time to make a plan that will free up cash for retirement savings and investments.
 

Later-career docs: Calculate your spending level in retirement

Financial success means having a portfolio that can support your retirement dreams – with the confidence that your money will last and you won’t need to watch every dollar you spend. As you near retirement, your focus will shift away from accumulating savings to calculating the annual expenses you will have to meet in retirement.

A good place to start is figuring out which expenses will be necessary and which will be more flexible. To do this, separate your anticipated spending into these two categories:

• Fixed expenses: You can confidently forecast your “must-have” fixed expenses – such as property taxes, property/casualty insurance, health care costs, utilities, and groceries – because they remain steady from month to month.
• Discretionary expenses: These “like-to-have” expenses vary from month to month. This makes them harder to predict but easier to control. They might include dining out, travel, and charitable contributions.

As a retiree, understanding your fixed and discretionary expenses can help you prepare for a bear market, when the stock market can decline by 20% or more. Your portfolio won’t consist entirely of stocks, so it shouldn’t drop to that degree. Still, it will decline significantly. You may need to cut back on spending for a year or 2 to allow your portfolio to recover, particularly if the portfolio declines early in retirement.

Are you ready for retirement?

During the long bull market preceding the great recession of 2007 and 2009, many physicians retired –only to return to their practices when their portfolio values plummeted. In the exuberance of the moment, many failed to heed the warnings of many economists and got caught flat-footed.

Right now it’s a bull market, but we’re seeing concerning signs, such as an out-of-control housing market and rumblings about inflation and rising consumer costs. Sound familiar? If you hope to retire soon, take the time to objectively look around the corner so you can plan appropriately – whether your goal is to retire completely, stay in practice part-time, or even take on a new opportunity.

In an “it-depends” world, don’t be lured by a fictitious magic number, no matter what comes up when you Google: “When can I retire?” Instead, save early, imagine your dream retirement, and calculate expenses later to see what’s possible.

Dr. Greenwald is a graduate of the Albert Einstein College of Medicine, New York. Dr. Greenwald completed his internal medicine residency at the University of Minnesota, Minneapolis. He practiced internal medicine in the Twin Cities for 11 years before making the transition to financial planning for physicians, beginning in 1998.

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

“What’s my number?” When I hear this from my financial planning clients, I know they mean: “What investment net worth do I need to be financially independent and make practicing medicine optional?” In my 20-year career, this “magic number” is by far the most common thing physicians want to know.

Wiroj Sidhisoradej/EyeEm/Getty Images

If you look online, articles may recommend having a portfolio valued at $2 million, $5 million, and not uncommonly $10 million or more to retire. Really? $10 million? You might be thinking that surely not everyone needs that amount. Luckily, that’s true.

There’s no magic number your portfolio should be – just your number.

It’s human nature to want a simple, clear target to shoot for. But unfortunately, there’s no generic answer when it comes to saving for retirement. Even after a comprehensive hour-long review of a client’s financial plan – including insurance, investments, estate planning, and other items – the most honest answer I can give is: “It depends.” Not satisfying, I know. But there are still too many holes to fill.

By far the most important factor in getting beyond “it depends” is having an accurate estimate of annual retirement expenses. I have clients who live comfortably on $50,000 a year in retirement and others who need $250,000 or more. Knowing how much you need – your personal number – depends on the individual’s unique dream for retirement and calculating what that dream will cost.

Form a guesstimate based on savings and anticipated expenses

The total portfolio value needed to sustain an annual expense of $50,000 a year in retirement spending versus the portfolio size needed for $250,000 or more, blows apart the fiction of a universal “magic number.” It’s just not that simple. While it’s hard to gauge exactly what you will need, the right information can lead to a logical guesstimate about what size portfolio will provide you with financial independence.

In the end, it’s up to you to determine your desired retirement lifestyle. Then, the only way to get there is to calculate how much it will cost and save up for it by following a well-informed financial plan. This plan will be based on strategy that shifts from the middle to the later stages of your medical career and into retirement.

Let’s see how it works.
 

Early to mid-career: Focus on building up retirement savings

We ultimately want to save enough to meet our retirement expenses. But figuring out how much to save when you’re in your 40s and 50s is difficult. A mid-career physician likely has significant family- and child-related expenses. When we become empty-nesters, those expenses will decline. In retirement they may disappear entirely, but new expenses may arise.

With large variations in expenses at different life stages, it’s hard to calculate exactly how much you will need to save. Early on, the most sensible thing is putting aside a “reasonable” percentage of gross income for retirement savings.

What is a ‘reasonable’ savings goal for retirement?

As is often the case with high-income earners, many of our clients don’t have a budget or a clear picture of their current expenses and spending habits. That’s alright as long as they are building up a reasonable nest egg for the future – which begs the question of what is reasonable.

For mid-career docs, a reasonable goal to aim for is putting aside 20% of gross income for retirement. What you spend the rest of your money on is less important than how much you’re saving.

This is quite different from how you’ll handle expenses during retirement, when you no longer have a steady stream of income; rather, you have a pot of money that needs to last you another 20, 30, or even 40 years. At that point, thinking about specific expenses becomes more important (more on this topic later). That said, if you’re a mid-career doctor who is not meeting this 20% savings goal, it’s time to make a plan that will free up cash for retirement savings and investments.
 

Later-career docs: Calculate your spending level in retirement

Financial success means having a portfolio that can support your retirement dreams – with the confidence that your money will last and you won’t need to watch every dollar you spend. As you near retirement, your focus will shift away from accumulating savings to calculating the annual expenses you will have to meet in retirement.

A good place to start is figuring out which expenses will be necessary and which will be more flexible. To do this, separate your anticipated spending into these two categories:

• Fixed expenses: You can confidently forecast your “must-have” fixed expenses – such as property taxes, property/casualty insurance, health care costs, utilities, and groceries – because they remain steady from month to month.
• Discretionary expenses: These “like-to-have” expenses vary from month to month. This makes them harder to predict but easier to control. They might include dining out, travel, and charitable contributions.

As a retiree, understanding your fixed and discretionary expenses can help you prepare for a bear market, when the stock market can decline by 20% or more. Your portfolio won’t consist entirely of stocks, so it shouldn’t drop to that degree. Still, it will decline significantly. You may need to cut back on spending for a year or 2 to allow your portfolio to recover, particularly if the portfolio declines early in retirement.

Are you ready for retirement?

During the long bull market preceding the great recession of 2007 and 2009, many physicians retired –only to return to their practices when their portfolio values plummeted. In the exuberance of the moment, many failed to heed the warnings of many economists and got caught flat-footed.

Right now it’s a bull market, but we’re seeing concerning signs, such as an out-of-control housing market and rumblings about inflation and rising consumer costs. Sound familiar? If you hope to retire soon, take the time to objectively look around the corner so you can plan appropriately – whether your goal is to retire completely, stay in practice part-time, or even take on a new opportunity.

In an “it-depends” world, don’t be lured by a fictitious magic number, no matter what comes up when you Google: “When can I retire?” Instead, save early, imagine your dream retirement, and calculate expenses later to see what’s possible.

Dr. Greenwald is a graduate of the Albert Einstein College of Medicine, New York. Dr. Greenwald completed his internal medicine residency at the University of Minnesota, Minneapolis. He practiced internal medicine in the Twin Cities for 11 years before making the transition to financial planning for physicians, beginning in 1998.

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

Those suffering from postpartum depression may have a more convenient treatment option, compared with the only drug approved by the Food and Drug Administration to specifically treat this mood disorder.

Observations from phase 3 of a clinical trial published in JAMA Psychiatry shows that zuranolone, an oral drug, improved the core symptoms of postpartum depression after just 3 days.

Postpartum depression affects approximately one in eight women, according to the Centers for Disease Control and Prevention. Brexanolone (Zulresso), which was approved by the FDA in 2019 to treat this condition, is administered intravenously over a 60-hour period with medical supervision.

“Many women don’t have child care and are unable to go to a hospital setting for 72 hours to receive treatment,” study author Kristina Deligiannidis, MD, associate professor at the Feinstein Institutes for Medical Research, Manhasset, N.Y., said in an interview. “The field really does need a variety of new and novel treatments that are fast acting. It is of utmost importance that we treat [postpartum depression] as quickly as possible because it has significant effects on maternal function, mood, and the ability to care for infants.”

Dr. Deligiannidis and colleagues randomly placed 153 volunteers between the ages of 18 and 45 years, who were 6 months or less post partum, into a group that would receive either a placebo or 30 mg of zuranolone daily for 2 weeks. The participants were followed for 45 days to test the effect of the drug.

Researchers measured depression using the Hamilton Rating Scale for Depression (HAMD-17) – where a score of 10-13 means a patient has mild symptoms, 14-17 means mild to moderate symptoms, and anything over 17 equals moderate to severe symptoms. At the baseline of the study, the average HAMD-17 score of those in the zuranolone and placebo groups were 28.4 and 28.8, respectively.

Researchers found that after day 3, 41% of those in the zuranolone group had a 50% or greater reduction in HAMD-17 score from baseline. By day 15, the day after their last dose, 72% of those who had taken zuranolone had a reduction in HAMD-17 compared with 56% of those who had taken the placebo. By day 45, that increased to 75% in the zuranolone group and 57% in the placebo group.

Dr. Deligiannidis, who initially wasn’t sure how long it would take for patients to see the beneficial effects of zuranolone, was surprised by how fast-acting the oral drug appeared to be in the clinical trial. Unlike brexanolone, which is infused into the veins and has rapid access to the brain and nervous system, zuranolone is an oral medicine that has to go through the stomach and the gastrointestinal tract, and then it has to go into the blood system and then has to cross the blood-brain barrier, she explained.

By day 15, 45% of women who took zuranolone received a HAMD-17 score of 7 or under, meaning they have remitted depression. By day 45, 53% of women who had taken the drug were in remission.

Although the zuranolone was well tolerated, about 5% of the group experienced adverse events. Of those who experienced side effects, 15% experienced drowsiness, 9% suffered from headaches, and 8% experienced dizziness and developed an upper respiratory infection. Participants also suffered diarrhea and sedation.

Lissette Tanner, MD, MPH, FACOG, who was not involved with the study, thought the current study’s findings were promising and would be a great alternative to brexanolone.

“You have the additional benefit that it’s an oral agent as opposed to injection, which I know a lot of patients often have concerns about,” said Dr. Tanner, assistant professor of gynecology and obstetrics at Emory University, Atlanta. “[It’s] an exciting prospect for clinical care to be able to prescribe an oral agent patients can feel comfortable taking at home.”

When it comes to the study’s method, Dr. Tanner noted that the researchers used the HAMD-17 scale as opposed to the Edinburgh Postnatal Depression Scale (EPDS), something that is used “a lot more in clinical situations and providers are a lot more familiar with.” Using the EPDS score would be more applicable “in terms of introducing these medications into true clinical care.”

In terms of follow-up, Dr. Tanner said there may be a need for ongoing research that follows the study participants for more than 45 days.

“For depressive symptoms in particular, oftentimes those symptoms ebb and flow. So seeing if there is a long-term response to these medications or just kind of an immediate onset then wane will be important in the future,” she added.

Dr. Tanner is also interested in pharmacokinetic studies involving zuranolone to see how much of the medication may potentially pass into breast milk.

Dr. Deligiannidis and Dr. Tanner had no financial disclosures.

Those suffering from postpartum depression may have a more convenient treatment option, compared with the only drug approved by the Food and Drug Administration to specifically treat this mood disorder.

Observations from phase 3 of a clinical trial published in JAMA Psychiatry shows that zuranolone, an oral drug, improved the core symptoms of postpartum depression after just 3 days.

Postpartum depression affects approximately one in eight women, according to the Centers for Disease Control and Prevention. Brexanolone (Zulresso), which was approved by the FDA in 2019 to treat this condition, is administered intravenously over a 60-hour period with medical supervision.

“Many women don’t have child care and are unable to go to a hospital setting for 72 hours to receive treatment,” study author Kristina Deligiannidis, MD, associate professor at the Feinstein Institutes for Medical Research, Manhasset, N.Y., said in an interview. “The field really does need a variety of new and novel treatments that are fast acting. It is of utmost importance that we treat [postpartum depression] as quickly as possible because it has significant effects on maternal function, mood, and the ability to care for infants.”

Dr. Deligiannidis and colleagues randomly placed 153 volunteers between the ages of 18 and 45 years, who were 6 months or less post partum, into a group that would receive either a placebo or 30 mg of zuranolone daily for 2 weeks. The participants were followed for 45 days to test the effect of the drug.

Researchers measured depression using the Hamilton Rating Scale for Depression (HAMD-17) – where a score of 10-13 means a patient has mild symptoms, 14-17 means mild to moderate symptoms, and anything over 17 equals moderate to severe symptoms. At the baseline of the study, the average HAMD-17 score of those in the zuranolone and placebo groups were 28.4 and 28.8, respectively.

Researchers found that after day 3, 41% of those in the zuranolone group had a 50% or greater reduction in HAMD-17 score from baseline. By day 15, the day after their last dose, 72% of those who had taken zuranolone had a reduction in HAMD-17 compared with 56% of those who had taken the placebo. By day 45, that increased to 75% in the zuranolone group and 57% in the placebo group.

Dr. Deligiannidis, who initially wasn’t sure how long it would take for patients to see the beneficial effects of zuranolone, was surprised by how fast-acting the oral drug appeared to be in the clinical trial. Unlike brexanolone, which is infused into the veins and has rapid access to the brain and nervous system, zuranolone is an oral medicine that has to go through the stomach and the gastrointestinal tract, and then it has to go into the blood system and then has to cross the blood-brain barrier, she explained.

By day 15, 45% of women who took zuranolone received a HAMD-17 score of 7 or under, meaning they have remitted depression. By day 45, 53% of women who had taken the drug were in remission.

Although the zuranolone was well tolerated, about 5% of the group experienced adverse events. Of those who experienced side effects, 15% experienced drowsiness, 9% suffered from headaches, and 8% experienced dizziness and developed an upper respiratory infection. Participants also suffered diarrhea and sedation.

Lissette Tanner, MD, MPH, FACOG, who was not involved with the study, thought the current study’s findings were promising and would be a great alternative to brexanolone.

“You have the additional benefit that it’s an oral agent as opposed to injection, which I know a lot of patients often have concerns about,” said Dr. Tanner, assistant professor of gynecology and obstetrics at Emory University, Atlanta. “[It’s] an exciting prospect for clinical care to be able to prescribe an oral agent patients can feel comfortable taking at home.”

When it comes to the study’s method, Dr. Tanner noted that the researchers used the HAMD-17 scale as opposed to the Edinburgh Postnatal Depression Scale (EPDS), something that is used “a lot more in clinical situations and providers are a lot more familiar with.” Using the EPDS score would be more applicable “in terms of introducing these medications into true clinical care.”

In terms of follow-up, Dr. Tanner said there may be a need for ongoing research that follows the study participants for more than 45 days.

“For depressive symptoms in particular, oftentimes those symptoms ebb and flow. So seeing if there is a long-term response to these medications or just kind of an immediate onset then wane will be important in the future,” she added.

Dr. Tanner is also interested in pharmacokinetic studies involving zuranolone to see how much of the medication may potentially pass into breast milk.

Dr. Deligiannidis and Dr. Tanner had no financial disclosures.

Those suffering from postpartum depression may have a more convenient treatment option, compared with the only drug approved by the Food and Drug Administration to specifically treat this mood disorder.

Observations from phase 3 of a clinical trial published in JAMA Psychiatry shows that zuranolone, an oral drug, improved the core symptoms of postpartum depression after just 3 days.

Postpartum depression affects approximately one in eight women, according to the Centers for Disease Control and Prevention. Brexanolone (Zulresso), which was approved by the FDA in 2019 to treat this condition, is administered intravenously over a 60-hour period with medical supervision.

“Many women don’t have child care and are unable to go to a hospital setting for 72 hours to receive treatment,” study author Kristina Deligiannidis, MD, associate professor at the Feinstein Institutes for Medical Research, Manhasset, N.Y., said in an interview. “The field really does need a variety of new and novel treatments that are fast acting. It is of utmost importance that we treat [postpartum depression] as quickly as possible because it has significant effects on maternal function, mood, and the ability to care for infants.”

Dr. Deligiannidis and colleagues randomly placed 153 volunteers between the ages of 18 and 45 years, who were 6 months or less post partum, into a group that would receive either a placebo or 30 mg of zuranolone daily for 2 weeks. The participants were followed for 45 days to test the effect of the drug.

Researchers measured depression using the Hamilton Rating Scale for Depression (HAMD-17) – where a score of 10-13 means a patient has mild symptoms, 14-17 means mild to moderate symptoms, and anything over 17 equals moderate to severe symptoms. At the baseline of the study, the average HAMD-17 score of those in the zuranolone and placebo groups were 28.4 and 28.8, respectively.

Researchers found that after day 3, 41% of those in the zuranolone group had a 50% or greater reduction in HAMD-17 score from baseline. By day 15, the day after their last dose, 72% of those who had taken zuranolone had a reduction in HAMD-17 compared with 56% of those who had taken the placebo. By day 45, that increased to 75% in the zuranolone group and 57% in the placebo group.

Dr. Deligiannidis, who initially wasn’t sure how long it would take for patients to see the beneficial effects of zuranolone, was surprised by how fast-acting the oral drug appeared to be in the clinical trial. Unlike brexanolone, which is infused into the veins and has rapid access to the brain and nervous system, zuranolone is an oral medicine that has to go through the stomach and the gastrointestinal tract, and then it has to go into the blood system and then has to cross the blood-brain barrier, she explained.

By day 15, 45% of women who took zuranolone received a HAMD-17 score of 7 or under, meaning they have remitted depression. By day 45, 53% of women who had taken the drug were in remission.

Although the zuranolone was well tolerated, about 5% of the group experienced adverse events. Of those who experienced side effects, 15% experienced drowsiness, 9% suffered from headaches, and 8% experienced dizziness and developed an upper respiratory infection. Participants also suffered diarrhea and sedation.

Lissette Tanner, MD, MPH, FACOG, who was not involved with the study, thought the current study’s findings were promising and would be a great alternative to brexanolone.

“You have the additional benefit that it’s an oral agent as opposed to injection, which I know a lot of patients often have concerns about,” said Dr. Tanner, assistant professor of gynecology and obstetrics at Emory University, Atlanta. “[It’s] an exciting prospect for clinical care to be able to prescribe an oral agent patients can feel comfortable taking at home.”

When it comes to the study’s method, Dr. Tanner noted that the researchers used the HAMD-17 scale as opposed to the Edinburgh Postnatal Depression Scale (EPDS), something that is used “a lot more in clinical situations and providers are a lot more familiar with.” Using the EPDS score would be more applicable “in terms of introducing these medications into true clinical care.”

In terms of follow-up, Dr. Tanner said there may be a need for ongoing research that follows the study participants for more than 45 days.

“For depressive symptoms in particular, oftentimes those symptoms ebb and flow. So seeing if there is a long-term response to these medications or just kind of an immediate onset then wane will be important in the future,” she added.

Dr. Tanner is also interested in pharmacokinetic studies involving zuranolone to see how much of the medication may potentially pass into breast milk.

Dr. Deligiannidis and Dr. Tanner had no financial disclosures.

The hashtag #BigHoopEnergy has sparked an online conversation about how women of color in the medical field are pressured to conform to traditional standards of professional appearance.

It started when a Latina doctor tweeted that she lost points on a practical exam in medical school because of her hoop earrings, with the evaluator writing “earrings, unprofessional.”

That led other female doctors to cite their own experiences, reported The Lily, a Washington Post publication aimed at millennial women. Many women posted photos of themselves wearing hoops, which have long been associated with Latina and African American women, the outlet said.

“There’s a big movement to police women of color and how they present themselves in medical spaces,” said Briana Christophers, an MD-PhD student at the Tri-Institutional MD-PhD Program in New York. “I think in part it’s a way of trying to make people who don’t usually fit the mold, fit the mold.”

Ms. Christophers, who identifies as Latina, said she was urged to wear a black or navy suit when interviewing for doctorate programs. She wore a black suit with a lavender blouse and received comments about that – some positive, some not, she said.

“Sometimes you don’t know how to interpret those sorts of comments,” Ms. Christophers said. “Do you remember because you like the shirt, or because you don’t think I should have done that?”

Doctors of color still stand out in American medicine. The Lily cited the Association of American Medical Colleges as saying that in 2018, Hispanics made up 5.8% of active American doctors and African Americans made up 5%.

Studies show that medical professionals of color often don’t receive the same respect as their White counterparts, with some people questioning whether they’re actually doctors.

“At work, wearing my white coat that has my name pretty big on it with a badge that says doctor on it, I still get asked if I’m the environmental services staff,” Alexandra Sims, MD, a pediatrician in Cincinnati, told The Lily. “I think it just demonstrates how deeply ingrained bias, racism, and sexism are in society and that we have a lot of work to do to disrupt that.”

Dr. Sims said the tweet about hoop earrings led her to wonder about daily decisions she makes about dress.

“Am I too much? Is this too much? Is this earring too big? Is this nail polish color too loud? And how will that be received at work?” she said, noting that she may opt not to wear hoops in certain situations, such as when she’s dealing with a grabby baby.

Monica Verduzco-Gutierrez, MD, professor and chair of the department of rehabilitation medicine at University of Texas Health, San Antonio, said doctors should be judged on the care they provide, not their appearance.

“Judging someone based on their earrings or their jumpsuit or whatever else that they’re noticing about the student is not an appropriate way to judge the student’s ability to take care of a patient,” Dr. Verduzco-Gutierrez said, noting that she was not speaking on behalf of the school.
 

A version of this article was first published on WebMD.com .

The hashtag #BigHoopEnergy has sparked an online conversation about how women of color in the medical field are pressured to conform to traditional standards of professional appearance.

It started when a Latina doctor tweeted that she lost points on a practical exam in medical school because of her hoop earrings, with the evaluator writing “earrings, unprofessional.”

That led other female doctors to cite their own experiences, reported The Lily, a Washington Post publication aimed at millennial women. Many women posted photos of themselves wearing hoops, which have long been associated with Latina and African American women, the outlet said.

“There’s a big movement to police women of color and how they present themselves in medical spaces,” said Briana Christophers, an MD-PhD student at the Tri-Institutional MD-PhD Program in New York. “I think in part it’s a way of trying to make people who don’t usually fit the mold, fit the mold.”

Ms. Christophers, who identifies as Latina, said she was urged to wear a black or navy suit when interviewing for doctorate programs. She wore a black suit with a lavender blouse and received comments about that – some positive, some not, she said.

“Sometimes you don’t know how to interpret those sorts of comments,” Ms. Christophers said. “Do you remember because you like the shirt, or because you don’t think I should have done that?”

Doctors of color still stand out in American medicine. The Lily cited the Association of American Medical Colleges as saying that in 2018, Hispanics made up 5.8% of active American doctors and African Americans made up 5%.

Studies show that medical professionals of color often don’t receive the same respect as their White counterparts, with some people questioning whether they’re actually doctors.

“At work, wearing my white coat that has my name pretty big on it with a badge that says doctor on it, I still get asked if I’m the environmental services staff,” Alexandra Sims, MD, a pediatrician in Cincinnati, told The Lily. “I think it just demonstrates how deeply ingrained bias, racism, and sexism are in society and that we have a lot of work to do to disrupt that.”

Dr. Sims said the tweet about hoop earrings led her to wonder about daily decisions she makes about dress.

“Am I too much? Is this too much? Is this earring too big? Is this nail polish color too loud? And how will that be received at work?” she said, noting that she may opt not to wear hoops in certain situations, such as when she’s dealing with a grabby baby.

Monica Verduzco-Gutierrez, MD, professor and chair of the department of rehabilitation medicine at University of Texas Health, San Antonio, said doctors should be judged on the care they provide, not their appearance.

“Judging someone based on their earrings or their jumpsuit or whatever else that they’re noticing about the student is not an appropriate way to judge the student’s ability to take care of a patient,” Dr. Verduzco-Gutierrez said, noting that she was not speaking on behalf of the school.
 

A version of this article was first published on WebMD.com .

The hashtag #BigHoopEnergy has sparked an online conversation about how women of color in the medical field are pressured to conform to traditional standards of professional appearance.

It started when a Latina doctor tweeted that she lost points on a practical exam in medical school because of her hoop earrings, with the evaluator writing “earrings, unprofessional.”

That led other female doctors to cite their own experiences, reported The Lily, a Washington Post publication aimed at millennial women. Many women posted photos of themselves wearing hoops, which have long been associated with Latina and African American women, the outlet said.

“There’s a big movement to police women of color and how they present themselves in medical spaces,” said Briana Christophers, an MD-PhD student at the Tri-Institutional MD-PhD Program in New York. “I think in part it’s a way of trying to make people who don’t usually fit the mold, fit the mold.”

Ms. Christophers, who identifies as Latina, said she was urged to wear a black or navy suit when interviewing for doctorate programs. She wore a black suit with a lavender blouse and received comments about that – some positive, some not, she said.

“Sometimes you don’t know how to interpret those sorts of comments,” Ms. Christophers said. “Do you remember because you like the shirt, or because you don’t think I should have done that?”

Doctors of color still stand out in American medicine. The Lily cited the Association of American Medical Colleges as saying that in 2018, Hispanics made up 5.8% of active American doctors and African Americans made up 5%.

Studies show that medical professionals of color often don’t receive the same respect as their White counterparts, with some people questioning whether they’re actually doctors.

“At work, wearing my white coat that has my name pretty big on it with a badge that says doctor on it, I still get asked if I’m the environmental services staff,” Alexandra Sims, MD, a pediatrician in Cincinnati, told The Lily. “I think it just demonstrates how deeply ingrained bias, racism, and sexism are in society and that we have a lot of work to do to disrupt that.”

Dr. Sims said the tweet about hoop earrings led her to wonder about daily decisions she makes about dress.

“Am I too much? Is this too much? Is this earring too big? Is this nail polish color too loud? And how will that be received at work?” she said, noting that she may opt not to wear hoops in certain situations, such as when she’s dealing with a grabby baby.

Monica Verduzco-Gutierrez, MD, professor and chair of the department of rehabilitation medicine at University of Texas Health, San Antonio, said doctors should be judged on the care they provide, not their appearance.

“Judging someone based on their earrings or their jumpsuit or whatever else that they’re noticing about the student is not an appropriate way to judge the student’s ability to take care of a patient,” Dr. Verduzco-Gutierrez said, noting that she was not speaking on behalf of the school.
 

A version of this article was first published on WebMD.com .