MDedge Psychiatry

Two recent articles in the medical literature provide new information on mucocutaneous manifestations of COVID-19 in children, which may help guide dermatologists in making accurate diagnoses and stratifying children at risk for serious, systemic illness due to the virus.

In a single-center descriptive study carried out over a 9-month period, researchers in Madrid found that of 50 hospitalized children infected with COVID-19, 21 (42%) had mucocutaneous symptoms, most commonly exanthem, followed by conjunctival hyperemia without secretion and red cracked lips or strawberry tongue. In addition, 18 (36%) fulfilled criteria for Multisystem Inflammatory Syndrome in Children (MIS-C).

“Based on findings in adult patients, the skin manifestations of COVID-19 have been classified under five categories: acral pseudo-chilblain, vesicular eruptions, urticarial lesions, maculopapular eruptions, and livedo or necrosis,” David Andina-Martinez, MD, of Hospital Infantil Universitario Niño Jesús, Madrid, and colleagues wrote in the study, which was published online on April 2 in the Journal of the American Academy of Dermatology.

“Chilblain lesions in healthy children and adolescents have received much attention; these lesions resolve without complications after a few weeks,” they added. “Besides, other cutaneous manifestations of COVID-19 in children have been the matter of case reports or small case series. Nevertheless, the mucocutaneous manifestations in hospitalized children infected with SARS-CoV-2 and their implications on the clinical course have not yet been extensively described.”

In an effort to describe the mucocutaneous manifestations in children hospitalized for COVID-19, the researchers evaluated 50 children up to 18 years of age who were admitted between March 1 and Nov. 30, 2020, to Hospital Infantil Universitario Niño Jesús, which was designated as a pediatric reference center during the peak of the pandemic. The main reasons for admission were respiratory illness (40%) and MIS-C (40%).

Of the 50 patients, 44 (88%) had a positive RT-PCR for SARS-CoV-2 and 6 (12%) met clinical suspicion criteria and had a negative RT-PCR with a positive IgG serology. In 34 patients (68%), a close contact with a suspected or confirmed case of COVID-19 was referred, while the source of the infection remained unknown in the remaining 16 patients (32%).

The researchers reported that 21 patients (42%) had mucocutaneous symptoms, most commonly maculopapular exanthem (86%), conjunctival hyperemia (81%), and red cracked lips or strawberry tongue (43%). In addition, 18 of the 21 patients (86%) fulfilled criteria for MIS-C.

“A tricky thing about MIS-C is that it often manifests 4-5 weeks after a child had COVID-19,” said Christine Ko, MD, professor of dermatology and pathology at Yale University, New Haven, Conn., who was asked to comment on the study. “MIS-C is associated with characteristic bright red lips and a red tongue that might resemble a strawberry. Such oral findings should prompt rapid evaluation for other signs and symptoms. There can be redness of the eyes or other more nonspecific skin findings (large or small areas of redness on the trunk or limbs, sometimes with surface change), but more importantly, fever, a rapid heartbeat, diarrhea, or breathing issues. The risk with MIS-C is a rapid decline in a child’s health, with admission to an intensive care unit.”

Dr. Andina-Martinez and his colleagues also contrast the skin findings of MIS-C, which are not generally on the hands or feet, with the so-called “COVID toe” or finger phenomenon, which has also been associated with SARS-CoV-2, particularly in children. “Only one of the patients in this series had skin involvement of a finger, and it only appeared after recovery from MIS-C,” Dr. Ko noted. “Distinguishing COVID toes from MIS-C is important, as COVID toes has a very good outcome, while MIS-C can have severe consequences, including protracted heart disease.”

In other findings, patients who presented with mucocutaneous signs tended to be older than those without skin signs and they presented at the emergency department with poor general status and extreme tachycardia. They also had higher C-reactive protein and D-dimer levels and lower lymphocyte counts and faced a more than a 10-fold increased risk of being admitted to the PICU, compared with patients who did not have skin signs (OR, 10.24; P = .003).

In a separate study published online on April 7 in JAMA Dermatology, Zachary E. Holcomb, MD, of the combined dermatology residency program at Massachusetts General Hospital, Boston, and colleagues presented what is believed to be the first case report of reactive infectious mucocutaneous eruption (RIME) triggered by SARS-CoV-2. RIME is the preferred term for pediatric patients who present with mucositis and rash (often a scant or even absent skin eruption) triggered by various infectious agents.

The patient, a 17-year-old male, presented to the emergency department with 3 days of mouth pain and nonpainful penile erosions. “One week prior, he experienced transient anosmia and ageusia that had since spontaneously resolved,” the researchers wrote. “At that time, he was tested for SARS-CoV-2 infection via nasopharyngeal polymerase chain reaction (PCR), the results of which were positive.”

At presentation, the patient had no fever, his vital signs were normal, and the physical exam revealed shallow erosions of the vermilion lips and hard palate, circumferential erythematous erosions of the periurethral glans penis, and five small vesicles on the trunk and upper extremities. Serum analysis revealed a normal white blood cell count with mild absolute lymphopenia, slightly elevated creatinine level, normal liver function, slightly elevated C-reactive protein level, and normal ferritin level.

Dr. Holcomb and colleagues made a diagnosis of SARS-CoV-2–associated RIME based on microbiological results, which revealed positive repeated SARS-CoV-2 nasopharyngeal PCR and negative nasopharyngeal PCR testing for Mycoplasma pneumoniae, adenovirus, Chlamydophila pneumoniae, human metapneumovirus, influenza A/B, parainfluenza 1 to 4, rhinovirus, and respiratory syncytial virus. In addition, titers of Mycoplasma pneumoniae IgM levels were negative, but Mycoplasma pneumoniae IgG levels were elevated.

The lesions resolved with 60 mg of oral prednisone taken daily for 4 days. A recurrence of oral mucositis 3 months later responded to 80 mg oral prednisone taken daily for 6 days.

“It’s not surprising that SARS-CoV-2 is yet another trigger for RIME,” said Anna Yasmine Kirkorian, MD, chief of the division of dermatology at Children’s National Hospital, Washington, who was asked to comment about the case report.

“The take-home message is for clinicians to be aware of this association and distinguish these patients from those with MIS-C, because patients with MIS-C require monitoring and urgent systemic treatment. RIME and MIS-C may potentially be distinguished clinically based on the nature of the mucositis (hemorrhagic and erosive in RIME, dry, cracked lips with ‘strawberry tongue’ in MIS-C) but more importantly patients with RIME lack laboratory evidence of severe systemic inflammation,” such as ESR, CRP, or ferritin, she said.

“A final interesting point in this article was the recurrence of mucositis in this patient, which could mean that recurrent mucositis/recurrent RIME might be yet another manifestation of ‘long-COVID’ (now called post-Acute Sequelae of SARS-CoV-2 infection) in some patients,” Dr. Kirkorian added. She noted that the American Academy of Dermatology–International League of Dermatologic Societies COVID-19 Dermatology Registry and articles like these “provide invaluable ‘hot off the presses’ information for clinicians who are facing the protean manifestations of a novel viral epidemic.”

The researchers reported having no financial disclosures.
 

[email protected]

Two recent articles in the medical literature provide new information on mucocutaneous manifestations of COVID-19 in children, which may help guide dermatologists in making accurate diagnoses and stratifying children at risk for serious, systemic illness due to the virus.

In a single-center descriptive study carried out over a 9-month period, researchers in Madrid found that of 50 hospitalized children infected with COVID-19, 21 (42%) had mucocutaneous symptoms, most commonly exanthem, followed by conjunctival hyperemia without secretion and red cracked lips or strawberry tongue. In addition, 18 (36%) fulfilled criteria for Multisystem Inflammatory Syndrome in Children (MIS-C).

“Based on findings in adult patients, the skin manifestations of COVID-19 have been classified under five categories: acral pseudo-chilblain, vesicular eruptions, urticarial lesions, maculopapular eruptions, and livedo or necrosis,” David Andina-Martinez, MD, of Hospital Infantil Universitario Niño Jesús, Madrid, and colleagues wrote in the study, which was published online on April 2 in the Journal of the American Academy of Dermatology.

“Chilblain lesions in healthy children and adolescents have received much attention; these lesions resolve without complications after a few weeks,” they added. “Besides, other cutaneous manifestations of COVID-19 in children have been the matter of case reports or small case series. Nevertheless, the mucocutaneous manifestations in hospitalized children infected with SARS-CoV-2 and their implications on the clinical course have not yet been extensively described.”

In an effort to describe the mucocutaneous manifestations in children hospitalized for COVID-19, the researchers evaluated 50 children up to 18 years of age who were admitted between March 1 and Nov. 30, 2020, to Hospital Infantil Universitario Niño Jesús, which was designated as a pediatric reference center during the peak of the pandemic. The main reasons for admission were respiratory illness (40%) and MIS-C (40%).

Of the 50 patients, 44 (88%) had a positive RT-PCR for SARS-CoV-2 and 6 (12%) met clinical suspicion criteria and had a negative RT-PCR with a positive IgG serology. In 34 patients (68%), a close contact with a suspected or confirmed case of COVID-19 was referred, while the source of the infection remained unknown in the remaining 16 patients (32%).

The researchers reported that 21 patients (42%) had mucocutaneous symptoms, most commonly maculopapular exanthem (86%), conjunctival hyperemia (81%), and red cracked lips or strawberry tongue (43%). In addition, 18 of the 21 patients (86%) fulfilled criteria for MIS-C.

“A tricky thing about MIS-C is that it often manifests 4-5 weeks after a child had COVID-19,” said Christine Ko, MD, professor of dermatology and pathology at Yale University, New Haven, Conn., who was asked to comment on the study. “MIS-C is associated with characteristic bright red lips and a red tongue that might resemble a strawberry. Such oral findings should prompt rapid evaluation for other signs and symptoms. There can be redness of the eyes or other more nonspecific skin findings (large or small areas of redness on the trunk or limbs, sometimes with surface change), but more importantly, fever, a rapid heartbeat, diarrhea, or breathing issues. The risk with MIS-C is a rapid decline in a child’s health, with admission to an intensive care unit.”

Dr. Andina-Martinez and his colleagues also contrast the skin findings of MIS-C, which are not generally on the hands or feet, with the so-called “COVID toe” or finger phenomenon, which has also been associated with SARS-CoV-2, particularly in children. “Only one of the patients in this series had skin involvement of a finger, and it only appeared after recovery from MIS-C,” Dr. Ko noted. “Distinguishing COVID toes from MIS-C is important, as COVID toes has a very good outcome, while MIS-C can have severe consequences, including protracted heart disease.”

In other findings, patients who presented with mucocutaneous signs tended to be older than those without skin signs and they presented at the emergency department with poor general status and extreme tachycardia. They also had higher C-reactive protein and D-dimer levels and lower lymphocyte counts and faced a more than a 10-fold increased risk of being admitted to the PICU, compared with patients who did not have skin signs (OR, 10.24; P = .003).

In a separate study published online on April 7 in JAMA Dermatology, Zachary E. Holcomb, MD, of the combined dermatology residency program at Massachusetts General Hospital, Boston, and colleagues presented what is believed to be the first case report of reactive infectious mucocutaneous eruption (RIME) triggered by SARS-CoV-2. RIME is the preferred term for pediatric patients who present with mucositis and rash (often a scant or even absent skin eruption) triggered by various infectious agents.

The patient, a 17-year-old male, presented to the emergency department with 3 days of mouth pain and nonpainful penile erosions. “One week prior, he experienced transient anosmia and ageusia that had since spontaneously resolved,” the researchers wrote. “At that time, he was tested for SARS-CoV-2 infection via nasopharyngeal polymerase chain reaction (PCR), the results of which were positive.”

At presentation, the patient had no fever, his vital signs were normal, and the physical exam revealed shallow erosions of the vermilion lips and hard palate, circumferential erythematous erosions of the periurethral glans penis, and five small vesicles on the trunk and upper extremities. Serum analysis revealed a normal white blood cell count with mild absolute lymphopenia, slightly elevated creatinine level, normal liver function, slightly elevated C-reactive protein level, and normal ferritin level.

Dr. Holcomb and colleagues made a diagnosis of SARS-CoV-2–associated RIME based on microbiological results, which revealed positive repeated SARS-CoV-2 nasopharyngeal PCR and negative nasopharyngeal PCR testing for Mycoplasma pneumoniae, adenovirus, Chlamydophila pneumoniae, human metapneumovirus, influenza A/B, parainfluenza 1 to 4, rhinovirus, and respiratory syncytial virus. In addition, titers of Mycoplasma pneumoniae IgM levels were negative, but Mycoplasma pneumoniae IgG levels were elevated.

The lesions resolved with 60 mg of oral prednisone taken daily for 4 days. A recurrence of oral mucositis 3 months later responded to 80 mg oral prednisone taken daily for 6 days.

“It’s not surprising that SARS-CoV-2 is yet another trigger for RIME,” said Anna Yasmine Kirkorian, MD, chief of the division of dermatology at Children’s National Hospital, Washington, who was asked to comment about the case report.

“The take-home message is for clinicians to be aware of this association and distinguish these patients from those with MIS-C, because patients with MIS-C require monitoring and urgent systemic treatment. RIME and MIS-C may potentially be distinguished clinically based on the nature of the mucositis (hemorrhagic and erosive in RIME, dry, cracked lips with ‘strawberry tongue’ in MIS-C) but more importantly patients with RIME lack laboratory evidence of severe systemic inflammation,” such as ESR, CRP, or ferritin, she said.

“A final interesting point in this article was the recurrence of mucositis in this patient, which could mean that recurrent mucositis/recurrent RIME might be yet another manifestation of ‘long-COVID’ (now called post-Acute Sequelae of SARS-CoV-2 infection) in some patients,” Dr. Kirkorian added. She noted that the American Academy of Dermatology–International League of Dermatologic Societies COVID-19 Dermatology Registry and articles like these “provide invaluable ‘hot off the presses’ information for clinicians who are facing the protean manifestations of a novel viral epidemic.”

The researchers reported having no financial disclosures.
 

[email protected]

Two recent articles in the medical literature provide new information on mucocutaneous manifestations of COVID-19 in children, which may help guide dermatologists in making accurate diagnoses and stratifying children at risk for serious, systemic illness due to the virus.

In a single-center descriptive study carried out over a 9-month period, researchers in Madrid found that of 50 hospitalized children infected with COVID-19, 21 (42%) had mucocutaneous symptoms, most commonly exanthem, followed by conjunctival hyperemia without secretion and red cracked lips or strawberry tongue. In addition, 18 (36%) fulfilled criteria for Multisystem Inflammatory Syndrome in Children (MIS-C).

“Based on findings in adult patients, the skin manifestations of COVID-19 have been classified under five categories: acral pseudo-chilblain, vesicular eruptions, urticarial lesions, maculopapular eruptions, and livedo or necrosis,” David Andina-Martinez, MD, of Hospital Infantil Universitario Niño Jesús, Madrid, and colleagues wrote in the study, which was published online on April 2 in the Journal of the American Academy of Dermatology.

“Chilblain lesions in healthy children and adolescents have received much attention; these lesions resolve without complications after a few weeks,” they added. “Besides, other cutaneous manifestations of COVID-19 in children have been the matter of case reports or small case series. Nevertheless, the mucocutaneous manifestations in hospitalized children infected with SARS-CoV-2 and their implications on the clinical course have not yet been extensively described.”

In an effort to describe the mucocutaneous manifestations in children hospitalized for COVID-19, the researchers evaluated 50 children up to 18 years of age who were admitted between March 1 and Nov. 30, 2020, to Hospital Infantil Universitario Niño Jesús, which was designated as a pediatric reference center during the peak of the pandemic. The main reasons for admission were respiratory illness (40%) and MIS-C (40%).

Of the 50 patients, 44 (88%) had a positive RT-PCR for SARS-CoV-2 and 6 (12%) met clinical suspicion criteria and had a negative RT-PCR with a positive IgG serology. In 34 patients (68%), a close contact with a suspected or confirmed case of COVID-19 was referred, while the source of the infection remained unknown in the remaining 16 patients (32%).

The researchers reported that 21 patients (42%) had mucocutaneous symptoms, most commonly maculopapular exanthem (86%), conjunctival hyperemia (81%), and red cracked lips or strawberry tongue (43%). In addition, 18 of the 21 patients (86%) fulfilled criteria for MIS-C.

“A tricky thing about MIS-C is that it often manifests 4-5 weeks after a child had COVID-19,” said Christine Ko, MD, professor of dermatology and pathology at Yale University, New Haven, Conn., who was asked to comment on the study. “MIS-C is associated with characteristic bright red lips and a red tongue that might resemble a strawberry. Such oral findings should prompt rapid evaluation for other signs and symptoms. There can be redness of the eyes or other more nonspecific skin findings (large or small areas of redness on the trunk or limbs, sometimes with surface change), but more importantly, fever, a rapid heartbeat, diarrhea, or breathing issues. The risk with MIS-C is a rapid decline in a child’s health, with admission to an intensive care unit.”

Dr. Andina-Martinez and his colleagues also contrast the skin findings of MIS-C, which are not generally on the hands or feet, with the so-called “COVID toe” or finger phenomenon, which has also been associated with SARS-CoV-2, particularly in children. “Only one of the patients in this series had skin involvement of a finger, and it only appeared after recovery from MIS-C,” Dr. Ko noted. “Distinguishing COVID toes from MIS-C is important, as COVID toes has a very good outcome, while MIS-C can have severe consequences, including protracted heart disease.”

In other findings, patients who presented with mucocutaneous signs tended to be older than those without skin signs and they presented at the emergency department with poor general status and extreme tachycardia. They also had higher C-reactive protein and D-dimer levels and lower lymphocyte counts and faced a more than a 10-fold increased risk of being admitted to the PICU, compared with patients who did not have skin signs (OR, 10.24; P = .003).

In a separate study published online on April 7 in JAMA Dermatology, Zachary E. Holcomb, MD, of the combined dermatology residency program at Massachusetts General Hospital, Boston, and colleagues presented what is believed to be the first case report of reactive infectious mucocutaneous eruption (RIME) triggered by SARS-CoV-2. RIME is the preferred term for pediatric patients who present with mucositis and rash (often a scant or even absent skin eruption) triggered by various infectious agents.

The patient, a 17-year-old male, presented to the emergency department with 3 days of mouth pain and nonpainful penile erosions. “One week prior, he experienced transient anosmia and ageusia that had since spontaneously resolved,” the researchers wrote. “At that time, he was tested for SARS-CoV-2 infection via nasopharyngeal polymerase chain reaction (PCR), the results of which were positive.”

At presentation, the patient had no fever, his vital signs were normal, and the physical exam revealed shallow erosions of the vermilion lips and hard palate, circumferential erythematous erosions of the periurethral glans penis, and five small vesicles on the trunk and upper extremities. Serum analysis revealed a normal white blood cell count with mild absolute lymphopenia, slightly elevated creatinine level, normal liver function, slightly elevated C-reactive protein level, and normal ferritin level.

Dr. Holcomb and colleagues made a diagnosis of SARS-CoV-2–associated RIME based on microbiological results, which revealed positive repeated SARS-CoV-2 nasopharyngeal PCR and negative nasopharyngeal PCR testing for Mycoplasma pneumoniae, adenovirus, Chlamydophila pneumoniae, human metapneumovirus, influenza A/B, parainfluenza 1 to 4, rhinovirus, and respiratory syncytial virus. In addition, titers of Mycoplasma pneumoniae IgM levels were negative, but Mycoplasma pneumoniae IgG levels were elevated.

The lesions resolved with 60 mg of oral prednisone taken daily for 4 days. A recurrence of oral mucositis 3 months later responded to 80 mg oral prednisone taken daily for 6 days.

“It’s not surprising that SARS-CoV-2 is yet another trigger for RIME,” said Anna Yasmine Kirkorian, MD, chief of the division of dermatology at Children’s National Hospital, Washington, who was asked to comment about the case report.

“The take-home message is for clinicians to be aware of this association and distinguish these patients from those with MIS-C, because patients with MIS-C require monitoring and urgent systemic treatment. RIME and MIS-C may potentially be distinguished clinically based on the nature of the mucositis (hemorrhagic and erosive in RIME, dry, cracked lips with ‘strawberry tongue’ in MIS-C) but more importantly patients with RIME lack laboratory evidence of severe systemic inflammation,” such as ESR, CRP, or ferritin, she said.

“A final interesting point in this article was the recurrence of mucositis in this patient, which could mean that recurrent mucositis/recurrent RIME might be yet another manifestation of ‘long-COVID’ (now called post-Acute Sequelae of SARS-CoV-2 infection) in some patients,” Dr. Kirkorian added. She noted that the American Academy of Dermatology–International League of Dermatologic Societies COVID-19 Dermatology Registry and articles like these “provide invaluable ‘hot off the presses’ information for clinicians who are facing the protean manifestations of a novel viral epidemic.”

The researchers reported having no financial disclosures.
 

[email protected]

The World Psychiatric Association (WPA) has released new global telemedicine guidelines.

Prompted by the worldwide explosion of interest in telepsychiatry driven by the COVID-19 pandemic, the guidelines emphasize the need for international collaboration in psychiatry.

“Global teamwork is the light at the end of the tunnel” of the current crisis, lead author Davor Mucic, MD, The Little Prince Treatment Center, Copenhagen, told meeting attendees.

“Now is the time to build a user-friendly digital health care system that can better meet the inevitable future challenges,” Dr. Mucic said. “The hope is that WPA’s global guidelines for telepsychiatry can help us to move forward.”

The guidelines, which also address concerns over data security and device intercompatibility, were presented at the virtual European Psychiatric Association (EPA) 2021 Congress.
 

Breaking down barriers

Although telepsychiatry has been around since 1959, only with the rapid technologic advances of the past decade has it become available to the majority of psychiatric patients, Dr. Mucic noted.

“Unfortunately, regulatory constraints, in combination with clinicians’ concerns, kept telepsychiatry from being widely adopted and implemented prior to the current COVID-19 pandemic,” he added.

Concerns have been with regard to data safety, reimbursement for consultations, quality of care, lack of technical experience, and difficulties in changing routines.

For many clinicians, the pandemic was the “first time they used telepsychiatry, and very few have received training in how to do it,” Dr. Mucic said.

He pointed out that guidelines are available in the United States, Canada, Australia, and India, including the 2018 Best Practices in Videoconferencing-Based Telemental Health, released by the American Psychiatric Association and the American Telemedicine Association.

Dr. Mucic noted that because these documents are relevant and useful, clinicians may wonder, “Why do we need another set of guidelines?”

He explained that the current WPA guidelines outline universal recommendations that apply “regardless of local or regional regulations.” Therefore, they can be used just as easily in low- and middle-income countries as in countries where telepsychiatry is already established.
 

A new paradigm

Similar to other guidelines, the WPA’s guidelines discuss legal and regulatory requirements, informed consent, billing and reimbursement, patient selection, clinician training, the clinical setting, and more.

However, what makes the new document “so new and special” is that it opens the door to “some new and previously undiscussed aspects of telepsychiatry ... that are capable of changing the whole delivery of mental health care,” Dr. Mucic said.

The first of these new aspects is in regard to cross-cultural telepsychiatry. The goal is to eliminate the need for interpreters or competency in a different language for patients who do not speak the host country’s language by connecting them remotely with a bilingual health care professional who shares their cultural or ethnic background.

This “ethnic matching” model may lead to a “more precise and detailed symptomatology,” the authors note. They add that minimizing the risk for misinterpretation and misunderstanding can enable better diagnosis and treatment.

The second area highlighted by Dr. Mucic is in regard to international telepsychiatry; the technology could be used to obtain a second opinion from colleagues who share the relevant cultural and linguistic background.

“Further, international expertise may be brought via [telepsychiatry] to local health workers as a part of education, supervision, and scientific collaboration,” he said.

“The hope is the guidelines will pave the way for improved international collaboration, not only by clinicians but also by policymakers.”
 

A blended future?

Also at EPA 2021, two experts debated whether the COVID-19 pandemic represented a turning point for e-health in psychiatry.

Taking the pro stance, Heleen Riper, PhD, professor of eMental-Health at the Vrije Universiteit Amsterdam, argued that the future is likely to blend face-to-face interaction with video conferencing.

She believes that to maintain current progress, the focus should be on treatment personalization, engagement, and improvement, rather than cost-effectiveness.

Hans-Jürgen Möller, MD, professor emeritus, department of psychiatry, Ludwig-Maximilians-University, Munich, argued against the idea that e-health represented a turning point in psychiatry. He noted that a survey of German psychotherapists indicated that there have been a number of drawbacks to video sessions during the pandemic.

Cautious optimism

Session chair Judit Simon, MD, DPhil, professor of health economics, Medical University of Vienna, asked the debaters whether video interventions will continue to replace in-person interventions once the pandemic is over or whether things will return to “where we were prepandemic.”

Dr. Riper said she did not believe that clinicians will return completely to in-patient practice. However, she emphasized the need for training and the development of new skills to improve the therapeutic relationship with patients.

Although Dr. Riper believes there is still a need for in-person doctor/patient interactions, “we will never get back to the pre-COVID phase, both in terms of diagnostics and treatment,” she said.

Dr. Möller added that although he has “some reservations” regarding the adoption of technologies by older patients and the lack of long-term data on telepsychiatry, he partially shares Dr. Riper’s optimism.

He suggested that there is an opportunity in psychiatry to use video conferencing for multidisciplinary team meetings similar to those seen in oncology.

This would allow discussion of patient diagnosis and treatment and would enable experts in mental health to help clinicians in other specialties. For example, it could help a general practitioner differentiate between depression and a depressive phase of schizophrenia, Dr. Riper said.

The presenters have disclosed no relevant financial relationships.

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

The World Psychiatric Association (WPA) has released new global telemedicine guidelines.

Prompted by the worldwide explosion of interest in telepsychiatry driven by the COVID-19 pandemic, the guidelines emphasize the need for international collaboration in psychiatry.

“Global teamwork is the light at the end of the tunnel” of the current crisis, lead author Davor Mucic, MD, The Little Prince Treatment Center, Copenhagen, told meeting attendees.

“Now is the time to build a user-friendly digital health care system that can better meet the inevitable future challenges,” Dr. Mucic said. “The hope is that WPA’s global guidelines for telepsychiatry can help us to move forward.”

The guidelines, which also address concerns over data security and device intercompatibility, were presented at the virtual European Psychiatric Association (EPA) 2021 Congress.
 

Breaking down barriers

Although telepsychiatry has been around since 1959, only with the rapid technologic advances of the past decade has it become available to the majority of psychiatric patients, Dr. Mucic noted.

“Unfortunately, regulatory constraints, in combination with clinicians’ concerns, kept telepsychiatry from being widely adopted and implemented prior to the current COVID-19 pandemic,” he added.

Concerns have been with regard to data safety, reimbursement for consultations, quality of care, lack of technical experience, and difficulties in changing routines.

For many clinicians, the pandemic was the “first time they used telepsychiatry, and very few have received training in how to do it,” Dr. Mucic said.

He pointed out that guidelines are available in the United States, Canada, Australia, and India, including the 2018 Best Practices in Videoconferencing-Based Telemental Health, released by the American Psychiatric Association and the American Telemedicine Association.

Dr. Mucic noted that because these documents are relevant and useful, clinicians may wonder, “Why do we need another set of guidelines?”

He explained that the current WPA guidelines outline universal recommendations that apply “regardless of local or regional regulations.” Therefore, they can be used just as easily in low- and middle-income countries as in countries where telepsychiatry is already established.
 

A new paradigm

Similar to other guidelines, the WPA’s guidelines discuss legal and regulatory requirements, informed consent, billing and reimbursement, patient selection, clinician training, the clinical setting, and more.

However, what makes the new document “so new and special” is that it opens the door to “some new and previously undiscussed aspects of telepsychiatry ... that are capable of changing the whole delivery of mental health care,” Dr. Mucic said.

The first of these new aspects is in regard to cross-cultural telepsychiatry. The goal is to eliminate the need for interpreters or competency in a different language for patients who do not speak the host country’s language by connecting them remotely with a bilingual health care professional who shares their cultural or ethnic background.

This “ethnic matching” model may lead to a “more precise and detailed symptomatology,” the authors note. They add that minimizing the risk for misinterpretation and misunderstanding can enable better diagnosis and treatment.

The second area highlighted by Dr. Mucic is in regard to international telepsychiatry; the technology could be used to obtain a second opinion from colleagues who share the relevant cultural and linguistic background.

“Further, international expertise may be brought via [telepsychiatry] to local health workers as a part of education, supervision, and scientific collaboration,” he said.

“The hope is the guidelines will pave the way for improved international collaboration, not only by clinicians but also by policymakers.”
 

A blended future?

Also at EPA 2021, two experts debated whether the COVID-19 pandemic represented a turning point for e-health in psychiatry.

Taking the pro stance, Heleen Riper, PhD, professor of eMental-Health at the Vrije Universiteit Amsterdam, argued that the future is likely to blend face-to-face interaction with video conferencing.

She believes that to maintain current progress, the focus should be on treatment personalization, engagement, and improvement, rather than cost-effectiveness.

Hans-Jürgen Möller, MD, professor emeritus, department of psychiatry, Ludwig-Maximilians-University, Munich, argued against the idea that e-health represented a turning point in psychiatry. He noted that a survey of German psychotherapists indicated that there have been a number of drawbacks to video sessions during the pandemic.

Cautious optimism

Session chair Judit Simon, MD, DPhil, professor of health economics, Medical University of Vienna, asked the debaters whether video interventions will continue to replace in-person interventions once the pandemic is over or whether things will return to “where we were prepandemic.”

Dr. Riper said she did not believe that clinicians will return completely to in-patient practice. However, she emphasized the need for training and the development of new skills to improve the therapeutic relationship with patients.

Although Dr. Riper believes there is still a need for in-person doctor/patient interactions, “we will never get back to the pre-COVID phase, both in terms of diagnostics and treatment,” she said.

Dr. Möller added that although he has “some reservations” regarding the adoption of technologies by older patients and the lack of long-term data on telepsychiatry, he partially shares Dr. Riper’s optimism.

He suggested that there is an opportunity in psychiatry to use video conferencing for multidisciplinary team meetings similar to those seen in oncology.

This would allow discussion of patient diagnosis and treatment and would enable experts in mental health to help clinicians in other specialties. For example, it could help a general practitioner differentiate between depression and a depressive phase of schizophrenia, Dr. Riper said.

The presenters have disclosed no relevant financial relationships.

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

The World Psychiatric Association (WPA) has released new global telemedicine guidelines.

Prompted by the worldwide explosion of interest in telepsychiatry driven by the COVID-19 pandemic, the guidelines emphasize the need for international collaboration in psychiatry.

“Global teamwork is the light at the end of the tunnel” of the current crisis, lead author Davor Mucic, MD, The Little Prince Treatment Center, Copenhagen, told meeting attendees.

“Now is the time to build a user-friendly digital health care system that can better meet the inevitable future challenges,” Dr. Mucic said. “The hope is that WPA’s global guidelines for telepsychiatry can help us to move forward.”

The guidelines, which also address concerns over data security and device intercompatibility, were presented at the virtual European Psychiatric Association (EPA) 2021 Congress.
 

Breaking down barriers

Although telepsychiatry has been around since 1959, only with the rapid technologic advances of the past decade has it become available to the majority of psychiatric patients, Dr. Mucic noted.

“Unfortunately, regulatory constraints, in combination with clinicians’ concerns, kept telepsychiatry from being widely adopted and implemented prior to the current COVID-19 pandemic,” he added.

Concerns have been with regard to data safety, reimbursement for consultations, quality of care, lack of technical experience, and difficulties in changing routines.

For many clinicians, the pandemic was the “first time they used telepsychiatry, and very few have received training in how to do it,” Dr. Mucic said.

He pointed out that guidelines are available in the United States, Canada, Australia, and India, including the 2018 Best Practices in Videoconferencing-Based Telemental Health, released by the American Psychiatric Association and the American Telemedicine Association.

Dr. Mucic noted that because these documents are relevant and useful, clinicians may wonder, “Why do we need another set of guidelines?”

He explained that the current WPA guidelines outline universal recommendations that apply “regardless of local or regional regulations.” Therefore, they can be used just as easily in low- and middle-income countries as in countries where telepsychiatry is already established.
 

A new paradigm

Similar to other guidelines, the WPA’s guidelines discuss legal and regulatory requirements, informed consent, billing and reimbursement, patient selection, clinician training, the clinical setting, and more.

However, what makes the new document “so new and special” is that it opens the door to “some new and previously undiscussed aspects of telepsychiatry ... that are capable of changing the whole delivery of mental health care,” Dr. Mucic said.

The first of these new aspects is in regard to cross-cultural telepsychiatry. The goal is to eliminate the need for interpreters or competency in a different language for patients who do not speak the host country’s language by connecting them remotely with a bilingual health care professional who shares their cultural or ethnic background.

This “ethnic matching” model may lead to a “more precise and detailed symptomatology,” the authors note. They add that minimizing the risk for misinterpretation and misunderstanding can enable better diagnosis and treatment.

The second area highlighted by Dr. Mucic is in regard to international telepsychiatry; the technology could be used to obtain a second opinion from colleagues who share the relevant cultural and linguistic background.

“Further, international expertise may be brought via [telepsychiatry] to local health workers as a part of education, supervision, and scientific collaboration,” he said.

“The hope is the guidelines will pave the way for improved international collaboration, not only by clinicians but also by policymakers.”
 

A blended future?

Also at EPA 2021, two experts debated whether the COVID-19 pandemic represented a turning point for e-health in psychiatry.

Taking the pro stance, Heleen Riper, PhD, professor of eMental-Health at the Vrije Universiteit Amsterdam, argued that the future is likely to blend face-to-face interaction with video conferencing.

She believes that to maintain current progress, the focus should be on treatment personalization, engagement, and improvement, rather than cost-effectiveness.

Hans-Jürgen Möller, MD, professor emeritus, department of psychiatry, Ludwig-Maximilians-University, Munich, argued against the idea that e-health represented a turning point in psychiatry. He noted that a survey of German psychotherapists indicated that there have been a number of drawbacks to video sessions during the pandemic.

Cautious optimism

Session chair Judit Simon, MD, DPhil, professor of health economics, Medical University of Vienna, asked the debaters whether video interventions will continue to replace in-person interventions once the pandemic is over or whether things will return to “where we were prepandemic.”

Dr. Riper said she did not believe that clinicians will return completely to in-patient practice. However, she emphasized the need for training and the development of new skills to improve the therapeutic relationship with patients.

Although Dr. Riper believes there is still a need for in-person doctor/patient interactions, “we will never get back to the pre-COVID phase, both in terms of diagnostics and treatment,” she said.

Dr. Möller added that although he has “some reservations” regarding the adoption of technologies by older patients and the lack of long-term data on telepsychiatry, he partially shares Dr. Riper’s optimism.

He suggested that there is an opportunity in psychiatry to use video conferencing for multidisciplinary team meetings similar to those seen in oncology.

This would allow discussion of patient diagnosis and treatment and would enable experts in mental health to help clinicians in other specialties. For example, it could help a general practitioner differentiate between depression and a depressive phase of schizophrenia, Dr. Riper said.

The presenters have disclosed no relevant financial relationships.

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

When I was asked to write a regular “Holistic Mental Health” column, I decided to write about the Herculean forces that must come together to create a holistic psychiatrist – someone who specializes in helping patients off their medications rather than on.

My journey began when I told a training psychiatrist that I wanted to stop being a psychiatrist. It was a year after my daughter was born, and I had started my third year of adult psychiatry residency at the University of Maryland in Baltimore. I was stressed and exhausted from working on inpatient psychiatric wards for 2 years, countless unpleasant nights on call, and additional sleepless nights caring for an infant.

I told the training psychiatrist that life wasn’t worth living. Was I suicidal, he asked? I laughed bitterly: “All the time!” Once he heard the S-word, he wanted me to take an antidepressant. I finally gave in and began taking Zoloft 25 mg every morning. Within a week, my angst disappeared; but 5 years, another child, and a fellowship later, I was still taking Zoloft. Why? Without much thought, I stopped it. A month later, I found myself brooding on the sofa, numb with depression, and feeling astonishingly suicidal. This “depression” led me to restart my Zoloft. In a week, my mood normalized. I did this on and off for about a year until a light bulb went off: This can’t be depression. It’s withdrawal. I’ve become dependent on Zoloft! Once I realized this, I began taking some St. John’s wort, an herbal alternative that was supposed to help with depression. I used cheaper brands and discovered that brands do matter, because the cheaper ones didn’t work. Through my haphazard exploration of natural alternatives, I came off Zoloft completely. During this time, I developed greater empathy for my patients, openness to natural alternatives, appreciation for supplement quality, and learned about psychotropic withdrawal. Most importantly, I came to understand a patient’s need to be free.

Five years later, in 2002, I had a thriving, but conventional, private practice. Instead of being content, however, I once again wanted to quit psychiatry. Medicating patients felt unrewarding, but I didn’t have another approach. Simultaneously, my practice was filling up with chronically ill, heavily medicated, bipolar patients. Their intense suffering combined with my discontent with psychiatry made me desperate for something better. In this ripe setting, the mother of a patient with bipolar disorder casually mentioned a supplement called EMPower by Truehope that lessened bipolar symptoms. Though my withdrawal from Zoloft allowed me to be more open to holistic approaches, I waited 3 months before calling. I used the supplement for the first time to help a heavily medicated bipolar patient in her 30’s, whose Depakote side effects caused her to wear a diaper, lack any emotions, and suffer severe tremors. Once I made this decision to walk down this new path, I never went back. With guidance from the company, I used this supplement to help many patients lower their medications. At the time, I wondered whether EMPower would be the solution for all my patients. The simplicity and ease of one supplement approach for all mental illnesses appealed to my laziness, so I continued down the holistic path.

Hundreds of supplements, glandulars, essential oils, and homeopathic remedies later, I learned that every patient requires their own unique approach. A year into using the supplement, I discovered that, if patients took too much of it, their old symptoms would reappear. Eventually, I moved out of my comfort zone and tried other supplements. Subsequently, the universe orchestrated two people to tell me about the miraculous outcomes from “thought-field therapy,” an energy-medicine technique. I began exploring “energy medicine” through the support and instruction of a holistic psychotherapist, Mark Bottinick, LCSW-C. Soon, I was connecting the dots between emotional freedom technique and immediate positive changes. Energy medicine allowed me to heal problems without using a pill! I felt as if I had arrived at Solla Sollew by the banks of the Beautiful River Wah-Hoo.

As I discovered and attended conferences in holistic medicine, I got certified in integrative medicine and became a Reiki master. What kept me along this holistic path? Happy patients with positive clinical outcomes. Even as a novice in holistic medicine, I began to experience patients crying with joy, rather than sadness. One psychotic patient got better on some supplements and got a new job in just 2 weeks.

On Feb. 17, 2021, I launched a podcast called “The Holistic Psychiatrist,” with interviews of patients, conversations with practitioners, and insights from me. Of the initial interviews, two of the three patients had bipolar disorder, and were able to safely and successfully withdraw from many medications. They are no longer patients and are free to move on with their lives. A patient who smoothly and successfully lowered six psychiatric medications will be sharing her wisdom and healing journey soon. A naturopathic doctor will also be sharing his insights and successes. He once was a suicidal high school student failing his classes, depressed and anxious, and dependent on marijuana. His recovery occurred more than a decade ago in my holistic practice.

These patients are living proof that holistic approaches can be very powerful and effective. They demonstrate that chronicity may reflect inadequate treatment and not a definition of disease. Over the course of this Holistic Mental Health column, I want to share many incredible healing journeys and insights on holistic psychiatry. I hope that you will be open to this new paradigm and begin your own holistic journey.

Dr. Lee is a psychiatrist with a solo private practice in Lehi, Utah. She integrates functional/orthomolecular medicine and mind/body/energy medicine in her work with patients. Contact her at holisticpsychiatrist.com. She has no conflicts of interest.

When I was asked to write a regular “Holistic Mental Health” column, I decided to write about the Herculean forces that must come together to create a holistic psychiatrist – someone who specializes in helping patients off their medications rather than on.

My journey began when I told a training psychiatrist that I wanted to stop being a psychiatrist. It was a year after my daughter was born, and I had started my third year of adult psychiatry residency at the University of Maryland in Baltimore. I was stressed and exhausted from working on inpatient psychiatric wards for 2 years, countless unpleasant nights on call, and additional sleepless nights caring for an infant.

I told the training psychiatrist that life wasn’t worth living. Was I suicidal, he asked? I laughed bitterly: “All the time!” Once he heard the S-word, he wanted me to take an antidepressant. I finally gave in and began taking Zoloft 25 mg every morning. Within a week, my angst disappeared; but 5 years, another child, and a fellowship later, I was still taking Zoloft. Why? Without much thought, I stopped it. A month later, I found myself brooding on the sofa, numb with depression, and feeling astonishingly suicidal. This “depression” led me to restart my Zoloft. In a week, my mood normalized. I did this on and off for about a year until a light bulb went off: This can’t be depression. It’s withdrawal. I’ve become dependent on Zoloft! Once I realized this, I began taking some St. John’s wort, an herbal alternative that was supposed to help with depression. I used cheaper brands and discovered that brands do matter, because the cheaper ones didn’t work. Through my haphazard exploration of natural alternatives, I came off Zoloft completely. During this time, I developed greater empathy for my patients, openness to natural alternatives, appreciation for supplement quality, and learned about psychotropic withdrawal. Most importantly, I came to understand a patient’s need to be free.

Five years later, in 2002, I had a thriving, but conventional, private practice. Instead of being content, however, I once again wanted to quit psychiatry. Medicating patients felt unrewarding, but I didn’t have another approach. Simultaneously, my practice was filling up with chronically ill, heavily medicated, bipolar patients. Their intense suffering combined with my discontent with psychiatry made me desperate for something better. In this ripe setting, the mother of a patient with bipolar disorder casually mentioned a supplement called EMPower by Truehope that lessened bipolar symptoms. Though my withdrawal from Zoloft allowed me to be more open to holistic approaches, I waited 3 months before calling. I used the supplement for the first time to help a heavily medicated bipolar patient in her 30’s, whose Depakote side effects caused her to wear a diaper, lack any emotions, and suffer severe tremors. Once I made this decision to walk down this new path, I never went back. With guidance from the company, I used this supplement to help many patients lower their medications. At the time, I wondered whether EMPower would be the solution for all my patients. The simplicity and ease of one supplement approach for all mental illnesses appealed to my laziness, so I continued down the holistic path.

Hundreds of supplements, glandulars, essential oils, and homeopathic remedies later, I learned that every patient requires their own unique approach. A year into using the supplement, I discovered that, if patients took too much of it, their old symptoms would reappear. Eventually, I moved out of my comfort zone and tried other supplements. Subsequently, the universe orchestrated two people to tell me about the miraculous outcomes from “thought-field therapy,” an energy-medicine technique. I began exploring “energy medicine” through the support and instruction of a holistic psychotherapist, Mark Bottinick, LCSW-C. Soon, I was connecting the dots between emotional freedom technique and immediate positive changes. Energy medicine allowed me to heal problems without using a pill! I felt as if I had arrived at Solla Sollew by the banks of the Beautiful River Wah-Hoo.

As I discovered and attended conferences in holistic medicine, I got certified in integrative medicine and became a Reiki master. What kept me along this holistic path? Happy patients with positive clinical outcomes. Even as a novice in holistic medicine, I began to experience patients crying with joy, rather than sadness. One psychotic patient got better on some supplements and got a new job in just 2 weeks.

On Feb. 17, 2021, I launched a podcast called “The Holistic Psychiatrist,” with interviews of patients, conversations with practitioners, and insights from me. Of the initial interviews, two of the three patients had bipolar disorder, and were able to safely and successfully withdraw from many medications. They are no longer patients and are free to move on with their lives. A patient who smoothly and successfully lowered six psychiatric medications will be sharing her wisdom and healing journey soon. A naturopathic doctor will also be sharing his insights and successes. He once was a suicidal high school student failing his classes, depressed and anxious, and dependent on marijuana. His recovery occurred more than a decade ago in my holistic practice.

These patients are living proof that holistic approaches can be very powerful and effective. They demonstrate that chronicity may reflect inadequate treatment and not a definition of disease. Over the course of this Holistic Mental Health column, I want to share many incredible healing journeys and insights on holistic psychiatry. I hope that you will be open to this new paradigm and begin your own holistic journey.

Dr. Lee is a psychiatrist with a solo private practice in Lehi, Utah. She integrates functional/orthomolecular medicine and mind/body/energy medicine in her work with patients. Contact her at holisticpsychiatrist.com. She has no conflicts of interest.

When I was asked to write a regular “Holistic Mental Health” column, I decided to write about the Herculean forces that must come together to create a holistic psychiatrist – someone who specializes in helping patients off their medications rather than on.

My journey began when I told a training psychiatrist that I wanted to stop being a psychiatrist. It was a year after my daughter was born, and I had started my third year of adult psychiatry residency at the University of Maryland in Baltimore. I was stressed and exhausted from working on inpatient psychiatric wards for 2 years, countless unpleasant nights on call, and additional sleepless nights caring for an infant.

I told the training psychiatrist that life wasn’t worth living. Was I suicidal, he asked? I laughed bitterly: “All the time!” Once he heard the S-word, he wanted me to take an antidepressant. I finally gave in and began taking Zoloft 25 mg every morning. Within a week, my angst disappeared; but 5 years, another child, and a fellowship later, I was still taking Zoloft. Why? Without much thought, I stopped it. A month later, I found myself brooding on the sofa, numb with depression, and feeling astonishingly suicidal. This “depression” led me to restart my Zoloft. In a week, my mood normalized. I did this on and off for about a year until a light bulb went off: This can’t be depression. It’s withdrawal. I’ve become dependent on Zoloft! Once I realized this, I began taking some St. John’s wort, an herbal alternative that was supposed to help with depression. I used cheaper brands and discovered that brands do matter, because the cheaper ones didn’t work. Through my haphazard exploration of natural alternatives, I came off Zoloft completely. During this time, I developed greater empathy for my patients, openness to natural alternatives, appreciation for supplement quality, and learned about psychotropic withdrawal. Most importantly, I came to understand a patient’s need to be free.

Five years later, in 2002, I had a thriving, but conventional, private practice. Instead of being content, however, I once again wanted to quit psychiatry. Medicating patients felt unrewarding, but I didn’t have another approach. Simultaneously, my practice was filling up with chronically ill, heavily medicated, bipolar patients. Their intense suffering combined with my discontent with psychiatry made me desperate for something better. In this ripe setting, the mother of a patient with bipolar disorder casually mentioned a supplement called EMPower by Truehope that lessened bipolar symptoms. Though my withdrawal from Zoloft allowed me to be more open to holistic approaches, I waited 3 months before calling. I used the supplement for the first time to help a heavily medicated bipolar patient in her 30’s, whose Depakote side effects caused her to wear a diaper, lack any emotions, and suffer severe tremors. Once I made this decision to walk down this new path, I never went back. With guidance from the company, I used this supplement to help many patients lower their medications. At the time, I wondered whether EMPower would be the solution for all my patients. The simplicity and ease of one supplement approach for all mental illnesses appealed to my laziness, so I continued down the holistic path.

Hundreds of supplements, glandulars, essential oils, and homeopathic remedies later, I learned that every patient requires their own unique approach. A year into using the supplement, I discovered that, if patients took too much of it, their old symptoms would reappear. Eventually, I moved out of my comfort zone and tried other supplements. Subsequently, the universe orchestrated two people to tell me about the miraculous outcomes from “thought-field therapy,” an energy-medicine technique. I began exploring “energy medicine” through the support and instruction of a holistic psychotherapist, Mark Bottinick, LCSW-C. Soon, I was connecting the dots between emotional freedom technique and immediate positive changes. Energy medicine allowed me to heal problems without using a pill! I felt as if I had arrived at Solla Sollew by the banks of the Beautiful River Wah-Hoo.

As I discovered and attended conferences in holistic medicine, I got certified in integrative medicine and became a Reiki master. What kept me along this holistic path? Happy patients with positive clinical outcomes. Even as a novice in holistic medicine, I began to experience patients crying with joy, rather than sadness. One psychotic patient got better on some supplements and got a new job in just 2 weeks.

On Feb. 17, 2021, I launched a podcast called “The Holistic Psychiatrist,” with interviews of patients, conversations with practitioners, and insights from me. Of the initial interviews, two of the three patients had bipolar disorder, and were able to safely and successfully withdraw from many medications. They are no longer patients and are free to move on with their lives. A patient who smoothly and successfully lowered six psychiatric medications will be sharing her wisdom and healing journey soon. A naturopathic doctor will also be sharing his insights and successes. He once was a suicidal high school student failing his classes, depressed and anxious, and dependent on marijuana. His recovery occurred more than a decade ago in my holistic practice.

These patients are living proof that holistic approaches can be very powerful and effective. They demonstrate that chronicity may reflect inadequate treatment and not a definition of disease. Over the course of this Holistic Mental Health column, I want to share many incredible healing journeys and insights on holistic psychiatry. I hope that you will be open to this new paradigm and begin your own holistic journey.

Dr. Lee is a psychiatrist with a solo private practice in Lehi, Utah. She integrates functional/orthomolecular medicine and mind/body/energy medicine in her work with patients. Contact her at holisticpsychiatrist.com. She has no conflicts of interest.

Clinicians in pediatrics have noticed a troubling pattern emerge during the pandemic, something that is darkly referred to as “the COVID 19,” or the 19 or more pounds that many of our patients have gained in the past year. This phenomenon has underscored many maxims in pediatric weight management: Mainly that frequent snacking, decreased physical activity, and less parental supervision lead to increased weight gain. But could we be missing another lesson this trend is teaching us? What about the relationship between catastrophe and childhood obesity?

Beyond the increased weight gain with lockdowns, I have observed other evidence in my own practice that childhood trauma or adverse experiences increase obesity. Our electronic medical record system gives an alert when a chart with sensitive information is accessed. One example might be if the patient had been seen at a clinic for children who have been abused. I am heartbroken at how often this happens. Academically, I understand the dire statistics about the incidence of child abuse, but the frequency at which I see this pattern is jarring.

Over the years, one striking correlation became clear among my patient population: Children with obesity were more likely to have been seen in the child abuse clinic than normal-weight peers.

I am far from the only one to have observed this relationship. Television shows focusing on severe obesity, such as “My 600-Pound Life,” often show trauma as both a cause and effect of severe obesity. This theme also became apparent on the show “The Biggest Loser,” which highlighted the difficulty of achieving and maintaining substantial weight loss. If even Hollywood has noticed this association, shouldn’t we be much farther ahead?
 

Pathways to obesity

Adverse childhood experiences (ACE) encompass various causes of child trauma, including abuse or neglect; poverty; household or neighborhood violence; and death, illness, or incarceration of a parent. A pivotal report in 1998 formalized the suspicion that many of us could plainly see: People who suffered ACE have higher incidence of heart disease, COPD, liver disease, incarceration, and drug abuse. For those with six or more ACE, life expectancy averaged 20 years less than those who had none. More recently, a meta-analysis found an odds ratio of 1.46 for adult obesity with known history of childhood trauma.

As a pediatric endocrinologist living in the poorest state of the country, I have clearly observed the correlation between childhood obesity and poverty. While prior generations may have associated child poverty with malnutrition and starvation, we are seeing in modern times that obesity has become a disease of lack. Calorie-dense and processed foods tend to be less expensive, more shelf-stable, and more accessible to people living in both urban and rural food deserts.

I am also a foster mother and have received extensive training in parenting children who have lived through trauma and neglect. For children who have endured food scarcity and deprivation, hoarding food and overeating are expected responses.

But the pathways to abnormal weight gain are myriad and expand beyond binge eating or numbing with food. ACE are particularly troubling because they affect developing brains and the neuroendocrine system; they alter epigenetics and cause heritable changes. Structural brain differences have been evident in the frontopolar cortex, which is linked to centers in the hypothalamus that control appetite. And increased stress raises cortisol release, increases insulin resistance, and alters satiety.
 

Shifting our approach to treatment

The significant cost of ACE is enormous and affects us all. Health professionals in pediatrics must understand these connections to effectively counsel children and their families dealing with obesity. Handing someone a diet plan and lecturing them about weight loss is never effective, but this common tactic is especially cruel if we do not assess for and address underlying pain. Obviously, blame and shame are ineffective motivators for lifestyle change in any circumstance, but these tactics may be especially harmful in the light of childhood trauma.

Screening for ACE is important in every aspect of pediatric care. The presence of obesity, however, should remind us to be more sensitive to the possibility of causative trauma. Clinicians for adults are not off the hook either. Fully 60% of adults suffered ACE and are dealing with the aftermath.

To improve health outcomes across the board, we must screen for trauma and become educated on trauma-informed care. Perhaps the most important first referral for a child suffering ACE and obesity is to a trained counselor or a social worker. Shepherding children through trauma will be more effective for attaining healthy weight than any remedy I can prescribe as an endocrinologist. Furthermore, this is our necessary role as healers. More than ever, we need to approach chronic diseases, including obesity, with the utmost compassion.

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

Clinicians in pediatrics have noticed a troubling pattern emerge during the pandemic, something that is darkly referred to as “the COVID 19,” or the 19 or more pounds that many of our patients have gained in the past year. This phenomenon has underscored many maxims in pediatric weight management: Mainly that frequent snacking, decreased physical activity, and less parental supervision lead to increased weight gain. But could we be missing another lesson this trend is teaching us? What about the relationship between catastrophe and childhood obesity?

Beyond the increased weight gain with lockdowns, I have observed other evidence in my own practice that childhood trauma or adverse experiences increase obesity. Our electronic medical record system gives an alert when a chart with sensitive information is accessed. One example might be if the patient had been seen at a clinic for children who have been abused. I am heartbroken at how often this happens. Academically, I understand the dire statistics about the incidence of child abuse, but the frequency at which I see this pattern is jarring.

Over the years, one striking correlation became clear among my patient population: Children with obesity were more likely to have been seen in the child abuse clinic than normal-weight peers.

I am far from the only one to have observed this relationship. Television shows focusing on severe obesity, such as “My 600-Pound Life,” often show trauma as both a cause and effect of severe obesity. This theme also became apparent on the show “The Biggest Loser,” which highlighted the difficulty of achieving and maintaining substantial weight loss. If even Hollywood has noticed this association, shouldn’t we be much farther ahead?
 

Pathways to obesity

Adverse childhood experiences (ACE) encompass various causes of child trauma, including abuse or neglect; poverty; household or neighborhood violence; and death, illness, or incarceration of a parent. A pivotal report in 1998 formalized the suspicion that many of us could plainly see: People who suffered ACE have higher incidence of heart disease, COPD, liver disease, incarceration, and drug abuse. For those with six or more ACE, life expectancy averaged 20 years less than those who had none. More recently, a meta-analysis found an odds ratio of 1.46 for adult obesity with known history of childhood trauma.

As a pediatric endocrinologist living in the poorest state of the country, I have clearly observed the correlation between childhood obesity and poverty. While prior generations may have associated child poverty with malnutrition and starvation, we are seeing in modern times that obesity has become a disease of lack. Calorie-dense and processed foods tend to be less expensive, more shelf-stable, and more accessible to people living in both urban and rural food deserts.

I am also a foster mother and have received extensive training in parenting children who have lived through trauma and neglect. For children who have endured food scarcity and deprivation, hoarding food and overeating are expected responses.

But the pathways to abnormal weight gain are myriad and expand beyond binge eating or numbing with food. ACE are particularly troubling because they affect developing brains and the neuroendocrine system; they alter epigenetics and cause heritable changes. Structural brain differences have been evident in the frontopolar cortex, which is linked to centers in the hypothalamus that control appetite. And increased stress raises cortisol release, increases insulin resistance, and alters satiety.
 

Shifting our approach to treatment

The significant cost of ACE is enormous and affects us all. Health professionals in pediatrics must understand these connections to effectively counsel children and their families dealing with obesity. Handing someone a diet plan and lecturing them about weight loss is never effective, but this common tactic is especially cruel if we do not assess for and address underlying pain. Obviously, blame and shame are ineffective motivators for lifestyle change in any circumstance, but these tactics may be especially harmful in the light of childhood trauma.

Screening for ACE is important in every aspect of pediatric care. The presence of obesity, however, should remind us to be more sensitive to the possibility of causative trauma. Clinicians for adults are not off the hook either. Fully 60% of adults suffered ACE and are dealing with the aftermath.

To improve health outcomes across the board, we must screen for trauma and become educated on trauma-informed care. Perhaps the most important first referral for a child suffering ACE and obesity is to a trained counselor or a social worker. Shepherding children through trauma will be more effective for attaining healthy weight than any remedy I can prescribe as an endocrinologist. Furthermore, this is our necessary role as healers. More than ever, we need to approach chronic diseases, including obesity, with the utmost compassion.

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

Clinicians in pediatrics have noticed a troubling pattern emerge during the pandemic, something that is darkly referred to as “the COVID 19,” or the 19 or more pounds that many of our patients have gained in the past year. This phenomenon has underscored many maxims in pediatric weight management: Mainly that frequent snacking, decreased physical activity, and less parental supervision lead to increased weight gain. But could we be missing another lesson this trend is teaching us? What about the relationship between catastrophe and childhood obesity?

Beyond the increased weight gain with lockdowns, I have observed other evidence in my own practice that childhood trauma or adverse experiences increase obesity. Our electronic medical record system gives an alert when a chart with sensitive information is accessed. One example might be if the patient had been seen at a clinic for children who have been abused. I am heartbroken at how often this happens. Academically, I understand the dire statistics about the incidence of child abuse, but the frequency at which I see this pattern is jarring.

Over the years, one striking correlation became clear among my patient population: Children with obesity were more likely to have been seen in the child abuse clinic than normal-weight peers.

I am far from the only one to have observed this relationship. Television shows focusing on severe obesity, such as “My 600-Pound Life,” often show trauma as both a cause and effect of severe obesity. This theme also became apparent on the show “The Biggest Loser,” which highlighted the difficulty of achieving and maintaining substantial weight loss. If even Hollywood has noticed this association, shouldn’t we be much farther ahead?
 

Pathways to obesity

Adverse childhood experiences (ACE) encompass various causes of child trauma, including abuse or neglect; poverty; household or neighborhood violence; and death, illness, or incarceration of a parent. A pivotal report in 1998 formalized the suspicion that many of us could plainly see: People who suffered ACE have higher incidence of heart disease, COPD, liver disease, incarceration, and drug abuse. For those with six or more ACE, life expectancy averaged 20 years less than those who had none. More recently, a meta-analysis found an odds ratio of 1.46 for adult obesity with known history of childhood trauma.

As a pediatric endocrinologist living in the poorest state of the country, I have clearly observed the correlation between childhood obesity and poverty. While prior generations may have associated child poverty with malnutrition and starvation, we are seeing in modern times that obesity has become a disease of lack. Calorie-dense and processed foods tend to be less expensive, more shelf-stable, and more accessible to people living in both urban and rural food deserts.

I am also a foster mother and have received extensive training in parenting children who have lived through trauma and neglect. For children who have endured food scarcity and deprivation, hoarding food and overeating are expected responses.

But the pathways to abnormal weight gain are myriad and expand beyond binge eating or numbing with food. ACE are particularly troubling because they affect developing brains and the neuroendocrine system; they alter epigenetics and cause heritable changes. Structural brain differences have been evident in the frontopolar cortex, which is linked to centers in the hypothalamus that control appetite. And increased stress raises cortisol release, increases insulin resistance, and alters satiety.
 

Shifting our approach to treatment

The significant cost of ACE is enormous and affects us all. Health professionals in pediatrics must understand these connections to effectively counsel children and their families dealing with obesity. Handing someone a diet plan and lecturing them about weight loss is never effective, but this common tactic is especially cruel if we do not assess for and address underlying pain. Obviously, blame and shame are ineffective motivators for lifestyle change in any circumstance, but these tactics may be especially harmful in the light of childhood trauma.

Screening for ACE is important in every aspect of pediatric care. The presence of obesity, however, should remind us to be more sensitive to the possibility of causative trauma. Clinicians for adults are not off the hook either. Fully 60% of adults suffered ACE and are dealing with the aftermath.

To improve health outcomes across the board, we must screen for trauma and become educated on trauma-informed care. Perhaps the most important first referral for a child suffering ACE and obesity is to a trained counselor or a social worker. Shepherding children through trauma will be more effective for attaining healthy weight than any remedy I can prescribe as an endocrinologist. Furthermore, this is our necessary role as healers. More than ever, we need to approach chronic diseases, including obesity, with the utmost compassion.

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

It’s been more than a year since we came face to face with an unprecedented, unrelenting pandemic. Determined to overcome, determined to forge ahead, we worked tirelessly.

Drazen Zigic/Getty Images

Hours upon hours, days upon days, months upon months. Hoping for recovery while facing the devastation of death. We were praised, and lauded as heroes as we pleaded for essential protective gear and urged our communities to think critically, act responsibly, and distance safely. From the cities to small towns, we answered the call. Leaving long-practiced specialties, reassigned from our practices and training, we worked together uncertain of the future, but committed to safeguarding our present. Through sacrifice we toiled, leaving our families to protect against contagion, wading through halls of the sick and fighting against the threat of death.

Beginning at the beginning

Addressing these issues starts with training. As a new cohort of eager students enters medical/osteopathic school, the focus should lie not only on foundations of medicine and brute memorization of copious information but also on self-care, wellness checks, and group morale. The same emphasis placed upon patient care and advocacy must also be extended toward ensuring that the next generation of physicians will understand the importance of caring for themselves as much as they care for others.

In the same manner, past stereotypes of ruthless, cut-throat, competition must also evolve. Although the spirit of hard work and perseverance is essential, the manner it propagates is just as important. Aggressive questioning, myriad testing, rigid hierarchies, blind obedience, and ego inflation may separate the pack, but it also reinforces individualism and isolation. Students may shield their internal turmoil behind a mask. The mask of the Super Doctor.

However, as the pandemic has shown, even the most durable of masks will eventually fail. So how do we recognize and accept that help is needed? How do we access support? First, it is vital to acknowledge that there is no shame in asking for help. It is both surprising and reassuring that many of us have been there, an unspoken band of brothers and sisters. Second, remember the acronym for depressive symptoms SIGECAPS (sleep, interest, guilt, energy, concentration, appetite, psychomotor, suicide). Remember that these symptoms may develop gradually or feel sudden and overwhelming. Know that mood lability, tearfulness, and isolation may also be present but confused and disregarded as normal consequences of school, residency, or life as a physician. Third, recognize common behavioral changes associated with anxiety, such as irritability, avoidance, and physical symptoms, including headache, muscle aches, joint pain, GI discomfort, palpitations, and insomnia. Last, reach out to colleagues who have suddenly or gradually withdrawn. Schedule frequent check-ins for one another and do not be afraid to admit that you are human. There is no shame in vulnerability but there is bravery and strength.

If you are in school or residency training, reach out to health centers, training directors, supervisors, family and/or friends. Whether you are an early career physician or amid a decades-long career, connect with your peers, reach out to junior members, offer and accept support. Anonymous hotlines, listservs, email groups, virtual meetings, texts, and phone calls also provide opportunities for wellness checks, pep talks, or venting sessions. All are important. In the case where more specialized help is needed, contact your primary care physician, reach out to colleagues in mental health, contact the Suicide Prevention Lifeline at 1-800 273-8255. Know there is help; you are not alone.

In these unprecedented and uncertain times, remember the African proverb “It takes a village.” To ask for help reveals strength and fortitude. The more we advocate for ourselves and one another, the more we will prevail and shed the myth of infallibility.

Dr. Thomas is a board-certified adult psychiatrist with an interest in chronic illness, women’s behavioral health, and minority mental health. She currently practices in North Kingstown and East Providence, R.I. She has no conflicts of interest.

It’s been more than a year since we came face to face with an unprecedented, unrelenting pandemic. Determined to overcome, determined to forge ahead, we worked tirelessly.

Drazen Zigic/Getty Images

Hours upon hours, days upon days, months upon months. Hoping for recovery while facing the devastation of death. We were praised, and lauded as heroes as we pleaded for essential protective gear and urged our communities to think critically, act responsibly, and distance safely. From the cities to small towns, we answered the call. Leaving long-practiced specialties, reassigned from our practices and training, we worked together uncertain of the future, but committed to safeguarding our present. Through sacrifice we toiled, leaving our families to protect against contagion, wading through halls of the sick and fighting against the threat of death.

Beginning at the beginning

Addressing these issues starts with training. As a new cohort of eager students enters medical/osteopathic school, the focus should lie not only on foundations of medicine and brute memorization of copious information but also on self-care, wellness checks, and group morale. The same emphasis placed upon patient care and advocacy must also be extended toward ensuring that the next generation of physicians will understand the importance of caring for themselves as much as they care for others.

In the same manner, past stereotypes of ruthless, cut-throat, competition must also evolve. Although the spirit of hard work and perseverance is essential, the manner it propagates is just as important. Aggressive questioning, myriad testing, rigid hierarchies, blind obedience, and ego inflation may separate the pack, but it also reinforces individualism and isolation. Students may shield their internal turmoil behind a mask. The mask of the Super Doctor.

However, as the pandemic has shown, even the most durable of masks will eventually fail. So how do we recognize and accept that help is needed? How do we access support? First, it is vital to acknowledge that there is no shame in asking for help. It is both surprising and reassuring that many of us have been there, an unspoken band of brothers and sisters. Second, remember the acronym for depressive symptoms SIGECAPS (sleep, interest, guilt, energy, concentration, appetite, psychomotor, suicide). Remember that these symptoms may develop gradually or feel sudden and overwhelming. Know that mood lability, tearfulness, and isolation may also be present but confused and disregarded as normal consequences of school, residency, or life as a physician. Third, recognize common behavioral changes associated with anxiety, such as irritability, avoidance, and physical symptoms, including headache, muscle aches, joint pain, GI discomfort, palpitations, and insomnia. Last, reach out to colleagues who have suddenly or gradually withdrawn. Schedule frequent check-ins for one another and do not be afraid to admit that you are human. There is no shame in vulnerability but there is bravery and strength.

If you are in school or residency training, reach out to health centers, training directors, supervisors, family and/or friends. Whether you are an early career physician or amid a decades-long career, connect with your peers, reach out to junior members, offer and accept support. Anonymous hotlines, listservs, email groups, virtual meetings, texts, and phone calls also provide opportunities for wellness checks, pep talks, or venting sessions. All are important. In the case where more specialized help is needed, contact your primary care physician, reach out to colleagues in mental health, contact the Suicide Prevention Lifeline at 1-800 273-8255. Know there is help; you are not alone.

In these unprecedented and uncertain times, remember the African proverb “It takes a village.” To ask for help reveals strength and fortitude. The more we advocate for ourselves and one another, the more we will prevail and shed the myth of infallibility.

Dr. Thomas is a board-certified adult psychiatrist with an interest in chronic illness, women’s behavioral health, and minority mental health. She currently practices in North Kingstown and East Providence, R.I. She has no conflicts of interest.

It’s been more than a year since we came face to face with an unprecedented, unrelenting pandemic. Determined to overcome, determined to forge ahead, we worked tirelessly.

Drazen Zigic/Getty Images

Hours upon hours, days upon days, months upon months. Hoping for recovery while facing the devastation of death. We were praised, and lauded as heroes as we pleaded for essential protective gear and urged our communities to think critically, act responsibly, and distance safely. From the cities to small towns, we answered the call. Leaving long-practiced specialties, reassigned from our practices and training, we worked together uncertain of the future, but committed to safeguarding our present. Through sacrifice we toiled, leaving our families to protect against contagion, wading through halls of the sick and fighting against the threat of death.

Beginning at the beginning

Addressing these issues starts with training. As a new cohort of eager students enters medical/osteopathic school, the focus should lie not only on foundations of medicine and brute memorization of copious information but also on self-care, wellness checks, and group morale. The same emphasis placed upon patient care and advocacy must also be extended toward ensuring that the next generation of physicians will understand the importance of caring for themselves as much as they care for others.

In the same manner, past stereotypes of ruthless, cut-throat, competition must also evolve. Although the spirit of hard work and perseverance is essential, the manner it propagates is just as important. Aggressive questioning, myriad testing, rigid hierarchies, blind obedience, and ego inflation may separate the pack, but it also reinforces individualism and isolation. Students may shield their internal turmoil behind a mask. The mask of the Super Doctor.

However, as the pandemic has shown, even the most durable of masks will eventually fail. So how do we recognize and accept that help is needed? How do we access support? First, it is vital to acknowledge that there is no shame in asking for help. It is both surprising and reassuring that many of us have been there, an unspoken band of brothers and sisters. Second, remember the acronym for depressive symptoms SIGECAPS (sleep, interest, guilt, energy, concentration, appetite, psychomotor, suicide). Remember that these symptoms may develop gradually or feel sudden and overwhelming. Know that mood lability, tearfulness, and isolation may also be present but confused and disregarded as normal consequences of school, residency, or life as a physician. Third, recognize common behavioral changes associated with anxiety, such as irritability, avoidance, and physical symptoms, including headache, muscle aches, joint pain, GI discomfort, palpitations, and insomnia. Last, reach out to colleagues who have suddenly or gradually withdrawn. Schedule frequent check-ins for one another and do not be afraid to admit that you are human. There is no shame in vulnerability but there is bravery and strength.

If you are in school or residency training, reach out to health centers, training directors, supervisors, family and/or friends. Whether you are an early career physician or amid a decades-long career, connect with your peers, reach out to junior members, offer and accept support. Anonymous hotlines, listservs, email groups, virtual meetings, texts, and phone calls also provide opportunities for wellness checks, pep talks, or venting sessions. All are important. In the case where more specialized help is needed, contact your primary care physician, reach out to colleagues in mental health, contact the Suicide Prevention Lifeline at 1-800 273-8255. Know there is help; you are not alone.

In these unprecedented and uncertain times, remember the African proverb “It takes a village.” To ask for help reveals strength and fortitude. The more we advocate for ourselves and one another, the more we will prevail and shed the myth of infallibility.

Dr. Thomas is a board-certified adult psychiatrist with an interest in chronic illness, women’s behavioral health, and minority mental health. She currently practices in North Kingstown and East Providence, R.I. She has no conflicts of interest.

Dr. Margaret G. Klitzke is a board-certified child and adolescent psychiatrist who has worked across all settings of the Center for Autism and Developmental Disabilities at Bradley Hospital in East Providence, R.I.

Courtesy Dr. Margaret G. Klitzke

I spoke with Dr. Klitzke recently about her work as an outpatient psychiatrist at the center and about the important role of families in the treatment it provides. The center offers highly specialized clinical services for children and adolescents between the ages of 2 and 18 who show signs of serious emotional and behavioral problems in addition to a developmental disability, such as autism, Asperger’s, or intellectual disability.

ALISON M. HERU, MD: Hello, Dr. Klitzke and thank you for agreeing to this interview.

MARGARET G. KLITZKE, DO: My pleasure.

AMH: I admire your dedication to this population of children and adolescents. To me, it seems very hard to work with patients and families where there is significant disability and there is little hope of the patient “getting better.”

MGK: When parents come to us, they have great hopes their children can be helped. They often express understanding and acceptance of the child’s disability, and seek to understand the psychiatric or behavioral issues. These parents are often very dedicated to their children, giving up careers to care for them. But as professionals, we must be sensitive to the role each parent can play and how they can support each other and the family.

AMH: So much of your work focuses on family inclusion and family psychoeducation?

MGK: Yes. An example that stands out is a couple where the mother had become the voice for the family in dealing with professionals, but she was overwhelmed in this role. So, we invited the father in. He explained that medical professionals and school personnel would address their remarks to his wife and that he felt marginalized. We worked with the couple, now always including the father, and he has gone on to become a vocal advocate for children with disabilities. It is inspiring to watch families become advocates – to insist that others see the child’s strengths – not just weaknesses.

AMH: Do you feel that the families ever come to you with too high expectations of what you can do to help their child?

MGK: As a child psychiatrist, one must put oneself in the parents’ shoes. Charlie Zeanah Jr., MD, and others have done wonderful work in attachment. They have identified that parents have fantasies and beliefs about what the child will be like before the child is born. We all have fantasies about our babies before they come to us! For many families, they quickly come to understand that their child is not like other children. This new world of parenting is not what they expected. A mother once gave me a short piece called “Welcome to Holland,” written by a mother whose child has Down syndrome.

AMH: How do you begin to work with these families? There must be such a sense of loss and tragedy in their lives.

MGK: My first goal is to understand what it is like to have a child with developmental disability, not just for the parents but for the siblings, too. I strive to understand what the parents want for their child and how they see themselves as a family. I see us, the health care team, as agents to help the child and the family be the very best they can be.

AMH: How do you deal with parents who are not be on the same page?

MGK: It is important that parents are consistent and are able to work together. Even if they are divorced, I have seen families able to unite around the care of their child with a disability. This is quite an achievement given the high rates of divorce – although most of the families that I have worked with are intact. As in all families, each member has a role in helping the family function well. It means using the strength of each parent to help them become a parenting team.

AMH: What if the parents have unrealistic expectations of their child?

MGK: Yes, there are parents who come to us with unrealistic expectations, such as believing their nonverbal child will talk some day. In such a case, we must be certain that we have exhausted all methods to help this child communicate, and once we have done all we can, then we must accept where that child is; to accept and help the family accept, the child’s weaknesses and acknowledge their strengths. Change what you can and be a support for everything else.

AMH: I find it hard to imagine caring for a severely disabled child. How do these parents do this?

MGK: These are children who are nonverbal, and children who can be very fragile, even medically. What I see are parents who want to connect, who want to find that something inside that child, that special place where there is connection. That place of reciprocity. That is important to us all, helping the family find that place of reciprocal connection.

AMH: What language do you use to discuss this with families?

MGK: I say, “This is the child’s strength and this is the child’s weakness; capitalize on the strengths and let’s shore up their weaknesses.”

AMH: How do you approach the families? Where do you start?

MGK: I meet the family where they are. One cannot with these families or any families stand rigidly 10 feet away, and demand that they change. This never works, and we will be of no help to them. We must understand the family system and how they have arrived at their current place of functioning.

AMH: Can you give an example?

MGK: Yes, for example if a parent is drinking excessively, I help them understand why they are coping that way and see if they are willing to change.

AMH: What keeps you going ?

MGK: I think it comes back to the family work. For me, I believe the families are doing the very best they can. If the family is really impaired in some way, I see it as my job to figure out why that is their pattern of behavior, and I do what I can to help them facilitate change.

AMH: What inspires you about these families?

MGK: These families are able to recognize the strengths and beauty that their children bring them – the strength of these children, their personalities and their wills of steel! They are able to communicate what they need. Siblings, too, make life decisions based on their experiences. They often end up going down the path of caring for such children as professionals.

AMH: Do you have any recommendations for a young child psychiatrist who might be considering working with this population?

MGK: Developmental disabilities in child psychiatry is where medicine, neurology, and child development meet. The advances in genetics and neurology are major gifts to the field. It used to be that I would have to sell the field to medical students and residents. Now they are coming to me saying that they want to work in this area. It is an intellectually rich field in which to work. There is a real change happening. But the place where it becomes really magical is in working with the families.

AMH: What other changes have you seen?

MGK: With the closure of big institutions, it is less of an option for families to walk away. The families now feel that they need to take care of the child.

AMH: What has your career taught you?

MGK: These children and their families made us better people. It has taught me patience, to enter every situation without preconceived notions, and that there is something new to learn every day.

References

J Child Adolesc Psychiatry. 1975 Jun 1;14(3):387-421.

Evaluation and Treating Families: The McMaster Approach. Routledge/Taylor & Francis Group, 2005.

Movies to watch

Lorenzo’s Oil, 1992.

My Left Foot, 1989.

Dr. Heru is professor of psychiatry at the University of Colorado at Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (Routledge, 2013). She has no conflicts of interest.

Dr. Klitkze is a 1983 graduate of the Texas College of Osteopathic Medicine, and completed her residency and fellowship training at Brown University, Providence, R.I. She is a member of the American Psychiatric Association, the American Academy of Child and Adolescent Psychiatry, and the Rhode Island Medical Society, where she serves on the Physicians’ Health Committee. She is actively involved in teaching medical students, residents, and fellows, and has received several teaching awards from the department of psychiatry and human behavior at Brown.

Dr. Margaret G. Klitzke is a board-certified child and adolescent psychiatrist who has worked across all settings of the Center for Autism and Developmental Disabilities at Bradley Hospital in East Providence, R.I.

Courtesy Dr. Margaret G. Klitzke

I spoke with Dr. Klitzke recently about her work as an outpatient psychiatrist at the center and about the important role of families in the treatment it provides. The center offers highly specialized clinical services for children and adolescents between the ages of 2 and 18 who show signs of serious emotional and behavioral problems in addition to a developmental disability, such as autism, Asperger’s, or intellectual disability.

ALISON M. HERU, MD: Hello, Dr. Klitzke and thank you for agreeing to this interview.

MARGARET G. KLITZKE, DO: My pleasure.

AMH: I admire your dedication to this population of children and adolescents. To me, it seems very hard to work with patients and families where there is significant disability and there is little hope of the patient “getting better.”

MGK: When parents come to us, they have great hopes their children can be helped. They often express understanding and acceptance of the child’s disability, and seek to understand the psychiatric or behavioral issues. These parents are often very dedicated to their children, giving up careers to care for them. But as professionals, we must be sensitive to the role each parent can play and how they can support each other and the family.

AMH: So much of your work focuses on family inclusion and family psychoeducation?

MGK: Yes. An example that stands out is a couple where the mother had become the voice for the family in dealing with professionals, but she was overwhelmed in this role. So, we invited the father in. He explained that medical professionals and school personnel would address their remarks to his wife and that he felt marginalized. We worked with the couple, now always including the father, and he has gone on to become a vocal advocate for children with disabilities. It is inspiring to watch families become advocates – to insist that others see the child’s strengths – not just weaknesses.

AMH: Do you feel that the families ever come to you with too high expectations of what you can do to help their child?

MGK: As a child psychiatrist, one must put oneself in the parents’ shoes. Charlie Zeanah Jr., MD, and others have done wonderful work in attachment. They have identified that parents have fantasies and beliefs about what the child will be like before the child is born. We all have fantasies about our babies before they come to us! For many families, they quickly come to understand that their child is not like other children. This new world of parenting is not what they expected. A mother once gave me a short piece called “Welcome to Holland,” written by a mother whose child has Down syndrome.

AMH: How do you begin to work with these families? There must be such a sense of loss and tragedy in their lives.

MGK: My first goal is to understand what it is like to have a child with developmental disability, not just for the parents but for the siblings, too. I strive to understand what the parents want for their child and how they see themselves as a family. I see us, the health care team, as agents to help the child and the family be the very best they can be.

AMH: How do you deal with parents who are not be on the same page?

MGK: It is important that parents are consistent and are able to work together. Even if they are divorced, I have seen families able to unite around the care of their child with a disability. This is quite an achievement given the high rates of divorce – although most of the families that I have worked with are intact. As in all families, each member has a role in helping the family function well. It means using the strength of each parent to help them become a parenting team.

AMH: What if the parents have unrealistic expectations of their child?

MGK: Yes, there are parents who come to us with unrealistic expectations, such as believing their nonverbal child will talk some day. In such a case, we must be certain that we have exhausted all methods to help this child communicate, and once we have done all we can, then we must accept where that child is; to accept and help the family accept, the child’s weaknesses and acknowledge their strengths. Change what you can and be a support for everything else.

AMH: I find it hard to imagine caring for a severely disabled child. How do these parents do this?

MGK: These are children who are nonverbal, and children who can be very fragile, even medically. What I see are parents who want to connect, who want to find that something inside that child, that special place where there is connection. That place of reciprocity. That is important to us all, helping the family find that place of reciprocal connection.

AMH: What language do you use to discuss this with families?

MGK: I say, “This is the child’s strength and this is the child’s weakness; capitalize on the strengths and let’s shore up their weaknesses.”

AMH: How do you approach the families? Where do you start?

MGK: I meet the family where they are. One cannot with these families or any families stand rigidly 10 feet away, and demand that they change. This never works, and we will be of no help to them. We must understand the family system and how they have arrived at their current place of functioning.

AMH: Can you give an example?

MGK: Yes, for example if a parent is drinking excessively, I help them understand why they are coping that way and see if they are willing to change.

AMH: What keeps you going ?

MGK: I think it comes back to the family work. For me, I believe the families are doing the very best they can. If the family is really impaired in some way, I see it as my job to figure out why that is their pattern of behavior, and I do what I can to help them facilitate change.

AMH: What inspires you about these families?

MGK: These families are able to recognize the strengths and beauty that their children bring them – the strength of these children, their personalities and their wills of steel! They are able to communicate what they need. Siblings, too, make life decisions based on their experiences. They often end up going down the path of caring for such children as professionals.

AMH: Do you have any recommendations for a young child psychiatrist who might be considering working with this population?

MGK: Developmental disabilities in child psychiatry is where medicine, neurology, and child development meet. The advances in genetics and neurology are major gifts to the field. It used to be that I would have to sell the field to medical students and residents. Now they are coming to me saying that they want to work in this area. It is an intellectually rich field in which to work. There is a real change happening. But the place where it becomes really magical is in working with the families.

AMH: What other changes have you seen?

MGK: With the closure of big institutions, it is less of an option for families to walk away. The families now feel that they need to take care of the child.

AMH: What has your career taught you?

MGK: These children and their families made us better people. It has taught me patience, to enter every situation without preconceived notions, and that there is something new to learn every day.

References

J Child Adolesc Psychiatry. 1975 Jun 1;14(3):387-421.

Evaluation and Treating Families: The McMaster Approach. Routledge/Taylor & Francis Group, 2005.

Movies to watch

Lorenzo’s Oil, 1992.

My Left Foot, 1989.

Dr. Heru is professor of psychiatry at the University of Colorado at Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (Routledge, 2013). She has no conflicts of interest.

Dr. Klitkze is a 1983 graduate of the Texas College of Osteopathic Medicine, and completed her residency and fellowship training at Brown University, Providence, R.I. She is a member of the American Psychiatric Association, the American Academy of Child and Adolescent Psychiatry, and the Rhode Island Medical Society, where she serves on the Physicians’ Health Committee. She is actively involved in teaching medical students, residents, and fellows, and has received several teaching awards from the department of psychiatry and human behavior at Brown.

Dr. Margaret G. Klitzke is a board-certified child and adolescent psychiatrist who has worked across all settings of the Center for Autism and Developmental Disabilities at Bradley Hospital in East Providence, R.I.

Courtesy Dr. Margaret G. Klitzke

I spoke with Dr. Klitzke recently about her work as an outpatient psychiatrist at the center and about the important role of families in the treatment it provides. The center offers highly specialized clinical services for children and adolescents between the ages of 2 and 18 who show signs of serious emotional and behavioral problems in addition to a developmental disability, such as autism, Asperger’s, or intellectual disability.

ALISON M. HERU, MD: Hello, Dr. Klitzke and thank you for agreeing to this interview.

MARGARET G. KLITZKE, DO: My pleasure.

AMH: I admire your dedication to this population of children and adolescents. To me, it seems very hard to work with patients and families where there is significant disability and there is little hope of the patient “getting better.”

MGK: When parents come to us, they have great hopes their children can be helped. They often express understanding and acceptance of the child’s disability, and seek to understand the psychiatric or behavioral issues. These parents are often very dedicated to their children, giving up careers to care for them. But as professionals, we must be sensitive to the role each parent can play and how they can support each other and the family.

AMH: So much of your work focuses on family inclusion and family psychoeducation?

MGK: Yes. An example that stands out is a couple where the mother had become the voice for the family in dealing with professionals, but she was overwhelmed in this role. So, we invited the father in. He explained that medical professionals and school personnel would address their remarks to his wife and that he felt marginalized. We worked with the couple, now always including the father, and he has gone on to become a vocal advocate for children with disabilities. It is inspiring to watch families become advocates – to insist that others see the child’s strengths – not just weaknesses.

AMH: Do you feel that the families ever come to you with too high expectations of what you can do to help their child?

MGK: As a child psychiatrist, one must put oneself in the parents’ shoes. Charlie Zeanah Jr., MD, and others have done wonderful work in attachment. They have identified that parents have fantasies and beliefs about what the child will be like before the child is born. We all have fantasies about our babies before they come to us! For many families, they quickly come to understand that their child is not like other children. This new world of parenting is not what they expected. A mother once gave me a short piece called “Welcome to Holland,” written by a mother whose child has Down syndrome.

AMH: How do you begin to work with these families? There must be such a sense of loss and tragedy in their lives.

MGK: My first goal is to understand what it is like to have a child with developmental disability, not just for the parents but for the siblings, too. I strive to understand what the parents want for their child and how they see themselves as a family. I see us, the health care team, as agents to help the child and the family be the very best they can be.

AMH: How do you deal with parents who are not be on the same page?

MGK: It is important that parents are consistent and are able to work together. Even if they are divorced, I have seen families able to unite around the care of their child with a disability. This is quite an achievement given the high rates of divorce – although most of the families that I have worked with are intact. As in all families, each member has a role in helping the family function well. It means using the strength of each parent to help them become a parenting team.

AMH: What if the parents have unrealistic expectations of their child?

MGK: Yes, there are parents who come to us with unrealistic expectations, such as believing their nonverbal child will talk some day. In such a case, we must be certain that we have exhausted all methods to help this child communicate, and once we have done all we can, then we must accept where that child is; to accept and help the family accept, the child’s weaknesses and acknowledge their strengths. Change what you can and be a support for everything else.

AMH: I find it hard to imagine caring for a severely disabled child. How do these parents do this?

MGK: These are children who are nonverbal, and children who can be very fragile, even medically. What I see are parents who want to connect, who want to find that something inside that child, that special place where there is connection. That place of reciprocity. That is important to us all, helping the family find that place of reciprocal connection.

AMH: What language do you use to discuss this with families?

MGK: I say, “This is the child’s strength and this is the child’s weakness; capitalize on the strengths and let’s shore up their weaknesses.”

AMH: How do you approach the families? Where do you start?

MGK: I meet the family where they are. One cannot with these families or any families stand rigidly 10 feet away, and demand that they change. This never works, and we will be of no help to them. We must understand the family system and how they have arrived at their current place of functioning.

AMH: Can you give an example?

MGK: Yes, for example if a parent is drinking excessively, I help them understand why they are coping that way and see if they are willing to change.

AMH: What keeps you going ?

MGK: I think it comes back to the family work. For me, I believe the families are doing the very best they can. If the family is really impaired in some way, I see it as my job to figure out why that is their pattern of behavior, and I do what I can to help them facilitate change.

AMH: What inspires you about these families?

MGK: These families are able to recognize the strengths and beauty that their children bring them – the strength of these children, their personalities and their wills of steel! They are able to communicate what they need. Siblings, too, make life decisions based on their experiences. They often end up going down the path of caring for such children as professionals.

AMH: Do you have any recommendations for a young child psychiatrist who might be considering working with this population?

MGK: Developmental disabilities in child psychiatry is where medicine, neurology, and child development meet. The advances in genetics and neurology are major gifts to the field. It used to be that I would have to sell the field to medical students and residents. Now they are coming to me saying that they want to work in this area. It is an intellectually rich field in which to work. There is a real change happening. But the place where it becomes really magical is in working with the families.

AMH: What other changes have you seen?

MGK: With the closure of big institutions, it is less of an option for families to walk away. The families now feel that they need to take care of the child.

AMH: What has your career taught you?

MGK: These children and their families made us better people. It has taught me patience, to enter every situation without preconceived notions, and that there is something new to learn every day.

References

J Child Adolesc Psychiatry. 1975 Jun 1;14(3):387-421.

Evaluation and Treating Families: The McMaster Approach. Routledge/Taylor & Francis Group, 2005.

Movies to watch

Lorenzo’s Oil, 1992.

My Left Foot, 1989.

Dr. Heru is professor of psychiatry at the University of Colorado at Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (Routledge, 2013). She has no conflicts of interest.

Dr. Klitkze is a 1983 graduate of the Texas College of Osteopathic Medicine, and completed her residency and fellowship training at Brown University, Providence, R.I. She is a member of the American Psychiatric Association, the American Academy of Child and Adolescent Psychiatry, and the Rhode Island Medical Society, where she serves on the Physicians’ Health Committee. She is actively involved in teaching medical students, residents, and fellows, and has received several teaching awards from the department of psychiatry and human behavior at Brown.

It’s likely the United States will see another surge of COVID-19 this winter, warned Christopher Murray, MD, director of the Institute for Health Metrics and Evaluation (IHME) at the University of Washington in Seattle.

Speaking at the national conference of State of Reform on April 8, Dr. Murray cited the seasonality of the SARS-CoV-2 virus, which wanes in the summer and waxes in the winter. The “optimistic forecast” of IHME, which has modeled the course of the pandemic for the past 13 months, is that daily deaths will rise a bit in the next month, then decline from May through August, he said.

“Summer should be fairly quiet in terms of COVID, if vaccinations rise and people don’t stop wearing masks,” Dr. Murray said.

But he added that “a considerable surge will occur over next winter,” because the new variants are more transmissible, and people will likely relax social distancing and mask wearing. The IHME predicts that the percentage of Americans who usually don masks will decline from 73% today to 21% by Aug. 1.

With a rapid decline in mask use and a rise in mobility, there will still be more than 1,000 deaths each day by July 1, Dr. Murray said. In a forecast released the day after Dr. Murray spoke, the IHME predicted that by Aug. 1, there will be a total of 618,523 U.S. deaths from COVID-19. Deaths could be as high as 696,651 if mobility among the vaccinated returns to prepandemic levels, the institute forecasts.

Based on cell phone data, Dr. Murray said, the amount of mobility in the United States has already risen to the level of March 2020, when the pandemic was just getting underway.
 

Decreased infections

If there’s one piece of good news in the latest IHME report, it’s that the estimated number of people infected (including those not tested) will drop from 111,581 today to a projected 17,502 on Aug. 1. But in a worst-case scenario, with sharply higher mobility among vaccinated people, the case count on that date would only fall to 73,842.

The SARS-CoV-2 variants are another factor of concern. Dr. Murray distinguished between variants like the one first identified in the U.K. (B.1.1.7) and other “escape variants.”

B.1.1.7, which is now the dominant strain in the United States, increases transmission but doesn’t necessarily escape the immune system or vaccines, he explained.

In contrast, if someone is infected with a variant such as the South African or the Brazilian mutations, he said, a previous COVID-19 infection might not protect the person, and vaccines are less effective against those variants.

Cross-variant immunity may range from 0% to 60% for escape variants, based on the slim amount of data now available, Dr. Murray said. In his view, these variants will be the long-term driver of the pandemic in the United States, while the United Kingdom variant is the short-term driver.

The latest data, he said, show that the Pfizer/BioNTech and Moderna vaccines are 75% effective against the escape variants, with lower efficacy for other vaccines. But booster shots may still be required to protect people against some variants.
 

Human factors

Human behavior will also help determine the course of the pandemic, he noted. Vaccine hesitancy, for example, is still high in the United States.

By the end of May, he predicted, about 180 million people will have received about two doses of vaccine. After that, he said, “vaccination will flatline due to lack of demand.” The two unknowns are how much campaigns to promote vaccination will increase vaccine confidence, and when children will be vaccinated.

In the United States, he said, 69% of adults have been vaccinated or want to get a shot. But that percentage has dropped 5 points since February, and vaccine confidence varies by state.

Dr. Murray emphasized that the winter surge he predicts can be blocked if people change their behaviors. These include a rise in vaccine confidence to 80% and continued mask wearing by most people.

However, if vaccine confidence and mask wearing decline, state governments continue to drop social distancing rules, and the uptake of boosters is low, the winter surge could be more serious, he said.
 

Double surge

Murray also raised the possibility of a double surge of COVID-19 and influenza this winter. Widely expected last winter, this double surge never materialized here or elsewhere, partly because of mask wearing. But Dr. Murray said it could happen this year: History shows that the flu tends to be stronger in years after weak outbreaks.

He advised hospitals to prepare now for whatever might come later this year. Public health authorities, he said, should speed up vaccination, monitor variants closely with additional sequencing, and try to modify behavior in high-risk groups.

Asked to explain the recent surge of COVID-19 cases in Michigan, Dr. Murray attributed it partly to the spread of the B.1.1.7 (U.K.) variant. But he noted that the U.K. variant has expanded even more widely in some other states that haven’t had an explosive surge like Michigan’s.

Moreover, he noted, Michigan doesn’t have low mask use or high mobility. So the upward spiral of COVID-19 infections there is very concerning, he said.

In regard to the role of children as reservoirs of the virus, Dr. Murray pointed out that views on this have changed around the world. For a while, people thought kids didn’t spread COVID-19 very much. That view shifted when U.K. data showed that child transmission of the B.1.1.7 variant increased by half to 9% of contacts in comparison with the original virus strain.

Dutch data, similarly, showed schools contributing to the latest outbreaks, and some European nations have closed schools. In the United States, the trend is to open them.

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

It’s likely the United States will see another surge of COVID-19 this winter, warned Christopher Murray, MD, director of the Institute for Health Metrics and Evaluation (IHME) at the University of Washington in Seattle.

Speaking at the national conference of State of Reform on April 8, Dr. Murray cited the seasonality of the SARS-CoV-2 virus, which wanes in the summer and waxes in the winter. The “optimistic forecast” of IHME, which has modeled the course of the pandemic for the past 13 months, is that daily deaths will rise a bit in the next month, then decline from May through August, he said.

“Summer should be fairly quiet in terms of COVID, if vaccinations rise and people don’t stop wearing masks,” Dr. Murray said.

But he added that “a considerable surge will occur over next winter,” because the new variants are more transmissible, and people will likely relax social distancing and mask wearing. The IHME predicts that the percentage of Americans who usually don masks will decline from 73% today to 21% by Aug. 1.

With a rapid decline in mask use and a rise in mobility, there will still be more than 1,000 deaths each day by July 1, Dr. Murray said. In a forecast released the day after Dr. Murray spoke, the IHME predicted that by Aug. 1, there will be a total of 618,523 U.S. deaths from COVID-19. Deaths could be as high as 696,651 if mobility among the vaccinated returns to prepandemic levels, the institute forecasts.

Based on cell phone data, Dr. Murray said, the amount of mobility in the United States has already risen to the level of March 2020, when the pandemic was just getting underway.
 

Decreased infections

If there’s one piece of good news in the latest IHME report, it’s that the estimated number of people infected (including those not tested) will drop from 111,581 today to a projected 17,502 on Aug. 1. But in a worst-case scenario, with sharply higher mobility among vaccinated people, the case count on that date would only fall to 73,842.

The SARS-CoV-2 variants are another factor of concern. Dr. Murray distinguished between variants like the one first identified in the U.K. (B.1.1.7) and other “escape variants.”

B.1.1.7, which is now the dominant strain in the United States, increases transmission but doesn’t necessarily escape the immune system or vaccines, he explained.

In contrast, if someone is infected with a variant such as the South African or the Brazilian mutations, he said, a previous COVID-19 infection might not protect the person, and vaccines are less effective against those variants.

Cross-variant immunity may range from 0% to 60% for escape variants, based on the slim amount of data now available, Dr. Murray said. In his view, these variants will be the long-term driver of the pandemic in the United States, while the United Kingdom variant is the short-term driver.

The latest data, he said, show that the Pfizer/BioNTech and Moderna vaccines are 75% effective against the escape variants, with lower efficacy for other vaccines. But booster shots may still be required to protect people against some variants.
 

Human factors

Human behavior will also help determine the course of the pandemic, he noted. Vaccine hesitancy, for example, is still high in the United States.

By the end of May, he predicted, about 180 million people will have received about two doses of vaccine. After that, he said, “vaccination will flatline due to lack of demand.” The two unknowns are how much campaigns to promote vaccination will increase vaccine confidence, and when children will be vaccinated.

In the United States, he said, 69% of adults have been vaccinated or want to get a shot. But that percentage has dropped 5 points since February, and vaccine confidence varies by state.

Dr. Murray emphasized that the winter surge he predicts can be blocked if people change their behaviors. These include a rise in vaccine confidence to 80% and continued mask wearing by most people.

However, if vaccine confidence and mask wearing decline, state governments continue to drop social distancing rules, and the uptake of boosters is low, the winter surge could be more serious, he said.
 

Double surge

Murray also raised the possibility of a double surge of COVID-19 and influenza this winter. Widely expected last winter, this double surge never materialized here or elsewhere, partly because of mask wearing. But Dr. Murray said it could happen this year: History shows that the flu tends to be stronger in years after weak outbreaks.

He advised hospitals to prepare now for whatever might come later this year. Public health authorities, he said, should speed up vaccination, monitor variants closely with additional sequencing, and try to modify behavior in high-risk groups.

Asked to explain the recent surge of COVID-19 cases in Michigan, Dr. Murray attributed it partly to the spread of the B.1.1.7 (U.K.) variant. But he noted that the U.K. variant has expanded even more widely in some other states that haven’t had an explosive surge like Michigan’s.

Moreover, he noted, Michigan doesn’t have low mask use or high mobility. So the upward spiral of COVID-19 infections there is very concerning, he said.

In regard to the role of children as reservoirs of the virus, Dr. Murray pointed out that views on this have changed around the world. For a while, people thought kids didn’t spread COVID-19 very much. That view shifted when U.K. data showed that child transmission of the B.1.1.7 variant increased by half to 9% of contacts in comparison with the original virus strain.

Dutch data, similarly, showed schools contributing to the latest outbreaks, and some European nations have closed schools. In the United States, the trend is to open them.

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

It’s likely the United States will see another surge of COVID-19 this winter, warned Christopher Murray, MD, director of the Institute for Health Metrics and Evaluation (IHME) at the University of Washington in Seattle.

Speaking at the national conference of State of Reform on April 8, Dr. Murray cited the seasonality of the SARS-CoV-2 virus, which wanes in the summer and waxes in the winter. The “optimistic forecast” of IHME, which has modeled the course of the pandemic for the past 13 months, is that daily deaths will rise a bit in the next month, then decline from May through August, he said.

“Summer should be fairly quiet in terms of COVID, if vaccinations rise and people don’t stop wearing masks,” Dr. Murray said.

But he added that “a considerable surge will occur over next winter,” because the new variants are more transmissible, and people will likely relax social distancing and mask wearing. The IHME predicts that the percentage of Americans who usually don masks will decline from 73% today to 21% by Aug. 1.

With a rapid decline in mask use and a rise in mobility, there will still be more than 1,000 deaths each day by July 1, Dr. Murray said. In a forecast released the day after Dr. Murray spoke, the IHME predicted that by Aug. 1, there will be a total of 618,523 U.S. deaths from COVID-19. Deaths could be as high as 696,651 if mobility among the vaccinated returns to prepandemic levels, the institute forecasts.

Based on cell phone data, Dr. Murray said, the amount of mobility in the United States has already risen to the level of March 2020, when the pandemic was just getting underway.
 

Decreased infections

If there’s one piece of good news in the latest IHME report, it’s that the estimated number of people infected (including those not tested) will drop from 111,581 today to a projected 17,502 on Aug. 1. But in a worst-case scenario, with sharply higher mobility among vaccinated people, the case count on that date would only fall to 73,842.

The SARS-CoV-2 variants are another factor of concern. Dr. Murray distinguished between variants like the one first identified in the U.K. (B.1.1.7) and other “escape variants.”

B.1.1.7, which is now the dominant strain in the United States, increases transmission but doesn’t necessarily escape the immune system or vaccines, he explained.

In contrast, if someone is infected with a variant such as the South African or the Brazilian mutations, he said, a previous COVID-19 infection might not protect the person, and vaccines are less effective against those variants.

Cross-variant immunity may range from 0% to 60% for escape variants, based on the slim amount of data now available, Dr. Murray said. In his view, these variants will be the long-term driver of the pandemic in the United States, while the United Kingdom variant is the short-term driver.

The latest data, he said, show that the Pfizer/BioNTech and Moderna vaccines are 75% effective against the escape variants, with lower efficacy for other vaccines. But booster shots may still be required to protect people against some variants.
 

Human factors

Human behavior will also help determine the course of the pandemic, he noted. Vaccine hesitancy, for example, is still high in the United States.

By the end of May, he predicted, about 180 million people will have received about two doses of vaccine. After that, he said, “vaccination will flatline due to lack of demand.” The two unknowns are how much campaigns to promote vaccination will increase vaccine confidence, and when children will be vaccinated.

In the United States, he said, 69% of adults have been vaccinated or want to get a shot. But that percentage has dropped 5 points since February, and vaccine confidence varies by state.

Dr. Murray emphasized that the winter surge he predicts can be blocked if people change their behaviors. These include a rise in vaccine confidence to 80% and continued mask wearing by most people.

However, if vaccine confidence and mask wearing decline, state governments continue to drop social distancing rules, and the uptake of boosters is low, the winter surge could be more serious, he said.
 

Double surge

Murray also raised the possibility of a double surge of COVID-19 and influenza this winter. Widely expected last winter, this double surge never materialized here or elsewhere, partly because of mask wearing. But Dr. Murray said it could happen this year: History shows that the flu tends to be stronger in years after weak outbreaks.

He advised hospitals to prepare now for whatever might come later this year. Public health authorities, he said, should speed up vaccination, monitor variants closely with additional sequencing, and try to modify behavior in high-risk groups.

Asked to explain the recent surge of COVID-19 cases in Michigan, Dr. Murray attributed it partly to the spread of the B.1.1.7 (U.K.) variant. But he noted that the U.K. variant has expanded even more widely in some other states that haven’t had an explosive surge like Michigan’s.

Moreover, he noted, Michigan doesn’t have low mask use or high mobility. So the upward spiral of COVID-19 infections there is very concerning, he said.

In regard to the role of children as reservoirs of the virus, Dr. Murray pointed out that views on this have changed around the world. For a while, people thought kids didn’t spread COVID-19 very much. That view shifted when U.K. data showed that child transmission of the B.1.1.7 variant increased by half to 9% of contacts in comparison with the original virus strain.

Dutch data, similarly, showed schools contributing to the latest outbreaks, and some European nations have closed schools. In the United States, the trend is to open them.

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

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

This article was updated 4/13/21.

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

This article was updated 4/13/21.

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

This article was updated 4/13/21.

Separation anxiety plays a substantial role in suicidality in patients with mood and anxiety disorders, new research suggests.

Results of a study that included 500 outpatients with mood or anxiety disorders showed adult separation anxiety disorder (ASAD) was more frequent in patients with suicidal thoughts versus those who did not have the disorder. In addition, depression and separation anxiety also significantly predicted lifetime suicide risk.

“This study indicates a substantial role of separation anxiety in predicting suicidal thoughts, both as state-related symptoms ... and as longitudinal dimension symptoms,” say the investigators, led by Stefano Pini, MD, of the department of clinical and experimental medicine, section of psychiatry, University of Pisa (Italy).

“Greater understanding of the influence of separation anxiety in patients with affective disorders may encourage personalized interventions for reducing suicide risk,” they add.

The study was published in the March/April issue of the Journal of Clinical Psychiatry.
 

Frequently underdiagnosed

The authors describe a “close link between suicidal behaviors and interpersonal difficulties extending beyond the traditional approach of comprehending suicide as a phenomenon mainly related to depression.”

Previous research indicates that insecure adult attachment style might be associated with a greater likelihood of suicidal thoughts and attempts, and there might be an association between individual abnormal attachment sensitivity and suicide.

“Suicidal ideation or suicide attempts may be associated with disturbances in attachment, which may lead not only to a devastating experience of losing the feeling of interdependence and closeness but also to a rejection of life itself,” the authors suggest.

ASAD may be a “key factor” in understanding the relationship between individual attachment sensitivity to separation and suicidality.

An ASAD diagnosis was traditionally reserved for children and adolescents, but DSM-5 expanded the diagnosis to include adults over 18 years of age because research had “found a later onset to be common,” spanning the life course, even in the absence of a history of separation anxiety in childhood.

“Separation anxiety is an important clinical dimension, often with roots in childhood, but likely to manifest across the lifespan,” the authors note, adding that it is “frequently underdiagnosed.”

The relationship between ASAD and suicidality has not been explored extensively, so the researchers set out to examine the association.

The study included 509 consecutively recruited adult psychiatric outpatients with mood or anxiety disorders as a principle diagnosis.

Participants completed an array of scales, including item 3 on the Hamilton Depression Rating Scale (HDRS), which measures suicidality, as well as the Mood Spectrum Self-Report (MOODS-SR), a questionnaire evaluating lifetime suicidal symptoms.

Three scales were used to measure separation anxiety disorder: The Structured Interview for Separation Anxiety Symptoms in Adulthood/Childhood (SCI-SAS-A/C); the Separation Anxiety Symptom Inventory (SASI); and the Adult Separation Anxiety Scale (ASA-27).
 

Waxing and waning

Of the total sample, 215 patients were diagnosed with separation anxiety disorder (mean age at onset 15 years). Of the total sample, 19.9% scored ≥ 1 on the HDRS item 3, indicating the presence of suicidality.

Patients with suicidal thoughts more frequently experienced ASAD, compared with those without suicidal thoughts (53.6% vs. 39.6%, respectively, P = .01).

“All measures of adult as well as childhood separation anxiety were significantly elevated in the group of patients with current suicidality, based on HDRS item 3,” the authors report.

Logistic regression found that ASAD, major depression, bipolar I, and bipolar II disorders all predicted suicidal thoughts.

A linear regression model found that depression (P = .001) and ASA-27 separation anxiety (P = .001) significantly predicted lifetime suicide risk, based on the MOODS-SR scale.

In addition, “mediation analysis showed that, besides a direct effect, there is also an indirect effect of depression severity on the MOODS-SR suicidality score through the ASA-27 score, indicating that separation anxiety may act as an important mediating factor in the relationship between depression and suicidality,” the authors state.

The authors observe that separation anxiety “is an important clinical dimension, often with roots in childhood, but likely to wax and wane across the lifespan and even to manifest for the first time during adulthood.”
 

Treatment target?

Commenting on the study for this news organization, Megan Rogers, PhD, postdoctoral research fellow, Mount Sinai Beth Israel, New York, said the findings “point to symptoms of separation anxiety as a potential indicator of suicidal ideation, and should these findings be replicated and extended through longitudinal research, it suggests that symptoms of separation anxiety may be a relevant treatment target in certain populations to mitigate suicide risk.”

Dr. Rogers, who is the student division director at the American Association of Suicidology and was not involved with the study, said she thinks that studies of suicide have focused more on “individual symptoms of separation anxiety, such as excessive worry about loved ones or distress when anticipating separation from loved ones, rather than on separation anxiety as a categorical diagnosis.”

However, the study has an important take-home message for practicing clinicians, Dr. Rogers said. “In individuals with separation anxiety disorders, particularly those with comorbid mood conditions, it may be worth conducting a more thorough assessment of suicide risk, given the possibility of elevated suicidality in these patients.”

The study was supported in part by the German Research Foundation and the Fondazione Cassa di Risparmio di la Spezia. The authors and Dr. Rogers have disclosed no relevant financial relationships.

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

Separation anxiety plays a substantial role in suicidality in patients with mood and anxiety disorders, new research suggests.

Results of a study that included 500 outpatients with mood or anxiety disorders showed adult separation anxiety disorder (ASAD) was more frequent in patients with suicidal thoughts versus those who did not have the disorder. In addition, depression and separation anxiety also significantly predicted lifetime suicide risk.

“This study indicates a substantial role of separation anxiety in predicting suicidal thoughts, both as state-related symptoms ... and as longitudinal dimension symptoms,” say the investigators, led by Stefano Pini, MD, of the department of clinical and experimental medicine, section of psychiatry, University of Pisa (Italy).

“Greater understanding of the influence of separation anxiety in patients with affective disorders may encourage personalized interventions for reducing suicide risk,” they add.

The study was published in the March/April issue of the Journal of Clinical Psychiatry.
 

Frequently underdiagnosed

The authors describe a “close link between suicidal behaviors and interpersonal difficulties extending beyond the traditional approach of comprehending suicide as a phenomenon mainly related to depression.”

Previous research indicates that insecure adult attachment style might be associated with a greater likelihood of suicidal thoughts and attempts, and there might be an association between individual abnormal attachment sensitivity and suicide.

“Suicidal ideation or suicide attempts may be associated with disturbances in attachment, which may lead not only to a devastating experience of losing the feeling of interdependence and closeness but also to a rejection of life itself,” the authors suggest.

ASAD may be a “key factor” in understanding the relationship between individual attachment sensitivity to separation and suicidality.

An ASAD diagnosis was traditionally reserved for children and adolescents, but DSM-5 expanded the diagnosis to include adults over 18 years of age because research had “found a later onset to be common,” spanning the life course, even in the absence of a history of separation anxiety in childhood.

“Separation anxiety is an important clinical dimension, often with roots in childhood, but likely to manifest across the lifespan,” the authors note, adding that it is “frequently underdiagnosed.”

The relationship between ASAD and suicidality has not been explored extensively, so the researchers set out to examine the association.

The study included 509 consecutively recruited adult psychiatric outpatients with mood or anxiety disorders as a principle diagnosis.

Participants completed an array of scales, including item 3 on the Hamilton Depression Rating Scale (HDRS), which measures suicidality, as well as the Mood Spectrum Self-Report (MOODS-SR), a questionnaire evaluating lifetime suicidal symptoms.

Three scales were used to measure separation anxiety disorder: The Structured Interview for Separation Anxiety Symptoms in Adulthood/Childhood (SCI-SAS-A/C); the Separation Anxiety Symptom Inventory (SASI); and the Adult Separation Anxiety Scale (ASA-27).
 

Waxing and waning

Of the total sample, 215 patients were diagnosed with separation anxiety disorder (mean age at onset 15 years). Of the total sample, 19.9% scored ≥ 1 on the HDRS item 3, indicating the presence of suicidality.

Patients with suicidal thoughts more frequently experienced ASAD, compared with those without suicidal thoughts (53.6% vs. 39.6%, respectively, P = .01).

“All measures of adult as well as childhood separation anxiety were significantly elevated in the group of patients with current suicidality, based on HDRS item 3,” the authors report.

Logistic regression found that ASAD, major depression, bipolar I, and bipolar II disorders all predicted suicidal thoughts.

A linear regression model found that depression (P = .001) and ASA-27 separation anxiety (P = .001) significantly predicted lifetime suicide risk, based on the MOODS-SR scale.

In addition, “mediation analysis showed that, besides a direct effect, there is also an indirect effect of depression severity on the MOODS-SR suicidality score through the ASA-27 score, indicating that separation anxiety may act as an important mediating factor in the relationship between depression and suicidality,” the authors state.

The authors observe that separation anxiety “is an important clinical dimension, often with roots in childhood, but likely to wax and wane across the lifespan and even to manifest for the first time during adulthood.”
 

Treatment target?

Commenting on the study for this news organization, Megan Rogers, PhD, postdoctoral research fellow, Mount Sinai Beth Israel, New York, said the findings “point to symptoms of separation anxiety as a potential indicator of suicidal ideation, and should these findings be replicated and extended through longitudinal research, it suggests that symptoms of separation anxiety may be a relevant treatment target in certain populations to mitigate suicide risk.”

Dr. Rogers, who is the student division director at the American Association of Suicidology and was not involved with the study, said she thinks that studies of suicide have focused more on “individual symptoms of separation anxiety, such as excessive worry about loved ones or distress when anticipating separation from loved ones, rather than on separation anxiety as a categorical diagnosis.”

However, the study has an important take-home message for practicing clinicians, Dr. Rogers said. “In individuals with separation anxiety disorders, particularly those with comorbid mood conditions, it may be worth conducting a more thorough assessment of suicide risk, given the possibility of elevated suicidality in these patients.”

The study was supported in part by the German Research Foundation and the Fondazione Cassa di Risparmio di la Spezia. The authors and Dr. Rogers have disclosed no relevant financial relationships.

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

Separation anxiety plays a substantial role in suicidality in patients with mood and anxiety disorders, new research suggests.

Results of a study that included 500 outpatients with mood or anxiety disorders showed adult separation anxiety disorder (ASAD) was more frequent in patients with suicidal thoughts versus those who did not have the disorder. In addition, depression and separation anxiety also significantly predicted lifetime suicide risk.

“This study indicates a substantial role of separation anxiety in predicting suicidal thoughts, both as state-related symptoms ... and as longitudinal dimension symptoms,” say the investigators, led by Stefano Pini, MD, of the department of clinical and experimental medicine, section of psychiatry, University of Pisa (Italy).

“Greater understanding of the influence of separation anxiety in patients with affective disorders may encourage personalized interventions for reducing suicide risk,” they add.

The study was published in the March/April issue of the Journal of Clinical Psychiatry.
 

Frequently underdiagnosed

The authors describe a “close link between suicidal behaviors and interpersonal difficulties extending beyond the traditional approach of comprehending suicide as a phenomenon mainly related to depression.”

Previous research indicates that insecure adult attachment style might be associated with a greater likelihood of suicidal thoughts and attempts, and there might be an association between individual abnormal attachment sensitivity and suicide.

“Suicidal ideation or suicide attempts may be associated with disturbances in attachment, which may lead not only to a devastating experience of losing the feeling of interdependence and closeness but also to a rejection of life itself,” the authors suggest.

ASAD may be a “key factor” in understanding the relationship between individual attachment sensitivity to separation and suicidality.

An ASAD diagnosis was traditionally reserved for children and adolescents, but DSM-5 expanded the diagnosis to include adults over 18 years of age because research had “found a later onset to be common,” spanning the life course, even in the absence of a history of separation anxiety in childhood.

“Separation anxiety is an important clinical dimension, often with roots in childhood, but likely to manifest across the lifespan,” the authors note, adding that it is “frequently underdiagnosed.”

The relationship between ASAD and suicidality has not been explored extensively, so the researchers set out to examine the association.

The study included 509 consecutively recruited adult psychiatric outpatients with mood or anxiety disorders as a principle diagnosis.

Participants completed an array of scales, including item 3 on the Hamilton Depression Rating Scale (HDRS), which measures suicidality, as well as the Mood Spectrum Self-Report (MOODS-SR), a questionnaire evaluating lifetime suicidal symptoms.

Three scales were used to measure separation anxiety disorder: The Structured Interview for Separation Anxiety Symptoms in Adulthood/Childhood (SCI-SAS-A/C); the Separation Anxiety Symptom Inventory (SASI); and the Adult Separation Anxiety Scale (ASA-27).
 

Waxing and waning

Of the total sample, 215 patients were diagnosed with separation anxiety disorder (mean age at onset 15 years). Of the total sample, 19.9% scored ≥ 1 on the HDRS item 3, indicating the presence of suicidality.

Patients with suicidal thoughts more frequently experienced ASAD, compared with those without suicidal thoughts (53.6% vs. 39.6%, respectively, P = .01).

“All measures of adult as well as childhood separation anxiety were significantly elevated in the group of patients with current suicidality, based on HDRS item 3,” the authors report.

Logistic regression found that ASAD, major depression, bipolar I, and bipolar II disorders all predicted suicidal thoughts.

A linear regression model found that depression (P = .001) and ASA-27 separation anxiety (P = .001) significantly predicted lifetime suicide risk, based on the MOODS-SR scale.

In addition, “mediation analysis showed that, besides a direct effect, there is also an indirect effect of depression severity on the MOODS-SR suicidality score through the ASA-27 score, indicating that separation anxiety may act as an important mediating factor in the relationship between depression and suicidality,” the authors state.

The authors observe that separation anxiety “is an important clinical dimension, often with roots in childhood, but likely to wax and wane across the lifespan and even to manifest for the first time during adulthood.”
 

Treatment target?

Commenting on the study for this news organization, Megan Rogers, PhD, postdoctoral research fellow, Mount Sinai Beth Israel, New York, said the findings “point to symptoms of separation anxiety as a potential indicator of suicidal ideation, and should these findings be replicated and extended through longitudinal research, it suggests that symptoms of separation anxiety may be a relevant treatment target in certain populations to mitigate suicide risk.”

Dr. Rogers, who is the student division director at the American Association of Suicidology and was not involved with the study, said she thinks that studies of suicide have focused more on “individual symptoms of separation anxiety, such as excessive worry about loved ones or distress when anticipating separation from loved ones, rather than on separation anxiety as a categorical diagnosis.”

However, the study has an important take-home message for practicing clinicians, Dr. Rogers said. “In individuals with separation anxiety disorders, particularly those with comorbid mood conditions, it may be worth conducting a more thorough assessment of suicide risk, given the possibility of elevated suicidality in these patients.”

The study was supported in part by the German Research Foundation and the Fondazione Cassa di Risparmio di la Spezia. The authors and Dr. Rogers have disclosed no relevant financial relationships.

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

People who identify as transgender experience many health disparities, in addition to lack of access to quality care. The most commonly cited barrier is the lack of providers who are knowledgeable about transgender health care, according to past surveys.

Even those who do seek care often have unpleasant experiences. A 2015 survey conducted by the National Center for Transgender Equality found that 33% of those who saw a health care provider reported at least one  unfavorable experience related to being transgender, such as being verbally harassed or refused treatment because of their gender identity. In fact, 23% of those surveyed say they did not seek health care they needed in the past year because of fear of being mistreated as a transgender person.

To find out how physicians can provide more compassionate, effective care for this group, this news organization spoke with K. Ashley Brandt, DO, gender-affirming surgeon and obstetrician/gynecologist in West Reading, Penn. This interview has been edited for length and clarity.

Question: Surveys have shown that many people who identify as transgender will seek only transition care, not primary or preventive care. Why is that?

Dr. Brandt: My answer is multifactorial. Transgender patients do seek primary care – just not as readily. There’s a lot of misconceptions about health care needs for the LGBT community in general. For example, lesbian or bisexual women may be not as well informed about the need for Pap smears compared with their heterosexual counterparts. These misconceptions are further exacerbated in the transgender community.

The fact that a lot of patients seek only transition-related care, but not preventive services, such as primary care and gynecologic care, is also related to fears of discrimination and lack of education of providers. These patients are afraid when they walk into an office that they will be misgendered or their physician won’t be familiar with their health care needs.

What can clinics and clinicians do to create a safe and welcoming environment?

Dr. Brandt: It starts with educating office staff about terminology and gender identities.

A key feature of our EHR is the sexual orientation and gender identity platform, which asks questions about a patient’s gender identity, sexual orientation, sex assigned at birth, and organ inventory. These data are then found in the patient information tab and are just as relevant as their insurance status, age, and date of birth.

There are many ways a doctor’s office can signal to patients that they are inclusive. They can hang LGBTQ-friendly flags or symbols or a sign saying, “We have an anti-discrimination policy” in the waiting room.  A welcoming environment can also be achieved by revising patient questionnaires or forms so that they aren’t gender-specific or binary.

Given that the patient may have limited contact with a primary care clinician, how do you prioritize what you address during the visit?

Dr. Brandt: Similar to cisgender patients, it depends initially on the age of the patient and the reason for the visit. The priorities of an otherwise healthy transgender patient in their 20s are going to be largely the same as for a cisgender patient of the same age. As patients age in the primary care world, you’re addressing more issues, such as colorectal screening, lipid disorders, and mammograms, and that doesn’t change. For the most part, the problems that you address should be specific for that age group.

It becomes more complicated when you add in factors such as hormone therapy and whether patients have had any type of gender-affirming surgery. Those things can change the usual recommendations for screening or risk assessment. We try to figure out what routine health maintenance and cancer screening a patient needs based on age and risk factors, in addition to hormone status and surgical state.

Do you think that many physicians are educated about the care of underserved populations such as transgender patients?

Dr. Brandt: Yes and no. We are definitely getting better at it. For example, the American College of Obstetricians and Gynecologists published a committee opinion highlighting transgender care. So organizations are starting to prioritize these populations and recognize that they are, in fact, underserved and they have special health care needs.

However, the knowledge gaps are still pretty big. I get calls daily from providers asking questions about how to manage patients on hormones, or how to examine a patient who has undergone a vaginoplasty. I hear a lot of horror stories from transgender patients who had their hormones stopped for absurd and medically misinformed reasons.

But I definitely think it’s getting better and it’s being addressed at all levels – the medical school level, the residency level, and the attending level. It just takes time to inform people and for people to get used to the health care needs of these patients.

What should physicians keep in mind when treating patients who identify as transgender?

Dr. Brandt: First and foremost, understanding the terminology and the difference between gender identity, sex, and sexual orientation. Being familiar with that language and being able to speak that language very comfortably and not being awkward about it is a really important thing for primary care physicians and indeed any physician who treats transgender patients.

Physicians should also be aware that any underserved population has higher rates of mental health issues, such as depression and anxiety. Obviously, that goes along with being underserved and the stigma and the disparities that exist for these patients. Having providers educate themselves about what those disparities are and how they impact a patient’s daily life and health is paramount to knowing how to treat patients.

What are your top health concerns for these patients and how do you address them?

Dr. Brandt: I think mental health and safety is probably the number one for me. About 41% of transgender adults have attempted suicide. That number is roughly 51% in transgender youth. That is an astonishing number. These patients have much higher rates of domestic violence, intimate partner violence, and sexual assault, especially trans women and trans women of color. So understanding those statistics is huge.

Obesity, smoking, and substance abuse are my next three. Again, those are things that should be addressed at any visit, regardless of the gender identity or sexual orientation of the patient, but those rates are particularly high in this population.

Fertility and long-term care for patients should be addressed. Many patients who identify as transgender are told they can’t have a family. As a primary care physician, you may see a patient before they are seen by an ob.gyn. or surgeon. Talking about what a patient’s long-term life goals are with fertility and family planning, and what that looks like for them, is a big thing for me. Other providers may not feel that’s a concern, but I believe it should be discussed before initiation of hormone therapy, which can significantly impact fertility in some patients.

Are there nuances to the physical examination that primary care physicians should be aware of when dealing with transmasculine patients vs. transfeminine patients?

Dr. Brandt: Absolutely. And this interview can’t cover the scope of those nuances. An example that comes to mind is the genital exam. For transgender women who have undergone a vaginoplasty, the pelvic exam can be very affirming. Whereas for transgender men, a gynecologic exam can significantly exacerbate dysphoria and there are ways to conduct the exam to limit this discomfort and avoid creating a traumatic experience for the patient. It’s important to be aware that the genital exam, or any type of genitourinary exam, can be either affirming or not affirming.

Sexually transmitted infections are up in the general population, and the trans population is at even higher risk. What should physicians think about when they assess this risk?

Dr. Brandt: It’s really important for primary care clinicians and for gynecologists to learn to be comfortable talking about sexual practices, because what people do behind closed doors is really a key to how to counsel patients about safe sex.

People are well aware of the need to have safe sex. However, depending on the type of sex that you’re having, what body parts go where, what is truly safe can vary and people may not know, for example, to wear a condom when sex toys are involved or that a transgender male on testosterone can become pregnant during penile-vaginal intercourse. Providers really should be very educated on the array of sexual practices that people have and how to counsel them about those. They should know how to ask patients the gender identity of their sexual partners, the sexual orientation of their partners, and what parts go where during sex.

Providers should also talk to patients about PrEP [pre-exposure prophylaxis], whether they identify as cisgender or transgender. My trans patients tend to be a lot more educated about PrEP than other patients. It’s something that many of the residents, even in a standard gynecologic clinic, for example, don’t talk to cisgender patients about because of the stigma surrounding HIV. Many providers still think that the only people who are at risk for HIV are men who have sex with men. And while those rates are higher in some populations, depending on sexual practices, those aren’t the only patients who qualify for PrEP.

Overall, in order to counsel patients about STIs and safe sexual practices, providers should learn to be comfortable talking about sex.

Do you have any strategies on how to make the appointment more successful in addressing those issues?

Dr. Brandt: Bedside manner is a hard thing to teach, and comfort in talking about sex, gender identity, and sexual orientation can vary – but there are a lot of continuing medical education courses that physicians can utilize through the World Professional Association for Transgender Health.

If providers start to notice an influx of patients who identify as transgender or if they want to start seeing transgender patients, it’s really important for them to have that training before they start interacting with patients. In all of medicine, we sort of learn as we go, but this patient population has been subjected to discrimination, violence, error, and misgendering. They have dealt with providers who didn’t understand their health care needs. While this field is evolving, knowing how to appropriately address a patient (using their correct name, pronouns, etc.) is an absolute must.

That needs to be part of a provider’s routine vernacular and not something that they sort of stumble through. You can scare a patient away as soon as they walk into the office with an uneducated front desk staff and things that are seen in the office. Seeking out those educational tools, being aware of your own deficits as a provider and the educational needs of your office, and addressing those needs is really key.

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

People who identify as transgender experience many health disparities, in addition to lack of access to quality care. The most commonly cited barrier is the lack of providers who are knowledgeable about transgender health care, according to past surveys.

Even those who do seek care often have unpleasant experiences. A 2015 survey conducted by the National Center for Transgender Equality found that 33% of those who saw a health care provider reported at least one  unfavorable experience related to being transgender, such as being verbally harassed or refused treatment because of their gender identity. In fact, 23% of those surveyed say they did not seek health care they needed in the past year because of fear of being mistreated as a transgender person.

To find out how physicians can provide more compassionate, effective care for this group, this news organization spoke with K. Ashley Brandt, DO, gender-affirming surgeon and obstetrician/gynecologist in West Reading, Penn. This interview has been edited for length and clarity.

Question: Surveys have shown that many people who identify as transgender will seek only transition care, not primary or preventive care. Why is that?

Dr. Brandt: My answer is multifactorial. Transgender patients do seek primary care – just not as readily. There’s a lot of misconceptions about health care needs for the LGBT community in general. For example, lesbian or bisexual women may be not as well informed about the need for Pap smears compared with their heterosexual counterparts. These misconceptions are further exacerbated in the transgender community.

The fact that a lot of patients seek only transition-related care, but not preventive services, such as primary care and gynecologic care, is also related to fears of discrimination and lack of education of providers. These patients are afraid when they walk into an office that they will be misgendered or their physician won’t be familiar with their health care needs.

What can clinics and clinicians do to create a safe and welcoming environment?

Dr. Brandt: It starts with educating office staff about terminology and gender identities.

A key feature of our EHR is the sexual orientation and gender identity platform, which asks questions about a patient’s gender identity, sexual orientation, sex assigned at birth, and organ inventory. These data are then found in the patient information tab and are just as relevant as their insurance status, age, and date of birth.

There are many ways a doctor’s office can signal to patients that they are inclusive. They can hang LGBTQ-friendly flags or symbols or a sign saying, “We have an anti-discrimination policy” in the waiting room.  A welcoming environment can also be achieved by revising patient questionnaires or forms so that they aren’t gender-specific or binary.

Given that the patient may have limited contact with a primary care clinician, how do you prioritize what you address during the visit?

Dr. Brandt: Similar to cisgender patients, it depends initially on the age of the patient and the reason for the visit. The priorities of an otherwise healthy transgender patient in their 20s are going to be largely the same as for a cisgender patient of the same age. As patients age in the primary care world, you’re addressing more issues, such as colorectal screening, lipid disorders, and mammograms, and that doesn’t change. For the most part, the problems that you address should be specific for that age group.

It becomes more complicated when you add in factors such as hormone therapy and whether patients have had any type of gender-affirming surgery. Those things can change the usual recommendations for screening or risk assessment. We try to figure out what routine health maintenance and cancer screening a patient needs based on age and risk factors, in addition to hormone status and surgical state.

Do you think that many physicians are educated about the care of underserved populations such as transgender patients?

Dr. Brandt: Yes and no. We are definitely getting better at it. For example, the American College of Obstetricians and Gynecologists published a committee opinion highlighting transgender care. So organizations are starting to prioritize these populations and recognize that they are, in fact, underserved and they have special health care needs.

However, the knowledge gaps are still pretty big. I get calls daily from providers asking questions about how to manage patients on hormones, or how to examine a patient who has undergone a vaginoplasty. I hear a lot of horror stories from transgender patients who had their hormones stopped for absurd and medically misinformed reasons.

But I definitely think it’s getting better and it’s being addressed at all levels – the medical school level, the residency level, and the attending level. It just takes time to inform people and for people to get used to the health care needs of these patients.

What should physicians keep in mind when treating patients who identify as transgender?

Dr. Brandt: First and foremost, understanding the terminology and the difference between gender identity, sex, and sexual orientation. Being familiar with that language and being able to speak that language very comfortably and not being awkward about it is a really important thing for primary care physicians and indeed any physician who treats transgender patients.

Physicians should also be aware that any underserved population has higher rates of mental health issues, such as depression and anxiety. Obviously, that goes along with being underserved and the stigma and the disparities that exist for these patients. Having providers educate themselves about what those disparities are and how they impact a patient’s daily life and health is paramount to knowing how to treat patients.

What are your top health concerns for these patients and how do you address them?

Dr. Brandt: I think mental health and safety is probably the number one for me. About 41% of transgender adults have attempted suicide. That number is roughly 51% in transgender youth. That is an astonishing number. These patients have much higher rates of domestic violence, intimate partner violence, and sexual assault, especially trans women and trans women of color. So understanding those statistics is huge.

Obesity, smoking, and substance abuse are my next three. Again, those are things that should be addressed at any visit, regardless of the gender identity or sexual orientation of the patient, but those rates are particularly high in this population.

Fertility and long-term care for patients should be addressed. Many patients who identify as transgender are told they can’t have a family. As a primary care physician, you may see a patient before they are seen by an ob.gyn. or surgeon. Talking about what a patient’s long-term life goals are with fertility and family planning, and what that looks like for them, is a big thing for me. Other providers may not feel that’s a concern, but I believe it should be discussed before initiation of hormone therapy, which can significantly impact fertility in some patients.

Are there nuances to the physical examination that primary care physicians should be aware of when dealing with transmasculine patients vs. transfeminine patients?

Dr. Brandt: Absolutely. And this interview can’t cover the scope of those nuances. An example that comes to mind is the genital exam. For transgender women who have undergone a vaginoplasty, the pelvic exam can be very affirming. Whereas for transgender men, a gynecologic exam can significantly exacerbate dysphoria and there are ways to conduct the exam to limit this discomfort and avoid creating a traumatic experience for the patient. It’s important to be aware that the genital exam, or any type of genitourinary exam, can be either affirming or not affirming.

Sexually transmitted infections are up in the general population, and the trans population is at even higher risk. What should physicians think about when they assess this risk?

Dr. Brandt: It’s really important for primary care clinicians and for gynecologists to learn to be comfortable talking about sexual practices, because what people do behind closed doors is really a key to how to counsel patients about safe sex.

People are well aware of the need to have safe sex. However, depending on the type of sex that you’re having, what body parts go where, what is truly safe can vary and people may not know, for example, to wear a condom when sex toys are involved or that a transgender male on testosterone can become pregnant during penile-vaginal intercourse. Providers really should be very educated on the array of sexual practices that people have and how to counsel them about those. They should know how to ask patients the gender identity of their sexual partners, the sexual orientation of their partners, and what parts go where during sex.

Providers should also talk to patients about PrEP [pre-exposure prophylaxis], whether they identify as cisgender or transgender. My trans patients tend to be a lot more educated about PrEP than other patients. It’s something that many of the residents, even in a standard gynecologic clinic, for example, don’t talk to cisgender patients about because of the stigma surrounding HIV. Many providers still think that the only people who are at risk for HIV are men who have sex with men. And while those rates are higher in some populations, depending on sexual practices, those aren’t the only patients who qualify for PrEP.

Overall, in order to counsel patients about STIs and safe sexual practices, providers should learn to be comfortable talking about sex.

Do you have any strategies on how to make the appointment more successful in addressing those issues?

Dr. Brandt: Bedside manner is a hard thing to teach, and comfort in talking about sex, gender identity, and sexual orientation can vary – but there are a lot of continuing medical education courses that physicians can utilize through the World Professional Association for Transgender Health.

If providers start to notice an influx of patients who identify as transgender or if they want to start seeing transgender patients, it’s really important for them to have that training before they start interacting with patients. In all of medicine, we sort of learn as we go, but this patient population has been subjected to discrimination, violence, error, and misgendering. They have dealt with providers who didn’t understand their health care needs. While this field is evolving, knowing how to appropriately address a patient (using their correct name, pronouns, etc.) is an absolute must.

That needs to be part of a provider’s routine vernacular and not something that they sort of stumble through. You can scare a patient away as soon as they walk into the office with an uneducated front desk staff and things that are seen in the office. Seeking out those educational tools, being aware of your own deficits as a provider and the educational needs of your office, and addressing those needs is really key.

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

People who identify as transgender experience many health disparities, in addition to lack of access to quality care. The most commonly cited barrier is the lack of providers who are knowledgeable about transgender health care, according to past surveys.

Even those who do seek care often have unpleasant experiences. A 2015 survey conducted by the National Center for Transgender Equality found that 33% of those who saw a health care provider reported at least one  unfavorable experience related to being transgender, such as being verbally harassed or refused treatment because of their gender identity. In fact, 23% of those surveyed say they did not seek health care they needed in the past year because of fear of being mistreated as a transgender person.

To find out how physicians can provide more compassionate, effective care for this group, this news organization spoke with K. Ashley Brandt, DO, gender-affirming surgeon and obstetrician/gynecologist in West Reading, Penn. This interview has been edited for length and clarity.

Question: Surveys have shown that many people who identify as transgender will seek only transition care, not primary or preventive care. Why is that?

Dr. Brandt: My answer is multifactorial. Transgender patients do seek primary care – just not as readily. There’s a lot of misconceptions about health care needs for the LGBT community in general. For example, lesbian or bisexual women may be not as well informed about the need for Pap smears compared with their heterosexual counterparts. These misconceptions are further exacerbated in the transgender community.

The fact that a lot of patients seek only transition-related care, but not preventive services, such as primary care and gynecologic care, is also related to fears of discrimination and lack of education of providers. These patients are afraid when they walk into an office that they will be misgendered or their physician won’t be familiar with their health care needs.

What can clinics and clinicians do to create a safe and welcoming environment?

Dr. Brandt: It starts with educating office staff about terminology and gender identities.

A key feature of our EHR is the sexual orientation and gender identity platform, which asks questions about a patient’s gender identity, sexual orientation, sex assigned at birth, and organ inventory. These data are then found in the patient information tab and are just as relevant as their insurance status, age, and date of birth.

There are many ways a doctor’s office can signal to patients that they are inclusive. They can hang LGBTQ-friendly flags or symbols or a sign saying, “We have an anti-discrimination policy” in the waiting room.  A welcoming environment can also be achieved by revising patient questionnaires or forms so that they aren’t gender-specific or binary.

Given that the patient may have limited contact with a primary care clinician, how do you prioritize what you address during the visit?

Dr. Brandt: Similar to cisgender patients, it depends initially on the age of the patient and the reason for the visit. The priorities of an otherwise healthy transgender patient in their 20s are going to be largely the same as for a cisgender patient of the same age. As patients age in the primary care world, you’re addressing more issues, such as colorectal screening, lipid disorders, and mammograms, and that doesn’t change. For the most part, the problems that you address should be specific for that age group.

It becomes more complicated when you add in factors such as hormone therapy and whether patients have had any type of gender-affirming surgery. Those things can change the usual recommendations for screening or risk assessment. We try to figure out what routine health maintenance and cancer screening a patient needs based on age and risk factors, in addition to hormone status and surgical state.

Do you think that many physicians are educated about the care of underserved populations such as transgender patients?

Dr. Brandt: Yes and no. We are definitely getting better at it. For example, the American College of Obstetricians and Gynecologists published a committee opinion highlighting transgender care. So organizations are starting to prioritize these populations and recognize that they are, in fact, underserved and they have special health care needs.

However, the knowledge gaps are still pretty big. I get calls daily from providers asking questions about how to manage patients on hormones, or how to examine a patient who has undergone a vaginoplasty. I hear a lot of horror stories from transgender patients who had their hormones stopped for absurd and medically misinformed reasons.

But I definitely think it’s getting better and it’s being addressed at all levels – the medical school level, the residency level, and the attending level. It just takes time to inform people and for people to get used to the health care needs of these patients.

What should physicians keep in mind when treating patients who identify as transgender?

Dr. Brandt: First and foremost, understanding the terminology and the difference between gender identity, sex, and sexual orientation. Being familiar with that language and being able to speak that language very comfortably and not being awkward about it is a really important thing for primary care physicians and indeed any physician who treats transgender patients.

Physicians should also be aware that any underserved population has higher rates of mental health issues, such as depression and anxiety. Obviously, that goes along with being underserved and the stigma and the disparities that exist for these patients. Having providers educate themselves about what those disparities are and how they impact a patient’s daily life and health is paramount to knowing how to treat patients.

What are your top health concerns for these patients and how do you address them?

Dr. Brandt: I think mental health and safety is probably the number one for me. About 41% of transgender adults have attempted suicide. That number is roughly 51% in transgender youth. That is an astonishing number. These patients have much higher rates of domestic violence, intimate partner violence, and sexual assault, especially trans women and trans women of color. So understanding those statistics is huge.

Obesity, smoking, and substance abuse are my next three. Again, those are things that should be addressed at any visit, regardless of the gender identity or sexual orientation of the patient, but those rates are particularly high in this population.

Fertility and long-term care for patients should be addressed. Many patients who identify as transgender are told they can’t have a family. As a primary care physician, you may see a patient before they are seen by an ob.gyn. or surgeon. Talking about what a patient’s long-term life goals are with fertility and family planning, and what that looks like for them, is a big thing for me. Other providers may not feel that’s a concern, but I believe it should be discussed before initiation of hormone therapy, which can significantly impact fertility in some patients.

Are there nuances to the physical examination that primary care physicians should be aware of when dealing with transmasculine patients vs. transfeminine patients?

Dr. Brandt: Absolutely. And this interview can’t cover the scope of those nuances. An example that comes to mind is the genital exam. For transgender women who have undergone a vaginoplasty, the pelvic exam can be very affirming. Whereas for transgender men, a gynecologic exam can significantly exacerbate dysphoria and there are ways to conduct the exam to limit this discomfort and avoid creating a traumatic experience for the patient. It’s important to be aware that the genital exam, or any type of genitourinary exam, can be either affirming or not affirming.

Sexually transmitted infections are up in the general population, and the trans population is at even higher risk. What should physicians think about when they assess this risk?

Dr. Brandt: It’s really important for primary care clinicians and for gynecologists to learn to be comfortable talking about sexual practices, because what people do behind closed doors is really a key to how to counsel patients about safe sex.

People are well aware of the need to have safe sex. However, depending on the type of sex that you’re having, what body parts go where, what is truly safe can vary and people may not know, for example, to wear a condom when sex toys are involved or that a transgender male on testosterone can become pregnant during penile-vaginal intercourse. Providers really should be very educated on the array of sexual practices that people have and how to counsel them about those. They should know how to ask patients the gender identity of their sexual partners, the sexual orientation of their partners, and what parts go where during sex.

Providers should also talk to patients about PrEP [pre-exposure prophylaxis], whether they identify as cisgender or transgender. My trans patients tend to be a lot more educated about PrEP than other patients. It’s something that many of the residents, even in a standard gynecologic clinic, for example, don’t talk to cisgender patients about because of the stigma surrounding HIV. Many providers still think that the only people who are at risk for HIV are men who have sex with men. And while those rates are higher in some populations, depending on sexual practices, those aren’t the only patients who qualify for PrEP.

Overall, in order to counsel patients about STIs and safe sexual practices, providers should learn to be comfortable talking about sex.

Do you have any strategies on how to make the appointment more successful in addressing those issues?

Dr. Brandt: Bedside manner is a hard thing to teach, and comfort in talking about sex, gender identity, and sexual orientation can vary – but there are a lot of continuing medical education courses that physicians can utilize through the World Professional Association for Transgender Health.

If providers start to notice an influx of patients who identify as transgender or if they want to start seeing transgender patients, it’s really important for them to have that training before they start interacting with patients. In all of medicine, we sort of learn as we go, but this patient population has been subjected to discrimination, violence, error, and misgendering. They have dealt with providers who didn’t understand their health care needs. While this field is evolving, knowing how to appropriately address a patient (using their correct name, pronouns, etc.) is an absolute must.

That needs to be part of a provider’s routine vernacular and not something that they sort of stumble through. You can scare a patient away as soon as they walk into the office with an uneducated front desk staff and things that are seen in the office. Seeking out those educational tools, being aware of your own deficits as a provider and the educational needs of your office, and addressing those needs is really key.

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