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Is HIPAA critical?
Ignorance may be bliss for some. But as I sit here in my scenic social isolation on the Maine coast I find that, like most people, what I don’t know unsettles me. How is the COVID-19 virus spread? Does my wife’s wipe down of the doorknobs after I return from the grocery store really make us any less likely to contract the virus? Is wearing my homemade bandana face mask doing anything to protect me? I suspect not, but I wear it as a statement of courtesy and solidarity to my fellow community members.
Does the 6-foot rule make any sense? I’ve read that it is based on a study dating back to the 1930s. I’ve seen images of the 25-foot droplet plume blasting out from a sneeze and understand that, as a bicyclist, I may be generating a shower of droplets in my wake. But, are those droplets a threat to anyone I pedal by if I am symptom free? What does being a carrier mean when we are talking about COVID-19?
What makes me more vulnerable to this particular virus as an apparently healthy septuagenarian? What collection of misfortunes have fallen on those younger victims of the pandemic? How often was it genetic?
Of course, none of us has the information yet that can provide us answers. This vacuum has attracted scores of “experts” bold enough or careless enough to venture an opinion. They may have also issued a caveat, but how often have the media failed to include it in the report or buried it in the fine print at the end of the story?
My discomfort with this information void has left me and you and everyone else to our imaginations to craft our own explanations. So, I try to piece together a construct based on what I can glean from what I read and see in the news because like most people I fortunately have no first-hand information about even a single case. The number of deaths is horrifying, but may not have hit close to home and given most of us a real personal sense of the illness and its character.
Maine is a small state with just over a million inhabitants, and most of us have some connection to one another. It may be that a person is the second cousin of someone who used to live 2 miles down the road. But, there is some feeling of familiarity. We have had deaths related to COVID-19, but very scanty information other than the county about where they occurred and whether the victim was a resident of an extended care facility. We are told very little if any details about exposure as officials invoke HIPAA regulations that leave us in the dark. Other than one vague reference to a “traveling salesman” who may have introduced the virus to several nursing homes, there has been very little information about how the virus may have been spread here in Maine. Even national reports of the deaths of high-profile entertainers and retired athletes are usually draped in the same haze of privacy.
Most of us don’t need to know the names and street addresses of the victims but a few anonymous narratives that include some general information on how epidemiologists believe clusters began and propagated would help us understand our risks with just a glimmer of clarity.
Of course the epidemiologists may not have the answers we are seeking because they too are struggling to untangle connections hampered by concerns of privacy. There is no question that privacy must remain an important part of the physician-patient relationship. But a pandemic has thrown us into a situation where common sense demands that HIPAA be interpreted with an emphasis on the greater good. Finding that balance between privacy and public knowledge will continue to be one of our greatest challenges.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
Ignorance may be bliss for some. But as I sit here in my scenic social isolation on the Maine coast I find that, like most people, what I don’t know unsettles me. How is the COVID-19 virus spread? Does my wife’s wipe down of the doorknobs after I return from the grocery store really make us any less likely to contract the virus? Is wearing my homemade bandana face mask doing anything to protect me? I suspect not, but I wear it as a statement of courtesy and solidarity to my fellow community members.
Does the 6-foot rule make any sense? I’ve read that it is based on a study dating back to the 1930s. I’ve seen images of the 25-foot droplet plume blasting out from a sneeze and understand that, as a bicyclist, I may be generating a shower of droplets in my wake. But, are those droplets a threat to anyone I pedal by if I am symptom free? What does being a carrier mean when we are talking about COVID-19?
What makes me more vulnerable to this particular virus as an apparently healthy septuagenarian? What collection of misfortunes have fallen on those younger victims of the pandemic? How often was it genetic?
Of course, none of us has the information yet that can provide us answers. This vacuum has attracted scores of “experts” bold enough or careless enough to venture an opinion. They may have also issued a caveat, but how often have the media failed to include it in the report or buried it in the fine print at the end of the story?
My discomfort with this information void has left me and you and everyone else to our imaginations to craft our own explanations. So, I try to piece together a construct based on what I can glean from what I read and see in the news because like most people I fortunately have no first-hand information about even a single case. The number of deaths is horrifying, but may not have hit close to home and given most of us a real personal sense of the illness and its character.
Maine is a small state with just over a million inhabitants, and most of us have some connection to one another. It may be that a person is the second cousin of someone who used to live 2 miles down the road. But, there is some feeling of familiarity. We have had deaths related to COVID-19, but very scanty information other than the county about where they occurred and whether the victim was a resident of an extended care facility. We are told very little if any details about exposure as officials invoke HIPAA regulations that leave us in the dark. Other than one vague reference to a “traveling salesman” who may have introduced the virus to several nursing homes, there has been very little information about how the virus may have been spread here in Maine. Even national reports of the deaths of high-profile entertainers and retired athletes are usually draped in the same haze of privacy.
Most of us don’t need to know the names and street addresses of the victims but a few anonymous narratives that include some general information on how epidemiologists believe clusters began and propagated would help us understand our risks with just a glimmer of clarity.
Of course the epidemiologists may not have the answers we are seeking because they too are struggling to untangle connections hampered by concerns of privacy. There is no question that privacy must remain an important part of the physician-patient relationship. But a pandemic has thrown us into a situation where common sense demands that HIPAA be interpreted with an emphasis on the greater good. Finding that balance between privacy and public knowledge will continue to be one of our greatest challenges.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
Ignorance may be bliss for some. But as I sit here in my scenic social isolation on the Maine coast I find that, like most people, what I don’t know unsettles me. How is the COVID-19 virus spread? Does my wife’s wipe down of the doorknobs after I return from the grocery store really make us any less likely to contract the virus? Is wearing my homemade bandana face mask doing anything to protect me? I suspect not, but I wear it as a statement of courtesy and solidarity to my fellow community members.
Does the 6-foot rule make any sense? I’ve read that it is based on a study dating back to the 1930s. I’ve seen images of the 25-foot droplet plume blasting out from a sneeze and understand that, as a bicyclist, I may be generating a shower of droplets in my wake. But, are those droplets a threat to anyone I pedal by if I am symptom free? What does being a carrier mean when we are talking about COVID-19?
What makes me more vulnerable to this particular virus as an apparently healthy septuagenarian? What collection of misfortunes have fallen on those younger victims of the pandemic? How often was it genetic?
Of course, none of us has the information yet that can provide us answers. This vacuum has attracted scores of “experts” bold enough or careless enough to venture an opinion. They may have also issued a caveat, but how often have the media failed to include it in the report or buried it in the fine print at the end of the story?
My discomfort with this information void has left me and you and everyone else to our imaginations to craft our own explanations. So, I try to piece together a construct based on what I can glean from what I read and see in the news because like most people I fortunately have no first-hand information about even a single case. The number of deaths is horrifying, but may not have hit close to home and given most of us a real personal sense of the illness and its character.
Maine is a small state with just over a million inhabitants, and most of us have some connection to one another. It may be that a person is the second cousin of someone who used to live 2 miles down the road. But, there is some feeling of familiarity. We have had deaths related to COVID-19, but very scanty information other than the county about where they occurred and whether the victim was a resident of an extended care facility. We are told very little if any details about exposure as officials invoke HIPAA regulations that leave us in the dark. Other than one vague reference to a “traveling salesman” who may have introduced the virus to several nursing homes, there has been very little information about how the virus may have been spread here in Maine. Even national reports of the deaths of high-profile entertainers and retired athletes are usually draped in the same haze of privacy.
Most of us don’t need to know the names and street addresses of the victims but a few anonymous narratives that include some general information on how epidemiologists believe clusters began and propagated would help us understand our risks with just a glimmer of clarity.
Of course the epidemiologists may not have the answers we are seeking because they too are struggling to untangle connections hampered by concerns of privacy. There is no question that privacy must remain an important part of the physician-patient relationship. But a pandemic has thrown us into a situation where common sense demands that HIPAA be interpreted with an emphasis on the greater good. Finding that balance between privacy and public knowledge will continue to be one of our greatest challenges.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
Changes in patient behavior during COVID-19: What I’ve observed
Unprecedented circumstances, extraordinary times, continental shift, life-altering experience—the descriptions of the coronavirus disease 2019 (COVID-19) pandemic have been endless, and accurate. Every clinician who has cared for patients during these trying times has noticed new patterns in patient behavior. Psychiatrists are acutely aware of the emotional, behavioral, and cognitive methods that patients are using to protect themselves from the chaos around them, and the ways in which they process a societal catastrophe such as COVID-19 (Figure). Here are some new patterns I have noticed among my own patients.
Physical and emotional separation
I first noticed the changes in my patients’ behavior at the front desk, where they now spend less time talking with the staff. They bring their own pens for filling out the paperwork, avoid touching items around them, and try to keep social interactions brief and to the point. Patients have been more cooperative about scheduling and rescheduling their appointments. They have generally been nicer to the staff, frequently thanking us for the work we do, and verbalizing their support for health care professionals in general.
Patients have been more supportive of their family members and other patients in the clinic, with some noticeable exceptions, such as maintaining social distancing for their own comfort and safety. Some patients wear face masks not just for safety but also to separate themselves and hide their emotions from the world. This allows them to feel more emotionally secure when interacting with other people.
The use of telehealth has given many patients the security of not having to leave their home, and the decreased need for travel adds to their comfort.
Changes I didn’t expect
The COVID-19 pandemic has resulted in some unexpected changes in my patients. Only a minority of my patients have expressed increased anxiety, while most have become less anxious overall on issues other than the pandemic. Many of my patients who have stressful jobs, especially teachers, say they feel more comfortable working from home and have less anxiety and depression because they are removed from their daily stressors. There also has been an increase in patients’ use of humor, including inappropriate humor, to defend against their fear of COVID-19.
Our clinic is a multidisciplinary facility that specializes in integrating mental and physical health treatments for pain, and for some patients, increased anxiety is clearly associated with an increase in pain. However, during the COVID-19 pandemic, patients have recognized this connection and verbalized their concerns. Some somatic patients have had a decrease in their physical symptoms, including chronic pain, because they see that the whole world is not well, which somehow helps to validate their concerns.
The changes in our patients’ psychological well-being will likely continue to morph as we enter a more stable period. The eventual resolution of the pandemic will bring further changes to our patients’ emotional lives. As we go through these times together, we will continue to uncover new ways that our patients will use to defend themselves against stress and adversities.
Unprecedented circumstances, extraordinary times, continental shift, life-altering experience—the descriptions of the coronavirus disease 2019 (COVID-19) pandemic have been endless, and accurate. Every clinician who has cared for patients during these trying times has noticed new patterns in patient behavior. Psychiatrists are acutely aware of the emotional, behavioral, and cognitive methods that patients are using to protect themselves from the chaos around them, and the ways in which they process a societal catastrophe such as COVID-19 (Figure). Here are some new patterns I have noticed among my own patients.
Physical and emotional separation
I first noticed the changes in my patients’ behavior at the front desk, where they now spend less time talking with the staff. They bring their own pens for filling out the paperwork, avoid touching items around them, and try to keep social interactions brief and to the point. Patients have been more cooperative about scheduling and rescheduling their appointments. They have generally been nicer to the staff, frequently thanking us for the work we do, and verbalizing their support for health care professionals in general.
Patients have been more supportive of their family members and other patients in the clinic, with some noticeable exceptions, such as maintaining social distancing for their own comfort and safety. Some patients wear face masks not just for safety but also to separate themselves and hide their emotions from the world. This allows them to feel more emotionally secure when interacting with other people.
The use of telehealth has given many patients the security of not having to leave their home, and the decreased need for travel adds to their comfort.
Changes I didn’t expect
The COVID-19 pandemic has resulted in some unexpected changes in my patients. Only a minority of my patients have expressed increased anxiety, while most have become less anxious overall on issues other than the pandemic. Many of my patients who have stressful jobs, especially teachers, say they feel more comfortable working from home and have less anxiety and depression because they are removed from their daily stressors. There also has been an increase in patients’ use of humor, including inappropriate humor, to defend against their fear of COVID-19.
Our clinic is a multidisciplinary facility that specializes in integrating mental and physical health treatments for pain, and for some patients, increased anxiety is clearly associated with an increase in pain. However, during the COVID-19 pandemic, patients have recognized this connection and verbalized their concerns. Some somatic patients have had a decrease in their physical symptoms, including chronic pain, because they see that the whole world is not well, which somehow helps to validate their concerns.
The changes in our patients’ psychological well-being will likely continue to morph as we enter a more stable period. The eventual resolution of the pandemic will bring further changes to our patients’ emotional lives. As we go through these times together, we will continue to uncover new ways that our patients will use to defend themselves against stress and adversities.
Unprecedented circumstances, extraordinary times, continental shift, life-altering experience—the descriptions of the coronavirus disease 2019 (COVID-19) pandemic have been endless, and accurate. Every clinician who has cared for patients during these trying times has noticed new patterns in patient behavior. Psychiatrists are acutely aware of the emotional, behavioral, and cognitive methods that patients are using to protect themselves from the chaos around them, and the ways in which they process a societal catastrophe such as COVID-19 (Figure). Here are some new patterns I have noticed among my own patients.
Physical and emotional separation
I first noticed the changes in my patients’ behavior at the front desk, where they now spend less time talking with the staff. They bring their own pens for filling out the paperwork, avoid touching items around them, and try to keep social interactions brief and to the point. Patients have been more cooperative about scheduling and rescheduling their appointments. They have generally been nicer to the staff, frequently thanking us for the work we do, and verbalizing their support for health care professionals in general.
Patients have been more supportive of their family members and other patients in the clinic, with some noticeable exceptions, such as maintaining social distancing for their own comfort and safety. Some patients wear face masks not just for safety but also to separate themselves and hide their emotions from the world. This allows them to feel more emotionally secure when interacting with other people.
The use of telehealth has given many patients the security of not having to leave their home, and the decreased need for travel adds to their comfort.
Changes I didn’t expect
The COVID-19 pandemic has resulted in some unexpected changes in my patients. Only a minority of my patients have expressed increased anxiety, while most have become less anxious overall on issues other than the pandemic. Many of my patients who have stressful jobs, especially teachers, say they feel more comfortable working from home and have less anxiety and depression because they are removed from their daily stressors. There also has been an increase in patients’ use of humor, including inappropriate humor, to defend against their fear of COVID-19.
Our clinic is a multidisciplinary facility that specializes in integrating mental and physical health treatments for pain, and for some patients, increased anxiety is clearly associated with an increase in pain. However, during the COVID-19 pandemic, patients have recognized this connection and verbalized their concerns. Some somatic patients have had a decrease in their physical symptoms, including chronic pain, because they see that the whole world is not well, which somehow helps to validate their concerns.
The changes in our patients’ psychological well-being will likely continue to morph as we enter a more stable period. The eventual resolution of the pandemic will bring further changes to our patients’ emotional lives. As we go through these times together, we will continue to uncover new ways that our patients will use to defend themselves against stress and adversities.
Tool-less but not clueless
There is apparently some debate about which of our ancestors was the first to use tools. It probably was Homo habilis, the “handy man.” But it could have been a relative of Lucy, of the Australopithecus afarensis tribe. Regardless of which pile of chipped rocks looks more tool-like to you, it is generally agreed that our ability to make and use tools is one of the key ingredients to our evolutionary success.
I have always enjoyed the feel of good quality knife when I am woodcarving, and the tool collection hanging on the wall over my work bench is one of my most prized possessions. But when I was practicing general pediatrics, I could never really warm up to the screening tools that were being touted as must-haves for detecting developmental delays.
It turns out I was not alone. A recent study published in Pediatrics found that the number of pediatricians who reported using developmental screening tools increased from 21% to 63% between 2002 and 2016. (Pediatrics. 2020 Apr. doi: 10.1542/peds.2019-0851). However, this means that, despite a significant increase in usage, more than a third of pediatricians still are not employing screening tools. Does this suggest that one out of every three pediatricians, including me and maybe you, is a knuckle-dragging pre–Homo sapiens practicing in blissful and clueless ignorance?
Mei Elansary MD, MPhil, and Michael Silverstein, MD, MPH, who wrote a companion commentary in the same journal, suggested that maybe those of us who have resisted the call to be tool users aren’t prehistoric ignoramuses (Pediatrics. 2020 Apr. doi: 10.1542/peds.2020-0164). They observed that, regardless of whether the pediatricians were using screening tools, more than 40% of the those surveyed did not refer patients for early intervention.
The commentators pointed out that the decision of when, whom, and how to screen must be viewed as part of a “complicated web of changing epidemiology, time and reimbursement constraints, and service availability.” They observe that pediatricians facing this landscape in upheaval “default to what they know best: clinical judgment.” Citing one study of the management of febrile infants, the authors point out that relying on guidelines doesn’t always result in improved clinical care.
My decision of when to refer a patient for early intervention was based on what I had observed over a series of visits and whether I thought that the early intervention resources available in my community would have a significant benefit for any particular child. Because I crafted my practice around a model that put a strong emphasis on continuity, my patients almost never saw another provider for a health maintenance visit and usually saw me for their sick visits, including ear rechecks.
I guess you could argue that there are situations in which seeing a variety of providers, each with a slightly different perspective, might benefit the patient. But when we are talking about a domain like development that is defined by change, or lack of change, over time, multiple observations by a single observer usually can be more valuable.
If I were practicing in a situation in which I didn’t have the luxury of continuity, I think I would be more likely to use a screening tool. Although I have found screening guidelines can be helpful as mnemonics in some situations, they aren’t equally applicable in all clinical settings.
While I may be asking for trouble by questioning anything even remotely related to the concept of early intervention, I must say that I wholeheartedly agree with Dr. Elansary and Dr. Silverstein when they wrote “the pediatrics community may have something to learn from the significant minority of pediatricians who do not practice formalized screening.”
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
There is apparently some debate about which of our ancestors was the first to use tools. It probably was Homo habilis, the “handy man.” But it could have been a relative of Lucy, of the Australopithecus afarensis tribe. Regardless of which pile of chipped rocks looks more tool-like to you, it is generally agreed that our ability to make and use tools is one of the key ingredients to our evolutionary success.
I have always enjoyed the feel of good quality knife when I am woodcarving, and the tool collection hanging on the wall over my work bench is one of my most prized possessions. But when I was practicing general pediatrics, I could never really warm up to the screening tools that were being touted as must-haves for detecting developmental delays.
It turns out I was not alone. A recent study published in Pediatrics found that the number of pediatricians who reported using developmental screening tools increased from 21% to 63% between 2002 and 2016. (Pediatrics. 2020 Apr. doi: 10.1542/peds.2019-0851). However, this means that, despite a significant increase in usage, more than a third of pediatricians still are not employing screening tools. Does this suggest that one out of every three pediatricians, including me and maybe you, is a knuckle-dragging pre–Homo sapiens practicing in blissful and clueless ignorance?
Mei Elansary MD, MPhil, and Michael Silverstein, MD, MPH, who wrote a companion commentary in the same journal, suggested that maybe those of us who have resisted the call to be tool users aren’t prehistoric ignoramuses (Pediatrics. 2020 Apr. doi: 10.1542/peds.2020-0164). They observed that, regardless of whether the pediatricians were using screening tools, more than 40% of the those surveyed did not refer patients for early intervention.
The commentators pointed out that the decision of when, whom, and how to screen must be viewed as part of a “complicated web of changing epidemiology, time and reimbursement constraints, and service availability.” They observe that pediatricians facing this landscape in upheaval “default to what they know best: clinical judgment.” Citing one study of the management of febrile infants, the authors point out that relying on guidelines doesn’t always result in improved clinical care.
My decision of when to refer a patient for early intervention was based on what I had observed over a series of visits and whether I thought that the early intervention resources available in my community would have a significant benefit for any particular child. Because I crafted my practice around a model that put a strong emphasis on continuity, my patients almost never saw another provider for a health maintenance visit and usually saw me for their sick visits, including ear rechecks.
I guess you could argue that there are situations in which seeing a variety of providers, each with a slightly different perspective, might benefit the patient. But when we are talking about a domain like development that is defined by change, or lack of change, over time, multiple observations by a single observer usually can be more valuable.
If I were practicing in a situation in which I didn’t have the luxury of continuity, I think I would be more likely to use a screening tool. Although I have found screening guidelines can be helpful as mnemonics in some situations, they aren’t equally applicable in all clinical settings.
While I may be asking for trouble by questioning anything even remotely related to the concept of early intervention, I must say that I wholeheartedly agree with Dr. Elansary and Dr. Silverstein when they wrote “the pediatrics community may have something to learn from the significant minority of pediatricians who do not practice formalized screening.”
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
There is apparently some debate about which of our ancestors was the first to use tools. It probably was Homo habilis, the “handy man.” But it could have been a relative of Lucy, of the Australopithecus afarensis tribe. Regardless of which pile of chipped rocks looks more tool-like to you, it is generally agreed that our ability to make and use tools is one of the key ingredients to our evolutionary success.
I have always enjoyed the feel of good quality knife when I am woodcarving, and the tool collection hanging on the wall over my work bench is one of my most prized possessions. But when I was practicing general pediatrics, I could never really warm up to the screening tools that were being touted as must-haves for detecting developmental delays.
It turns out I was not alone. A recent study published in Pediatrics found that the number of pediatricians who reported using developmental screening tools increased from 21% to 63% between 2002 and 2016. (Pediatrics. 2020 Apr. doi: 10.1542/peds.2019-0851). However, this means that, despite a significant increase in usage, more than a third of pediatricians still are not employing screening tools. Does this suggest that one out of every three pediatricians, including me and maybe you, is a knuckle-dragging pre–Homo sapiens practicing in blissful and clueless ignorance?
Mei Elansary MD, MPhil, and Michael Silverstein, MD, MPH, who wrote a companion commentary in the same journal, suggested that maybe those of us who have resisted the call to be tool users aren’t prehistoric ignoramuses (Pediatrics. 2020 Apr. doi: 10.1542/peds.2020-0164). They observed that, regardless of whether the pediatricians were using screening tools, more than 40% of the those surveyed did not refer patients for early intervention.
The commentators pointed out that the decision of when, whom, and how to screen must be viewed as part of a “complicated web of changing epidemiology, time and reimbursement constraints, and service availability.” They observe that pediatricians facing this landscape in upheaval “default to what they know best: clinical judgment.” Citing one study of the management of febrile infants, the authors point out that relying on guidelines doesn’t always result in improved clinical care.
My decision of when to refer a patient for early intervention was based on what I had observed over a series of visits and whether I thought that the early intervention resources available in my community would have a significant benefit for any particular child. Because I crafted my practice around a model that put a strong emphasis on continuity, my patients almost never saw another provider for a health maintenance visit and usually saw me for their sick visits, including ear rechecks.
I guess you could argue that there are situations in which seeing a variety of providers, each with a slightly different perspective, might benefit the patient. But when we are talking about a domain like development that is defined by change, or lack of change, over time, multiple observations by a single observer usually can be more valuable.
If I were practicing in a situation in which I didn’t have the luxury of continuity, I think I would be more likely to use a screening tool. Although I have found screening guidelines can be helpful as mnemonics in some situations, they aren’t equally applicable in all clinical settings.
While I may be asking for trouble by questioning anything even remotely related to the concept of early intervention, I must say that I wholeheartedly agree with Dr. Elansary and Dr. Silverstein when they wrote “the pediatrics community may have something to learn from the significant minority of pediatricians who do not practice formalized screening.”
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
Stop calling it ‘behavioral health’: Psychiatry is much more
Psychiatry has been historically plagued by absurd misnomers. It started with the laughable “mental hygiene,” coined by William Sweetser, MD, in 1843, 1 year before the original 13 members of the Association of Medical Superintendents of American Institutions for the Insane established what in 1921 was renamed the American Psychiatric Association. Mental hygiene evokes an image of psychiatrists scrubbing the brains of mentally ill patients with soap and water! That term was neither medically nor scientifically appropriate, but it stuck for decades.
Enter “mental health.” In 1949, the National Institute of Mental Health was established. It is the 5th oldest of the 27 Institutes and Centers of the National Institutes of Health. Then, in 1963, Congress passed the Community Mental Health Act, which established Community Mental Health Centers around the country. It is perplexing that the term “health” was used instead of “illness,” when psychiatry is a medical specialty that treats mental disorders. Health is certainly the goal of all medical specialties, but cardiology was never called “heart health,” neurology was never called “brain health,” and pediatrics was never called “children’s health.” Like all its sister medical specialties, psychiatry treats disease and syndromes, but somehow, it has been transmogrified into “mental health.” Perhaps it was meant to be a euphemism to disguise and avert the unfortunate stigma associated with mental illness back during the institutionalization era.
The advent of ‘behavioral health’
Then suddenly, the term “behavioral health” was coined and began to be used as a substitute for psychiatry, further distorting psychiatry’s medical identity. Behavioral health is completely different from psychiatry. It refers to healthy behaviors that people should uphold throughout their lives to maintain their overall health and well-being, including eating a balanced diet, exercising regularly, avoiding tobacco and drugs of abuse, practicing safe sex, and establishing meaningful social relationships. So behavioral health promotes a healthy lifestyle, and that could very aptly apply to cardiology, pulmonology, nephrology, or hepatology, where good nutrition and avoiding weight gain, smoking, and sedentary living can reduce the risk for various medical diseases and early mortality. For dermatologists, behavioral health is avoiding sunburn, and for dentists, it is regular brushing and flossing.
Thus, behavioral health is a term that broadly promotes physical health and well-being, and should not be conflated with mental disorders. It is by no means synonymous with psychiatry, a medical discipline that addresses serious disorders of thought, emotions, affect, delusions, hallucinations, suicide, homicide, impulsivity, obsessions and compulsions, motivation, memory, attention, and judgment. Psychiatry is far more than behaviors that promote healthy living. Psychiatry contends with acute and chronic mental disorders, similar to other chronic medical conditions such as chronic heart, lung, gastrointestinal, or kidney diseases. Psychiatric disorders can emerge in individuals despite—and irrespective of—a healthy lifestyle promoted by behavioral health. Most psychiatric disorders have been shown to be highly genetic, and can be triggered by gene-environment interactions, even in the context of a healthful life that behavioral health advocates and fecundates.
I dislike conspiracy theories, but it is legitimate to inquire: Was there a “malicious intent” by insurance companies and managed-care entities when they abruptly replaced the medically accurate term “psychiatry” with the counterfactual “behavioral health”? Did they intend to portray psychiatry as somehow “different” from other medical specialties? Did this phraseological acrobatics facilitate and justify the carving out of psychiatric and addiction care, cursed with an anemic budget and absence of parity for persons with psychiatric brain disorders? Somehow, using behavioral health instead of psychiatry has the unfortunate connotation that patients with mental illness are “misbehaving” by not practicing healthy living, rather than being genuinely medically ill through no fault of their own. That’s a surreptitious de-medicalization of psychiatric brain disorders. It is very likely that the same companies that propagated behavioral health are the ones who came up with the demeaning term “providers,” which lumps physicians with nonphysicians, diluting the medical identify of psychiatrists, and implying a non-equivalence of psychiatric disorders with other medical conditions, which perpetuates stigma.
An erroneous epithet
We are psychiatric physicians, not “behavioral health advisors.” We are graduates of medical schools where we had clinical psychiatric experiences rotating with internal medicine, surgery, obstetrics and gynecology, and pediatrics. We did not have behavioral health rotations. And after graduating with an MD, we spent 4 additional years in psychiatric residency training, not behavioral health training, and we treated very sick patients in emergency departments and on inpatient units, not on behavioral health wards. We receive our board certification from the American Board of Psychiatry and Neurology, not from a behavioral health board. As psychiatrists, we are regularly consulted on the cases of medical and surgical patients who develop psychiatric disorders, which has absolutely nothing to do with behavioral health. Our psychiatric outpatient clinics require extensive medical knowledge and psychopharmacological skills, not behavioral health.
As part of our work as physicians and psychiatrists, we do counsel patients on adopting a healthy lifestyle because many of them have comorbid medical conditions such as diabetes, hypertension, dyslipidemia, chronic obstructive pulmonary disease, asthma, and kidney and gastrointestinal disorders. We practice collaborative care with primary care physicians so we can jointly manage patients’ physical and mental disorders, and help them optimize their lifestyles. Thus, behavioral health is a tiny component of what psychiatrists do, and it does not come close to defining our comprehensive medical care. Similarly, neurologists and cardiologists should not be labeled as behavior health specialties simply because they counsel their patients on how to lower the risk of strokes or heart attacks due to unhealthy lifestyles.
So, let’s call a spade a spade. Psychiatry is psychiatric medical care, not behavioral health. Let’s abandon this erroneous epithet and change the signs outside hospitals and clinics to “psychiatric medicine” facilities. I guarantee that orthopedists would not like it all if you call their specialty “bone health,” and may break your leg if you label their discipline “bone hygiene”… after washing it with soap and water, of course!
Psychiatry has been historically plagued by absurd misnomers. It started with the laughable “mental hygiene,” coined by William Sweetser, MD, in 1843, 1 year before the original 13 members of the Association of Medical Superintendents of American Institutions for the Insane established what in 1921 was renamed the American Psychiatric Association. Mental hygiene evokes an image of psychiatrists scrubbing the brains of mentally ill patients with soap and water! That term was neither medically nor scientifically appropriate, but it stuck for decades.
Enter “mental health.” In 1949, the National Institute of Mental Health was established. It is the 5th oldest of the 27 Institutes and Centers of the National Institutes of Health. Then, in 1963, Congress passed the Community Mental Health Act, which established Community Mental Health Centers around the country. It is perplexing that the term “health” was used instead of “illness,” when psychiatry is a medical specialty that treats mental disorders. Health is certainly the goal of all medical specialties, but cardiology was never called “heart health,” neurology was never called “brain health,” and pediatrics was never called “children’s health.” Like all its sister medical specialties, psychiatry treats disease and syndromes, but somehow, it has been transmogrified into “mental health.” Perhaps it was meant to be a euphemism to disguise and avert the unfortunate stigma associated with mental illness back during the institutionalization era.
The advent of ‘behavioral health’
Then suddenly, the term “behavioral health” was coined and began to be used as a substitute for psychiatry, further distorting psychiatry’s medical identity. Behavioral health is completely different from psychiatry. It refers to healthy behaviors that people should uphold throughout their lives to maintain their overall health and well-being, including eating a balanced diet, exercising regularly, avoiding tobacco and drugs of abuse, practicing safe sex, and establishing meaningful social relationships. So behavioral health promotes a healthy lifestyle, and that could very aptly apply to cardiology, pulmonology, nephrology, or hepatology, where good nutrition and avoiding weight gain, smoking, and sedentary living can reduce the risk for various medical diseases and early mortality. For dermatologists, behavioral health is avoiding sunburn, and for dentists, it is regular brushing and flossing.
Thus, behavioral health is a term that broadly promotes physical health and well-being, and should not be conflated with mental disorders. It is by no means synonymous with psychiatry, a medical discipline that addresses serious disorders of thought, emotions, affect, delusions, hallucinations, suicide, homicide, impulsivity, obsessions and compulsions, motivation, memory, attention, and judgment. Psychiatry is far more than behaviors that promote healthy living. Psychiatry contends with acute and chronic mental disorders, similar to other chronic medical conditions such as chronic heart, lung, gastrointestinal, or kidney diseases. Psychiatric disorders can emerge in individuals despite—and irrespective of—a healthy lifestyle promoted by behavioral health. Most psychiatric disorders have been shown to be highly genetic, and can be triggered by gene-environment interactions, even in the context of a healthful life that behavioral health advocates and fecundates.
I dislike conspiracy theories, but it is legitimate to inquire: Was there a “malicious intent” by insurance companies and managed-care entities when they abruptly replaced the medically accurate term “psychiatry” with the counterfactual “behavioral health”? Did they intend to portray psychiatry as somehow “different” from other medical specialties? Did this phraseological acrobatics facilitate and justify the carving out of psychiatric and addiction care, cursed with an anemic budget and absence of parity for persons with psychiatric brain disorders? Somehow, using behavioral health instead of psychiatry has the unfortunate connotation that patients with mental illness are “misbehaving” by not practicing healthy living, rather than being genuinely medically ill through no fault of their own. That’s a surreptitious de-medicalization of psychiatric brain disorders. It is very likely that the same companies that propagated behavioral health are the ones who came up with the demeaning term “providers,” which lumps physicians with nonphysicians, diluting the medical identify of psychiatrists, and implying a non-equivalence of psychiatric disorders with other medical conditions, which perpetuates stigma.
An erroneous epithet
We are psychiatric physicians, not “behavioral health advisors.” We are graduates of medical schools where we had clinical psychiatric experiences rotating with internal medicine, surgery, obstetrics and gynecology, and pediatrics. We did not have behavioral health rotations. And after graduating with an MD, we spent 4 additional years in psychiatric residency training, not behavioral health training, and we treated very sick patients in emergency departments and on inpatient units, not on behavioral health wards. We receive our board certification from the American Board of Psychiatry and Neurology, not from a behavioral health board. As psychiatrists, we are regularly consulted on the cases of medical and surgical patients who develop psychiatric disorders, which has absolutely nothing to do with behavioral health. Our psychiatric outpatient clinics require extensive medical knowledge and psychopharmacological skills, not behavioral health.
As part of our work as physicians and psychiatrists, we do counsel patients on adopting a healthy lifestyle because many of them have comorbid medical conditions such as diabetes, hypertension, dyslipidemia, chronic obstructive pulmonary disease, asthma, and kidney and gastrointestinal disorders. We practice collaborative care with primary care physicians so we can jointly manage patients’ physical and mental disorders, and help them optimize their lifestyles. Thus, behavioral health is a tiny component of what psychiatrists do, and it does not come close to defining our comprehensive medical care. Similarly, neurologists and cardiologists should not be labeled as behavior health specialties simply because they counsel their patients on how to lower the risk of strokes or heart attacks due to unhealthy lifestyles.
So, let’s call a spade a spade. Psychiatry is psychiatric medical care, not behavioral health. Let’s abandon this erroneous epithet and change the signs outside hospitals and clinics to “psychiatric medicine” facilities. I guarantee that orthopedists would not like it all if you call their specialty “bone health,” and may break your leg if you label their discipline “bone hygiene”… after washing it with soap and water, of course!
Psychiatry has been historically plagued by absurd misnomers. It started with the laughable “mental hygiene,” coined by William Sweetser, MD, in 1843, 1 year before the original 13 members of the Association of Medical Superintendents of American Institutions for the Insane established what in 1921 was renamed the American Psychiatric Association. Mental hygiene evokes an image of psychiatrists scrubbing the brains of mentally ill patients with soap and water! That term was neither medically nor scientifically appropriate, but it stuck for decades.
Enter “mental health.” In 1949, the National Institute of Mental Health was established. It is the 5th oldest of the 27 Institutes and Centers of the National Institutes of Health. Then, in 1963, Congress passed the Community Mental Health Act, which established Community Mental Health Centers around the country. It is perplexing that the term “health” was used instead of “illness,” when psychiatry is a medical specialty that treats mental disorders. Health is certainly the goal of all medical specialties, but cardiology was never called “heart health,” neurology was never called “brain health,” and pediatrics was never called “children’s health.” Like all its sister medical specialties, psychiatry treats disease and syndromes, but somehow, it has been transmogrified into “mental health.” Perhaps it was meant to be a euphemism to disguise and avert the unfortunate stigma associated with mental illness back during the institutionalization era.
The advent of ‘behavioral health’
Then suddenly, the term “behavioral health” was coined and began to be used as a substitute for psychiatry, further distorting psychiatry’s medical identity. Behavioral health is completely different from psychiatry. It refers to healthy behaviors that people should uphold throughout their lives to maintain their overall health and well-being, including eating a balanced diet, exercising regularly, avoiding tobacco and drugs of abuse, practicing safe sex, and establishing meaningful social relationships. So behavioral health promotes a healthy lifestyle, and that could very aptly apply to cardiology, pulmonology, nephrology, or hepatology, where good nutrition and avoiding weight gain, smoking, and sedentary living can reduce the risk for various medical diseases and early mortality. For dermatologists, behavioral health is avoiding sunburn, and for dentists, it is regular brushing and flossing.
Thus, behavioral health is a term that broadly promotes physical health and well-being, and should not be conflated with mental disorders. It is by no means synonymous with psychiatry, a medical discipline that addresses serious disorders of thought, emotions, affect, delusions, hallucinations, suicide, homicide, impulsivity, obsessions and compulsions, motivation, memory, attention, and judgment. Psychiatry is far more than behaviors that promote healthy living. Psychiatry contends with acute and chronic mental disorders, similar to other chronic medical conditions such as chronic heart, lung, gastrointestinal, or kidney diseases. Psychiatric disorders can emerge in individuals despite—and irrespective of—a healthy lifestyle promoted by behavioral health. Most psychiatric disorders have been shown to be highly genetic, and can be triggered by gene-environment interactions, even in the context of a healthful life that behavioral health advocates and fecundates.
I dislike conspiracy theories, but it is legitimate to inquire: Was there a “malicious intent” by insurance companies and managed-care entities when they abruptly replaced the medically accurate term “psychiatry” with the counterfactual “behavioral health”? Did they intend to portray psychiatry as somehow “different” from other medical specialties? Did this phraseological acrobatics facilitate and justify the carving out of psychiatric and addiction care, cursed with an anemic budget and absence of parity for persons with psychiatric brain disorders? Somehow, using behavioral health instead of psychiatry has the unfortunate connotation that patients with mental illness are “misbehaving” by not practicing healthy living, rather than being genuinely medically ill through no fault of their own. That’s a surreptitious de-medicalization of psychiatric brain disorders. It is very likely that the same companies that propagated behavioral health are the ones who came up with the demeaning term “providers,” which lumps physicians with nonphysicians, diluting the medical identify of psychiatrists, and implying a non-equivalence of psychiatric disorders with other medical conditions, which perpetuates stigma.
An erroneous epithet
We are psychiatric physicians, not “behavioral health advisors.” We are graduates of medical schools where we had clinical psychiatric experiences rotating with internal medicine, surgery, obstetrics and gynecology, and pediatrics. We did not have behavioral health rotations. And after graduating with an MD, we spent 4 additional years in psychiatric residency training, not behavioral health training, and we treated very sick patients in emergency departments and on inpatient units, not on behavioral health wards. We receive our board certification from the American Board of Psychiatry and Neurology, not from a behavioral health board. As psychiatrists, we are regularly consulted on the cases of medical and surgical patients who develop psychiatric disorders, which has absolutely nothing to do with behavioral health. Our psychiatric outpatient clinics require extensive medical knowledge and psychopharmacological skills, not behavioral health.
As part of our work as physicians and psychiatrists, we do counsel patients on adopting a healthy lifestyle because many of them have comorbid medical conditions such as diabetes, hypertension, dyslipidemia, chronic obstructive pulmonary disease, asthma, and kidney and gastrointestinal disorders. We practice collaborative care with primary care physicians so we can jointly manage patients’ physical and mental disorders, and help them optimize their lifestyles. Thus, behavioral health is a tiny component of what psychiatrists do, and it does not come close to defining our comprehensive medical care. Similarly, neurologists and cardiologists should not be labeled as behavior health specialties simply because they counsel their patients on how to lower the risk of strokes or heart attacks due to unhealthy lifestyles.
So, let’s call a spade a spade. Psychiatry is psychiatric medical care, not behavioral health. Let’s abandon this erroneous epithet and change the signs outside hospitals and clinics to “psychiatric medicine” facilities. I guarantee that orthopedists would not like it all if you call their specialty “bone health,” and may break your leg if you label their discipline “bone hygiene”… after washing it with soap and water, of course!
The injustice of pre-authorization
I agree with Dr. Nasrallah’s clear description of the malign nature of the pre-authorization system, as described in his editorial “Pre-authorization is illegal, unethical, and adversely disrupts patient care” (From the Editor,
As an example of the latter, I was recently told by a pharmacist that I needed to call the insurer to justify why a patient was going from a prescription for #30 citalopram to #45 citalopram. The request had triggered a quantity limit. The pharmacist had explained to the insurer that more pills were required because the dosage was being lowered from 40 to 30 mg/d. Because there are no 30-mg tablets available, it made most sense for the patient to take one and a half 20-mg tablets, which totals 45 pills per month.
The insurer—probably a screener, not a pharmacist—would not accept that explanation and insisted that I call them myself. I bitterly resented how casually the insurer expected busy doctors to interrupt their clinical work to comply with arbitrary micromanagement of pill quantities! I’ve seldom seen such nonsense in more than 40 years of practice.
When doctors call these insurers, they are connected to a screener, but never a pharmacist. The screener asks a series of questions prompted by a computer. We give them verbal answers, but they don’t comprehend what they input into their system. The reasons we give to the screener may not even make it into the report that the screener passes on to the staff member who makes the decision. The doctor is not told what is in the report, or who is reviewing it. So much for transparency in this era that supposedly values it!
In any case, answering all the computer-prompted questions can take a long time. And time, as we know (but they do not), is not elastic.
Serious consequences may ensue if an insurer denies coverage for the doctor’s first choice. Many patients cannot afford to pay hundreds of extra dollars out of pocket. The insurer may ask the doctor to choose a different medication. Aside from the disrespect for the doctor’s decision implied by such a request, another problem is that the patient knows the new medication is his/her doctor’s second (or third) choice. Any positive placebo effect that may have existed before has now been lost. Most doctors would be glad to have a positive placebo effect augmenting the physiologic effects of the medication, especially when the patient is already feeling helpless or hopeless. These negative feelings would likely increase when the patient feels pressured into starting a medication that they know was their doctor’s second choice.
These are just a few reasons pre-authorization is a horrid system; Dr. Nasrallah covered many others in his editorial. The system, as currently structured, needs to be eliminated.
Arthur Mode, MD
Private psychiatric practice
Falls Church, Virginia
Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
Continue to: Hooray for...
Hooray for Dr. Nasrallah’s editorial about pre-authorization! I worry, however, that he missed some important considerations.
He writes, “The welfare of the patient is not on the insurance company’s radar screen, perhaps because it is crowded out by dollar signs.” But the welfare of the patient is exactly what is on their radar screens! If the patient dies, the insurance company profits, because it will not have to pay for treatment. This is like having a Red Sox employee manage the Yankees, except we are talking about human lives, not baseball games. Dr. Nasrallah asks (but does not answer), “How did for-profit insurance companies empower themselves to tyrannize clinical practice so that the treatment administered isn’t customized to the patient’s need but instead to fatten the profits of the insurance company?” The answer: Physicians let them. Many physicians are paid by insurers directly or through work for clinics or hospitals. He who pays the piper calls the tune. And because employers often select the insurer, patients have no say.
Honesty is most important. Pre-authorization is a dishonest term, because pre-authorization actually is pre-denial. The term pre-authorization should be replaced by “pre-denial.” It is also fraudulent when insurance companies call themselves health care companies, because they only provide insurance, not health care. Similarly, the term “evidence-based medicine” is typically only an excuse that insurers use to refuse to cover the cost of treatment. In another scenario of Dr. Nasrallah’s patient with treatment-resistant depression who responded to modafinil, what if the evidence for using this medication was based on the patient’s psychiatric history alone, without any evidence from a meta-analysis of randomized controlled trials? That would not be “evidence-based” in the dishonest world of insurance. Evidence to insurers does not include what is evident in the patient’s response to a given treatment.
What about amnesty, especially for physicians who work in the so-called pre-authorization denial business? Some even claim to be peers (ie, the “peer to peer reviews” they conduct) and insist they cannot be on speakerphone, so that their identity is kept secret from the patient. Not all of these “physicians” are incompetent. Not all of them have criminal minds or lack empathy. Some may have had exceptional circumstances leading them to such a profession, which Dr. Nasrallah correctly notes as felonious behavior. For these physicians, I think some kind of amnesty program would be appropriate, rather than prosecution.
John Jacobs, MD
Private psychiatric practice
Manchester, New Hampshire
Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
Continue to: I have just finished reading...
I have just finished reading Dr. Nasrallah’s editorial about pre-authorization. I agree with everything he said, but I do have a couple of comments:
1. Many of our colleagues do not accept insurance because their practices operate on a cash basis. This seems to obviate the problem of pre-authorization, and suggests that if we truly want to get rid of pre-authorization, we should get rid of insurance.
2. In practices that do not accept insurance, some patients may be filing their own insurance claims. Do you have any information on this approach? Are patients able to apply pressure to their insurance companies? Do patients get frustrated with their insurance companies and pay cash, rather than trying to negotiate with their insurance companies?
Katherine Hankins, MD
Private psychiatric practice
Omaha, Nebraska
Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
Continue to: Why not address...
Why not address the underlying (and actual) cause of the “pre-authorization” scam/scandal: the private health insurance industry.
Other countries in the western world have figured out how to provide guaranteed health care to their citizens without resorting to a costly insurance industry. This parasitic business suborns 10% to 20% of the health care bill while wasting our money on withholding health care deemed “not eligible” for patients who need it. Meanwhile, the executives who manage this insurance racket are paid enormous salaries not to deliver services.
Moreover, we reap a double loss to the health care system because hospitals must employ a building full of clerks to submit (and then, when rejected, re-submit) bills for reimbursement of hospital charges.
Franz Kafka would immediately grasp the despicable workings of this self-serving scheme.
David Link, MD
Associate Professor of Pediatrics
Harvard Medical School
Boston, Massachusetts
Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
Continue to: Dr. Nasrallah responds
Dr. Nasrallah responds
Thanks to all my colleagues who commented on (and unanimously agreed with) my editorial. It is clearly one of the most outrageous hurdles that all psychiatric practitioners face every day.
For the sake of our patients who deserve optimal medical care (laboratory tests, procedures, and medications), insurance companies must be tightly regulated to avoid second-guessing the treating clinicians, and readily cover what is prescribed. Some patients who can afford it resort to paying out of pocket for privacy reasons or for rapid access to psychiatric care, and may or may not file for insurance coverage, but they will certainly receive what their psychiatrist deems appropriate after a direct evaluation.
I hope the American Psychiatric Association and American Medical Association will continue to forcefully pursue legislation to eliminate pre-authorization and restore some sanity to the critical process of good clinical care.
Henry A. Nasrallah, MD
Professor of Psychiatry, Neurology, and Neuroscience
Medical Director: Neuropsychiatry
Director, Schizophrenia and Neuropsychiatry Programs
University of Cincinnati College of Medicine
Cincinnati, Ohio
Professor Emeritus, Saint Louis University
St. Louis, Missouri
I agree with Dr. Nasrallah’s clear description of the malign nature of the pre-authorization system, as described in his editorial “Pre-authorization is illegal, unethical, and adversely disrupts patient care” (From the Editor,
As an example of the latter, I was recently told by a pharmacist that I needed to call the insurer to justify why a patient was going from a prescription for #30 citalopram to #45 citalopram. The request had triggered a quantity limit. The pharmacist had explained to the insurer that more pills were required because the dosage was being lowered from 40 to 30 mg/d. Because there are no 30-mg tablets available, it made most sense for the patient to take one and a half 20-mg tablets, which totals 45 pills per month.
The insurer—probably a screener, not a pharmacist—would not accept that explanation and insisted that I call them myself. I bitterly resented how casually the insurer expected busy doctors to interrupt their clinical work to comply with arbitrary micromanagement of pill quantities! I’ve seldom seen such nonsense in more than 40 years of practice.
When doctors call these insurers, they are connected to a screener, but never a pharmacist. The screener asks a series of questions prompted by a computer. We give them verbal answers, but they don’t comprehend what they input into their system. The reasons we give to the screener may not even make it into the report that the screener passes on to the staff member who makes the decision. The doctor is not told what is in the report, or who is reviewing it. So much for transparency in this era that supposedly values it!
In any case, answering all the computer-prompted questions can take a long time. And time, as we know (but they do not), is not elastic.
Serious consequences may ensue if an insurer denies coverage for the doctor’s first choice. Many patients cannot afford to pay hundreds of extra dollars out of pocket. The insurer may ask the doctor to choose a different medication. Aside from the disrespect for the doctor’s decision implied by such a request, another problem is that the patient knows the new medication is his/her doctor’s second (or third) choice. Any positive placebo effect that may have existed before has now been lost. Most doctors would be glad to have a positive placebo effect augmenting the physiologic effects of the medication, especially when the patient is already feeling helpless or hopeless. These negative feelings would likely increase when the patient feels pressured into starting a medication that they know was their doctor’s second choice.
These are just a few reasons pre-authorization is a horrid system; Dr. Nasrallah covered many others in his editorial. The system, as currently structured, needs to be eliminated.
Arthur Mode, MD
Private psychiatric practice
Falls Church, Virginia
Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
Continue to: Hooray for...
Hooray for Dr. Nasrallah’s editorial about pre-authorization! I worry, however, that he missed some important considerations.
He writes, “The welfare of the patient is not on the insurance company’s radar screen, perhaps because it is crowded out by dollar signs.” But the welfare of the patient is exactly what is on their radar screens! If the patient dies, the insurance company profits, because it will not have to pay for treatment. This is like having a Red Sox employee manage the Yankees, except we are talking about human lives, not baseball games. Dr. Nasrallah asks (but does not answer), “How did for-profit insurance companies empower themselves to tyrannize clinical practice so that the treatment administered isn’t customized to the patient’s need but instead to fatten the profits of the insurance company?” The answer: Physicians let them. Many physicians are paid by insurers directly or through work for clinics or hospitals. He who pays the piper calls the tune. And because employers often select the insurer, patients have no say.
Honesty is most important. Pre-authorization is a dishonest term, because pre-authorization actually is pre-denial. The term pre-authorization should be replaced by “pre-denial.” It is also fraudulent when insurance companies call themselves health care companies, because they only provide insurance, not health care. Similarly, the term “evidence-based medicine” is typically only an excuse that insurers use to refuse to cover the cost of treatment. In another scenario of Dr. Nasrallah’s patient with treatment-resistant depression who responded to modafinil, what if the evidence for using this medication was based on the patient’s psychiatric history alone, without any evidence from a meta-analysis of randomized controlled trials? That would not be “evidence-based” in the dishonest world of insurance. Evidence to insurers does not include what is evident in the patient’s response to a given treatment.
What about amnesty, especially for physicians who work in the so-called pre-authorization denial business? Some even claim to be peers (ie, the “peer to peer reviews” they conduct) and insist they cannot be on speakerphone, so that their identity is kept secret from the patient. Not all of these “physicians” are incompetent. Not all of them have criminal minds or lack empathy. Some may have had exceptional circumstances leading them to such a profession, which Dr. Nasrallah correctly notes as felonious behavior. For these physicians, I think some kind of amnesty program would be appropriate, rather than prosecution.
John Jacobs, MD
Private psychiatric practice
Manchester, New Hampshire
Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
Continue to: I have just finished reading...
I have just finished reading Dr. Nasrallah’s editorial about pre-authorization. I agree with everything he said, but I do have a couple of comments:
1. Many of our colleagues do not accept insurance because their practices operate on a cash basis. This seems to obviate the problem of pre-authorization, and suggests that if we truly want to get rid of pre-authorization, we should get rid of insurance.
2. In practices that do not accept insurance, some patients may be filing their own insurance claims. Do you have any information on this approach? Are patients able to apply pressure to their insurance companies? Do patients get frustrated with their insurance companies and pay cash, rather than trying to negotiate with their insurance companies?
Katherine Hankins, MD
Private psychiatric practice
Omaha, Nebraska
Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
Continue to: Why not address...
Why not address the underlying (and actual) cause of the “pre-authorization” scam/scandal: the private health insurance industry.
Other countries in the western world have figured out how to provide guaranteed health care to their citizens without resorting to a costly insurance industry. This parasitic business suborns 10% to 20% of the health care bill while wasting our money on withholding health care deemed “not eligible” for patients who need it. Meanwhile, the executives who manage this insurance racket are paid enormous salaries not to deliver services.
Moreover, we reap a double loss to the health care system because hospitals must employ a building full of clerks to submit (and then, when rejected, re-submit) bills for reimbursement of hospital charges.
Franz Kafka would immediately grasp the despicable workings of this self-serving scheme.
David Link, MD
Associate Professor of Pediatrics
Harvard Medical School
Boston, Massachusetts
Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
Continue to: Dr. Nasrallah responds
Dr. Nasrallah responds
Thanks to all my colleagues who commented on (and unanimously agreed with) my editorial. It is clearly one of the most outrageous hurdles that all psychiatric practitioners face every day.
For the sake of our patients who deserve optimal medical care (laboratory tests, procedures, and medications), insurance companies must be tightly regulated to avoid second-guessing the treating clinicians, and readily cover what is prescribed. Some patients who can afford it resort to paying out of pocket for privacy reasons or for rapid access to psychiatric care, and may or may not file for insurance coverage, but they will certainly receive what their psychiatrist deems appropriate after a direct evaluation.
I hope the American Psychiatric Association and American Medical Association will continue to forcefully pursue legislation to eliminate pre-authorization and restore some sanity to the critical process of good clinical care.
Henry A. Nasrallah, MD
Professor of Psychiatry, Neurology, and Neuroscience
Medical Director: Neuropsychiatry
Director, Schizophrenia and Neuropsychiatry Programs
University of Cincinnati College of Medicine
Cincinnati, Ohio
Professor Emeritus, Saint Louis University
St. Louis, Missouri
I agree with Dr. Nasrallah’s clear description of the malign nature of the pre-authorization system, as described in his editorial “Pre-authorization is illegal, unethical, and adversely disrupts patient care” (From the Editor,
As an example of the latter, I was recently told by a pharmacist that I needed to call the insurer to justify why a patient was going from a prescription for #30 citalopram to #45 citalopram. The request had triggered a quantity limit. The pharmacist had explained to the insurer that more pills were required because the dosage was being lowered from 40 to 30 mg/d. Because there are no 30-mg tablets available, it made most sense for the patient to take one and a half 20-mg tablets, which totals 45 pills per month.
The insurer—probably a screener, not a pharmacist—would not accept that explanation and insisted that I call them myself. I bitterly resented how casually the insurer expected busy doctors to interrupt their clinical work to comply with arbitrary micromanagement of pill quantities! I’ve seldom seen such nonsense in more than 40 years of practice.
When doctors call these insurers, they are connected to a screener, but never a pharmacist. The screener asks a series of questions prompted by a computer. We give them verbal answers, but they don’t comprehend what they input into their system. The reasons we give to the screener may not even make it into the report that the screener passes on to the staff member who makes the decision. The doctor is not told what is in the report, or who is reviewing it. So much for transparency in this era that supposedly values it!
In any case, answering all the computer-prompted questions can take a long time. And time, as we know (but they do not), is not elastic.
Serious consequences may ensue if an insurer denies coverage for the doctor’s first choice. Many patients cannot afford to pay hundreds of extra dollars out of pocket. The insurer may ask the doctor to choose a different medication. Aside from the disrespect for the doctor’s decision implied by such a request, another problem is that the patient knows the new medication is his/her doctor’s second (or third) choice. Any positive placebo effect that may have existed before has now been lost. Most doctors would be glad to have a positive placebo effect augmenting the physiologic effects of the medication, especially when the patient is already feeling helpless or hopeless. These negative feelings would likely increase when the patient feels pressured into starting a medication that they know was their doctor’s second choice.
These are just a few reasons pre-authorization is a horrid system; Dr. Nasrallah covered many others in his editorial. The system, as currently structured, needs to be eliminated.
Arthur Mode, MD
Private psychiatric practice
Falls Church, Virginia
Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
Continue to: Hooray for...
Hooray for Dr. Nasrallah’s editorial about pre-authorization! I worry, however, that he missed some important considerations.
He writes, “The welfare of the patient is not on the insurance company’s radar screen, perhaps because it is crowded out by dollar signs.” But the welfare of the patient is exactly what is on their radar screens! If the patient dies, the insurance company profits, because it will not have to pay for treatment. This is like having a Red Sox employee manage the Yankees, except we are talking about human lives, not baseball games. Dr. Nasrallah asks (but does not answer), “How did for-profit insurance companies empower themselves to tyrannize clinical practice so that the treatment administered isn’t customized to the patient’s need but instead to fatten the profits of the insurance company?” The answer: Physicians let them. Many physicians are paid by insurers directly or through work for clinics or hospitals. He who pays the piper calls the tune. And because employers often select the insurer, patients have no say.
Honesty is most important. Pre-authorization is a dishonest term, because pre-authorization actually is pre-denial. The term pre-authorization should be replaced by “pre-denial.” It is also fraudulent when insurance companies call themselves health care companies, because they only provide insurance, not health care. Similarly, the term “evidence-based medicine” is typically only an excuse that insurers use to refuse to cover the cost of treatment. In another scenario of Dr. Nasrallah’s patient with treatment-resistant depression who responded to modafinil, what if the evidence for using this medication was based on the patient’s psychiatric history alone, without any evidence from a meta-analysis of randomized controlled trials? That would not be “evidence-based” in the dishonest world of insurance. Evidence to insurers does not include what is evident in the patient’s response to a given treatment.
What about amnesty, especially for physicians who work in the so-called pre-authorization denial business? Some even claim to be peers (ie, the “peer to peer reviews” they conduct) and insist they cannot be on speakerphone, so that their identity is kept secret from the patient. Not all of these “physicians” are incompetent. Not all of them have criminal minds or lack empathy. Some may have had exceptional circumstances leading them to such a profession, which Dr. Nasrallah correctly notes as felonious behavior. For these physicians, I think some kind of amnesty program would be appropriate, rather than prosecution.
John Jacobs, MD
Private psychiatric practice
Manchester, New Hampshire
Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
Continue to: I have just finished reading...
I have just finished reading Dr. Nasrallah’s editorial about pre-authorization. I agree with everything he said, but I do have a couple of comments:
1. Many of our colleagues do not accept insurance because their practices operate on a cash basis. This seems to obviate the problem of pre-authorization, and suggests that if we truly want to get rid of pre-authorization, we should get rid of insurance.
2. In practices that do not accept insurance, some patients may be filing their own insurance claims. Do you have any information on this approach? Are patients able to apply pressure to their insurance companies? Do patients get frustrated with their insurance companies and pay cash, rather than trying to negotiate with their insurance companies?
Katherine Hankins, MD
Private psychiatric practice
Omaha, Nebraska
Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
Continue to: Why not address...
Why not address the underlying (and actual) cause of the “pre-authorization” scam/scandal: the private health insurance industry.
Other countries in the western world have figured out how to provide guaranteed health care to their citizens without resorting to a costly insurance industry. This parasitic business suborns 10% to 20% of the health care bill while wasting our money on withholding health care deemed “not eligible” for patients who need it. Meanwhile, the executives who manage this insurance racket are paid enormous salaries not to deliver services.
Moreover, we reap a double loss to the health care system because hospitals must employ a building full of clerks to submit (and then, when rejected, re-submit) bills for reimbursement of hospital charges.
Franz Kafka would immediately grasp the despicable workings of this self-serving scheme.
David Link, MD
Associate Professor of Pediatrics
Harvard Medical School
Boston, Massachusetts
Disclosure: The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
Continue to: Dr. Nasrallah responds
Dr. Nasrallah responds
Thanks to all my colleagues who commented on (and unanimously agreed with) my editorial. It is clearly one of the most outrageous hurdles that all psychiatric practitioners face every day.
For the sake of our patients who deserve optimal medical care (laboratory tests, procedures, and medications), insurance companies must be tightly regulated to avoid second-guessing the treating clinicians, and readily cover what is prescribed. Some patients who can afford it resort to paying out of pocket for privacy reasons or for rapid access to psychiatric care, and may or may not file for insurance coverage, but they will certainly receive what their psychiatrist deems appropriate after a direct evaluation.
I hope the American Psychiatric Association and American Medical Association will continue to forcefully pursue legislation to eliminate pre-authorization and restore some sanity to the critical process of good clinical care.
Henry A. Nasrallah, MD
Professor of Psychiatry, Neurology, and Neuroscience
Medical Director: Neuropsychiatry
Director, Schizophrenia and Neuropsychiatry Programs
University of Cincinnati College of Medicine
Cincinnati, Ohio
Professor Emeritus, Saint Louis University
St. Louis, Missouri
Armchair epidemiology
Real epidemiologists are out knocking on doors, chasing down contacts, or hunched over their computers trying to make sense out of screens full of data and maps. A few are trying valiantly to talk some sense into our elected officials.
This leaves the rest of us with time on our hands to fabricate our own less-than-scientific explanations for the behavior of the SARS-CoV-2 virus. So I have decided to put on hold my current mental challenge of choosing which pasta shape to pair with the sauce I’ve prepared from an online recipe. Here is my educated guess based on what I can glean from media sources that may have been filtered through a variety politically biased lenses. Remember, I did go to medical school; however, when I was in college the DNA helix was still just theoretical.
From those halcyon days of mid-February when our attention was focused on the Diamond Princess quarantined in Yokohama Harbor, it didn’t take a board-certified epidemiologist to suspect that the virus was spreading through the ventilating system in the ship’s tight quarters. Subsequent outbreaks on U.S. and French military ships suggests a similar explanation.
While still not proven, it sounds like SARS-CoV-2 jumped to humans from bats. It should not surprise us that having evolved in a dense population of mammals it would thrive in other high-density populations such as New York and nursing homes. Because we have lacked a robust testing capability, it has been less obvious until recently that, while it is easily transmitted, the virus has infected many who are asymptomatic (“Antibody surveys suggesting vast undercount of coronavirus infections may be unreliable,” Gretchen Vogel, Science, April 21, 2020). Subsequent surveys seem to confirm this higher level carrier state; it suggests that the virus is far less deadly than was previously suggested. However, it seems to be a crafty little bug attacking just about any organ system it lands on.
I don’t think any of us are surprised that the elderly population with weakened immune systems, particularly those in congregate housing, has been much more vulnerable. However, many of the deaths among younger apparently healthy people have defied explanation. The anecdotal observations that physicians, particularly those who practice in-your-face medicine (e.g., ophthalmologists and otolaryngologists) may be more vulnerable raises the issue of viral load. It may be that, although it can be extremely contagious, the virus is not terribly dangerous for most people until the inoculum dose of the virus reaches a certain level. To my knowledge this dose is unknown.
A published survey of more than 300 outbreaks from 120 Chinese cities also may support my suspicion that viral load is of critical importance. The researchers found that all the “identified outbreaks of three or more cases occurred in an indoor environment, which confirms that sharing indoor space is a major SARS-CoV-2 infection risk” (Huan Qian et al. “Indoor transmission of SARS-CoV-2,” MedRxiv. 2020 Apr 7. doi: 10.1101/2020.04.04.20053058). Again, this data shouldn’t surprise us when we look back at what little we know about the outbreaks in the confined spaces on cruise ships and in nursing homes.
I’m not sure that we have any data that helps us determine whether wearing a mask in an outdoor space has any more than symbolic value when we are talking about this particular virus. We may read that the virus in a droplet can survive on the surface it lands on for 8 minutes, and we can see those slow motion videos of the impressive plume of snot spray released by a sneeze. It would seem obvious that even outside someone within 10 feet of the sneeze has a good chance of being infected. However, how much of a threat is the asymptomatic carrier who passes within three feet of you while you are out on lovely summer day stroll? This armchair epidemiologist suspects that, when we are talking about an outside space, the 6-foot guideline for small groups of a dozen or less is overly restrictive. But until we know, I’m staying put in my armchair ... outside on the porch overlooking Casco Bay.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” He has no disclosures. Email him at [email protected].
Real epidemiologists are out knocking on doors, chasing down contacts, or hunched over their computers trying to make sense out of screens full of data and maps. A few are trying valiantly to talk some sense into our elected officials.
This leaves the rest of us with time on our hands to fabricate our own less-than-scientific explanations for the behavior of the SARS-CoV-2 virus. So I have decided to put on hold my current mental challenge of choosing which pasta shape to pair with the sauce I’ve prepared from an online recipe. Here is my educated guess based on what I can glean from media sources that may have been filtered through a variety politically biased lenses. Remember, I did go to medical school; however, when I was in college the DNA helix was still just theoretical.
From those halcyon days of mid-February when our attention was focused on the Diamond Princess quarantined in Yokohama Harbor, it didn’t take a board-certified epidemiologist to suspect that the virus was spreading through the ventilating system in the ship’s tight quarters. Subsequent outbreaks on U.S. and French military ships suggests a similar explanation.
While still not proven, it sounds like SARS-CoV-2 jumped to humans from bats. It should not surprise us that having evolved in a dense population of mammals it would thrive in other high-density populations such as New York and nursing homes. Because we have lacked a robust testing capability, it has been less obvious until recently that, while it is easily transmitted, the virus has infected many who are asymptomatic (“Antibody surveys suggesting vast undercount of coronavirus infections may be unreliable,” Gretchen Vogel, Science, April 21, 2020). Subsequent surveys seem to confirm this higher level carrier state; it suggests that the virus is far less deadly than was previously suggested. However, it seems to be a crafty little bug attacking just about any organ system it lands on.
I don’t think any of us are surprised that the elderly population with weakened immune systems, particularly those in congregate housing, has been much more vulnerable. However, many of the deaths among younger apparently healthy people have defied explanation. The anecdotal observations that physicians, particularly those who practice in-your-face medicine (e.g., ophthalmologists and otolaryngologists) may be more vulnerable raises the issue of viral load. It may be that, although it can be extremely contagious, the virus is not terribly dangerous for most people until the inoculum dose of the virus reaches a certain level. To my knowledge this dose is unknown.
A published survey of more than 300 outbreaks from 120 Chinese cities also may support my suspicion that viral load is of critical importance. The researchers found that all the “identified outbreaks of three or more cases occurred in an indoor environment, which confirms that sharing indoor space is a major SARS-CoV-2 infection risk” (Huan Qian et al. “Indoor transmission of SARS-CoV-2,” MedRxiv. 2020 Apr 7. doi: 10.1101/2020.04.04.20053058). Again, this data shouldn’t surprise us when we look back at what little we know about the outbreaks in the confined spaces on cruise ships and in nursing homes.
I’m not sure that we have any data that helps us determine whether wearing a mask in an outdoor space has any more than symbolic value when we are talking about this particular virus. We may read that the virus in a droplet can survive on the surface it lands on for 8 minutes, and we can see those slow motion videos of the impressive plume of snot spray released by a sneeze. It would seem obvious that even outside someone within 10 feet of the sneeze has a good chance of being infected. However, how much of a threat is the asymptomatic carrier who passes within three feet of you while you are out on lovely summer day stroll? This armchair epidemiologist suspects that, when we are talking about an outside space, the 6-foot guideline for small groups of a dozen or less is overly restrictive. But until we know, I’m staying put in my armchair ... outside on the porch overlooking Casco Bay.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” He has no disclosures. Email him at [email protected].
Real epidemiologists are out knocking on doors, chasing down contacts, or hunched over their computers trying to make sense out of screens full of data and maps. A few are trying valiantly to talk some sense into our elected officials.
This leaves the rest of us with time on our hands to fabricate our own less-than-scientific explanations for the behavior of the SARS-CoV-2 virus. So I have decided to put on hold my current mental challenge of choosing which pasta shape to pair with the sauce I’ve prepared from an online recipe. Here is my educated guess based on what I can glean from media sources that may have been filtered through a variety politically biased lenses. Remember, I did go to medical school; however, when I was in college the DNA helix was still just theoretical.
From those halcyon days of mid-February when our attention was focused on the Diamond Princess quarantined in Yokohama Harbor, it didn’t take a board-certified epidemiologist to suspect that the virus was spreading through the ventilating system in the ship’s tight quarters. Subsequent outbreaks on U.S. and French military ships suggests a similar explanation.
While still not proven, it sounds like SARS-CoV-2 jumped to humans from bats. It should not surprise us that having evolved in a dense population of mammals it would thrive in other high-density populations such as New York and nursing homes. Because we have lacked a robust testing capability, it has been less obvious until recently that, while it is easily transmitted, the virus has infected many who are asymptomatic (“Antibody surveys suggesting vast undercount of coronavirus infections may be unreliable,” Gretchen Vogel, Science, April 21, 2020). Subsequent surveys seem to confirm this higher level carrier state; it suggests that the virus is far less deadly than was previously suggested. However, it seems to be a crafty little bug attacking just about any organ system it lands on.
I don’t think any of us are surprised that the elderly population with weakened immune systems, particularly those in congregate housing, has been much more vulnerable. However, many of the deaths among younger apparently healthy people have defied explanation. The anecdotal observations that physicians, particularly those who practice in-your-face medicine (e.g., ophthalmologists and otolaryngologists) may be more vulnerable raises the issue of viral load. It may be that, although it can be extremely contagious, the virus is not terribly dangerous for most people until the inoculum dose of the virus reaches a certain level. To my knowledge this dose is unknown.
A published survey of more than 300 outbreaks from 120 Chinese cities also may support my suspicion that viral load is of critical importance. The researchers found that all the “identified outbreaks of three or more cases occurred in an indoor environment, which confirms that sharing indoor space is a major SARS-CoV-2 infection risk” (Huan Qian et al. “Indoor transmission of SARS-CoV-2,” MedRxiv. 2020 Apr 7. doi: 10.1101/2020.04.04.20053058). Again, this data shouldn’t surprise us when we look back at what little we know about the outbreaks in the confined spaces on cruise ships and in nursing homes.
I’m not sure that we have any data that helps us determine whether wearing a mask in an outdoor space has any more than symbolic value when we are talking about this particular virus. We may read that the virus in a droplet can survive on the surface it lands on for 8 minutes, and we can see those slow motion videos of the impressive plume of snot spray released by a sneeze. It would seem obvious that even outside someone within 10 feet of the sneeze has a good chance of being infected. However, how much of a threat is the asymptomatic carrier who passes within three feet of you while you are out on lovely summer day stroll? This armchair epidemiologist suspects that, when we are talking about an outside space, the 6-foot guideline for small groups of a dozen or less is overly restrictive. But until we know, I’m staying put in my armchair ... outside on the porch overlooking Casco Bay.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” He has no disclosures. Email him at [email protected].
Time series analysis of poison control data
The US Poison Control Centers’ National Poison Data System (NPDS) publishes annual reports describing exposures to various substances among the general population.1 Table 22B of each NPDS report shows the number of outcomes from exposures to different pharmacologic treatments in the United States, including psychotropic medications.2 In this Table, the relative morbidity (RM) of a medication is calculated as the ratio of serious outcomes (SO) to single exposures (SE), where SO = moderate + major + death. In this article, I use the NPDS data to demonstrate how time series analysis of the RM ratios for hypertension and psychiatric medications can help predict SO associated with these agents, which may help guide clinicians’ prescribing decisions.2,3
Time series analysis of hypertension medications
Due to the high prevalence of hypertension, it is not surprising that more suicide deaths occur each year from calcium channel blockers (CCB) than from lithium (37 vs 2, according to 2017 NPDS data).3 I used time series analysis to compare SO during 2006-2017 for 5 classes of hypertension medications: CCB, beta blockers (BB), angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB), and diuretics (Figure 1).
Time series analysis of 2006-2017 data predicted the following number of deaths for 2018: CCB ≥33, BB ≥17, ACEI ≤2, ARB 0, and diuretics ≤1. The observed deaths in 2018 were 41, 23, 0, 0, and 1, respectively.2 The 2018 predicted RM were CCB 10.66%, BB 11.10%, ACEI 3.51%, ARB 2.04%, and diuretics 3.38%. The 2018 observed RM for these medications were 11.01%, 11.37%, 3.02%, 2.40%, and 2.88%, respectively.2
Because the NPDS data for hypertension medications was only provided by class, in order to detect differences within each class, I used the relative lethality (RL) equation: RL = 310x / LD50, where x is the maximum daily dose of a medication prescribed for 30 days, and LD50 is the rat oral lethal dose 50. The RL equation represents the ratio of a 30-day supply of medication to the human equivalent LD50 for a 60-kg person.4 The RL equation is useful for comparing the safety of various medications, and can help clinicians avoid prescribing a lethal amount of a given medication (Figure 2). For example, the equation shows that among CCB, felodipine is 466 times safer than verapamil and 101 times safer than diltiazem. Not surprisingly, 2006-2018 data shows many deaths via intentional verapamil or diltiazem overdose vs only 1 reference to felodipine. A regression model shows significant correlation and causality between RL and SO over time.5 Integrating all 3 mathematical models suggests that the higher RM of CCB and BB may be caused by the high RL of verapamil, diltiazem, nicardipine, propranolol, and labetalol.
These mathematical models can help physicians consider whether to switch the patient’s current medication to another class with a lower RM. For patients who need a BB or CCB, prescribing a medication with a lower RL within the same class may be another option. The data suggest that avoiding hypertension medications with RL >100% may significantly decrease morbidity and mortality.
Predicting serious outcomes of psychiatric medications
The 2018 NPDS data for psychiatric medications show similarly important results.2 For example, the lithium RM is predictable over time (Figure 3) and has been consistently the highest among psychiatric medications. Using 2006-2017 NPDS data,3 I predicted that the 2018 lithium RM would be 41.56%. The 2018 observed lithium RM was 41.45%.2 I created a linear regression model for each NPDS report from 2013 to 2018 to illustrate the correlation between RL and adjusted SO for 13 psychiatric medications.2,3,6,7 To account for different sample sizes among medications, the lithium SE for each respective year was used for all medications (adjusted SO = SE × RM). A time series analysis of these regression models shows that SO data points hover in the same y-axis region from year to year, with a corresponding RL on the x-axis: escitalopram 6.33%, citalopram 15.50%, mirtazapine 28.47%, paroxetine 37.35%, sertraline 46.72%, fluoxetine 54.87%, venlafaxine 99.64%, duloxetine 133.33%, trazodone 269.57%, bupropion 289.42%, amitriptyline 387.50%, doxepin 632.65%, and lithium 1062.86% (Figure 4). Every year, the scatter plot shape remains approximately the same, which suggests that both SO and RM can be predicted over time. Medications with RL >300% have SO ≈ 1500 (RM ≈ 40%), and those with RL <100% have SO ≈ 500 (RM ≈ 13%).
Time series analysis of NPDS data sheds light on hidden patterns. It may help clinicians discern patterns of potential SO associated with various hypertension and psychiatric medications. RL based on rat experimental data is highly correlated to RM based on human observational data, and the causality is self-evident. On a global scale, data-driven prescribing of medications with RL <100% could potentially help prevent millions of SO every year.
1. National Poison Data System Annual Reports. American Association of Poison Control Centers. https://www.aapcc.org/annual-reports. Updated November 2019. Accessed May 5, 2020.
2. Gummin DD, Mowry JB, Spyker DA, et al. 2018 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 36th Annual Report. Clin Toxicol (Phila). 2019;57(12):1220-1413.
3. Gummin DD, Mowry JB, Spyker DA, et al. 2017 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 35th Annual Report. Clin Toxicol (Phila). 2018;56(12):1213-1415.
4. Giurca D. Decreasing suicide risk with math. Current Psychiatry. 2018;17(2):57-59,A,B.
5. Giurca D. Data-driven prescribing. Current Psychiatry. 2018;17(10):e6-e8.
6. Mowry JB, Spyker DA, Brooks DE, et al. 2015 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 33rd Annual Report. Clin Toxicol (Phila). 2016;54(10):924-1109.
7. Gummin DD, Mowry JB, Spyker DA, et al. 2016 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 34th Annual Report. Clin Toxicol (Phila). 2017;55(10):1072-1252.
The US Poison Control Centers’ National Poison Data System (NPDS) publishes annual reports describing exposures to various substances among the general population.1 Table 22B of each NPDS report shows the number of outcomes from exposures to different pharmacologic treatments in the United States, including psychotropic medications.2 In this Table, the relative morbidity (RM) of a medication is calculated as the ratio of serious outcomes (SO) to single exposures (SE), where SO = moderate + major + death. In this article, I use the NPDS data to demonstrate how time series analysis of the RM ratios for hypertension and psychiatric medications can help predict SO associated with these agents, which may help guide clinicians’ prescribing decisions.2,3
Time series analysis of hypertension medications
Due to the high prevalence of hypertension, it is not surprising that more suicide deaths occur each year from calcium channel blockers (CCB) than from lithium (37 vs 2, according to 2017 NPDS data).3 I used time series analysis to compare SO during 2006-2017 for 5 classes of hypertension medications: CCB, beta blockers (BB), angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB), and diuretics (Figure 1).
Time series analysis of 2006-2017 data predicted the following number of deaths for 2018: CCB ≥33, BB ≥17, ACEI ≤2, ARB 0, and diuretics ≤1. The observed deaths in 2018 were 41, 23, 0, 0, and 1, respectively.2 The 2018 predicted RM were CCB 10.66%, BB 11.10%, ACEI 3.51%, ARB 2.04%, and diuretics 3.38%. The 2018 observed RM for these medications were 11.01%, 11.37%, 3.02%, 2.40%, and 2.88%, respectively.2
Because the NPDS data for hypertension medications was only provided by class, in order to detect differences within each class, I used the relative lethality (RL) equation: RL = 310x / LD50, where x is the maximum daily dose of a medication prescribed for 30 days, and LD50 is the rat oral lethal dose 50. The RL equation represents the ratio of a 30-day supply of medication to the human equivalent LD50 for a 60-kg person.4 The RL equation is useful for comparing the safety of various medications, and can help clinicians avoid prescribing a lethal amount of a given medication (Figure 2). For example, the equation shows that among CCB, felodipine is 466 times safer than verapamil and 101 times safer than diltiazem. Not surprisingly, 2006-2018 data shows many deaths via intentional verapamil or diltiazem overdose vs only 1 reference to felodipine. A regression model shows significant correlation and causality between RL and SO over time.5 Integrating all 3 mathematical models suggests that the higher RM of CCB and BB may be caused by the high RL of verapamil, diltiazem, nicardipine, propranolol, and labetalol.
These mathematical models can help physicians consider whether to switch the patient’s current medication to another class with a lower RM. For patients who need a BB or CCB, prescribing a medication with a lower RL within the same class may be another option. The data suggest that avoiding hypertension medications with RL >100% may significantly decrease morbidity and mortality.
Predicting serious outcomes of psychiatric medications
The 2018 NPDS data for psychiatric medications show similarly important results.2 For example, the lithium RM is predictable over time (Figure 3) and has been consistently the highest among psychiatric medications. Using 2006-2017 NPDS data,3 I predicted that the 2018 lithium RM would be 41.56%. The 2018 observed lithium RM was 41.45%.2 I created a linear regression model for each NPDS report from 2013 to 2018 to illustrate the correlation between RL and adjusted SO for 13 psychiatric medications.2,3,6,7 To account for different sample sizes among medications, the lithium SE for each respective year was used for all medications (adjusted SO = SE × RM). A time series analysis of these regression models shows that SO data points hover in the same y-axis region from year to year, with a corresponding RL on the x-axis: escitalopram 6.33%, citalopram 15.50%, mirtazapine 28.47%, paroxetine 37.35%, sertraline 46.72%, fluoxetine 54.87%, venlafaxine 99.64%, duloxetine 133.33%, trazodone 269.57%, bupropion 289.42%, amitriptyline 387.50%, doxepin 632.65%, and lithium 1062.86% (Figure 4). Every year, the scatter plot shape remains approximately the same, which suggests that both SO and RM can be predicted over time. Medications with RL >300% have SO ≈ 1500 (RM ≈ 40%), and those with RL <100% have SO ≈ 500 (RM ≈ 13%).
Time series analysis of NPDS data sheds light on hidden patterns. It may help clinicians discern patterns of potential SO associated with various hypertension and psychiatric medications. RL based on rat experimental data is highly correlated to RM based on human observational data, and the causality is self-evident. On a global scale, data-driven prescribing of medications with RL <100% could potentially help prevent millions of SO every year.
The US Poison Control Centers’ National Poison Data System (NPDS) publishes annual reports describing exposures to various substances among the general population.1 Table 22B of each NPDS report shows the number of outcomes from exposures to different pharmacologic treatments in the United States, including psychotropic medications.2 In this Table, the relative morbidity (RM) of a medication is calculated as the ratio of serious outcomes (SO) to single exposures (SE), where SO = moderate + major + death. In this article, I use the NPDS data to demonstrate how time series analysis of the RM ratios for hypertension and psychiatric medications can help predict SO associated with these agents, which may help guide clinicians’ prescribing decisions.2,3
Time series analysis of hypertension medications
Due to the high prevalence of hypertension, it is not surprising that more suicide deaths occur each year from calcium channel blockers (CCB) than from lithium (37 vs 2, according to 2017 NPDS data).3 I used time series analysis to compare SO during 2006-2017 for 5 classes of hypertension medications: CCB, beta blockers (BB), angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB), and diuretics (Figure 1).
Time series analysis of 2006-2017 data predicted the following number of deaths for 2018: CCB ≥33, BB ≥17, ACEI ≤2, ARB 0, and diuretics ≤1. The observed deaths in 2018 were 41, 23, 0, 0, and 1, respectively.2 The 2018 predicted RM were CCB 10.66%, BB 11.10%, ACEI 3.51%, ARB 2.04%, and diuretics 3.38%. The 2018 observed RM for these medications were 11.01%, 11.37%, 3.02%, 2.40%, and 2.88%, respectively.2
Because the NPDS data for hypertension medications was only provided by class, in order to detect differences within each class, I used the relative lethality (RL) equation: RL = 310x / LD50, where x is the maximum daily dose of a medication prescribed for 30 days, and LD50 is the rat oral lethal dose 50. The RL equation represents the ratio of a 30-day supply of medication to the human equivalent LD50 for a 60-kg person.4 The RL equation is useful for comparing the safety of various medications, and can help clinicians avoid prescribing a lethal amount of a given medication (Figure 2). For example, the equation shows that among CCB, felodipine is 466 times safer than verapamil and 101 times safer than diltiazem. Not surprisingly, 2006-2018 data shows many deaths via intentional verapamil or diltiazem overdose vs only 1 reference to felodipine. A regression model shows significant correlation and causality between RL and SO over time.5 Integrating all 3 mathematical models suggests that the higher RM of CCB and BB may be caused by the high RL of verapamil, diltiazem, nicardipine, propranolol, and labetalol.
These mathematical models can help physicians consider whether to switch the patient’s current medication to another class with a lower RM. For patients who need a BB or CCB, prescribing a medication with a lower RL within the same class may be another option. The data suggest that avoiding hypertension medications with RL >100% may significantly decrease morbidity and mortality.
Predicting serious outcomes of psychiatric medications
The 2018 NPDS data for psychiatric medications show similarly important results.2 For example, the lithium RM is predictable over time (Figure 3) and has been consistently the highest among psychiatric medications. Using 2006-2017 NPDS data,3 I predicted that the 2018 lithium RM would be 41.56%. The 2018 observed lithium RM was 41.45%.2 I created a linear regression model for each NPDS report from 2013 to 2018 to illustrate the correlation between RL and adjusted SO for 13 psychiatric medications.2,3,6,7 To account for different sample sizes among medications, the lithium SE for each respective year was used for all medications (adjusted SO = SE × RM). A time series analysis of these regression models shows that SO data points hover in the same y-axis region from year to year, with a corresponding RL on the x-axis: escitalopram 6.33%, citalopram 15.50%, mirtazapine 28.47%, paroxetine 37.35%, sertraline 46.72%, fluoxetine 54.87%, venlafaxine 99.64%, duloxetine 133.33%, trazodone 269.57%, bupropion 289.42%, amitriptyline 387.50%, doxepin 632.65%, and lithium 1062.86% (Figure 4). Every year, the scatter plot shape remains approximately the same, which suggests that both SO and RM can be predicted over time. Medications with RL >300% have SO ≈ 1500 (RM ≈ 40%), and those with RL <100% have SO ≈ 500 (RM ≈ 13%).
Time series analysis of NPDS data sheds light on hidden patterns. It may help clinicians discern patterns of potential SO associated with various hypertension and psychiatric medications. RL based on rat experimental data is highly correlated to RM based on human observational data, and the causality is self-evident. On a global scale, data-driven prescribing of medications with RL <100% could potentially help prevent millions of SO every year.
1. National Poison Data System Annual Reports. American Association of Poison Control Centers. https://www.aapcc.org/annual-reports. Updated November 2019. Accessed May 5, 2020.
2. Gummin DD, Mowry JB, Spyker DA, et al. 2018 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 36th Annual Report. Clin Toxicol (Phila). 2019;57(12):1220-1413.
3. Gummin DD, Mowry JB, Spyker DA, et al. 2017 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 35th Annual Report. Clin Toxicol (Phila). 2018;56(12):1213-1415.
4. Giurca D. Decreasing suicide risk with math. Current Psychiatry. 2018;17(2):57-59,A,B.
5. Giurca D. Data-driven prescribing. Current Psychiatry. 2018;17(10):e6-e8.
6. Mowry JB, Spyker DA, Brooks DE, et al. 2015 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 33rd Annual Report. Clin Toxicol (Phila). 2016;54(10):924-1109.
7. Gummin DD, Mowry JB, Spyker DA, et al. 2016 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 34th Annual Report. Clin Toxicol (Phila). 2017;55(10):1072-1252.
1. National Poison Data System Annual Reports. American Association of Poison Control Centers. https://www.aapcc.org/annual-reports. Updated November 2019. Accessed May 5, 2020.
2. Gummin DD, Mowry JB, Spyker DA, et al. 2018 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 36th Annual Report. Clin Toxicol (Phila). 2019;57(12):1220-1413.
3. Gummin DD, Mowry JB, Spyker DA, et al. 2017 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 35th Annual Report. Clin Toxicol (Phila). 2018;56(12):1213-1415.
4. Giurca D. Decreasing suicide risk with math. Current Psychiatry. 2018;17(2):57-59,A,B.
5. Giurca D. Data-driven prescribing. Current Psychiatry. 2018;17(10):e6-e8.
6. Mowry JB, Spyker DA, Brooks DE, et al. 2015 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 33rd Annual Report. Clin Toxicol (Phila). 2016;54(10):924-1109.
7. Gummin DD, Mowry JB, Spyker DA, et al. 2016 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 34th Annual Report. Clin Toxicol (Phila). 2017;55(10):1072-1252.
Telepsychiatry during COVID-19: Understanding the rules
In addition to affecting our personal lives, coronavirus disease 2019 (COVID-19) has altered the way we practice psychiatry. Telepsychiatry—the delivery of mental health services via remote communication—is being used to replace face-to-face outpatient encounters. Several rules and regulations governing the provision of care and prescribing have been temporarily modified or suspended to allow clinicians to more easily use telepsychiatry to care for their patients. Although these requirements are continually changing, here I review some of the telepsychiatry rules and regulations clinicians need to understand to minimize their risk for liability.
Changes in light of COVID-19
In March 2020, the Centers for Medicare & Medicaid Services (CMS) released guidance that allows Medicare beneficiaries to receive various services at home through telehealth without having to travel to a doctor’s office or hospital.1 Many commercial insurers also are allowing patients to receive telehealth services in their home. The US Department of Health & Human Services Office for Civil Rights, which enforces the Health Insurance Portability and Accountability Act (HIPAA), reported in March 2020 that it will not impose penalties for not complying with HIPAA requirements on clinicians who provide good-faith telepsychiatry during the COVID-19 crisis.2
Clinicians who want to use audio or video remote communication to provide any type of telehealth services (not just those related to COVID-19) should use “non-public facing” products.2 Non-public facing products (eg, Skype, WhatsApp video call, Zoom) allow only the intended parties to participate in the communication.3 Usually, these products employ end-to-end encryption, which allows only those engaging in communication to see and hear what is transmitted.3 To limit access and verify the participants, these products also support individual user accounts, login names, and passwords.3 In addition, these products usually allow participants and/or “the host” to exert some degree of control over particular features, such as choosing to record the communication, mute, or turn off the video or audio signal.3 When using these products, clinicians should enable all available encryption and privacy modes.2
“Public-facing” products (eg, Facebook Live, TikTok, Twitch) should not be used to provide telepsychiatry services because they are designed to be open to the public or allow for wide or indiscriminate access to the communication.2,3 Clinicians who desire additional privacy protections (and a more permanent solution) should choose a HIPAA-compliant telehealth vendor (eg, Doxy.me, VSee, Zoom for Healthcare) and obtain a Business Associate Agreement with the vendor to ensure data protection and security.2,4
Regardless of the product, obtain informed consent from your patients that authorizes the use of remote communication.4 Inform your patients of any potential privacy or security breaches, the need for interactions to be conducted in a location that provides privacy, and whether the specific technology used is HIPAA-compliant.4 Document that your patients understand these issues before using remote communication.4
How licensing requirements have changed
As of March 31, 2020, the CMS temporarily waived the requirement that out-of-state clinicians be licensed in the state where they are providing services to Medicare beneficiaries.5 The CMS waived this requirement for clinicians who meet the following 4 conditions5,6:
- must be enrolled in Medicare
- must possess a valid license to practice in the state that relates to his/her Medicare enrollment
- are furnishing services—whether in person or via telepsychiatry—in a state where the emergency is occurring to contribute to relief efforts in his/her professional capacity
- are not excluded from practicing in any state that is part of the nationally declared emergency area.
Note that individual state licensure requirements continue to apply unless waived by the state.6 Therefore, in order for clinicians to see Medicare patients via remote communication under the 4 conditions described above, the state also would have to waive its licensure requirements for the type of practice for which the clinicians are licensed in their own state.6 Regarding commercial payers, in general, clinicians providing telepsychiatry services need a license to practice in the state where the patient is located at the time services are provided.6 During the COVID-19 pandemic, many governors issued executive orders waiving licensure requirements, and many have accelerated granting temporary licenses to out-of-state clinicians who wish to provide telepsychiatry services to the residents of their state.4
Continue to: Prescribing via telepsychiatry
Prescribing via telepsychiatry
Effective March 31, 2020 and lasting for the duration of COVID-19 emergency declaration, the Drug Enforcement Agency (DEA) suspended the Ryan Haight Online Pharmacy Consumer Protection Act of 2008, which requires clinicians to conduct initial, in-person examinations of patients before they can prescribe controlled substances electronically.6,7 The DEA suspension allows clinicians to prescribe controlled substances after conducting an initial evaluation via remote communication. In addition, the DEA waived the requirement that a clinician needs to hold a DEA license in the state where the patient is located to be able to prescribe a controlled substance electronically.4,6 However, you still must comply with all other state laws and regulations for prescribing controlled substances.4
Staying informed
Although several telepsychiatry rules and regulations have been modified or suspended during the COVID-19 pandemic, the standard of care for services rendered via telepsychiatry remains the same as services provided via face-to-face encounters, including patient evaluation and assessment, treatment plans, medication, and documentation.4 Clinicians can keep up-to-date on how practicing telepsychiatry may evolve during these times by using the following resources from the American Psychiatric Association:
- Telepsychiatry Toolkit: www.psychiatry.org/psychiatrists/practice/telepsychiatry
- Practice Guidance for COVID-19: www.psychiatry.org/psychiatrists/covid-19-coronavirus/practice-guidance-for-covid-19.
1. Centers for Medicare and Medicaid Services. COVID-19: President Trump expands telehealth benefits for Medicare beneficiaries during COVID-19 outbreak. https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-03-17. Published March 17, 2020. Accessed May 6, 2020.
2. US Department of Health & Human Services. Notification of enforcement discretion for telehealth remote communications during the COVID-19 nationwide public health emergency. https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html. Updated March 30, 2020. Accessed May 6, 2020.
3. US Department of Health & Human Services. What is a “non-public facing” remote communication product? https://www.hhs.gov/hipaa/for-professionals/faq/3024/what-is-a-non-public-facing-remote-communication-product/index.html. Updated April 10, 2020. Accessed May 6, 2020.
4. Huben-Kearney A. Risk management amid a global pandemic. Psychiatric News. https://psychnews.psychiatryonline.org/doi/10.1176/appi.pn.2020.5a38. Published April 28, 2020. Accessed May 6, 2020.
5. Centers for Medicare & Medicaid Services. COVID-19 emergency declaration blanket waivers for health care providers. https://www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf. Published April 29, 2020. Accessed May 6, 2020.
6. American Psychiatric Association. Update on telehealth restrictions in response to COVID-19. https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/blog/apa-resources-on-telepsychiatry-and-covid-19. Updated May 1, 2020. Accessed May 6, 2020.
7. US Drug Enforcement Agency. How to prescribe controlled substances to patients during the COVID-19 public health emergency. https://www.deadiversion.usdoj.gov/GDP/(DEA-DC-023)(DEA075)Decision_Tree_(Final)_33120_2007.pdf. Published March 31, 2020. Accessed on May 6, 2020.
In addition to affecting our personal lives, coronavirus disease 2019 (COVID-19) has altered the way we practice psychiatry. Telepsychiatry—the delivery of mental health services via remote communication—is being used to replace face-to-face outpatient encounters. Several rules and regulations governing the provision of care and prescribing have been temporarily modified or suspended to allow clinicians to more easily use telepsychiatry to care for their patients. Although these requirements are continually changing, here I review some of the telepsychiatry rules and regulations clinicians need to understand to minimize their risk for liability.
Changes in light of COVID-19
In March 2020, the Centers for Medicare & Medicaid Services (CMS) released guidance that allows Medicare beneficiaries to receive various services at home through telehealth without having to travel to a doctor’s office or hospital.1 Many commercial insurers also are allowing patients to receive telehealth services in their home. The US Department of Health & Human Services Office for Civil Rights, which enforces the Health Insurance Portability and Accountability Act (HIPAA), reported in March 2020 that it will not impose penalties for not complying with HIPAA requirements on clinicians who provide good-faith telepsychiatry during the COVID-19 crisis.2
Clinicians who want to use audio or video remote communication to provide any type of telehealth services (not just those related to COVID-19) should use “non-public facing” products.2 Non-public facing products (eg, Skype, WhatsApp video call, Zoom) allow only the intended parties to participate in the communication.3 Usually, these products employ end-to-end encryption, which allows only those engaging in communication to see and hear what is transmitted.3 To limit access and verify the participants, these products also support individual user accounts, login names, and passwords.3 In addition, these products usually allow participants and/or “the host” to exert some degree of control over particular features, such as choosing to record the communication, mute, or turn off the video or audio signal.3 When using these products, clinicians should enable all available encryption and privacy modes.2
“Public-facing” products (eg, Facebook Live, TikTok, Twitch) should not be used to provide telepsychiatry services because they are designed to be open to the public or allow for wide or indiscriminate access to the communication.2,3 Clinicians who desire additional privacy protections (and a more permanent solution) should choose a HIPAA-compliant telehealth vendor (eg, Doxy.me, VSee, Zoom for Healthcare) and obtain a Business Associate Agreement with the vendor to ensure data protection and security.2,4
Regardless of the product, obtain informed consent from your patients that authorizes the use of remote communication.4 Inform your patients of any potential privacy or security breaches, the need for interactions to be conducted in a location that provides privacy, and whether the specific technology used is HIPAA-compliant.4 Document that your patients understand these issues before using remote communication.4
How licensing requirements have changed
As of March 31, 2020, the CMS temporarily waived the requirement that out-of-state clinicians be licensed in the state where they are providing services to Medicare beneficiaries.5 The CMS waived this requirement for clinicians who meet the following 4 conditions5,6:
- must be enrolled in Medicare
- must possess a valid license to practice in the state that relates to his/her Medicare enrollment
- are furnishing services—whether in person or via telepsychiatry—in a state where the emergency is occurring to contribute to relief efforts in his/her professional capacity
- are not excluded from practicing in any state that is part of the nationally declared emergency area.
Note that individual state licensure requirements continue to apply unless waived by the state.6 Therefore, in order for clinicians to see Medicare patients via remote communication under the 4 conditions described above, the state also would have to waive its licensure requirements for the type of practice for which the clinicians are licensed in their own state.6 Regarding commercial payers, in general, clinicians providing telepsychiatry services need a license to practice in the state where the patient is located at the time services are provided.6 During the COVID-19 pandemic, many governors issued executive orders waiving licensure requirements, and many have accelerated granting temporary licenses to out-of-state clinicians who wish to provide telepsychiatry services to the residents of their state.4
Continue to: Prescribing via telepsychiatry
Prescribing via telepsychiatry
Effective March 31, 2020 and lasting for the duration of COVID-19 emergency declaration, the Drug Enforcement Agency (DEA) suspended the Ryan Haight Online Pharmacy Consumer Protection Act of 2008, which requires clinicians to conduct initial, in-person examinations of patients before they can prescribe controlled substances electronically.6,7 The DEA suspension allows clinicians to prescribe controlled substances after conducting an initial evaluation via remote communication. In addition, the DEA waived the requirement that a clinician needs to hold a DEA license in the state where the patient is located to be able to prescribe a controlled substance electronically.4,6 However, you still must comply with all other state laws and regulations for prescribing controlled substances.4
Staying informed
Although several telepsychiatry rules and regulations have been modified or suspended during the COVID-19 pandemic, the standard of care for services rendered via telepsychiatry remains the same as services provided via face-to-face encounters, including patient evaluation and assessment, treatment plans, medication, and documentation.4 Clinicians can keep up-to-date on how practicing telepsychiatry may evolve during these times by using the following resources from the American Psychiatric Association:
- Telepsychiatry Toolkit: www.psychiatry.org/psychiatrists/practice/telepsychiatry
- Practice Guidance for COVID-19: www.psychiatry.org/psychiatrists/covid-19-coronavirus/practice-guidance-for-covid-19.
In addition to affecting our personal lives, coronavirus disease 2019 (COVID-19) has altered the way we practice psychiatry. Telepsychiatry—the delivery of mental health services via remote communication—is being used to replace face-to-face outpatient encounters. Several rules and regulations governing the provision of care and prescribing have been temporarily modified or suspended to allow clinicians to more easily use telepsychiatry to care for their patients. Although these requirements are continually changing, here I review some of the telepsychiatry rules and regulations clinicians need to understand to minimize their risk for liability.
Changes in light of COVID-19
In March 2020, the Centers for Medicare & Medicaid Services (CMS) released guidance that allows Medicare beneficiaries to receive various services at home through telehealth without having to travel to a doctor’s office or hospital.1 Many commercial insurers also are allowing patients to receive telehealth services in their home. The US Department of Health & Human Services Office for Civil Rights, which enforces the Health Insurance Portability and Accountability Act (HIPAA), reported in March 2020 that it will not impose penalties for not complying with HIPAA requirements on clinicians who provide good-faith telepsychiatry during the COVID-19 crisis.2
Clinicians who want to use audio or video remote communication to provide any type of telehealth services (not just those related to COVID-19) should use “non-public facing” products.2 Non-public facing products (eg, Skype, WhatsApp video call, Zoom) allow only the intended parties to participate in the communication.3 Usually, these products employ end-to-end encryption, which allows only those engaging in communication to see and hear what is transmitted.3 To limit access and verify the participants, these products also support individual user accounts, login names, and passwords.3 In addition, these products usually allow participants and/or “the host” to exert some degree of control over particular features, such as choosing to record the communication, mute, or turn off the video or audio signal.3 When using these products, clinicians should enable all available encryption and privacy modes.2
“Public-facing” products (eg, Facebook Live, TikTok, Twitch) should not be used to provide telepsychiatry services because they are designed to be open to the public or allow for wide or indiscriminate access to the communication.2,3 Clinicians who desire additional privacy protections (and a more permanent solution) should choose a HIPAA-compliant telehealth vendor (eg, Doxy.me, VSee, Zoom for Healthcare) and obtain a Business Associate Agreement with the vendor to ensure data protection and security.2,4
Regardless of the product, obtain informed consent from your patients that authorizes the use of remote communication.4 Inform your patients of any potential privacy or security breaches, the need for interactions to be conducted in a location that provides privacy, and whether the specific technology used is HIPAA-compliant.4 Document that your patients understand these issues before using remote communication.4
How licensing requirements have changed
As of March 31, 2020, the CMS temporarily waived the requirement that out-of-state clinicians be licensed in the state where they are providing services to Medicare beneficiaries.5 The CMS waived this requirement for clinicians who meet the following 4 conditions5,6:
- must be enrolled in Medicare
- must possess a valid license to practice in the state that relates to his/her Medicare enrollment
- are furnishing services—whether in person or via telepsychiatry—in a state where the emergency is occurring to contribute to relief efforts in his/her professional capacity
- are not excluded from practicing in any state that is part of the nationally declared emergency area.
Note that individual state licensure requirements continue to apply unless waived by the state.6 Therefore, in order for clinicians to see Medicare patients via remote communication under the 4 conditions described above, the state also would have to waive its licensure requirements for the type of practice for which the clinicians are licensed in their own state.6 Regarding commercial payers, in general, clinicians providing telepsychiatry services need a license to practice in the state where the patient is located at the time services are provided.6 During the COVID-19 pandemic, many governors issued executive orders waiving licensure requirements, and many have accelerated granting temporary licenses to out-of-state clinicians who wish to provide telepsychiatry services to the residents of their state.4
Continue to: Prescribing via telepsychiatry
Prescribing via telepsychiatry
Effective March 31, 2020 and lasting for the duration of COVID-19 emergency declaration, the Drug Enforcement Agency (DEA) suspended the Ryan Haight Online Pharmacy Consumer Protection Act of 2008, which requires clinicians to conduct initial, in-person examinations of patients before they can prescribe controlled substances electronically.6,7 The DEA suspension allows clinicians to prescribe controlled substances after conducting an initial evaluation via remote communication. In addition, the DEA waived the requirement that a clinician needs to hold a DEA license in the state where the patient is located to be able to prescribe a controlled substance electronically.4,6 However, you still must comply with all other state laws and regulations for prescribing controlled substances.4
Staying informed
Although several telepsychiatry rules and regulations have been modified or suspended during the COVID-19 pandemic, the standard of care for services rendered via telepsychiatry remains the same as services provided via face-to-face encounters, including patient evaluation and assessment, treatment plans, medication, and documentation.4 Clinicians can keep up-to-date on how practicing telepsychiatry may evolve during these times by using the following resources from the American Psychiatric Association:
- Telepsychiatry Toolkit: www.psychiatry.org/psychiatrists/practice/telepsychiatry
- Practice Guidance for COVID-19: www.psychiatry.org/psychiatrists/covid-19-coronavirus/practice-guidance-for-covid-19.
1. Centers for Medicare and Medicaid Services. COVID-19: President Trump expands telehealth benefits for Medicare beneficiaries during COVID-19 outbreak. https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-03-17. Published March 17, 2020. Accessed May 6, 2020.
2. US Department of Health & Human Services. Notification of enforcement discretion for telehealth remote communications during the COVID-19 nationwide public health emergency. https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html. Updated March 30, 2020. Accessed May 6, 2020.
3. US Department of Health & Human Services. What is a “non-public facing” remote communication product? https://www.hhs.gov/hipaa/for-professionals/faq/3024/what-is-a-non-public-facing-remote-communication-product/index.html. Updated April 10, 2020. Accessed May 6, 2020.
4. Huben-Kearney A. Risk management amid a global pandemic. Psychiatric News. https://psychnews.psychiatryonline.org/doi/10.1176/appi.pn.2020.5a38. Published April 28, 2020. Accessed May 6, 2020.
5. Centers for Medicare & Medicaid Services. COVID-19 emergency declaration blanket waivers for health care providers. https://www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf. Published April 29, 2020. Accessed May 6, 2020.
6. American Psychiatric Association. Update on telehealth restrictions in response to COVID-19. https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/blog/apa-resources-on-telepsychiatry-and-covid-19. Updated May 1, 2020. Accessed May 6, 2020.
7. US Drug Enforcement Agency. How to prescribe controlled substances to patients during the COVID-19 public health emergency. https://www.deadiversion.usdoj.gov/GDP/(DEA-DC-023)(DEA075)Decision_Tree_(Final)_33120_2007.pdf. Published March 31, 2020. Accessed on May 6, 2020.
1. Centers for Medicare and Medicaid Services. COVID-19: President Trump expands telehealth benefits for Medicare beneficiaries during COVID-19 outbreak. https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-03-17. Published March 17, 2020. Accessed May 6, 2020.
2. US Department of Health & Human Services. Notification of enforcement discretion for telehealth remote communications during the COVID-19 nationwide public health emergency. https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html. Updated March 30, 2020. Accessed May 6, 2020.
3. US Department of Health & Human Services. What is a “non-public facing” remote communication product? https://www.hhs.gov/hipaa/for-professionals/faq/3024/what-is-a-non-public-facing-remote-communication-product/index.html. Updated April 10, 2020. Accessed May 6, 2020.
4. Huben-Kearney A. Risk management amid a global pandemic. Psychiatric News. https://psychnews.psychiatryonline.org/doi/10.1176/appi.pn.2020.5a38. Published April 28, 2020. Accessed May 6, 2020.
5. Centers for Medicare & Medicaid Services. COVID-19 emergency declaration blanket waivers for health care providers. https://www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf. Published April 29, 2020. Accessed May 6, 2020.
6. American Psychiatric Association. Update on telehealth restrictions in response to COVID-19. https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/blog/apa-resources-on-telepsychiatry-and-covid-19. Updated May 1, 2020. Accessed May 6, 2020.
7. US Drug Enforcement Agency. How to prescribe controlled substances to patients during the COVID-19 public health emergency. https://www.deadiversion.usdoj.gov/GDP/(DEA-DC-023)(DEA075)Decision_Tree_(Final)_33120_2007.pdf. Published March 31, 2020. Accessed on May 6, 2020.
The resident’s role in combating burnout among medical students
Burnout among health care professionals has been increasingly recognized by the medical community over the past several years. The concern for burnout among medical students is equally serious. In this article, I review the prevalence of burnout among medical students, and the personal and clinical effects they experience. I also discuss how as psychiatry residents we can be more effective in preventing and identifying medical student burnout.
An underappreciated problem
Burnout has been defined as long-term unresolvable job stress that leads to exhaustion and feeling overwhelmed, cynical, and detached from work, and lacking a sense of personal accomplishment. It can lead to depression, anxiety, and suicidal ideation—one survey found that 5.8% of medical students had experienced suicidal ideation at some point in the previous 12 months.1 Burnout affects not only the individual, but also his/her team and patients. One study found that compared to medical students who didn’t report burnout, medical students who did had lower scores on measures of empathy and professionalism.2
While burnout among physicians and residents has received increasing attention, it often may go unrecognized and unreported in medical students. A literature review that included 51 studies found 28% to 45% of medical students report burnout.3 In a survey at one institution, 60% of medical students reported burnout.4 It is evident that medical schools have an important role in helping to minimize burnout rates in their students, and many schools are working toward this goal. However, what happens when students leave the classroom setting for clinical rotations?
A recent study found burnout among medical students peaks during the third year of medical school.5 This is when students are on their clinical rotations, new to the hospital environment, and without the inherent structure and support of being at school.
How residents can help
Like most medical students, while on my clinical rotations, I spent most of my day with residents, and I believe residents can help to both recognize burnout in medical students and prevent it.
The first step in addressing this problem is to understand why it occurs. A survey of medical students showed that inadequate sleep and decreased exercise play a significant role in burnout rates.6 Another study found a correlation between burnout and feeling emotionally exhausted and a decreased perceived quality of life.7 A medical student I recently worked with stated, “How can you not feel burnt out? Juggling work hours, studying, debt, health, and trying to have a life… something always gets dropped.”
So as residents, what can we do to identify and assist medical students who are experiencing burnout, or are at risk of getting there? When needed, we can utilize our psychiatry training to assess our students for depression and substance use disorders, and connect them with appropriate resources. When identifying a medical student with burnout, I believe it can become necessary to notify the attending, the site director responsible for the student, and often the school, so that the student has access to all available resources.
Continue to: It's as important to be proactive...
It’s as important to be proactive as it is to be reactive. Engaging in regular check-ins with our students about self-care and workload, as well as asking about how they are feeling, can offer them opportunities to talk about issues that they might not be getting anywhere else. One medical student I worked with told me, “It’s easy to fade into the background as the student, or to feel like I can’t complain because this is just how medical school is supposed to be.” We have the ability to change this notion with each student we work with.
It is likely that as residents we have worked with a student struggling with burnout without even realizing it. I believe we can play an important role in helping to prevent burnout by identifying at-risk students, offering assistance, and encouraging them to seek professional help. Someone’s life may depend on it.
1. Dyrbye L, Thomas M, Massie F, et al. Burnout and suicidal ideation among U.S. medical students. Ann Intern Med. 2008;149(5):334-341.
2. Brazeau C, Schroeder R, Rovi S. Relationships between medical student burnout, empathy, and professionalism climate. Acad Med. 2010;85(suppl 10):S33-S36. doi: 10.1097/ACM.0b013e3181ed4c47.
3. IsHak WW, Lederer S, Mandili C, et al. Burnout during residency training: a literature review. J Grad Med Educ. 2009;1(2):236-242.
4. Chang E, Eddins-Folensbee F, Coverdale J. Survey of the prevalence of burnout, stress, depression, and the use of supports by medical students at one school. Acad Psychiatry. 2012;36(3):177-182.
5. Hansell MW, Ungerleider RM, Brooks CA, et al. Temporal trends in medical student burnout. Fam Med. 2019;51(5):399-404.
6. Wolf M, Rosenstock J. Inadequate sleep and exercise associated with burnout and depression among medical students. Acad Psychiatry. 2017;41(2):174-179.
7. Colby L, Mareka M, Pillay S, et al. The association between the levels of burnout and quality of life among fourth-year medical students at the University of the Free State. S Afr J Psychiatr. 2018;24:1101.
Burnout among health care professionals has been increasingly recognized by the medical community over the past several years. The concern for burnout among medical students is equally serious. In this article, I review the prevalence of burnout among medical students, and the personal and clinical effects they experience. I also discuss how as psychiatry residents we can be more effective in preventing and identifying medical student burnout.
An underappreciated problem
Burnout has been defined as long-term unresolvable job stress that leads to exhaustion and feeling overwhelmed, cynical, and detached from work, and lacking a sense of personal accomplishment. It can lead to depression, anxiety, and suicidal ideation—one survey found that 5.8% of medical students had experienced suicidal ideation at some point in the previous 12 months.1 Burnout affects not only the individual, but also his/her team and patients. One study found that compared to medical students who didn’t report burnout, medical students who did had lower scores on measures of empathy and professionalism.2
While burnout among physicians and residents has received increasing attention, it often may go unrecognized and unreported in medical students. A literature review that included 51 studies found 28% to 45% of medical students report burnout.3 In a survey at one institution, 60% of medical students reported burnout.4 It is evident that medical schools have an important role in helping to minimize burnout rates in their students, and many schools are working toward this goal. However, what happens when students leave the classroom setting for clinical rotations?
A recent study found burnout among medical students peaks during the third year of medical school.5 This is when students are on their clinical rotations, new to the hospital environment, and without the inherent structure and support of being at school.
How residents can help
Like most medical students, while on my clinical rotations, I spent most of my day with residents, and I believe residents can help to both recognize burnout in medical students and prevent it.
The first step in addressing this problem is to understand why it occurs. A survey of medical students showed that inadequate sleep and decreased exercise play a significant role in burnout rates.6 Another study found a correlation between burnout and feeling emotionally exhausted and a decreased perceived quality of life.7 A medical student I recently worked with stated, “How can you not feel burnt out? Juggling work hours, studying, debt, health, and trying to have a life… something always gets dropped.”
So as residents, what can we do to identify and assist medical students who are experiencing burnout, or are at risk of getting there? When needed, we can utilize our psychiatry training to assess our students for depression and substance use disorders, and connect them with appropriate resources. When identifying a medical student with burnout, I believe it can become necessary to notify the attending, the site director responsible for the student, and often the school, so that the student has access to all available resources.
Continue to: It's as important to be proactive...
It’s as important to be proactive as it is to be reactive. Engaging in regular check-ins with our students about self-care and workload, as well as asking about how they are feeling, can offer them opportunities to talk about issues that they might not be getting anywhere else. One medical student I worked with told me, “It’s easy to fade into the background as the student, or to feel like I can’t complain because this is just how medical school is supposed to be.” We have the ability to change this notion with each student we work with.
It is likely that as residents we have worked with a student struggling with burnout without even realizing it. I believe we can play an important role in helping to prevent burnout by identifying at-risk students, offering assistance, and encouraging them to seek professional help. Someone’s life may depend on it.
Burnout among health care professionals has been increasingly recognized by the medical community over the past several years. The concern for burnout among medical students is equally serious. In this article, I review the prevalence of burnout among medical students, and the personal and clinical effects they experience. I also discuss how as psychiatry residents we can be more effective in preventing and identifying medical student burnout.
An underappreciated problem
Burnout has been defined as long-term unresolvable job stress that leads to exhaustion and feeling overwhelmed, cynical, and detached from work, and lacking a sense of personal accomplishment. It can lead to depression, anxiety, and suicidal ideation—one survey found that 5.8% of medical students had experienced suicidal ideation at some point in the previous 12 months.1 Burnout affects not only the individual, but also his/her team and patients. One study found that compared to medical students who didn’t report burnout, medical students who did had lower scores on measures of empathy and professionalism.2
While burnout among physicians and residents has received increasing attention, it often may go unrecognized and unreported in medical students. A literature review that included 51 studies found 28% to 45% of medical students report burnout.3 In a survey at one institution, 60% of medical students reported burnout.4 It is evident that medical schools have an important role in helping to minimize burnout rates in their students, and many schools are working toward this goal. However, what happens when students leave the classroom setting for clinical rotations?
A recent study found burnout among medical students peaks during the third year of medical school.5 This is when students are on their clinical rotations, new to the hospital environment, and without the inherent structure and support of being at school.
How residents can help
Like most medical students, while on my clinical rotations, I spent most of my day with residents, and I believe residents can help to both recognize burnout in medical students and prevent it.
The first step in addressing this problem is to understand why it occurs. A survey of medical students showed that inadequate sleep and decreased exercise play a significant role in burnout rates.6 Another study found a correlation between burnout and feeling emotionally exhausted and a decreased perceived quality of life.7 A medical student I recently worked with stated, “How can you not feel burnt out? Juggling work hours, studying, debt, health, and trying to have a life… something always gets dropped.”
So as residents, what can we do to identify and assist medical students who are experiencing burnout, or are at risk of getting there? When needed, we can utilize our psychiatry training to assess our students for depression and substance use disorders, and connect them with appropriate resources. When identifying a medical student with burnout, I believe it can become necessary to notify the attending, the site director responsible for the student, and often the school, so that the student has access to all available resources.
Continue to: It's as important to be proactive...
It’s as important to be proactive as it is to be reactive. Engaging in regular check-ins with our students about self-care and workload, as well as asking about how they are feeling, can offer them opportunities to talk about issues that they might not be getting anywhere else. One medical student I worked with told me, “It’s easy to fade into the background as the student, or to feel like I can’t complain because this is just how medical school is supposed to be.” We have the ability to change this notion with each student we work with.
It is likely that as residents we have worked with a student struggling with burnout without even realizing it. I believe we can play an important role in helping to prevent burnout by identifying at-risk students, offering assistance, and encouraging them to seek professional help. Someone’s life may depend on it.
1. Dyrbye L, Thomas M, Massie F, et al. Burnout and suicidal ideation among U.S. medical students. Ann Intern Med. 2008;149(5):334-341.
2. Brazeau C, Schroeder R, Rovi S. Relationships between medical student burnout, empathy, and professionalism climate. Acad Med. 2010;85(suppl 10):S33-S36. doi: 10.1097/ACM.0b013e3181ed4c47.
3. IsHak WW, Lederer S, Mandili C, et al. Burnout during residency training: a literature review. J Grad Med Educ. 2009;1(2):236-242.
4. Chang E, Eddins-Folensbee F, Coverdale J. Survey of the prevalence of burnout, stress, depression, and the use of supports by medical students at one school. Acad Psychiatry. 2012;36(3):177-182.
5. Hansell MW, Ungerleider RM, Brooks CA, et al. Temporal trends in medical student burnout. Fam Med. 2019;51(5):399-404.
6. Wolf M, Rosenstock J. Inadequate sleep and exercise associated with burnout and depression among medical students. Acad Psychiatry. 2017;41(2):174-179.
7. Colby L, Mareka M, Pillay S, et al. The association between the levels of burnout and quality of life among fourth-year medical students at the University of the Free State. S Afr J Psychiatr. 2018;24:1101.
1. Dyrbye L, Thomas M, Massie F, et al. Burnout and suicidal ideation among U.S. medical students. Ann Intern Med. 2008;149(5):334-341.
2. Brazeau C, Schroeder R, Rovi S. Relationships between medical student burnout, empathy, and professionalism climate. Acad Med. 2010;85(suppl 10):S33-S36. doi: 10.1097/ACM.0b013e3181ed4c47.
3. IsHak WW, Lederer S, Mandili C, et al. Burnout during residency training: a literature review. J Grad Med Educ. 2009;1(2):236-242.
4. Chang E, Eddins-Folensbee F, Coverdale J. Survey of the prevalence of burnout, stress, depression, and the use of supports by medical students at one school. Acad Psychiatry. 2012;36(3):177-182.
5. Hansell MW, Ungerleider RM, Brooks CA, et al. Temporal trends in medical student burnout. Fam Med. 2019;51(5):399-404.
6. Wolf M, Rosenstock J. Inadequate sleep and exercise associated with burnout and depression among medical students. Acad Psychiatry. 2017;41(2):174-179.
7. Colby L, Mareka M, Pillay S, et al. The association between the levels of burnout and quality of life among fourth-year medical students at the University of the Free State. S Afr J Psychiatr. 2018;24:1101.
Life during COVID-19: A pandemic of silence
Our world has radically changed during the coronavirus disease 2019 (COVID-19) crisis, and this impact has quickly transformed many lives. Whether you’re on the front lines of the COVID-19 pandemic or waiting in eager anticipation to return to practice, there is no denying that a few months ago we could never have imagined the health care and humanitarian crisis that is now before us. While we are united in our longing for a better time, we couldn’t be further apart socially and emotionally … and I’m not just talking about 6 feet.
One thing that has been truly striking to me is the silence. While experts have suggested there is a “silent pandemic” of mental illness on the horizon,1 I’ve been struck by the actual silence that exists as we walk through our stores and neighborhoods. We’re not speaking to each other anymore; it’s almost as if we’re afraid to make eye contact with one another.
Humans are social creatures, and the isolation that many people are experiencing during this pandemic could have detrimental and lasting effects if we don’t take action. While I highly encourage and support efforts to employ social distancing and mitigate the spread of this illness, I’m increasingly concerned about another kind of truly silent pandemic brewing beneath the surface of the COVID-19 crisis. Even under the best conditions, many individuals with posttraumatic stress disorder, depression, anxiety, bipolar disorder, schizophrenia, and other psychiatric disorders may lack adequate social interaction and experience feelings of isolation. These individuals need connection—not silence.
What happens to people who already felt intense isolation before COVID-19 and may have had invaluable lifelines cut off during this time of social distancing? What about individuals with alcohol or substance use disorders, or families who are sheltered in place in unsafe or violent home conditions? How can they reach out in silence? How can we help?
Fostering human connection
To address this, we must actively work to engage our patients and communities. One simple way to help is to acknowledge the people you encounter. Yes, stay 6 feet apart, and wear appropriate personal protective equipment. However, it is still OK to smile and greet someone with a nod, a smile, or a “hello.” A genuine smile can still be seen in someone’s eyes. We need these types of human connection, perhaps now more than ever before. We need each other.
Most importantly, during this time, we need to be aware of individuals who are most at risk in this silent pandemic. We can offer our patients appointments via video conferencing. We can use texting, e-mail, social media, phone calls, and video conferencing to check in with our families, friends, and neighbors. We’re at war with a terrible foe, but let’s not let the human connection become collateral damage.
1. Galea S, Merchant RM, Lurie N, et al. The mental health consequences of COVID-19 and physical distancing: the need for prevention and early intervention [published online April 10, 2020]. JAMA Intern Med. 2020. doi: 10.1001/jamainternmed.2020.1562.
Our world has radically changed during the coronavirus disease 2019 (COVID-19) crisis, and this impact has quickly transformed many lives. Whether you’re on the front lines of the COVID-19 pandemic or waiting in eager anticipation to return to practice, there is no denying that a few months ago we could never have imagined the health care and humanitarian crisis that is now before us. While we are united in our longing for a better time, we couldn’t be further apart socially and emotionally … and I’m not just talking about 6 feet.
One thing that has been truly striking to me is the silence. While experts have suggested there is a “silent pandemic” of mental illness on the horizon,1 I’ve been struck by the actual silence that exists as we walk through our stores and neighborhoods. We’re not speaking to each other anymore; it’s almost as if we’re afraid to make eye contact with one another.
Humans are social creatures, and the isolation that many people are experiencing during this pandemic could have detrimental and lasting effects if we don’t take action. While I highly encourage and support efforts to employ social distancing and mitigate the spread of this illness, I’m increasingly concerned about another kind of truly silent pandemic brewing beneath the surface of the COVID-19 crisis. Even under the best conditions, many individuals with posttraumatic stress disorder, depression, anxiety, bipolar disorder, schizophrenia, and other psychiatric disorders may lack adequate social interaction and experience feelings of isolation. These individuals need connection—not silence.
What happens to people who already felt intense isolation before COVID-19 and may have had invaluable lifelines cut off during this time of social distancing? What about individuals with alcohol or substance use disorders, or families who are sheltered in place in unsafe or violent home conditions? How can they reach out in silence? How can we help?
Fostering human connection
To address this, we must actively work to engage our patients and communities. One simple way to help is to acknowledge the people you encounter. Yes, stay 6 feet apart, and wear appropriate personal protective equipment. However, it is still OK to smile and greet someone with a nod, a smile, or a “hello.” A genuine smile can still be seen in someone’s eyes. We need these types of human connection, perhaps now more than ever before. We need each other.
Most importantly, during this time, we need to be aware of individuals who are most at risk in this silent pandemic. We can offer our patients appointments via video conferencing. We can use texting, e-mail, social media, phone calls, and video conferencing to check in with our families, friends, and neighbors. We’re at war with a terrible foe, but let’s not let the human connection become collateral damage.
Our world has radically changed during the coronavirus disease 2019 (COVID-19) crisis, and this impact has quickly transformed many lives. Whether you’re on the front lines of the COVID-19 pandemic or waiting in eager anticipation to return to practice, there is no denying that a few months ago we could never have imagined the health care and humanitarian crisis that is now before us. While we are united in our longing for a better time, we couldn’t be further apart socially and emotionally … and I’m not just talking about 6 feet.
One thing that has been truly striking to me is the silence. While experts have suggested there is a “silent pandemic” of mental illness on the horizon,1 I’ve been struck by the actual silence that exists as we walk through our stores and neighborhoods. We’re not speaking to each other anymore; it’s almost as if we’re afraid to make eye contact with one another.
Humans are social creatures, and the isolation that many people are experiencing during this pandemic could have detrimental and lasting effects if we don’t take action. While I highly encourage and support efforts to employ social distancing and mitigate the spread of this illness, I’m increasingly concerned about another kind of truly silent pandemic brewing beneath the surface of the COVID-19 crisis. Even under the best conditions, many individuals with posttraumatic stress disorder, depression, anxiety, bipolar disorder, schizophrenia, and other psychiatric disorders may lack adequate social interaction and experience feelings of isolation. These individuals need connection—not silence.
What happens to people who already felt intense isolation before COVID-19 and may have had invaluable lifelines cut off during this time of social distancing? What about individuals with alcohol or substance use disorders, or families who are sheltered in place in unsafe or violent home conditions? How can they reach out in silence? How can we help?
Fostering human connection
To address this, we must actively work to engage our patients and communities. One simple way to help is to acknowledge the people you encounter. Yes, stay 6 feet apart, and wear appropriate personal protective equipment. However, it is still OK to smile and greet someone with a nod, a smile, or a “hello.” A genuine smile can still be seen in someone’s eyes. We need these types of human connection, perhaps now more than ever before. We need each other.
Most importantly, during this time, we need to be aware of individuals who are most at risk in this silent pandemic. We can offer our patients appointments via video conferencing. We can use texting, e-mail, social media, phone calls, and video conferencing to check in with our families, friends, and neighbors. We’re at war with a terrible foe, but let’s not let the human connection become collateral damage.
1. Galea S, Merchant RM, Lurie N, et al. The mental health consequences of COVID-19 and physical distancing: the need for prevention and early intervention [published online April 10, 2020]. JAMA Intern Med. 2020. doi: 10.1001/jamainternmed.2020.1562.
1. Galea S, Merchant RM, Lurie N, et al. The mental health consequences of COVID-19 and physical distancing: the need for prevention and early intervention [published online April 10, 2020]. JAMA Intern Med. 2020. doi: 10.1001/jamainternmed.2020.1562.
