Commentary

The Goldwater Rule and free speech

In his editorial, “The toxic zeitgeist of hyper-partisanship: A psychiatric perspective” (From the Editor, Current Psychiatry, February 2018, p. 17-18), Dr. Nasrallah notes that he “adheres” to the APA’s Goldwater Rule. The Goldwater Rule and the reason for its creation and current implementation in the United States cannot be fully understood without appreciating the political circumstances that led to its creation in 1964. The conservative movement had been using the slogan “better dead than red” to criticize Democrats who they felt were soft on communism. Unfortunately, some psychiatrists took these words and the views of Arizona senator Barry Goldwater quite literally. They claimed they understood his psychological structure by listening to his political views, and feared that he would risk starting a nuclear war. Of course, no psychiatrist actually examined senator Goldwater. During the 1964 presidential campaign, a television commercial from President Lyndon B. Johnson’s campaign included a mushroom cloud of a nuclear explosion with an implicit reference to senator Goldwater and the “better dead than red” slogan. In the end, psychiatry, and particularly psychoanalysis, as well as President Johnson’s campaign, were embarrassed.

One’s political views do not inform us of his or her mental health status. This appreciation can be obtained only by a thorough psychological assessment. This is the basis of the Goldwater Rule, coupled with the ethical responsibility not to discuss patients’ private communications.

Today, this rule is tested by the behavior and actions of President Donald Trump. Proponents of the Goldwater Rule state that a psychiatrist cannot diagnose someone without performing a face-to-face diagnostic evaluation. This assumes psychiatrists diagnose patients only by interviewing them. However, any psychiatrist who has worked in an emergency room has signed involuntary commitment papers for a patient who refuses to talk to them. This clinical action typically is based on reports of the patient’s potential dangerousness from family, friends, or the police.

The diagnostic criteria for some personality disorders are based only on observed or reported behavior. They do not indicate a need for an interview.  The diagnosis of a personality disorder cannot be made solely by interviewing an individual without knowledge of his or her behavior. Interviewing Bernie Madoff would not have revealed his sociopathic behavior.

The critical question may not be whether one could ethically make a psychiatric diagnosis of the President (I believe you can), but rather would it indicate or imply that he is dangerous? History informs us that the existence of a psychiatric disorder does not determine a politician’s fitness for office or if they are dangerous. Behavioral accounts of President Abraham Lincoln and his self-reports seem to confirm that at times he was depressed, but he clearly served our country with distinction.

Finally, it is not clear whether the Goldwater Rule is legal. It arguably interferes with a psychiatrist’s right of free speech without the risk of being accused of unethical behavior. I wonder what would happen if it were tested in court. Does the First Amendment of the U.S. Constitution protect a psychiatrist’s right to speak freely?

Sidney Weissman, MD
Clinical Professor of Psychiatry and Behavioral Science
Feinberg School of Medicine
Northwestern University
Chicago, Illinois

The current ‘political morass’

Thank you, Dr. Nasrallah, for the wonderful synopsis of the current political morass in your editorial (From the Editor, Current Psychiatry, February 2018, p. 17-18). You followed Descartes’ dictum: you thought about matters in a novel fashion. I will assertively share this with others. It is a good piece of teaching.

James Gallagher, MD
Private psychiatric practice
Des Moines, Iowa

Continue to: The biological etiology of compulsive sexual behavior

Dr. Grant’s article, “Compulsive sexual behavior: A nonjudgmental approach” (Evidence-Based Reviews, Current Psychiatry, February 2018, p. 34,38-40,45-46), puts a well-deserved spotlight on a relatively underrecognized problem that most psychiatrists will encounter at least once during clinical practice. While the article is overall helpful, it completely leaves out any possible biological etiology and underpinnings to the condition that may be important to address while evaluating someone with compulsive sexual behavior. Specifically, are there any endocrine issues that should be considered that may also impact our approach to its treatment?

Mukesh Sanghadia, MD, MRCPsych (UK), Diplomate ABPN
PsychiatristCommunity Research Foundation
San Diego, California

The author responds

Dr. Sanghadia highlights the lack of possible biological etiology of compulsive sexual behavior (CSB) in my article. This is a fair comment. The lack of agreed-upon diagnostic criteria, however, has resulted in a vast literature discussing sexual behaviors that may or may not be related to each other, and even suggest that what is currently referred to as CSB may in fact be quite heterogeneous. My article mentions the few neuroimaging and neurocognitive studies that address a more rigorously defined CSB. Other possible etiologies have been suggested for a range of out-of-control sexual behaviors, but have not been studied with a focus on this formal diagnostic category. For example, endocrine issues have been explored to some extent in individuals with paraphilic sexual behaviors (behaviors that appear to many to have no relationship to CSB as discussed in my article), and in those cases of paraphilic sexual behavior, a range of endocrine hormones have been examined—gonadotropin-releasing hormone, follicle-stimulating hormone, luteinizing hormone, testosterone/dihydrotestosterone, and estrogen/progesterone. But these studies have yielded no conclusive outcomes in terms of findings or treatments.

In summary, the biology of CSB lags far behind that of other mental health disorders (and even other psychiatric disorders lack conclusive biological etiologies). Establishing this behavior as a legitimate diagnostic entity with agreed-upon criteria may be the first step in furthering our understanding of its possible biology.

Jon E. Grant, JD, MD, MPH
Professor
Department of Psychiatry and Behavioral Neuroscience
University of Chicago, Pritzker School of Medicine
Chicago, Illinois

Continue to: A different view of patients with schizophrenia

After treating patients with schizophrenia for more than 30 years, I’ve observed a continuous flood of information about them. This overload has been consistent since my residency back in the 1980s. Theories ranging from the psychoanalytic to the biologic are numerous and valuable additions to our understanding of those who suffer with this malady, yet they provide no summation or overview with which to understand it.

For instance, we know that schizophrenia usually begins in the late teens or early twenties. We know that antidopaminergic medications usually help to varying degrees. Psychosocial interventions may contribute greatly to the ultimate outcome. Substance use invariably makes it worse. Establishing a connection with the patient can often be helpful. Medication compliance is crucial.

It is more or less accepted that there is deterioration of higher brain functions, hypofrontality, as well as so-called dysconnectivity of white matter. There is a genetic vulnerability, and there seems to be an excess of inflammation and changes in mitochondria. Most patients have low functioning, poor compensation, and a lack of social adeptness. However, some patients can recover quite nicely. Although most of us would agree that this is not dementia, we’d also concede that these patients’ cognitive functioning is not what it used to be. Electroconvulsive therapy also can sometimes be helpful.

So, how are we to view our patients with schizophrenia in a way that can be illuminating and give us a deeper sense of understanding this quizzical disorder? It has been helpful to me to regard these individuals as a people whose brain function has been usurped by a more primitive organization that is characterized by:

• a reduction in mental development, where patients function in a more childlike way with magical thinking and impaired reality-testing
• atrophy of higher brain structures, leading to hallucinatory experiences
• a hyper-dominergic state
• a usually gradual onset with some evidence of struggle between the old and new brain organizations
• impaired prepulse inhibition that’s likely secondary to diffuseness of thought
• eventual demise of higher brain structures with an inability to respond to anti-dopaminergics. (Antipsychotics can push the brain organization closer to the adult structure attained before the onset of the disease, at least initially.)

The list goes on. Thinking about patients with schizophrenia in this way allows me to appreciate what I feel is a more encompassing view of who they are and how they got there. I have some theories about where this more primitive organization may have originated, but whatever its origin, in a small percentage of people it is there, ready to assume control of their thinking just as they are reaching reproductive age. Early intervention and medication compliance may minimize damage.

If a theory helps us gain a greater understanding of our patients, then it’s worth considering. This proposition fits much of what we know about schizophrenia. Reading patients’ firsthand accounts of the illness helps confirm, in my opinion, this point of view.

Steven Lesk, MD
Private psychiatric practice
Fridley, Minnesota

Continue to: Cognitive impairment in schizophrenia

The authors of “Suspicious, sleepless, and smoking” (Cases That Test Your Skills, Current Psychiatry, September 2017, p. 49-50,52-54) assert that “…the severity of cognitive impairment in schizophrenia has no association with the positive symptoms of schizophrenia” and they add, “Treatment of the cognitive symptoms of schizophrenia with antipsychotics has been largely ineffective.” However, in the case they present, Mr. F appears to demonstrate just the opposite: He is given antipsychotics, and over the course of his hospital stay, both his positive symptoms and his cognition improve. His scores on the Montreal Cognitive Assessment increase from 9 (Day 11) to 15 (Day 16) to 21 (Day 24). Thus, in this particular case, treatment with antipsychotics is clearly associated with cognitive improvement.

During the past 15 years, I have routinely measured cognitive functioning in patients with schizophrenia. Some have no impairment, some have severe impairment, and some fall in between these extremes. Most often, impairment occurs in the area of executive function, which can lead to significant disability. Indeed, positive symptoms can clear up completely with treatment, but the deficits in executive functioning can remain.

I think it is fair to say that cognitive impairment is a common, although not nearly universal, feature of schizophrenia that sometimes improves with antipsychotic medication. I look forward to the advent of more clinicians paying attention to the issue of cognition in schizophrenia and, hopefully, better treatments for it.

John M. Mahoney, PhD
Shasta Psychiatric Hospital
Redding, California

The authors respond

We thank Dr. Mahoney for his thoughtful letter and queries into the case of Mr. F.

First, regarding the prevalence of cognitive impairment in schizophrenia, it is our opinion that cognitive impairment is a distinct, core, and nearly universal feature of schizophrenia. This also is the conclusion of many clinicians and researchers based on their significant work in the field; still, just as in our initial case study, we concede that these symptoms are not part of the DSM-5’s formal diagnostic criteria.

The core question Dr. Mahoney seems to pose is whether we contradicted ourselves. We assert that cognitive impairment in schizophrenia is not effectively treated with existing medications, and yet we described Mr. F’s cognitive improvement after he received risperidone, 2 mg/d, titrated up to 2 mg twice daily. We first pointed out that part of our treatment strategy was to target comorbid depression in this patient; nonetheless, Dr. Mahoney’s question remains valid, and we will attempt to answer.

Dr. Mahoney has observed that his patients with schizophrenia variably experience improved cognition, and notes that executive function is a particularly common lingering impairment. On this we wholly agree; this is a helpful point of clarification, and a useful distinction in light of the above question. Improvement in positive and negative symptoms of schizophrenia, as psychosis resolves, is a well-known and studied effect of antipsychotic therapy. As a result, the sensorium becomes more congruent with external reality, and one would expect the patient to display improved orientation. This then might be reasonably expected to produce mental status improvements; however, while some improvement is frequently observed, this is neither consistent nor complete improvement. In the case of Mr. F, we document improvement, but also significant continued impairment. Thus, we maintain that treating the cognitive symptoms of schizophrenia with antipsychotics has been largely ineffective.

We do not see this as a slight distinction or an argument of minutiae. That patients frequently experience some degree of lingering impairment is a salient point. Neurocognitive impairment is a strong contributor to and predictor of disability in schizophrenia, and neurocognitive abilities most strongly predict functional outcomes. From a patient’s point of view, these symptoms have real-world consequences. Thus, we believe they should be evaluated and treated as aggressively and consistently as other schizophrenia symptoms.

In our case, we attempted to convey one primary message: Despite the challenges of treatment, there are viable options that should be pursued in the treatment of schizophrenia-related cognitive impairments. Nonpharmacologic modalities have shown encouraging results. Cognitive remediation therapy produces durable cognitive improvement—especially when combined with adjunctive therapies, such as small group therapy and vocational rehabilitation, and when comorbid conditions (major depressive disorder in Mr. F’s case) are treated.

In summary, we reiterate that cognitive impairments in schizophrenia represent a strong predictor of patient-oriented outcomes; we maintain our assertion regarding their inadequate treatment with existing medications; and we suggest that future trials attempt to find effective alternative strategies. We encourage psychiatric clinicians to approach treatment of this facet of pathology with an open mind, and to utilize alternative multi-modal therapies for the benefit of their patients with schizophrenia while waiting for new safe and effective pharmaceutical regimens.

Jarrett Dawson, MD
Family medicine resident
Department of Psychiatry
Saint Louis University
St. Louis, Missouri

Catalina Belean, MD
Assistant Professor
Department of Psychiatry
Saint Louis University
St. Louis, Missouri

The Goldwater Rule and free speech

In his editorial, “The toxic zeitgeist of hyper-partisanship: A psychiatric perspective” (From the Editor, Current Psychiatry, February 2018, p. 17-18), Dr. Nasrallah notes that he “adheres” to the APA’s Goldwater Rule. The Goldwater Rule and the reason for its creation and current implementation in the United States cannot be fully understood without appreciating the political circumstances that led to its creation in 1964. The conservative movement had been using the slogan “better dead than red” to criticize Democrats who they felt were soft on communism. Unfortunately, some psychiatrists took these words and the views of Arizona senator Barry Goldwater quite literally. They claimed they understood his psychological structure by listening to his political views, and feared that he would risk starting a nuclear war. Of course, no psychiatrist actually examined senator Goldwater. During the 1964 presidential campaign, a television commercial from President Lyndon B. Johnson’s campaign included a mushroom cloud of a nuclear explosion with an implicit reference to senator Goldwater and the “better dead than red” slogan. In the end, psychiatry, and particularly psychoanalysis, as well as President Johnson’s campaign, were embarrassed.

One’s political views do not inform us of his or her mental health status. This appreciation can be obtained only by a thorough psychological assessment. This is the basis of the Goldwater Rule, coupled with the ethical responsibility not to discuss patients’ private communications.

Today, this rule is tested by the behavior and actions of President Donald Trump. Proponents of the Goldwater Rule state that a psychiatrist cannot diagnose someone without performing a face-to-face diagnostic evaluation. This assumes psychiatrists diagnose patients only by interviewing them. However, any psychiatrist who has worked in an emergency room has signed involuntary commitment papers for a patient who refuses to talk to them. This clinical action typically is based on reports of the patient’s potential dangerousness from family, friends, or the police.

The diagnostic criteria for some personality disorders are based only on observed or reported behavior. They do not indicate a need for an interview.  The diagnosis of a personality disorder cannot be made solely by interviewing an individual without knowledge of his or her behavior. Interviewing Bernie Madoff would not have revealed his sociopathic behavior.

The critical question may not be whether one could ethically make a psychiatric diagnosis of the President (I believe you can), but rather would it indicate or imply that he is dangerous? History informs us that the existence of a psychiatric disorder does not determine a politician’s fitness for office or if they are dangerous. Behavioral accounts of President Abraham Lincoln and his self-reports seem to confirm that at times he was depressed, but he clearly served our country with distinction.

Finally, it is not clear whether the Goldwater Rule is legal. It arguably interferes with a psychiatrist’s right of free speech without the risk of being accused of unethical behavior. I wonder what would happen if it were tested in court. Does the First Amendment of the U.S. Constitution protect a psychiatrist’s right to speak freely?

Sidney Weissman, MD
Clinical Professor of Psychiatry and Behavioral Science
Feinberg School of Medicine
Northwestern University
Chicago, Illinois

The current ‘political morass’

Thank you, Dr. Nasrallah, for the wonderful synopsis of the current political morass in your editorial (From the Editor, Current Psychiatry, February 2018, p. 17-18). You followed Descartes’ dictum: you thought about matters in a novel fashion. I will assertively share this with others. It is a good piece of teaching.

James Gallagher, MD
Private psychiatric practice
Des Moines, Iowa

Continue to: The biological etiology of compulsive sexual behavior

Dr. Grant’s article, “Compulsive sexual behavior: A nonjudgmental approach” (Evidence-Based Reviews, Current Psychiatry, February 2018, p. 34,38-40,45-46), puts a well-deserved spotlight on a relatively underrecognized problem that most psychiatrists will encounter at least once during clinical practice. While the article is overall helpful, it completely leaves out any possible biological etiology and underpinnings to the condition that may be important to address while evaluating someone with compulsive sexual behavior. Specifically, are there any endocrine issues that should be considered that may also impact our approach to its treatment?

Mukesh Sanghadia, MD, MRCPsych (UK), Diplomate ABPN
PsychiatristCommunity Research Foundation
San Diego, California

The author responds

Dr. Sanghadia highlights the lack of possible biological etiology of compulsive sexual behavior (CSB) in my article. This is a fair comment. The lack of agreed-upon diagnostic criteria, however, has resulted in a vast literature discussing sexual behaviors that may or may not be related to each other, and even suggest that what is currently referred to as CSB may in fact be quite heterogeneous. My article mentions the few neuroimaging and neurocognitive studies that address a more rigorously defined CSB. Other possible etiologies have been suggested for a range of out-of-control sexual behaviors, but have not been studied with a focus on this formal diagnostic category. For example, endocrine issues have been explored to some extent in individuals with paraphilic sexual behaviors (behaviors that appear to many to have no relationship to CSB as discussed in my article), and in those cases of paraphilic sexual behavior, a range of endocrine hormones have been examined—gonadotropin-releasing hormone, follicle-stimulating hormone, luteinizing hormone, testosterone/dihydrotestosterone, and estrogen/progesterone. But these studies have yielded no conclusive outcomes in terms of findings or treatments.

In summary, the biology of CSB lags far behind that of other mental health disorders (and even other psychiatric disorders lack conclusive biological etiologies). Establishing this behavior as a legitimate diagnostic entity with agreed-upon criteria may be the first step in furthering our understanding of its possible biology.

Jon E. Grant, JD, MD, MPH
Professor
Department of Psychiatry and Behavioral Neuroscience
University of Chicago, Pritzker School of Medicine
Chicago, Illinois

Continue to: A different view of patients with schizophrenia

After treating patients with schizophrenia for more than 30 years, I’ve observed a continuous flood of information about them. This overload has been consistent since my residency back in the 1980s. Theories ranging from the psychoanalytic to the biologic are numerous and valuable additions to our understanding of those who suffer with this malady, yet they provide no summation or overview with which to understand it.

For instance, we know that schizophrenia usually begins in the late teens or early twenties. We know that antidopaminergic medications usually help to varying degrees. Psychosocial interventions may contribute greatly to the ultimate outcome. Substance use invariably makes it worse. Establishing a connection with the patient can often be helpful. Medication compliance is crucial.

It is more or less accepted that there is deterioration of higher brain functions, hypofrontality, as well as so-called dysconnectivity of white matter. There is a genetic vulnerability, and there seems to be an excess of inflammation and changes in mitochondria. Most patients have low functioning, poor compensation, and a lack of social adeptness. However, some patients can recover quite nicely. Although most of us would agree that this is not dementia, we’d also concede that these patients’ cognitive functioning is not what it used to be. Electroconvulsive therapy also can sometimes be helpful.

So, how are we to view our patients with schizophrenia in a way that can be illuminating and give us a deeper sense of understanding this quizzical disorder? It has been helpful to me to regard these individuals as a people whose brain function has been usurped by a more primitive organization that is characterized by:

• a reduction in mental development, where patients function in a more childlike way with magical thinking and impaired reality-testing
• atrophy of higher brain structures, leading to hallucinatory experiences
• a hyper-dominergic state
• a usually gradual onset with some evidence of struggle between the old and new brain organizations
• impaired prepulse inhibition that’s likely secondary to diffuseness of thought
• eventual demise of higher brain structures with an inability to respond to anti-dopaminergics. (Antipsychotics can push the brain organization closer to the adult structure attained before the onset of the disease, at least initially.)

The list goes on. Thinking about patients with schizophrenia in this way allows me to appreciate what I feel is a more encompassing view of who they are and how they got there. I have some theories about where this more primitive organization may have originated, but whatever its origin, in a small percentage of people it is there, ready to assume control of their thinking just as they are reaching reproductive age. Early intervention and medication compliance may minimize damage.

If a theory helps us gain a greater understanding of our patients, then it’s worth considering. This proposition fits much of what we know about schizophrenia. Reading patients’ firsthand accounts of the illness helps confirm, in my opinion, this point of view.

Steven Lesk, MD
Private psychiatric practice
Fridley, Minnesota

Continue to: Cognitive impairment in schizophrenia

The authors of “Suspicious, sleepless, and smoking” (Cases That Test Your Skills, Current Psychiatry, September 2017, p. 49-50,52-54) assert that “…the severity of cognitive impairment in schizophrenia has no association with the positive symptoms of schizophrenia” and they add, “Treatment of the cognitive symptoms of schizophrenia with antipsychotics has been largely ineffective.” However, in the case they present, Mr. F appears to demonstrate just the opposite: He is given antipsychotics, and over the course of his hospital stay, both his positive symptoms and his cognition improve. His scores on the Montreal Cognitive Assessment increase from 9 (Day 11) to 15 (Day 16) to 21 (Day 24). Thus, in this particular case, treatment with antipsychotics is clearly associated with cognitive improvement.

During the past 15 years, I have routinely measured cognitive functioning in patients with schizophrenia. Some have no impairment, some have severe impairment, and some fall in between these extremes. Most often, impairment occurs in the area of executive function, which can lead to significant disability. Indeed, positive symptoms can clear up completely with treatment, but the deficits in executive functioning can remain.

I think it is fair to say that cognitive impairment is a common, although not nearly universal, feature of schizophrenia that sometimes improves with antipsychotic medication. I look forward to the advent of more clinicians paying attention to the issue of cognition in schizophrenia and, hopefully, better treatments for it.

John M. Mahoney, PhD
Shasta Psychiatric Hospital
Redding, California

The authors respond

We thank Dr. Mahoney for his thoughtful letter and queries into the case of Mr. F.

First, regarding the prevalence of cognitive impairment in schizophrenia, it is our opinion that cognitive impairment is a distinct, core, and nearly universal feature of schizophrenia. This also is the conclusion of many clinicians and researchers based on their significant work in the field; still, just as in our initial case study, we concede that these symptoms are not part of the DSM-5’s formal diagnostic criteria.

The core question Dr. Mahoney seems to pose is whether we contradicted ourselves. We assert that cognitive impairment in schizophrenia is not effectively treated with existing medications, and yet we described Mr. F’s cognitive improvement after he received risperidone, 2 mg/d, titrated up to 2 mg twice daily. We first pointed out that part of our treatment strategy was to target comorbid depression in this patient; nonetheless, Dr. Mahoney’s question remains valid, and we will attempt to answer.

Dr. Mahoney has observed that his patients with schizophrenia variably experience improved cognition, and notes that executive function is a particularly common lingering impairment. On this we wholly agree; this is a helpful point of clarification, and a useful distinction in light of the above question. Improvement in positive and negative symptoms of schizophrenia, as psychosis resolves, is a well-known and studied effect of antipsychotic therapy. As a result, the sensorium becomes more congruent with external reality, and one would expect the patient to display improved orientation. This then might be reasonably expected to produce mental status improvements; however, while some improvement is frequently observed, this is neither consistent nor complete improvement. In the case of Mr. F, we document improvement, but also significant continued impairment. Thus, we maintain that treating the cognitive symptoms of schizophrenia with antipsychotics has been largely ineffective.

We do not see this as a slight distinction or an argument of minutiae. That patients frequently experience some degree of lingering impairment is a salient point. Neurocognitive impairment is a strong contributor to and predictor of disability in schizophrenia, and neurocognitive abilities most strongly predict functional outcomes. From a patient’s point of view, these symptoms have real-world consequences. Thus, we believe they should be evaluated and treated as aggressively and consistently as other schizophrenia symptoms.

In our case, we attempted to convey one primary message: Despite the challenges of treatment, there are viable options that should be pursued in the treatment of schizophrenia-related cognitive impairments. Nonpharmacologic modalities have shown encouraging results. Cognitive remediation therapy produces durable cognitive improvement—especially when combined with adjunctive therapies, such as small group therapy and vocational rehabilitation, and when comorbid conditions (major depressive disorder in Mr. F’s case) are treated.

In summary, we reiterate that cognitive impairments in schizophrenia represent a strong predictor of patient-oriented outcomes; we maintain our assertion regarding their inadequate treatment with existing medications; and we suggest that future trials attempt to find effective alternative strategies. We encourage psychiatric clinicians to approach treatment of this facet of pathology with an open mind, and to utilize alternative multi-modal therapies for the benefit of their patients with schizophrenia while waiting for new safe and effective pharmaceutical regimens.

Jarrett Dawson, MD
Family medicine resident
Department of Psychiatry
Saint Louis University
St. Louis, Missouri

Catalina Belean, MD
Assistant Professor
Department of Psychiatry
Saint Louis University
St. Louis, Missouri

The Goldwater Rule and free speech

In his editorial, “The toxic zeitgeist of hyper-partisanship: A psychiatric perspective” (From the Editor, Current Psychiatry, February 2018, p. 17-18), Dr. Nasrallah notes that he “adheres” to the APA’s Goldwater Rule. The Goldwater Rule and the reason for its creation and current implementation in the United States cannot be fully understood without appreciating the political circumstances that led to its creation in 1964. The conservative movement had been using the slogan “better dead than red” to criticize Democrats who they felt were soft on communism. Unfortunately, some psychiatrists took these words and the views of Arizona senator Barry Goldwater quite literally. They claimed they understood his psychological structure by listening to his political views, and feared that he would risk starting a nuclear war. Of course, no psychiatrist actually examined senator Goldwater. During the 1964 presidential campaign, a television commercial from President Lyndon B. Johnson’s campaign included a mushroom cloud of a nuclear explosion with an implicit reference to senator Goldwater and the “better dead than red” slogan. In the end, psychiatry, and particularly psychoanalysis, as well as President Johnson’s campaign, were embarrassed.

One’s political views do not inform us of his or her mental health status. This appreciation can be obtained only by a thorough psychological assessment. This is the basis of the Goldwater Rule, coupled with the ethical responsibility not to discuss patients’ private communications.

Today, this rule is tested by the behavior and actions of President Donald Trump. Proponents of the Goldwater Rule state that a psychiatrist cannot diagnose someone without performing a face-to-face diagnostic evaluation. This assumes psychiatrists diagnose patients only by interviewing them. However, any psychiatrist who has worked in an emergency room has signed involuntary commitment papers for a patient who refuses to talk to them. This clinical action typically is based on reports of the patient’s potential dangerousness from family, friends, or the police.

The diagnostic criteria for some personality disorders are based only on observed or reported behavior. They do not indicate a need for an interview.  The diagnosis of a personality disorder cannot be made solely by interviewing an individual without knowledge of his or her behavior. Interviewing Bernie Madoff would not have revealed his sociopathic behavior.

The critical question may not be whether one could ethically make a psychiatric diagnosis of the President (I believe you can), but rather would it indicate or imply that he is dangerous? History informs us that the existence of a psychiatric disorder does not determine a politician’s fitness for office or if they are dangerous. Behavioral accounts of President Abraham Lincoln and his self-reports seem to confirm that at times he was depressed, but he clearly served our country with distinction.

Finally, it is not clear whether the Goldwater Rule is legal. It arguably interferes with a psychiatrist’s right of free speech without the risk of being accused of unethical behavior. I wonder what would happen if it were tested in court. Does the First Amendment of the U.S. Constitution protect a psychiatrist’s right to speak freely?

Sidney Weissman, MD
Clinical Professor of Psychiatry and Behavioral Science
Feinberg School of Medicine
Northwestern University
Chicago, Illinois

The current ‘political morass’

Thank you, Dr. Nasrallah, for the wonderful synopsis of the current political morass in your editorial (From the Editor, Current Psychiatry, February 2018, p. 17-18). You followed Descartes’ dictum: you thought about matters in a novel fashion. I will assertively share this with others. It is a good piece of teaching.

James Gallagher, MD
Private psychiatric practice
Des Moines, Iowa

Continue to: The biological etiology of compulsive sexual behavior

Dr. Grant’s article, “Compulsive sexual behavior: A nonjudgmental approach” (Evidence-Based Reviews, Current Psychiatry, February 2018, p. 34,38-40,45-46), puts a well-deserved spotlight on a relatively underrecognized problem that most psychiatrists will encounter at least once during clinical practice. While the article is overall helpful, it completely leaves out any possible biological etiology and underpinnings to the condition that may be important to address while evaluating someone with compulsive sexual behavior. Specifically, are there any endocrine issues that should be considered that may also impact our approach to its treatment?

Mukesh Sanghadia, MD, MRCPsych (UK), Diplomate ABPN
PsychiatristCommunity Research Foundation
San Diego, California

The author responds

Dr. Sanghadia highlights the lack of possible biological etiology of compulsive sexual behavior (CSB) in my article. This is a fair comment. The lack of agreed-upon diagnostic criteria, however, has resulted in a vast literature discussing sexual behaviors that may or may not be related to each other, and even suggest that what is currently referred to as CSB may in fact be quite heterogeneous. My article mentions the few neuroimaging and neurocognitive studies that address a more rigorously defined CSB. Other possible etiologies have been suggested for a range of out-of-control sexual behaviors, but have not been studied with a focus on this formal diagnostic category. For example, endocrine issues have been explored to some extent in individuals with paraphilic sexual behaviors (behaviors that appear to many to have no relationship to CSB as discussed in my article), and in those cases of paraphilic sexual behavior, a range of endocrine hormones have been examined—gonadotropin-releasing hormone, follicle-stimulating hormone, luteinizing hormone, testosterone/dihydrotestosterone, and estrogen/progesterone. But these studies have yielded no conclusive outcomes in terms of findings or treatments.

In summary, the biology of CSB lags far behind that of other mental health disorders (and even other psychiatric disorders lack conclusive biological etiologies). Establishing this behavior as a legitimate diagnostic entity with agreed-upon criteria may be the first step in furthering our understanding of its possible biology.

Jon E. Grant, JD, MD, MPH
Professor
Department of Psychiatry and Behavioral Neuroscience
University of Chicago, Pritzker School of Medicine
Chicago, Illinois

Continue to: A different view of patients with schizophrenia

After treating patients with schizophrenia for more than 30 years, I’ve observed a continuous flood of information about them. This overload has been consistent since my residency back in the 1980s. Theories ranging from the psychoanalytic to the biologic are numerous and valuable additions to our understanding of those who suffer with this malady, yet they provide no summation or overview with which to understand it.

For instance, we know that schizophrenia usually begins in the late teens or early twenties. We know that antidopaminergic medications usually help to varying degrees. Psychosocial interventions may contribute greatly to the ultimate outcome. Substance use invariably makes it worse. Establishing a connection with the patient can often be helpful. Medication compliance is crucial.

It is more or less accepted that there is deterioration of higher brain functions, hypofrontality, as well as so-called dysconnectivity of white matter. There is a genetic vulnerability, and there seems to be an excess of inflammation and changes in mitochondria. Most patients have low functioning, poor compensation, and a lack of social adeptness. However, some patients can recover quite nicely. Although most of us would agree that this is not dementia, we’d also concede that these patients’ cognitive functioning is not what it used to be. Electroconvulsive therapy also can sometimes be helpful.

So, how are we to view our patients with schizophrenia in a way that can be illuminating and give us a deeper sense of understanding this quizzical disorder? It has been helpful to me to regard these individuals as a people whose brain function has been usurped by a more primitive organization that is characterized by:

• a reduction in mental development, where patients function in a more childlike way with magical thinking and impaired reality-testing
• atrophy of higher brain structures, leading to hallucinatory experiences
• a hyper-dominergic state
• a usually gradual onset with some evidence of struggle between the old and new brain organizations
• impaired prepulse inhibition that’s likely secondary to diffuseness of thought
• eventual demise of higher brain structures with an inability to respond to anti-dopaminergics. (Antipsychotics can push the brain organization closer to the adult structure attained before the onset of the disease, at least initially.)

The list goes on. Thinking about patients with schizophrenia in this way allows me to appreciate what I feel is a more encompassing view of who they are and how they got there. I have some theories about where this more primitive organization may have originated, but whatever its origin, in a small percentage of people it is there, ready to assume control of their thinking just as they are reaching reproductive age. Early intervention and medication compliance may minimize damage.

If a theory helps us gain a greater understanding of our patients, then it’s worth considering. This proposition fits much of what we know about schizophrenia. Reading patients’ firsthand accounts of the illness helps confirm, in my opinion, this point of view.

Steven Lesk, MD
Private psychiatric practice
Fridley, Minnesota

Continue to: Cognitive impairment in schizophrenia

The authors of “Suspicious, sleepless, and smoking” (Cases That Test Your Skills, Current Psychiatry, September 2017, p. 49-50,52-54) assert that “…the severity of cognitive impairment in schizophrenia has no association with the positive symptoms of schizophrenia” and they add, “Treatment of the cognitive symptoms of schizophrenia with antipsychotics has been largely ineffective.” However, in the case they present, Mr. F appears to demonstrate just the opposite: He is given antipsychotics, and over the course of his hospital stay, both his positive symptoms and his cognition improve. His scores on the Montreal Cognitive Assessment increase from 9 (Day 11) to 15 (Day 16) to 21 (Day 24). Thus, in this particular case, treatment with antipsychotics is clearly associated with cognitive improvement.

During the past 15 years, I have routinely measured cognitive functioning in patients with schizophrenia. Some have no impairment, some have severe impairment, and some fall in between these extremes. Most often, impairment occurs in the area of executive function, which can lead to significant disability. Indeed, positive symptoms can clear up completely with treatment, but the deficits in executive functioning can remain.

I think it is fair to say that cognitive impairment is a common, although not nearly universal, feature of schizophrenia that sometimes improves with antipsychotic medication. I look forward to the advent of more clinicians paying attention to the issue of cognition in schizophrenia and, hopefully, better treatments for it.

John M. Mahoney, PhD
Shasta Psychiatric Hospital
Redding, California

The authors respond

We thank Dr. Mahoney for his thoughtful letter and queries into the case of Mr. F.

First, regarding the prevalence of cognitive impairment in schizophrenia, it is our opinion that cognitive impairment is a distinct, core, and nearly universal feature of schizophrenia. This also is the conclusion of many clinicians and researchers based on their significant work in the field; still, just as in our initial case study, we concede that these symptoms are not part of the DSM-5’s formal diagnostic criteria.

The core question Dr. Mahoney seems to pose is whether we contradicted ourselves. We assert that cognitive impairment in schizophrenia is not effectively treated with existing medications, and yet we described Mr. F’s cognitive improvement after he received risperidone, 2 mg/d, titrated up to 2 mg twice daily. We first pointed out that part of our treatment strategy was to target comorbid depression in this patient; nonetheless, Dr. Mahoney’s question remains valid, and we will attempt to answer.

Dr. Mahoney has observed that his patients with schizophrenia variably experience improved cognition, and notes that executive function is a particularly common lingering impairment. On this we wholly agree; this is a helpful point of clarification, and a useful distinction in light of the above question. Improvement in positive and negative symptoms of schizophrenia, as psychosis resolves, is a well-known and studied effect of antipsychotic therapy. As a result, the sensorium becomes more congruent with external reality, and one would expect the patient to display improved orientation. This then might be reasonably expected to produce mental status improvements; however, while some improvement is frequently observed, this is neither consistent nor complete improvement. In the case of Mr. F, we document improvement, but also significant continued impairment. Thus, we maintain that treating the cognitive symptoms of schizophrenia with antipsychotics has been largely ineffective.

We do not see this as a slight distinction or an argument of minutiae. That patients frequently experience some degree of lingering impairment is a salient point. Neurocognitive impairment is a strong contributor to and predictor of disability in schizophrenia, and neurocognitive abilities most strongly predict functional outcomes. From a patient’s point of view, these symptoms have real-world consequences. Thus, we believe they should be evaluated and treated as aggressively and consistently as other schizophrenia symptoms.

In our case, we attempted to convey one primary message: Despite the challenges of treatment, there are viable options that should be pursued in the treatment of schizophrenia-related cognitive impairments. Nonpharmacologic modalities have shown encouraging results. Cognitive remediation therapy produces durable cognitive improvement—especially when combined with adjunctive therapies, such as small group therapy and vocational rehabilitation, and when comorbid conditions (major depressive disorder in Mr. F’s case) are treated.

In summary, we reiterate that cognitive impairments in schizophrenia represent a strong predictor of patient-oriented outcomes; we maintain our assertion regarding their inadequate treatment with existing medications; and we suggest that future trials attempt to find effective alternative strategies. We encourage psychiatric clinicians to approach treatment of this facet of pathology with an open mind, and to utilize alternative multi-modal therapies for the benefit of their patients with schizophrenia while waiting for new safe and effective pharmaceutical regimens.

Jarrett Dawson, MD
Family medicine resident
Department of Psychiatry
Saint Louis University
St. Louis, Missouri

Catalina Belean, MD
Assistant Professor
Department of Psychiatry
Saint Louis University
St. Louis, Missouri

In this issue of JFP, Dr. Mendoza reminds us that “Parkinson’s disease can be a tough diagnosis to navigate.”¹ Classically, Parkinson’s disease (PD) is associated with a resting tremor, but bradykinesia is actually the hallmark of the disease. PD can also present with subtle movement disorders, as well as depression and early dementia. It is, indeed, a difficult clinical diagnosis, and consultation with an expert to confirm or deny its presence can be quite helpful.

Other conundrums. PD, however, is not the only illness whose signs and symptoms can present a challenge. Chronic and intermittent shortness of breath, for example, can be very difficult to sort out. Is the shortness of breath due to congestive heart failure, chronic obstructive pulmonary disease, asthma, or a neurologic condition such as myasthenia gravis? Or is it the result of several causes?

When asthma isn’t asthma. Because it is a common illness, physicians often diagnose asthma in patients with shortness of breath or wheezing. But a recent study suggests that as many as 30% of primary care patients with a current diagnosis of asthma do not have asthma at all.²

In the study, Canadian researchers recruited 701 adults with physician-diagnosed asthma, all of whom were taking asthma medications regularly. The researchers did baseline pulmonary function testing (including methacholine challenge testing, if needed) and monitored symptoms frequently. Then they gradually withdrew asthma medications from those who did not appear to have a definitive diagnosis of asthma. They followed these patients for one year. One-third (203 of 613) of the patients with complete follow-up data were no longer taking asthma medications one year later and had no symptoms of asthma. Twelve patients had serious alternative diagnoses such as coronary artery disease and bronchiectasis.

Reevaluate your asthma patients to be sure they have the correct Dx, and keep Parkinson's in the differential for patients with atypical symptoms.

Closer to home. In my practice, I found 2 patients with long-standing diagnoses of asthma who didn’t, in fact, have the condition at all. In both cases, my suspicion was raised by lung examination. In one case, fine bibasilar rales suggested pulmonary fibrosis, which was the correct diagnosis, and the patient is now on the lung transplant list. In the other case, a loud venous hum suggested an arteriovenous malformation. Surgery corrected the patient’s “asthma.”

I urge you to reevaluate your asthma patients to be sure they have the correct diagnosis and to keep PD in your differential for patients who present with atypical symptoms. Primary care clinicians must be expert diagnosticians, willing to question prior diagnoses.

In this issue of JFP, Dr. Mendoza reminds us that “Parkinson’s disease can be a tough diagnosis to navigate.”¹ Classically, Parkinson’s disease (PD) is associated with a resting tremor, but bradykinesia is actually the hallmark of the disease. PD can also present with subtle movement disorders, as well as depression and early dementia. It is, indeed, a difficult clinical diagnosis, and consultation with an expert to confirm or deny its presence can be quite helpful.

Other conundrums. PD, however, is not the only illness whose signs and symptoms can present a challenge. Chronic and intermittent shortness of breath, for example, can be very difficult to sort out. Is the shortness of breath due to congestive heart failure, chronic obstructive pulmonary disease, asthma, or a neurologic condition such as myasthenia gravis? Or is it the result of several causes?

When asthma isn’t asthma. Because it is a common illness, physicians often diagnose asthma in patients with shortness of breath or wheezing. But a recent study suggests that as many as 30% of primary care patients with a current diagnosis of asthma do not have asthma at all.²

In the study, Canadian researchers recruited 701 adults with physician-diagnosed asthma, all of whom were taking asthma medications regularly. The researchers did baseline pulmonary function testing (including methacholine challenge testing, if needed) and monitored symptoms frequently. Then they gradually withdrew asthma medications from those who did not appear to have a definitive diagnosis of asthma. They followed these patients for one year. One-third (203 of 613) of the patients with complete follow-up data were no longer taking asthma medications one year later and had no symptoms of asthma. Twelve patients had serious alternative diagnoses such as coronary artery disease and bronchiectasis.

Reevaluate your asthma patients to be sure they have the correct Dx, and keep Parkinson's in the differential for patients with atypical symptoms.

Closer to home. In my practice, I found 2 patients with long-standing diagnoses of asthma who didn’t, in fact, have the condition at all. In both cases, my suspicion was raised by lung examination. In one case, fine bibasilar rales suggested pulmonary fibrosis, which was the correct diagnosis, and the patient is now on the lung transplant list. In the other case, a loud venous hum suggested an arteriovenous malformation. Surgery corrected the patient’s “asthma.”

I urge you to reevaluate your asthma patients to be sure they have the correct diagnosis and to keep PD in your differential for patients who present with atypical symptoms. Primary care clinicians must be expert diagnosticians, willing to question prior diagnoses.

In this issue of JFP, Dr. Mendoza reminds us that “Parkinson’s disease can be a tough diagnosis to navigate.”¹ Classically, Parkinson’s disease (PD) is associated with a resting tremor, but bradykinesia is actually the hallmark of the disease. PD can also present with subtle movement disorders, as well as depression and early dementia. It is, indeed, a difficult clinical diagnosis, and consultation with an expert to confirm or deny its presence can be quite helpful.

Other conundrums. PD, however, is not the only illness whose signs and symptoms can present a challenge. Chronic and intermittent shortness of breath, for example, can be very difficult to sort out. Is the shortness of breath due to congestive heart failure, chronic obstructive pulmonary disease, asthma, or a neurologic condition such as myasthenia gravis? Or is it the result of several causes?

When asthma isn’t asthma. Because it is a common illness, physicians often diagnose asthma in patients with shortness of breath or wheezing. But a recent study suggests that as many as 30% of primary care patients with a current diagnosis of asthma do not have asthma at all.²

In the study, Canadian researchers recruited 701 adults with physician-diagnosed asthma, all of whom were taking asthma medications regularly. The researchers did baseline pulmonary function testing (including methacholine challenge testing, if needed) and monitored symptoms frequently. Then they gradually withdrew asthma medications from those who did not appear to have a definitive diagnosis of asthma. They followed these patients for one year. One-third (203 of 613) of the patients with complete follow-up data were no longer taking asthma medications one year later and had no symptoms of asthma. Twelve patients had serious alternative diagnoses such as coronary artery disease and bronchiectasis.

Reevaluate your asthma patients to be sure they have the correct Dx, and keep Parkinson's in the differential for patients with atypical symptoms.

Closer to home. In my practice, I found 2 patients with long-standing diagnoses of asthma who didn’t, in fact, have the condition at all. In both cases, my suspicion was raised by lung examination. In one case, fine bibasilar rales suggested pulmonary fibrosis, which was the correct diagnosis, and the patient is now on the lung transplant list. In the other case, a loud venous hum suggested an arteriovenous malformation. Surgery corrected the patient’s “asthma.”

I urge you to reevaluate your asthma patients to be sure they have the correct diagnosis and to keep PD in your differential for patients who present with atypical symptoms. Primary care clinicians must be expert diagnosticians, willing to question prior diagnoses.

What percentage of your office visits are a response to an acute complaint? What percentage are prescheduled well-child visits? And how many are follow-ups to manage chronic conditions and behavioral problems?

You probably have a sense of how you are spending your time in the office, but do you really have the numbers to support your guesstimate of the patient mix? Does anyone in your organization have that data? You probably could come up with some numbers in a few hours with a pencil and your office schedule for the last 2 months. However, learning how much of your income is generated by each category of visit would be more difficult.

iStock

I know this is a heretical proposition but a mix of acute and chronic complaints keeps the practice of pediatrics stimulating and rewarding and is good for the patients. I found that I knew my patients better after seeing them when they were in need rather than in the less frequent but longer encounters of a health maintenance visit. It takes work, but there is room for both kinds of visit.

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].

What percentage of your office visits are a response to an acute complaint? What percentage are prescheduled well-child visits? And how many are follow-ups to manage chronic conditions and behavioral problems?

You probably have a sense of how you are spending your time in the office, but do you really have the numbers to support your guesstimate of the patient mix? Does anyone in your organization have that data? You probably could come up with some numbers in a few hours with a pencil and your office schedule for the last 2 months. However, learning how much of your income is generated by each category of visit would be more difficult.

iStock

I know this is a heretical proposition but a mix of acute and chronic complaints keeps the practice of pediatrics stimulating and rewarding and is good for the patients. I found that I knew my patients better after seeing them when they were in need rather than in the less frequent but longer encounters of a health maintenance visit. It takes work, but there is room for both kinds of visit.

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].

What percentage of your office visits are a response to an acute complaint? What percentage are prescheduled well-child visits? And how many are follow-ups to manage chronic conditions and behavioral problems?

You probably have a sense of how you are spending your time in the office, but do you really have the numbers to support your guesstimate of the patient mix? Does anyone in your organization have that data? You probably could come up with some numbers in a few hours with a pencil and your office schedule for the last 2 months. However, learning how much of your income is generated by each category of visit would be more difficult.

iStock

I know this is a heretical proposition but a mix of acute and chronic complaints keeps the practice of pediatrics stimulating and rewarding and is good for the patients. I found that I knew my patients better after seeing them when they were in need rather than in the less frequent but longer encounters of a health maintenance visit. It takes work, but there is room for both kinds of visit.

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].

Diagnosing and initiating treatment for bipolar disorders in children deserve the skills of a child psychiatrist. So why do we really need to know about these complicated conditions as pediatricians?

Although the prevalence of bipolar disorder is about 4% of the adult population, first presentation of significant symptoms usually occurs in adolescence (1% prevalence) with many affected adults recalling symptoms in childhood. To be called a disorder, symptoms have to significantly impact daily functioning. That means these children and their families – and often their schoolmates and teachers – are struggling, whether a diagnosis has been made or not. While bipolar disorder is clearly heritable (emerging in 10% of children of affected adults), environmental stresses such as trauma, family discord, life transitions, academic pressure, illness, puberty, and even lack of sleep can bring out a cycle of symptoms. There also is evidence that earlier treatment may reduce symptoms long term. These factors mean that we need to be vigilant for signs that behavior or mood problems actually are symptoms of bipolar disorder and take action.

KatarzynaBialasiewicz/Getty Images

While uncommon, medical conditions such as epilepsy, hyperthyroidism, multiple sclerosis, strokes, tumors, and infections are in the differential we are best positioned to consider. Prescribed medications such as steroids, Singulair, Accutane and, of course, illicit drugs such as cocaine and misused amphetamines also can cause severe mood changes. The psychiatric differential includes depression, ADHD, oppositional defiant disorder or conduct disorder, disruptive mood dysregulation disorder, generalized anxiety disorder, autism, substance use, and personality disorder.

Now that routine screening for depression is recommended for all children, the need to recognize bipolar disorder is even greater. The first thing you need to understand is the signs of mania, the feature that distinguishes depression (unipolar) from manic-depressive disorder (now called bipolar disorder). Walking into the chaos of a pediatric office, one might think all the patients have mania! In fact, it is now a common joke for ordinary people say their erratic or silly behavior is caused by “being bipolar.” As for all mental disorders, milder forms of the same behaviors that constitute mania may happen to any of us at times: elation often mixed with irritability, unrealistic beliefs about one’s abilities, racing thoughts or speech, trouble concentrating, acting with poor judgment for age, having a decreased need for sleep, and inappropriate sexual behaviors. To be considered mania, though, the child must have five of these behaviors with one being elation or irritability; have behavior distinctly different from usual behavior, and have behaviors that last at least 7 days or require hospitalization. Having the child or parent complete the Mood Disorders Questionnaire or the parent version of the Young Mania Rating Scale can help, but is not definitive. When mania has occurred and there is also a period of depression lasting 2 weeks, the condition is called Bipolar I. If the mania symptoms do not meet criteria or only irritability is present in distinct periods (hypomania), Bipolar II is diagnosed. In children there can be more rapid cycling than in adults, even four to five cycles per day, as well as briefer (1-2 days) or more persistent periods. Mania may manifest as irritability, aggression, rages, or inconsolability. Children with either Bipolar I or II (not otherwise specified or NOS) should be referred to a mental health specialist.

In addition to cueing the need for a referral, recognizing bipolar disorder is critical because some medications we may ordinarily feel comfortable prescribing, notably antidepressants and stimulants, can activate mania if given in the absence of mood stabilizing medications. While such activation can be reversible, the associated behaviors may be difficult to endure for everyone, and frighten parents and children so they won’t try needed treatments in the future. We must be vigilant for signs of bipolar in all children presenting with symptoms of ADHD, because more than 50% of children with bipolar disorder have comorbid ADHD, often as the presenting sign. Children with only ADHD, in contrast, do not have reduced sleep needs, hypersexuality, hallucinations, or suicidality. Similarly, depression is common, and a condition that we should diagnose and treat. About 20% of depressed children will go on to bipolar disorder. When starting medication for either ADHD or depression, we need to advise families of the signs of activation and monitor them closely, not only to optimize treatment for the condition we believe is present, but also for the possibility that our treatment could make them worse. We also need to advise that suicide is always a risk of bipolar disorder (33%-44% attempt if untreated).

You often may be asked to refill medications prescribed by specialists for a child’s bipolar disorder. It is important to become familiar with both the common and rare but dangerous side effects. Patients taking lithium need regular blood levels taken for dose adjustments as well as monitoring for renal, thyroid, and parathyroid insults. Atypical antipsychotics can raise lipid levels and prolactin, as well as cause diabetes, rapid weight gain, and tardive dyskinesia. Although neuroleptic malignant syndrome is a rare and reversible side effect, if undetected it can be fatal. Antiepileptic mood stabilizers can cause low platelets or white counts, and the potentially fatal Stevens-Johnson syndrome presenting as rash. Hydration is especially important, as well as watching for hyperthermia and hypothermia as temperature regulation is affected by these medicines. Drug interactions are common and must be anticipated, such as NSAIDs increase lithium levels; OTC cold and allergy medications increase sedation; and caffeine and smoking reduce effects of atypical antipsychotics.

You are crucial for communicating the expected recurring cyclic nature of episodes of depression and mania or hypomania, and the need for maintenance medication. Recovery from an episode is common (81%) within 2.5 years, but 62% recur within the next 1.5 years. Vigilance is needed, especially from parents, because the affected child is unlikely to be able to tell when a new cycle is starting. Establishing healthy routines of eating, sleep, and exercise, and learning stress-reduction strategies as well as avoiding pregnancy, smoking, and drugs (there is a sixfold risk of abuse) is important to lessen risk of recurrence, buffer stress, and optimize outcomes. We need to counsel or refer to help families learn to manage behaviors using transition reminders, positive reinforcers rather than punishment, and sometimes reduced expectations. We may be the best ones to educate schools and request emotion-based Individualized Education Program (IEP) and 504 accommodations. Cognitive impairment during cycles of bipolar disorder may require reduced workload, extended time, or breaks for support. It can be helpful to reflect on the high energy, creativity, and innovative thinking found in many people with bipolar disorder, including Van Gogh (artist), Sir Isaac Newton (scientist), Ted Turner (founder of CNN), and Mariah Carey (singer)! Children need our honesty and help accepting this chronic disorder with optimism about their futures, which, with good medical management, can be bright.
 

Dr. Howard is an assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at [email protected].

Diagnosing and initiating treatment for bipolar disorders in children deserve the skills of a child psychiatrist. So why do we really need to know about these complicated conditions as pediatricians?

Although the prevalence of bipolar disorder is about 4% of the adult population, first presentation of significant symptoms usually occurs in adolescence (1% prevalence) with many affected adults recalling symptoms in childhood. To be called a disorder, symptoms have to significantly impact daily functioning. That means these children and their families – and often their schoolmates and teachers – are struggling, whether a diagnosis has been made or not. While bipolar disorder is clearly heritable (emerging in 10% of children of affected adults), environmental stresses such as trauma, family discord, life transitions, academic pressure, illness, puberty, and even lack of sleep can bring out a cycle of symptoms. There also is evidence that earlier treatment may reduce symptoms long term. These factors mean that we need to be vigilant for signs that behavior or mood problems actually are symptoms of bipolar disorder and take action.

KatarzynaBialasiewicz/Getty Images

While uncommon, medical conditions such as epilepsy, hyperthyroidism, multiple sclerosis, strokes, tumors, and infections are in the differential we are best positioned to consider. Prescribed medications such as steroids, Singulair, Accutane and, of course, illicit drugs such as cocaine and misused amphetamines also can cause severe mood changes. The psychiatric differential includes depression, ADHD, oppositional defiant disorder or conduct disorder, disruptive mood dysregulation disorder, generalized anxiety disorder, autism, substance use, and personality disorder.

Now that routine screening for depression is recommended for all children, the need to recognize bipolar disorder is even greater. The first thing you need to understand is the signs of mania, the feature that distinguishes depression (unipolar) from manic-depressive disorder (now called bipolar disorder). Walking into the chaos of a pediatric office, one might think all the patients have mania! In fact, it is now a common joke for ordinary people say their erratic or silly behavior is caused by “being bipolar.” As for all mental disorders, milder forms of the same behaviors that constitute mania may happen to any of us at times: elation often mixed with irritability, unrealistic beliefs about one’s abilities, racing thoughts or speech, trouble concentrating, acting with poor judgment for age, having a decreased need for sleep, and inappropriate sexual behaviors. To be considered mania, though, the child must have five of these behaviors with one being elation or irritability; have behavior distinctly different from usual behavior, and have behaviors that last at least 7 days or require hospitalization. Having the child or parent complete the Mood Disorders Questionnaire or the parent version of the Young Mania Rating Scale can help, but is not definitive. When mania has occurred and there is also a period of depression lasting 2 weeks, the condition is called Bipolar I. If the mania symptoms do not meet criteria or only irritability is present in distinct periods (hypomania), Bipolar II is diagnosed. In children there can be more rapid cycling than in adults, even four to five cycles per day, as well as briefer (1-2 days) or more persistent periods. Mania may manifest as irritability, aggression, rages, or inconsolability. Children with either Bipolar I or II (not otherwise specified or NOS) should be referred to a mental health specialist.

In addition to cueing the need for a referral, recognizing bipolar disorder is critical because some medications we may ordinarily feel comfortable prescribing, notably antidepressants and stimulants, can activate mania if given in the absence of mood stabilizing medications. While such activation can be reversible, the associated behaviors may be difficult to endure for everyone, and frighten parents and children so they won’t try needed treatments in the future. We must be vigilant for signs of bipolar in all children presenting with symptoms of ADHD, because more than 50% of children with bipolar disorder have comorbid ADHD, often as the presenting sign. Children with only ADHD, in contrast, do not have reduced sleep needs, hypersexuality, hallucinations, or suicidality. Similarly, depression is common, and a condition that we should diagnose and treat. About 20% of depressed children will go on to bipolar disorder. When starting medication for either ADHD or depression, we need to advise families of the signs of activation and monitor them closely, not only to optimize treatment for the condition we believe is present, but also for the possibility that our treatment could make them worse. We also need to advise that suicide is always a risk of bipolar disorder (33%-44% attempt if untreated).

You often may be asked to refill medications prescribed by specialists for a child’s bipolar disorder. It is important to become familiar with both the common and rare but dangerous side effects. Patients taking lithium need regular blood levels taken for dose adjustments as well as monitoring for renal, thyroid, and parathyroid insults. Atypical antipsychotics can raise lipid levels and prolactin, as well as cause diabetes, rapid weight gain, and tardive dyskinesia. Although neuroleptic malignant syndrome is a rare and reversible side effect, if undetected it can be fatal. Antiepileptic mood stabilizers can cause low platelets or white counts, and the potentially fatal Stevens-Johnson syndrome presenting as rash. Hydration is especially important, as well as watching for hyperthermia and hypothermia as temperature regulation is affected by these medicines. Drug interactions are common and must be anticipated, such as NSAIDs increase lithium levels; OTC cold and allergy medications increase sedation; and caffeine and smoking reduce effects of atypical antipsychotics.

You are crucial for communicating the expected recurring cyclic nature of episodes of depression and mania or hypomania, and the need for maintenance medication. Recovery from an episode is common (81%) within 2.5 years, but 62% recur within the next 1.5 years. Vigilance is needed, especially from parents, because the affected child is unlikely to be able to tell when a new cycle is starting. Establishing healthy routines of eating, sleep, and exercise, and learning stress-reduction strategies as well as avoiding pregnancy, smoking, and drugs (there is a sixfold risk of abuse) is important to lessen risk of recurrence, buffer stress, and optimize outcomes. We need to counsel or refer to help families learn to manage behaviors using transition reminders, positive reinforcers rather than punishment, and sometimes reduced expectations. We may be the best ones to educate schools and request emotion-based Individualized Education Program (IEP) and 504 accommodations. Cognitive impairment during cycles of bipolar disorder may require reduced workload, extended time, or breaks for support. It can be helpful to reflect on the high energy, creativity, and innovative thinking found in many people with bipolar disorder, including Van Gogh (artist), Sir Isaac Newton (scientist), Ted Turner (founder of CNN), and Mariah Carey (singer)! Children need our honesty and help accepting this chronic disorder with optimism about their futures, which, with good medical management, can be bright.
 

Dr. Howard is an assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at [email protected].

Diagnosing and initiating treatment for bipolar disorders in children deserve the skills of a child psychiatrist. So why do we really need to know about these complicated conditions as pediatricians?

Although the prevalence of bipolar disorder is about 4% of the adult population, first presentation of significant symptoms usually occurs in adolescence (1% prevalence) with many affected adults recalling symptoms in childhood. To be called a disorder, symptoms have to significantly impact daily functioning. That means these children and their families – and often their schoolmates and teachers – are struggling, whether a diagnosis has been made or not. While bipolar disorder is clearly heritable (emerging in 10% of children of affected adults), environmental stresses such as trauma, family discord, life transitions, academic pressure, illness, puberty, and even lack of sleep can bring out a cycle of symptoms. There also is evidence that earlier treatment may reduce symptoms long term. These factors mean that we need to be vigilant for signs that behavior or mood problems actually are symptoms of bipolar disorder and take action.

KatarzynaBialasiewicz/Getty Images

While uncommon, medical conditions such as epilepsy, hyperthyroidism, multiple sclerosis, strokes, tumors, and infections are in the differential we are best positioned to consider. Prescribed medications such as steroids, Singulair, Accutane and, of course, illicit drugs such as cocaine and misused amphetamines also can cause severe mood changes. The psychiatric differential includes depression, ADHD, oppositional defiant disorder or conduct disorder, disruptive mood dysregulation disorder, generalized anxiety disorder, autism, substance use, and personality disorder.

Now that routine screening for depression is recommended for all children, the need to recognize bipolar disorder is even greater. The first thing you need to understand is the signs of mania, the feature that distinguishes depression (unipolar) from manic-depressive disorder (now called bipolar disorder). Walking into the chaos of a pediatric office, one might think all the patients have mania! In fact, it is now a common joke for ordinary people say their erratic or silly behavior is caused by “being bipolar.” As for all mental disorders, milder forms of the same behaviors that constitute mania may happen to any of us at times: elation often mixed with irritability, unrealistic beliefs about one’s abilities, racing thoughts or speech, trouble concentrating, acting with poor judgment for age, having a decreased need for sleep, and inappropriate sexual behaviors. To be considered mania, though, the child must have five of these behaviors with one being elation or irritability; have behavior distinctly different from usual behavior, and have behaviors that last at least 7 days or require hospitalization. Having the child or parent complete the Mood Disorders Questionnaire or the parent version of the Young Mania Rating Scale can help, but is not definitive. When mania has occurred and there is also a period of depression lasting 2 weeks, the condition is called Bipolar I. If the mania symptoms do not meet criteria or only irritability is present in distinct periods (hypomania), Bipolar II is diagnosed. In children there can be more rapid cycling than in adults, even four to five cycles per day, as well as briefer (1-2 days) or more persistent periods. Mania may manifest as irritability, aggression, rages, or inconsolability. Children with either Bipolar I or II (not otherwise specified or NOS) should be referred to a mental health specialist.

In addition to cueing the need for a referral, recognizing bipolar disorder is critical because some medications we may ordinarily feel comfortable prescribing, notably antidepressants and stimulants, can activate mania if given in the absence of mood stabilizing medications. While such activation can be reversible, the associated behaviors may be difficult to endure for everyone, and frighten parents and children so they won’t try needed treatments in the future. We must be vigilant for signs of bipolar in all children presenting with symptoms of ADHD, because more than 50% of children with bipolar disorder have comorbid ADHD, often as the presenting sign. Children with only ADHD, in contrast, do not have reduced sleep needs, hypersexuality, hallucinations, or suicidality. Similarly, depression is common, and a condition that we should diagnose and treat. About 20% of depressed children will go on to bipolar disorder. When starting medication for either ADHD or depression, we need to advise families of the signs of activation and monitor them closely, not only to optimize treatment for the condition we believe is present, but also for the possibility that our treatment could make them worse. We also need to advise that suicide is always a risk of bipolar disorder (33%-44% attempt if untreated).

You often may be asked to refill medications prescribed by specialists for a child’s bipolar disorder. It is important to become familiar with both the common and rare but dangerous side effects. Patients taking lithium need regular blood levels taken for dose adjustments as well as monitoring for renal, thyroid, and parathyroid insults. Atypical antipsychotics can raise lipid levels and prolactin, as well as cause diabetes, rapid weight gain, and tardive dyskinesia. Although neuroleptic malignant syndrome is a rare and reversible side effect, if undetected it can be fatal. Antiepileptic mood stabilizers can cause low platelets or white counts, and the potentially fatal Stevens-Johnson syndrome presenting as rash. Hydration is especially important, as well as watching for hyperthermia and hypothermia as temperature regulation is affected by these medicines. Drug interactions are common and must be anticipated, such as NSAIDs increase lithium levels; OTC cold and allergy medications increase sedation; and caffeine and smoking reduce effects of atypical antipsychotics.

You are crucial for communicating the expected recurring cyclic nature of episodes of depression and mania or hypomania, and the need for maintenance medication. Recovery from an episode is common (81%) within 2.5 years, but 62% recur within the next 1.5 years. Vigilance is needed, especially from parents, because the affected child is unlikely to be able to tell when a new cycle is starting. Establishing healthy routines of eating, sleep, and exercise, and learning stress-reduction strategies as well as avoiding pregnancy, smoking, and drugs (there is a sixfold risk of abuse) is important to lessen risk of recurrence, buffer stress, and optimize outcomes. We need to counsel or refer to help families learn to manage behaviors using transition reminders, positive reinforcers rather than punishment, and sometimes reduced expectations. We may be the best ones to educate schools and request emotion-based Individualized Education Program (IEP) and 504 accommodations. Cognitive impairment during cycles of bipolar disorder may require reduced workload, extended time, or breaks for support. It can be helpful to reflect on the high energy, creativity, and innovative thinking found in many people with bipolar disorder, including Van Gogh (artist), Sir Isaac Newton (scientist), Ted Turner (founder of CNN), and Mariah Carey (singer)! Children need our honesty and help accepting this chronic disorder with optimism about their futures, which, with good medical management, can be bright.
 

Dr. Howard is an assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at [email protected].

The prognosis of AML in the elderly is very poor, with 5-year survival rates less than 10% in patients aged 65 years and older. However, in recent years, novel therapeutic approaches have been developed to focus on the older AML population. Have we begun to witness an improvement in the survival of these patients?

Dr. Lancet is chair of the department of malignant hematology at H. Lee Moffitt Cancer Center in Tampa. He has received consulting fees from Astellas, BioSight, Celgene, Janssen R&D, and Jazz Pharmaceuticals.

References

1. Burnett AK et al. Cancer. 2007 Mar 15;109(6):1114-24.

2. Harousseau JL et al. Blood. 2009 Aug 6;114(6):1166-73.

3. Medeiros BC et al. Ann Hematol. 2015 Mar 20; 94(7):1127-38.

4. Oran B et al. Haematologica. 2012 Dec;97(12):1916-24.

5. Lancet JE et al. J Clin Oncol. 2017. doi: 10.1200/JCO.2017.35.15_suppl.7031.

6. Dombret H et al. Blood. 2015 Jul 16;126(3):291-9.

7. Kantarjian HM et al. J Clin Oncol. 2012 Jul 20;30(21):2670-7.

8. Lancet JE et al. Blood 2016 128:906.

9. Cortes JE et al. Blood 2016 128:99.

10. DiNardo CD et al. Blood 2017 130:2628.

11. Wei A et al. Blood 2017 130:890.

12. Extermann M et al. SIOG 2017.

The prognosis of AML in the elderly is very poor, with 5-year survival rates less than 10% in patients aged 65 years and older. However, in recent years, novel therapeutic approaches have been developed to focus on the older AML population. Have we begun to witness an improvement in the survival of these patients?

Dr. Lancet is chair of the department of malignant hematology at H. Lee Moffitt Cancer Center in Tampa. He has received consulting fees from Astellas, BioSight, Celgene, Janssen R&D, and Jazz Pharmaceuticals.

References

1. Burnett AK et al. Cancer. 2007 Mar 15;109(6):1114-24.

2. Harousseau JL et al. Blood. 2009 Aug 6;114(6):1166-73.

3. Medeiros BC et al. Ann Hematol. 2015 Mar 20; 94(7):1127-38.

4. Oran B et al. Haematologica. 2012 Dec;97(12):1916-24.

5. Lancet JE et al. J Clin Oncol. 2017. doi: 10.1200/JCO.2017.35.15_suppl.7031.

6. Dombret H et al. Blood. 2015 Jul 16;126(3):291-9.

7. Kantarjian HM et al. J Clin Oncol. 2012 Jul 20;30(21):2670-7.

8. Lancet JE et al. Blood 2016 128:906.

9. Cortes JE et al. Blood 2016 128:99.

10. DiNardo CD et al. Blood 2017 130:2628.

11. Wei A et al. Blood 2017 130:890.

12. Extermann M et al. SIOG 2017.

The prognosis of AML in the elderly is very poor, with 5-year survival rates less than 10% in patients aged 65 years and older. However, in recent years, novel therapeutic approaches have been developed to focus on the older AML population. Have we begun to witness an improvement in the survival of these patients?

Dr. Lancet is chair of the department of malignant hematology at H. Lee Moffitt Cancer Center in Tampa. He has received consulting fees from Astellas, BioSight, Celgene, Janssen R&D, and Jazz Pharmaceuticals.

References

1. Burnett AK et al. Cancer. 2007 Mar 15;109(6):1114-24.

2. Harousseau JL et al. Blood. 2009 Aug 6;114(6):1166-73.

3. Medeiros BC et al. Ann Hematol. 2015 Mar 20; 94(7):1127-38.

4. Oran B et al. Haematologica. 2012 Dec;97(12):1916-24.

5. Lancet JE et al. J Clin Oncol. 2017. doi: 10.1200/JCO.2017.35.15_suppl.7031.

6. Dombret H et al. Blood. 2015 Jul 16;126(3):291-9.

7. Kantarjian HM et al. J Clin Oncol. 2012 Jul 20;30(21):2670-7.

8. Lancet JE et al. Blood 2016 128:906.

9. Cortes JE et al. Blood 2016 128:99.

10. DiNardo CD et al. Blood 2017 130:2628.

11. Wei A et al. Blood 2017 130:890.

12. Extermann M et al. SIOG 2017.

It’s that time of year again. Many of your patients will join the 80.2 million Americans with plans for international travel this summer.

In 2016, Mexico (31.2 million) and Canada (13.9 million) were the top two destinations of U.S. residents. Based on 2016 U.S. Commerce data, an additional 35.1 million Americans headed to overseas destinations, including 9% who traveled with children. Vacation and visiting friends and relatives accounted for 55% and 27% of the reasons for all travel, respectively. Education accounted for 4% of travelers.

GOLFX/Getty Images

Required versus recommended vaccines

The goal of a required vaccine is to prevent international spread of disease. The host country is protecting its citizens from visitors importing and facilitating the spread of a disease. Yellow fever and meningococcal disease are the only vaccines required for entry into any country. Entry requirements vary by country. Yellow fever may be an entry requirement for all travelers or it may be limited to those who have been in, or have had transit through, a country where yellow fever can be transmitted at least 6 days prior to the arrival at their final destination – a reminder that the sequence of the patient’s itinerary is important. In addition, just because a vaccine is not required for entry does not mean the risk for exposure and acquisition is nonexistent.

In contrast, recommended vaccines are for the protection of the individual. Travelers may be exposed to vaccine-preventable diseases that do not exist in their country (such as measles, typhoid fever, and yellow fever). They are at risk for acquisition and may return home infected, which could create the potential to spread the disease to susceptible contacts.

Most travelers comprehend required vaccines but often fail to understand the importance of receiving recommended vaccines. Lammert et al. reported that, of 24,478 persons who received pretravel advice between July 2012 and June 2014 through Global TravEpiNet, a national consortium of U.S. clinics, 97% were eligible for at least one vaccine. The majority were eligible for typhoid (n = 20,092) and hepatitis A (n = 12,990). Of patients included in the study, 25% (6,573) refused one or more vaccines. The most common reason cited for refusal was a lack of concern about the illness. Travelers visiting friends and relatives were less likely to accept all recommended vaccines, compared with those who were not visiting friends and relatives (odds ratio, 0.74) (J Trav Med. 2017 Jan. doi: 10.1093/jtm/taw075). In the United States, international travel remains the most common risk factor for acquisition of both typhoid fever and hepatitis A.

What’s new

The U.S. Advisory Committee on Immunization Practices recommends administering the hepatitis A vaccine to infants aged 6-11 months with travel to or living in developing countries and areas with high to moderate risk for hepatitis A virus transmission. Any dose received at less than 12 months of age does not count, and the administration of two age-appropriate doses should occur following this dose.

Old but still relevant

Measles: The Advisory Committee on Immunization Practices recommends all infants aged 6-11 months receive one dose of MMR prior to international travel regardless of the destination. This should be followed by two additional countable doses. All persons at least 12 months of age and born after 1956 should receive two doses of MMR at least 28 days apart prior to international travel.

Prior to administering, determine whether your patient will travel to a yellow fever–endemic area because both are live vaccines and should be received the same day. Otherwise, administer MMR doses 28 days apart; coordination between facilities or receipt of both at one facility may be necessary.

Yellow fever vaccine: The U.S. supplies of YF-Vax by Sanofi Pasteur are not expected to be available again until the end of 2018. To provide vaccines for U.S. travelers, Stamaril – a yellow fever vaccine produced by Sanofi Pasteur in France – has been made available at more than 250 sites through an Expanded Access Investigational New Drug Program.

Since Stamaril is offered at a limited number of locations, persons with anticipated travel to a country where receipt of yellow fever vaccine is either required for entry or recommended for their protection should not wait until the last minute to obtain it. Postponing a trip or changing a destination is preferred if vaccine is not received, especially when the person is traveling to countries with an ongoing outbreak.

The vaccination does not become valid until 10 days after receipt. Infants aged at least 9 months may receive the vaccine. Since the yellow fever vaccine is a live vaccine, administration may be contraindicated in certain individuals. Exemption letters are provided for those with medical contraindication.

To locate a Stamaril site in your area: https://wwwnc.cdc.gov/travel/page/search-for-stamaril-clinics.

Current disease outbreaks

Yellow fever: Brazil

Since Dec. 2017, more than 1,100 laboratory-confirmed cases of yellow fever have been reported, including 17 reported in unvaccinated international travelers. Fatal cases also have been reported. In addition to areas in Brazil where yellow fever vaccination had been recommended prior to the recent outbreaks, the vaccine now also is recommended for people who are traveling to or living in all of Espírito Santo State, São Paulo State, and Rio de Janeiro State, as well as several cities in Bahia State. Unvaccinated travelers should avoid travel to areas where vaccination is recommended. Those previously vaccinated at 10 years ago or longer should consider a booster.

Listeria: South Africa

An ongoing outbreak has been reported since Jan. 2017. Around 1,000 people have been infected. Avoid consumption of processed meats including “Polony” (South African bologna).

Measles: Belarus, Japan, Liberia, and Taiwan

All countries have reported an increase in cases since April 2018. Measles outbreaks have been reported in an additional 13 countries since Jan. 2018, including France, Ireland, Italy, the Philippines, and the United Kingdom.

Norovirus: Canada

More than 120 cases have been linked to consumption of raw or lightly cooked oysters from western Canada.

Dr. Word is a pediatric infectious disease specialist and the director of the Houston Travel Medicine Clinic. She said she had no relevant financial disclosures.

It’s that time of year again. Many of your patients will join the 80.2 million Americans with plans for international travel this summer.

In 2016, Mexico (31.2 million) and Canada (13.9 million) were the top two destinations of U.S. residents. Based on 2016 U.S. Commerce data, an additional 35.1 million Americans headed to overseas destinations, including 9% who traveled with children. Vacation and visiting friends and relatives accounted for 55% and 27% of the reasons for all travel, respectively. Education accounted for 4% of travelers.

GOLFX/Getty Images

Required versus recommended vaccines

The goal of a required vaccine is to prevent international spread of disease. The host country is protecting its citizens from visitors importing and facilitating the spread of a disease. Yellow fever and meningococcal disease are the only vaccines required for entry into any country. Entry requirements vary by country. Yellow fever may be an entry requirement for all travelers or it may be limited to those who have been in, or have had transit through, a country where yellow fever can be transmitted at least 6 days prior to the arrival at their final destination – a reminder that the sequence of the patient’s itinerary is important. In addition, just because a vaccine is not required for entry does not mean the risk for exposure and acquisition is nonexistent.

In contrast, recommended vaccines are for the protection of the individual. Travelers may be exposed to vaccine-preventable diseases that do not exist in their country (such as measles, typhoid fever, and yellow fever). They are at risk for acquisition and may return home infected, which could create the potential to spread the disease to susceptible contacts.

Most travelers comprehend required vaccines but often fail to understand the importance of receiving recommended vaccines. Lammert et al. reported that, of 24,478 persons who received pretravel advice between July 2012 and June 2014 through Global TravEpiNet, a national consortium of U.S. clinics, 97% were eligible for at least one vaccine. The majority were eligible for typhoid (n = 20,092) and hepatitis A (n = 12,990). Of patients included in the study, 25% (6,573) refused one or more vaccines. The most common reason cited for refusal was a lack of concern about the illness. Travelers visiting friends and relatives were less likely to accept all recommended vaccines, compared with those who were not visiting friends and relatives (odds ratio, 0.74) (J Trav Med. 2017 Jan. doi: 10.1093/jtm/taw075). In the United States, international travel remains the most common risk factor for acquisition of both typhoid fever and hepatitis A.

What’s new

The U.S. Advisory Committee on Immunization Practices recommends administering the hepatitis A vaccine to infants aged 6-11 months with travel to or living in developing countries and areas with high to moderate risk for hepatitis A virus transmission. Any dose received at less than 12 months of age does not count, and the administration of two age-appropriate doses should occur following this dose.

Old but still relevant

Measles: The Advisory Committee on Immunization Practices recommends all infants aged 6-11 months receive one dose of MMR prior to international travel regardless of the destination. This should be followed by two additional countable doses. All persons at least 12 months of age and born after 1956 should receive two doses of MMR at least 28 days apart prior to international travel.

Prior to administering, determine whether your patient will travel to a yellow fever–endemic area because both are live vaccines and should be received the same day. Otherwise, administer MMR doses 28 days apart; coordination between facilities or receipt of both at one facility may be necessary.

Yellow fever vaccine: The U.S. supplies of YF-Vax by Sanofi Pasteur are not expected to be available again until the end of 2018. To provide vaccines for U.S. travelers, Stamaril – a yellow fever vaccine produced by Sanofi Pasteur in France – has been made available at more than 250 sites through an Expanded Access Investigational New Drug Program.

Since Stamaril is offered at a limited number of locations, persons with anticipated travel to a country where receipt of yellow fever vaccine is either required for entry or recommended for their protection should not wait until the last minute to obtain it. Postponing a trip or changing a destination is preferred if vaccine is not received, especially when the person is traveling to countries with an ongoing outbreak.

The vaccination does not become valid until 10 days after receipt. Infants aged at least 9 months may receive the vaccine. Since the yellow fever vaccine is a live vaccine, administration may be contraindicated in certain individuals. Exemption letters are provided for those with medical contraindication.

To locate a Stamaril site in your area: https://wwwnc.cdc.gov/travel/page/search-for-stamaril-clinics.

Current disease outbreaks

Yellow fever: Brazil

Since Dec. 2017, more than 1,100 laboratory-confirmed cases of yellow fever have been reported, including 17 reported in unvaccinated international travelers. Fatal cases also have been reported. In addition to areas in Brazil where yellow fever vaccination had been recommended prior to the recent outbreaks, the vaccine now also is recommended for people who are traveling to or living in all of Espírito Santo State, São Paulo State, and Rio de Janeiro State, as well as several cities in Bahia State. Unvaccinated travelers should avoid travel to areas where vaccination is recommended. Those previously vaccinated at 10 years ago or longer should consider a booster.

Listeria: South Africa

An ongoing outbreak has been reported since Jan. 2017. Around 1,000 people have been infected. Avoid consumption of processed meats including “Polony” (South African bologna).

Measles: Belarus, Japan, Liberia, and Taiwan

All countries have reported an increase in cases since April 2018. Measles outbreaks have been reported in an additional 13 countries since Jan. 2018, including France, Ireland, Italy, the Philippines, and the United Kingdom.

Norovirus: Canada

More than 120 cases have been linked to consumption of raw or lightly cooked oysters from western Canada.

Dr. Word is a pediatric infectious disease specialist and the director of the Houston Travel Medicine Clinic. She said she had no relevant financial disclosures.

It’s that time of year again. Many of your patients will join the 80.2 million Americans with plans for international travel this summer.

In 2016, Mexico (31.2 million) and Canada (13.9 million) were the top two destinations of U.S. residents. Based on 2016 U.S. Commerce data, an additional 35.1 million Americans headed to overseas destinations, including 9% who traveled with children. Vacation and visiting friends and relatives accounted for 55% and 27% of the reasons for all travel, respectively. Education accounted for 4% of travelers.

GOLFX/Getty Images

Required versus recommended vaccines

The goal of a required vaccine is to prevent international spread of disease. The host country is protecting its citizens from visitors importing and facilitating the spread of a disease. Yellow fever and meningococcal disease are the only vaccines required for entry into any country. Entry requirements vary by country. Yellow fever may be an entry requirement for all travelers or it may be limited to those who have been in, or have had transit through, a country where yellow fever can be transmitted at least 6 days prior to the arrival at their final destination – a reminder that the sequence of the patient’s itinerary is important. In addition, just because a vaccine is not required for entry does not mean the risk for exposure and acquisition is nonexistent.

In contrast, recommended vaccines are for the protection of the individual. Travelers may be exposed to vaccine-preventable diseases that do not exist in their country (such as measles, typhoid fever, and yellow fever). They are at risk for acquisition and may return home infected, which could create the potential to spread the disease to susceptible contacts.

Most travelers comprehend required vaccines but often fail to understand the importance of receiving recommended vaccines. Lammert et al. reported that, of 24,478 persons who received pretravel advice between July 2012 and June 2014 through Global TravEpiNet, a national consortium of U.S. clinics, 97% were eligible for at least one vaccine. The majority were eligible for typhoid (n = 20,092) and hepatitis A (n = 12,990). Of patients included in the study, 25% (6,573) refused one or more vaccines. The most common reason cited for refusal was a lack of concern about the illness. Travelers visiting friends and relatives were less likely to accept all recommended vaccines, compared with those who were not visiting friends and relatives (odds ratio, 0.74) (J Trav Med. 2017 Jan. doi: 10.1093/jtm/taw075). In the United States, international travel remains the most common risk factor for acquisition of both typhoid fever and hepatitis A.

What’s new

The U.S. Advisory Committee on Immunization Practices recommends administering the hepatitis A vaccine to infants aged 6-11 months with travel to or living in developing countries and areas with high to moderate risk for hepatitis A virus transmission. Any dose received at less than 12 months of age does not count, and the administration of two age-appropriate doses should occur following this dose.

Old but still relevant

Measles: The Advisory Committee on Immunization Practices recommends all infants aged 6-11 months receive one dose of MMR prior to international travel regardless of the destination. This should be followed by two additional countable doses. All persons at least 12 months of age and born after 1956 should receive two doses of MMR at least 28 days apart prior to international travel.

Prior to administering, determine whether your patient will travel to a yellow fever–endemic area because both are live vaccines and should be received the same day. Otherwise, administer MMR doses 28 days apart; coordination between facilities or receipt of both at one facility may be necessary.

Yellow fever vaccine: The U.S. supplies of YF-Vax by Sanofi Pasteur are not expected to be available again until the end of 2018. To provide vaccines for U.S. travelers, Stamaril – a yellow fever vaccine produced by Sanofi Pasteur in France – has been made available at more than 250 sites through an Expanded Access Investigational New Drug Program.

Since Stamaril is offered at a limited number of locations, persons with anticipated travel to a country where receipt of yellow fever vaccine is either required for entry or recommended for their protection should not wait until the last minute to obtain it. Postponing a trip or changing a destination is preferred if vaccine is not received, especially when the person is traveling to countries with an ongoing outbreak.

The vaccination does not become valid until 10 days after receipt. Infants aged at least 9 months may receive the vaccine. Since the yellow fever vaccine is a live vaccine, administration may be contraindicated in certain individuals. Exemption letters are provided for those with medical contraindication.

To locate a Stamaril site in your area: https://wwwnc.cdc.gov/travel/page/search-for-stamaril-clinics.

Current disease outbreaks

Yellow fever: Brazil

Since Dec. 2017, more than 1,100 laboratory-confirmed cases of yellow fever have been reported, including 17 reported in unvaccinated international travelers. Fatal cases also have been reported. In addition to areas in Brazil where yellow fever vaccination had been recommended prior to the recent outbreaks, the vaccine now also is recommended for people who are traveling to or living in all of Espírito Santo State, São Paulo State, and Rio de Janeiro State, as well as several cities in Bahia State. Unvaccinated travelers should avoid travel to areas where vaccination is recommended. Those previously vaccinated at 10 years ago or longer should consider a booster.

Listeria: South Africa

An ongoing outbreak has been reported since Jan. 2017. Around 1,000 people have been infected. Avoid consumption of processed meats including “Polony” (South African bologna).

Measles: Belarus, Japan, Liberia, and Taiwan

All countries have reported an increase in cases since April 2018. Measles outbreaks have been reported in an additional 13 countries since Jan. 2018, including France, Ireland, Italy, the Philippines, and the United Kingdom.

Norovirus: Canada

More than 120 cases have been linked to consumption of raw or lightly cooked oysters from western Canada.

Dr. Word is a pediatric infectious disease specialist and the director of the Houston Travel Medicine Clinic. She said she had no relevant financial disclosures.

Because I rarely perform surgery, my primary product is providing relevant information delivered with competence, compassion, and commitment. I must make the correct diagnosis and prescribe the correct treatment. I deliver that information with compassion to meet the emotional and spiritual needs of my patients and their parents. Parents can trust that I am committed to providing the best possible care for their child, rather than primarily seeking to enrich myself. After all, I chose pediatrics.

audioundwerbung/iStockphoto

Three years ago I wrote a column about the use of Google as an alternative to physicians. The public can access a massive amount of medical information through the Internet. That information has been growing exponentially. But let’s look at what else has happened in the past 3 years that reflects the difference between my professionalism and the merchandising of the Internet.

I am a medical professional committed to my patients. The purveyors of information via the Internet are primarily dedicated to increased advertising revenue through click baiting and profiling. Apple’s CEO Tim Cook put it this way: “A few years ago, users of Internet services began to realize that when an online service is free, you’re not the customer. You’re the product.”

Facebook and Google learn from the content of people’s messages and search terms to build a personal profile that is valuable to advertisers. Soon that profile could include health information. Recently, 300,000 users were tempted to download a survey app via Facebook. The app developer used Facebook tools to scrape profile information not just on those 300,000 users, but on 87,000,000 contacts who did not give explicit consent. This massive leak of privacy was used to target people’s votes. Similar profiles could be used in focused advertising of health care products and services.

I have a professional and legal responsibility to provide accurate information to my patients. Years ago, Internet service providers lobbied for and obtained legal protections saying that they were not responsible for content transmitted over their networks. That idea made some sense when Facebook was primarily sharing information within families and friends. But then Facebook began a news feed without reporters vetting information and without the ethics of journalism and the fourth estate. A generation ago, three television broadcasting companies competed to provide daily evening news programs consisting of four to six stories carefully chosen to be important and relevant. Now a myriad of polarized blogs on unaccountable social media are designed to solicit clicks, spread advertising, and influence shoppers. The result has been a massive, toxic spill of false information into the noosphere. Given the already poor state of health literacy, this fake news contributes to ongoing problems with vaccine hesitancy, worthless cures, and distrust of the medical profession.

It makes the BP/Deep Horizon oil spill into the Gulf look small by comparison. The cleanup of this social media mess is going to be costly and require new technology. Chemical companies used to dump vast quantities of toxic waste and byproducts into rivers and landfills. Superfund sites involve billion dollar cleanups. Efforts are made to trace where the chemicals came from and to bill the original companies. Under a “cradle to grave” concept, a chemical company cannot avoid liability by giving toxic waste to a fly-by-night waste disposal company. Two years ago, Volkswagen stock lost $15 billion overnight when fraud was exposed in diesel emissions testing. Fines and compensation exceeded $25 billion. It has gained it all back. Facebook stock is worth five times more that Volkswagen. So even billion dollar fines would be a small cost of doing business within social media.

One information technology that has resisted pollution is Wikipedia. Google has been featuring Wikipedia websites in its search engine results for many years. Now even Facebook is contemplating using Wikipedia to combat fake news. I would not treat a patient solely based on information I found on Wikipedia. But I do find it convenient to remind me of information I had learned in the past and to reassure me that my memory is neither faulty nor outdated.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. He said he had no relevant financial disclosures. Email him at [email protected].

Because I rarely perform surgery, my primary product is providing relevant information delivered with competence, compassion, and commitment. I must make the correct diagnosis and prescribe the correct treatment. I deliver that information with compassion to meet the emotional and spiritual needs of my patients and their parents. Parents can trust that I am committed to providing the best possible care for their child, rather than primarily seeking to enrich myself. After all, I chose pediatrics.

audioundwerbung/iStockphoto

Three years ago I wrote a column about the use of Google as an alternative to physicians. The public can access a massive amount of medical information through the Internet. That information has been growing exponentially. But let’s look at what else has happened in the past 3 years that reflects the difference between my professionalism and the merchandising of the Internet.

I am a medical professional committed to my patients. The purveyors of information via the Internet are primarily dedicated to increased advertising revenue through click baiting and profiling. Apple’s CEO Tim Cook put it this way: “A few years ago, users of Internet services began to realize that when an online service is free, you’re not the customer. You’re the product.”

Facebook and Google learn from the content of people’s messages and search terms to build a personal profile that is valuable to advertisers. Soon that profile could include health information. Recently, 300,000 users were tempted to download a survey app via Facebook. The app developer used Facebook tools to scrape profile information not just on those 300,000 users, but on 87,000,000 contacts who did not give explicit consent. This massive leak of privacy was used to target people’s votes. Similar profiles could be used in focused advertising of health care products and services.

I have a professional and legal responsibility to provide accurate information to my patients. Years ago, Internet service providers lobbied for and obtained legal protections saying that they were not responsible for content transmitted over their networks. That idea made some sense when Facebook was primarily sharing information within families and friends. But then Facebook began a news feed without reporters vetting information and without the ethics of journalism and the fourth estate. A generation ago, three television broadcasting companies competed to provide daily evening news programs consisting of four to six stories carefully chosen to be important and relevant. Now a myriad of polarized blogs on unaccountable social media are designed to solicit clicks, spread advertising, and influence shoppers. The result has been a massive, toxic spill of false information into the noosphere. Given the already poor state of health literacy, this fake news contributes to ongoing problems with vaccine hesitancy, worthless cures, and distrust of the medical profession.

It makes the BP/Deep Horizon oil spill into the Gulf look small by comparison. The cleanup of this social media mess is going to be costly and require new technology. Chemical companies used to dump vast quantities of toxic waste and byproducts into rivers and landfills. Superfund sites involve billion dollar cleanups. Efforts are made to trace where the chemicals came from and to bill the original companies. Under a “cradle to grave” concept, a chemical company cannot avoid liability by giving toxic waste to a fly-by-night waste disposal company. Two years ago, Volkswagen stock lost $15 billion overnight when fraud was exposed in diesel emissions testing. Fines and compensation exceeded $25 billion. It has gained it all back. Facebook stock is worth five times more that Volkswagen. So even billion dollar fines would be a small cost of doing business within social media.

One information technology that has resisted pollution is Wikipedia. Google has been featuring Wikipedia websites in its search engine results for many years. Now even Facebook is contemplating using Wikipedia to combat fake news. I would not treat a patient solely based on information I found on Wikipedia. But I do find it convenient to remind me of information I had learned in the past and to reassure me that my memory is neither faulty nor outdated.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. He said he had no relevant financial disclosures. Email him at [email protected].

Because I rarely perform surgery, my primary product is providing relevant information delivered with competence, compassion, and commitment. I must make the correct diagnosis and prescribe the correct treatment. I deliver that information with compassion to meet the emotional and spiritual needs of my patients and their parents. Parents can trust that I am committed to providing the best possible care for their child, rather than primarily seeking to enrich myself. After all, I chose pediatrics.

audioundwerbung/iStockphoto

Three years ago I wrote a column about the use of Google as an alternative to physicians. The public can access a massive amount of medical information through the Internet. That information has been growing exponentially. But let’s look at what else has happened in the past 3 years that reflects the difference between my professionalism and the merchandising of the Internet.

I am a medical professional committed to my patients. The purveyors of information via the Internet are primarily dedicated to increased advertising revenue through click baiting and profiling. Apple’s CEO Tim Cook put it this way: “A few years ago, users of Internet services began to realize that when an online service is free, you’re not the customer. You’re the product.”

Facebook and Google learn from the content of people’s messages and search terms to build a personal profile that is valuable to advertisers. Soon that profile could include health information. Recently, 300,000 users were tempted to download a survey app via Facebook. The app developer used Facebook tools to scrape profile information not just on those 300,000 users, but on 87,000,000 contacts who did not give explicit consent. This massive leak of privacy was used to target people’s votes. Similar profiles could be used in focused advertising of health care products and services.

I have a professional and legal responsibility to provide accurate information to my patients. Years ago, Internet service providers lobbied for and obtained legal protections saying that they were not responsible for content transmitted over their networks. That idea made some sense when Facebook was primarily sharing information within families and friends. But then Facebook began a news feed without reporters vetting information and without the ethics of journalism and the fourth estate. A generation ago, three television broadcasting companies competed to provide daily evening news programs consisting of four to six stories carefully chosen to be important and relevant. Now a myriad of polarized blogs on unaccountable social media are designed to solicit clicks, spread advertising, and influence shoppers. The result has been a massive, toxic spill of false information into the noosphere. Given the already poor state of health literacy, this fake news contributes to ongoing problems with vaccine hesitancy, worthless cures, and distrust of the medical profession.

It makes the BP/Deep Horizon oil spill into the Gulf look small by comparison. The cleanup of this social media mess is going to be costly and require new technology. Chemical companies used to dump vast quantities of toxic waste and byproducts into rivers and landfills. Superfund sites involve billion dollar cleanups. Efforts are made to trace where the chemicals came from and to bill the original companies. Under a “cradle to grave” concept, a chemical company cannot avoid liability by giving toxic waste to a fly-by-night waste disposal company. Two years ago, Volkswagen stock lost $15 billion overnight when fraud was exposed in diesel emissions testing. Fines and compensation exceeded $25 billion. It has gained it all back. Facebook stock is worth five times more that Volkswagen. So even billion dollar fines would be a small cost of doing business within social media.

One information technology that has resisted pollution is Wikipedia. Google has been featuring Wikipedia websites in its search engine results for many years. Now even Facebook is contemplating using Wikipedia to combat fake news. I would not treat a patient solely based on information I found on Wikipedia. But I do find it convenient to remind me of information I had learned in the past and to reassure me that my memory is neither faulty nor outdated.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. He said he had no relevant financial disclosures. Email him at [email protected].

In March 2018, the Human Rights Campaign (HRC), an advocacy organization dedicated to improving the lives of LGBTQ people, released its 11th Annual Healthcare Equality Index. The HEI is an indicator of how inclusive and equitable health care facilities are in providing care for their LGBTQ patients. My own institution, Children’s Hospital of Pittsburgh, scored very high on this index and received the “Leader in LGBTQ Healthcare Equality” designation. The process of receiving this designation is very rigorous, and I am proud of my institution for making great strides in expanding health care access for LGBTQ patients, especially transgender patients. However, this is no time to rest on one’s laurels, as many transgender people still experience challenges and barriers in navigating the health care system.

AlexRaths/Thinkstock

Dr. Montano is an assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at [email protected].

Resources

• HRC HEI: If you’re interested in learning what policies are inclusive and equitable for LGBT patients, check out the HRC HEI scoring criteria. It’s a good place to start if you want to expand health care access for transgender individuals.
• To find out more about the health care legal protections transgender individuals are entitled to, check out the National Center for Transgender Equality.

References

1. Psychol Bull. 2003 Sep;129(5):674-97.

2. “Injustice at every turn: A report of the National Transgender Discrimination Survey.” (Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011.)

3. J. Adolesc Health. 2018 Apr. doi: 10.1016/j.jadohealth.2018.02.003.

4. Int J Transgenderism. 2008. doi: 10.1300/J485v08n02_08.

5. Transgend Health. 2016 Nov 1;1(1):238-49.

In March 2018, the Human Rights Campaign (HRC), an advocacy organization dedicated to improving the lives of LGBTQ people, released its 11th Annual Healthcare Equality Index. The HEI is an indicator of how inclusive and equitable health care facilities are in providing care for their LGBTQ patients. My own institution, Children’s Hospital of Pittsburgh, scored very high on this index and received the “Leader in LGBTQ Healthcare Equality” designation. The process of receiving this designation is very rigorous, and I am proud of my institution for making great strides in expanding health care access for LGBTQ patients, especially transgender patients. However, this is no time to rest on one’s laurels, as many transgender people still experience challenges and barriers in navigating the health care system.

AlexRaths/Thinkstock

Dr. Montano is an assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at [email protected].

Resources

• HRC HEI: If you’re interested in learning what policies are inclusive and equitable for LGBT patients, check out the HRC HEI scoring criteria. It’s a good place to start if you want to expand health care access for transgender individuals.
• To find out more about the health care legal protections transgender individuals are entitled to, check out the National Center for Transgender Equality.

References

1. Psychol Bull. 2003 Sep;129(5):674-97.

2. “Injustice at every turn: A report of the National Transgender Discrimination Survey.” (Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011.)

3. J. Adolesc Health. 2018 Apr. doi: 10.1016/j.jadohealth.2018.02.003.

4. Int J Transgenderism. 2008. doi: 10.1300/J485v08n02_08.

5. Transgend Health. 2016 Nov 1;1(1):238-49.

In March 2018, the Human Rights Campaign (HRC), an advocacy organization dedicated to improving the lives of LGBTQ people, released its 11th Annual Healthcare Equality Index. The HEI is an indicator of how inclusive and equitable health care facilities are in providing care for their LGBTQ patients. My own institution, Children’s Hospital of Pittsburgh, scored very high on this index and received the “Leader in LGBTQ Healthcare Equality” designation. The process of receiving this designation is very rigorous, and I am proud of my institution for making great strides in expanding health care access for LGBTQ patients, especially transgender patients. However, this is no time to rest on one’s laurels, as many transgender people still experience challenges and barriers in navigating the health care system.

AlexRaths/Thinkstock

Dr. Montano is an assistant professor of pediatrics at the University of Pittsburgh and an adolescent medicine physician at Children’s Hospital of Pittsburgh of UPMC. Email him at [email protected].

Resources

• HRC HEI: If you’re interested in learning what policies are inclusive and equitable for LGBT patients, check out the HRC HEI scoring criteria. It’s a good place to start if you want to expand health care access for transgender individuals.
• To find out more about the health care legal protections transgender individuals are entitled to, check out the National Center for Transgender Equality.

References

1. Psychol Bull. 2003 Sep;129(5):674-97.

2. “Injustice at every turn: A report of the National Transgender Discrimination Survey.” (Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011.)

3. J. Adolesc Health. 2018 Apr. doi: 10.1016/j.jadohealth.2018.02.003.

4. Int J Transgenderism. 2008. doi: 10.1300/J485v08n02_08.

5. Transgend Health. 2016 Nov 1;1(1):238-49.