Commentary

If you’re like most primary care clinicians, your email inbox is flooded with messages from patients with questions about lab results. A common query: Should I be worried about an abnormal value on a test of thyroid-stimulating hormone (TSH)?

For guidance, this news organization spoke with Angela Leung, MD, associate professor of medicine in the Division of Endocrinology, Diabetes & Metabolism at the UCLA David Geffen School of Medicine and an endocrinologist at UCLA and the VA Greater Los Angeles Healthcare System, and Karen Tsai, MD, assistant clinical professor of endocrinology at City of Hope Comprehensive Cancer Center in Duarte, California. The following interview has been edited for length and clarity.

Question: Why do you usually start by measuring TSH levels?

Dr. Leung: We need to measure the thyroid status in a way that integrates more information about the long-term thyroid status and not small changes in thyroid hormone levels. TSH is made by the pituitary gland in the brain, which integrates information about the signals of high and low levels from each of the different thyroid hormones.

Now we can measure the actual thyroid hormones — primarily we’re talking about T3 and T4 — but if we do that, we are relying on a single snapshot in the bloodstream at that moment. The levels might change throughout the day in response to ongoing metabolism and outside stresses. So we usually start by measuring the TSH level, which is a good representation of the compilation of all those things over the past 30 days or so.

Question: How do you describe a low TSH result to patients?

Dr. Leung: Whenever we encounter a low TSH level, we want to repeat the test because it is a dynamic test, and it can change in response to several factors. If it is indeed low, we’re thinking that perhaps there’s a little bit of extra thyroid hormone in the body. It can be either temporary or more chronic, but that higher amount of thyroid hormone is telling the pituitary gland in the brain to start making less. So TSH levels go low when we need less thyroid hormone.

Question: What are some of the reasons for a low TSH level?

Dr. Leung: One of the most common situations for a temporarily low TSH level I see is what we call nonthyroidal illness, like a common cold or just being under the weather. Other things that can artifactually lower the TSH level could be the use of steroids, such as prednisone for asthma or some sort of a rheumatologic condition. Also, the TSH level could be low if a person has been recently exposed to very high amounts of iodine, such as iodinated contrast needed for a CT scan.

If the TSH level remains persistently low, usually in the presence of high thyroid hormone (T3 and/or T4) levels, the most common reason for hyperthyroidism is Graves disease, in which there are autoantibodies — measurable in the blood — that can stimulate the thyroid gland in the neck to make extra thyroid hormone.

Question: And what does an elevated TSH level mean?

Dr. Leung: Again, we want to confirm that it is elevated. We need at least two tests to confirm a high TSH level. A persistently elevated TSH level is a signal there might be low thyroid hormone levels in the body, which could be transient or more longer lasting.

Question: What are some of the most common causes of an elevated TSH level?

Dr. Leung: If the TSH level is confirmed high and the thyroid hormone levels are low, the most common cause of hypothyroidism here in the United States is Hashimoto thyroiditis.

Globally, iodine deficiency is the most common reason for hypothyroidism and may be a problem in parts of the globe where there are endemically low iodine levels in soil, crops, and the food supply like not having enough iodized salt. The thyroid is reliant on having enough iodine as a micronutrient to make thyroid hormone. If it doesn’t, the thyroid really can’t make thyroid hormone. It’s important to also remember, though, that having too much iodine can result in hypo- or hyperthyroidism.

Dr. Tsai: I take a glance at their medication list. Some of the patients are on methimazole or levothyroxine, and those medications should be adjusted first to normalize the TSH level. Other medications like lithium and amiodarone can also cause elevated TSH levels. We are also seeing a lot of patients on cancer therapies, such as tyrosine kinase inhibitors or immunotherapy, that can cause an elevated TSH level.

Question: If the repeat TSH test shows that TSH levels are still elevated, what comes next in your workup?

Dr. Tsai: If there’s not a real clear-cut diagnosis, I’ll order the thyroid peroxidase antibody and the thyroglobulin antibody, although thyroid peroxidase antibody, which is indicative of autoimmune thyroid disease, alone is usually sufficient to make that diagnosis.

Question: Should clinicians follow thyroid antibodies over time?

Dr. Tsai: I usually don’t repeat the antibody tests. In those circumstances where patients who were diagnosed 50-60 years ago and perhaps it is unknown if they had the thyroid antibodies measured at the time and now they’re saying, “Do I actually have Hashimoto’s?” or “Do I really need to continue this for the rest of my life?” I do repeat antibody tests to help gauge if the patient’s levothyroxine can be stopped.

Question: How important is it to follow T4 or T3 levels?

Dr. Tsai: T4 and T3 levels can help differentiate overt thyroid dysfunction — where T3 and/or T4 levels will be abnormal — from subclinical thyroid dysfunction — where T3 and T4 levels would be normal. In general, although we do not fully appreciate the best metric to monitor hypo- or hyperthyroidism, because some patients with a normal TSH level still may have symptoms of thyroid dysfunction, these peripheral thyroid hormone levels are usually the most helpful at the time of initial diagnosis.

Question: What are your criteria for initiating treatment for hypothyroidism?

Dr. Tsai: If the TSH level > 10 mIU/L, I recommend levothyroxine hormone replacement. A lot of published data support clinical benefit in this group.

There is a gray area in those patients who have a TSH level higher than the upper limit of the reference range but less than 10. If the patient doesn’t have overt hypothyroid symptoms, I discuss the findings with the patient but don’t really feel eager to treat. I recommend checking the levels again in 6 months to see where that TSH goes, and if it worsens or becomes greater than 10 mIU/L, I then recommend levothyroxine hormone replacement.

It is also important to note that a TSH level of 5-7 may be an acceptable range for older patients, and they do not require levothyroxine.

The other category is patients whose TSH level is greater than the upper limit of the normal reference range but less than 10 and with overt hypothyroid symptoms such as fatigue, unintentional weight gain, constipation, or cold intolerance. In these patients, it is worthwhile to try a low dose of levothyroxine (25-50 mcg/d) and repeat TSH and free T4 tests in 6-8 weeks and see if the TSH level normalizes.

Dr. Leung: When you look at subclinical hypothyroidism, the situation of an isolated high TSH level in the setting of normal T4 levels, if the TSH level is mildly elevated in the 5-7 mIU/L range, there’s a 60% chance that it will normalize within 6 months.

Going back to Karen’s point, a lot of people are started and maintained on low doses of thyroid hormone forever and ever. A recent study on levothyroxine use found half of the prescriptions were unnecessary.

Question: In an era where many patients obtain much of their health information from TikTok, what’s your approach with patients with a normal TSH level who feel that they should have more testing or start treatment?

Dr. Tsai: Fatigue is one of the common referrals we get into our endocrinology practice, and everyone is convinced that their thyroid is the culprit. It is important to note, however, that fatigue can be due to different diseases such as anemia, depression, sleep disorders, or a recent viral illness.

TSH tests are readily available and cheap. I don’t mind ordering the lab test again if it helps give the patient some reassurance. I also find that patients are relieved once they hear from their endocrinologist that their thyroid is unlikely to be the cause of their fatigue.

Some other endocrine causes we may consider additionally working up include adrenal insufficiency, vitamin D deficiency, and diabetes. A comprehensive metabolic panel and complete blood count is part of my workup to rule out any gross electrolyte abnormalities or any new diagnosis of anemia, liver disease, or chronic kidney disease.

Question: What are your criteria for recommending that someone see an endocrinologist?

Dr. Tsai: Our primary care colleagues can do a workup and interpretation of thyroid function tests in most cases. In the situations where the thyroid function test results are discordant (ie, elevated TSH and elevated free T4 levels or low TSH and low free T4 levels) or difficult to interpret, it would be appropriate to refer the patient to an endocrinologist.

One of the common referrals that we do get from the community is a patient’s thyroid function tests going from hyperthyroid to hypothyroid without a clear explanation or the patient is suboptimally controlled with levothyroxine or methimazole. In those circumstances, it would be worthwhile to send to an endocrinologist try to discern an underlying cause or for optimization of medication.

Dr. Leung and Dr. Tsai had no financial disclosures.
 

A version of this article appeared on Medscape.com.

If you’re like most primary care clinicians, your email inbox is flooded with messages from patients with questions about lab results. A common query: Should I be worried about an abnormal value on a test of thyroid-stimulating hormone (TSH)?

For guidance, this news organization spoke with Angela Leung, MD, associate professor of medicine in the Division of Endocrinology, Diabetes & Metabolism at the UCLA David Geffen School of Medicine and an endocrinologist at UCLA and the VA Greater Los Angeles Healthcare System, and Karen Tsai, MD, assistant clinical professor of endocrinology at City of Hope Comprehensive Cancer Center in Duarte, California. The following interview has been edited for length and clarity.

Question: Why do you usually start by measuring TSH levels?

Dr. Leung: We need to measure the thyroid status in a way that integrates more information about the long-term thyroid status and not small changes in thyroid hormone levels. TSH is made by the pituitary gland in the brain, which integrates information about the signals of high and low levels from each of the different thyroid hormones.

Now we can measure the actual thyroid hormones — primarily we’re talking about T3 and T4 — but if we do that, we are relying on a single snapshot in the bloodstream at that moment. The levels might change throughout the day in response to ongoing metabolism and outside stresses. So we usually start by measuring the TSH level, which is a good representation of the compilation of all those things over the past 30 days or so.

Question: How do you describe a low TSH result to patients?

Dr. Leung: Whenever we encounter a low TSH level, we want to repeat the test because it is a dynamic test, and it can change in response to several factors. If it is indeed low, we’re thinking that perhaps there’s a little bit of extra thyroid hormone in the body. It can be either temporary or more chronic, but that higher amount of thyroid hormone is telling the pituitary gland in the brain to start making less. So TSH levels go low when we need less thyroid hormone.

Question: What are some of the reasons for a low TSH level?

Dr. Leung: One of the most common situations for a temporarily low TSH level I see is what we call nonthyroidal illness, like a common cold or just being under the weather. Other things that can artifactually lower the TSH level could be the use of steroids, such as prednisone for asthma or some sort of a rheumatologic condition. Also, the TSH level could be low if a person has been recently exposed to very high amounts of iodine, such as iodinated contrast needed for a CT scan.

If the TSH level remains persistently low, usually in the presence of high thyroid hormone (T3 and/or T4) levels, the most common reason for hyperthyroidism is Graves disease, in which there are autoantibodies — measurable in the blood — that can stimulate the thyroid gland in the neck to make extra thyroid hormone.

Question: And what does an elevated TSH level mean?

Dr. Leung: Again, we want to confirm that it is elevated. We need at least two tests to confirm a high TSH level. A persistently elevated TSH level is a signal there might be low thyroid hormone levels in the body, which could be transient or more longer lasting.

Question: What are some of the most common causes of an elevated TSH level?

Dr. Leung: If the TSH level is confirmed high and the thyroid hormone levels are low, the most common cause of hypothyroidism here in the United States is Hashimoto thyroiditis.

Globally, iodine deficiency is the most common reason for hypothyroidism and may be a problem in parts of the globe where there are endemically low iodine levels in soil, crops, and the food supply like not having enough iodized salt. The thyroid is reliant on having enough iodine as a micronutrient to make thyroid hormone. If it doesn’t, the thyroid really can’t make thyroid hormone. It’s important to also remember, though, that having too much iodine can result in hypo- or hyperthyroidism.

Dr. Tsai: I take a glance at their medication list. Some of the patients are on methimazole or levothyroxine, and those medications should be adjusted first to normalize the TSH level. Other medications like lithium and amiodarone can also cause elevated TSH levels. We are also seeing a lot of patients on cancer therapies, such as tyrosine kinase inhibitors or immunotherapy, that can cause an elevated TSH level.

Question: If the repeat TSH test shows that TSH levels are still elevated, what comes next in your workup?

Dr. Tsai: If there’s not a real clear-cut diagnosis, I’ll order the thyroid peroxidase antibody and the thyroglobulin antibody, although thyroid peroxidase antibody, which is indicative of autoimmune thyroid disease, alone is usually sufficient to make that diagnosis.

Question: Should clinicians follow thyroid antibodies over time?

Dr. Tsai: I usually don’t repeat the antibody tests. In those circumstances where patients who were diagnosed 50-60 years ago and perhaps it is unknown if they had the thyroid antibodies measured at the time and now they’re saying, “Do I actually have Hashimoto’s?” or “Do I really need to continue this for the rest of my life?” I do repeat antibody tests to help gauge if the patient’s levothyroxine can be stopped.

Question: How important is it to follow T4 or T3 levels?

Dr. Tsai: T4 and T3 levels can help differentiate overt thyroid dysfunction — where T3 and/or T4 levels will be abnormal — from subclinical thyroid dysfunction — where T3 and T4 levels would be normal. In general, although we do not fully appreciate the best metric to monitor hypo- or hyperthyroidism, because some patients with a normal TSH level still may have symptoms of thyroid dysfunction, these peripheral thyroid hormone levels are usually the most helpful at the time of initial diagnosis.

Question: What are your criteria for initiating treatment for hypothyroidism?

Dr. Tsai: If the TSH level > 10 mIU/L, I recommend levothyroxine hormone replacement. A lot of published data support clinical benefit in this group.

There is a gray area in those patients who have a TSH level higher than the upper limit of the reference range but less than 10. If the patient doesn’t have overt hypothyroid symptoms, I discuss the findings with the patient but don’t really feel eager to treat. I recommend checking the levels again in 6 months to see where that TSH goes, and if it worsens or becomes greater than 10 mIU/L, I then recommend levothyroxine hormone replacement.

It is also important to note that a TSH level of 5-7 may be an acceptable range for older patients, and they do not require levothyroxine.

The other category is patients whose TSH level is greater than the upper limit of the normal reference range but less than 10 and with overt hypothyroid symptoms such as fatigue, unintentional weight gain, constipation, or cold intolerance. In these patients, it is worthwhile to try a low dose of levothyroxine (25-50 mcg/d) and repeat TSH and free T4 tests in 6-8 weeks and see if the TSH level normalizes.

Dr. Leung: When you look at subclinical hypothyroidism, the situation of an isolated high TSH level in the setting of normal T4 levels, if the TSH level is mildly elevated in the 5-7 mIU/L range, there’s a 60% chance that it will normalize within 6 months.

Going back to Karen’s point, a lot of people are started and maintained on low doses of thyroid hormone forever and ever. A recent study on levothyroxine use found half of the prescriptions were unnecessary.

Question: In an era where many patients obtain much of their health information from TikTok, what’s your approach with patients with a normal TSH level who feel that they should have more testing or start treatment?

Dr. Tsai: Fatigue is one of the common referrals we get into our endocrinology practice, and everyone is convinced that their thyroid is the culprit. It is important to note, however, that fatigue can be due to different diseases such as anemia, depression, sleep disorders, or a recent viral illness.

TSH tests are readily available and cheap. I don’t mind ordering the lab test again if it helps give the patient some reassurance. I also find that patients are relieved once they hear from their endocrinologist that their thyroid is unlikely to be the cause of their fatigue.

Some other endocrine causes we may consider additionally working up include adrenal insufficiency, vitamin D deficiency, and diabetes. A comprehensive metabolic panel and complete blood count is part of my workup to rule out any gross electrolyte abnormalities or any new diagnosis of anemia, liver disease, or chronic kidney disease.

Question: What are your criteria for recommending that someone see an endocrinologist?

Dr. Tsai: Our primary care colleagues can do a workup and interpretation of thyroid function tests in most cases. In the situations where the thyroid function test results are discordant (ie, elevated TSH and elevated free T4 levels or low TSH and low free T4 levels) or difficult to interpret, it would be appropriate to refer the patient to an endocrinologist.

One of the common referrals that we do get from the community is a patient’s thyroid function tests going from hyperthyroid to hypothyroid without a clear explanation or the patient is suboptimally controlled with levothyroxine or methimazole. In those circumstances, it would be worthwhile to send to an endocrinologist try to discern an underlying cause or for optimization of medication.

Dr. Leung and Dr. Tsai had no financial disclosures.
 

A version of this article appeared on Medscape.com.

If you’re like most primary care clinicians, your email inbox is flooded with messages from patients with questions about lab results. A common query: Should I be worried about an abnormal value on a test of thyroid-stimulating hormone (TSH)?

For guidance, this news organization spoke with Angela Leung, MD, associate professor of medicine in the Division of Endocrinology, Diabetes & Metabolism at the UCLA David Geffen School of Medicine and an endocrinologist at UCLA and the VA Greater Los Angeles Healthcare System, and Karen Tsai, MD, assistant clinical professor of endocrinology at City of Hope Comprehensive Cancer Center in Duarte, California. The following interview has been edited for length and clarity.

Question: Why do you usually start by measuring TSH levels?

Dr. Leung: We need to measure the thyroid status in a way that integrates more information about the long-term thyroid status and not small changes in thyroid hormone levels. TSH is made by the pituitary gland in the brain, which integrates information about the signals of high and low levels from each of the different thyroid hormones.

Now we can measure the actual thyroid hormones — primarily we’re talking about T3 and T4 — but if we do that, we are relying on a single snapshot in the bloodstream at that moment. The levels might change throughout the day in response to ongoing metabolism and outside stresses. So we usually start by measuring the TSH level, which is a good representation of the compilation of all those things over the past 30 days or so.

Question: How do you describe a low TSH result to patients?

Dr. Leung: Whenever we encounter a low TSH level, we want to repeat the test because it is a dynamic test, and it can change in response to several factors. If it is indeed low, we’re thinking that perhaps there’s a little bit of extra thyroid hormone in the body. It can be either temporary or more chronic, but that higher amount of thyroid hormone is telling the pituitary gland in the brain to start making less. So TSH levels go low when we need less thyroid hormone.

Question: What are some of the reasons for a low TSH level?

Dr. Leung: One of the most common situations for a temporarily low TSH level I see is what we call nonthyroidal illness, like a common cold or just being under the weather. Other things that can artifactually lower the TSH level could be the use of steroids, such as prednisone for asthma or some sort of a rheumatologic condition. Also, the TSH level could be low if a person has been recently exposed to very high amounts of iodine, such as iodinated contrast needed for a CT scan.

If the TSH level remains persistently low, usually in the presence of high thyroid hormone (T3 and/or T4) levels, the most common reason for hyperthyroidism is Graves disease, in which there are autoantibodies — measurable in the blood — that can stimulate the thyroid gland in the neck to make extra thyroid hormone.

Question: And what does an elevated TSH level mean?

Dr. Leung: Again, we want to confirm that it is elevated. We need at least two tests to confirm a high TSH level. A persistently elevated TSH level is a signal there might be low thyroid hormone levels in the body, which could be transient or more longer lasting.

Question: What are some of the most common causes of an elevated TSH level?

Dr. Leung: If the TSH level is confirmed high and the thyroid hormone levels are low, the most common cause of hypothyroidism here in the United States is Hashimoto thyroiditis.

Globally, iodine deficiency is the most common reason for hypothyroidism and may be a problem in parts of the globe where there are endemically low iodine levels in soil, crops, and the food supply like not having enough iodized salt. The thyroid is reliant on having enough iodine as a micronutrient to make thyroid hormone. If it doesn’t, the thyroid really can’t make thyroid hormone. It’s important to also remember, though, that having too much iodine can result in hypo- or hyperthyroidism.

Dr. Tsai: I take a glance at their medication list. Some of the patients are on methimazole or levothyroxine, and those medications should be adjusted first to normalize the TSH level. Other medications like lithium and amiodarone can also cause elevated TSH levels. We are also seeing a lot of patients on cancer therapies, such as tyrosine kinase inhibitors or immunotherapy, that can cause an elevated TSH level.

Question: If the repeat TSH test shows that TSH levels are still elevated, what comes next in your workup?

Dr. Tsai: If there’s not a real clear-cut diagnosis, I’ll order the thyroid peroxidase antibody and the thyroglobulin antibody, although thyroid peroxidase antibody, which is indicative of autoimmune thyroid disease, alone is usually sufficient to make that diagnosis.

Question: Should clinicians follow thyroid antibodies over time?

Dr. Tsai: I usually don’t repeat the antibody tests. In those circumstances where patients who were diagnosed 50-60 years ago and perhaps it is unknown if they had the thyroid antibodies measured at the time and now they’re saying, “Do I actually have Hashimoto’s?” or “Do I really need to continue this for the rest of my life?” I do repeat antibody tests to help gauge if the patient’s levothyroxine can be stopped.

Question: How important is it to follow T4 or T3 levels?

Dr. Tsai: T4 and T3 levels can help differentiate overt thyroid dysfunction — where T3 and/or T4 levels will be abnormal — from subclinical thyroid dysfunction — where T3 and T4 levels would be normal. In general, although we do not fully appreciate the best metric to monitor hypo- or hyperthyroidism, because some patients with a normal TSH level still may have symptoms of thyroid dysfunction, these peripheral thyroid hormone levels are usually the most helpful at the time of initial diagnosis.

Question: What are your criteria for initiating treatment for hypothyroidism?

Dr. Tsai: If the TSH level > 10 mIU/L, I recommend levothyroxine hormone replacement. A lot of published data support clinical benefit in this group.

There is a gray area in those patients who have a TSH level higher than the upper limit of the reference range but less than 10. If the patient doesn’t have overt hypothyroid symptoms, I discuss the findings with the patient but don’t really feel eager to treat. I recommend checking the levels again in 6 months to see where that TSH goes, and if it worsens or becomes greater than 10 mIU/L, I then recommend levothyroxine hormone replacement.

It is also important to note that a TSH level of 5-7 may be an acceptable range for older patients, and they do not require levothyroxine.

The other category is patients whose TSH level is greater than the upper limit of the normal reference range but less than 10 and with overt hypothyroid symptoms such as fatigue, unintentional weight gain, constipation, or cold intolerance. In these patients, it is worthwhile to try a low dose of levothyroxine (25-50 mcg/d) and repeat TSH and free T4 tests in 6-8 weeks and see if the TSH level normalizes.

Dr. Leung: When you look at subclinical hypothyroidism, the situation of an isolated high TSH level in the setting of normal T4 levels, if the TSH level is mildly elevated in the 5-7 mIU/L range, there’s a 60% chance that it will normalize within 6 months.

Going back to Karen’s point, a lot of people are started and maintained on low doses of thyroid hormone forever and ever. A recent study on levothyroxine use found half of the prescriptions were unnecessary.

Question: In an era where many patients obtain much of their health information from TikTok, what’s your approach with patients with a normal TSH level who feel that they should have more testing or start treatment?

Dr. Tsai: Fatigue is one of the common referrals we get into our endocrinology practice, and everyone is convinced that their thyroid is the culprit. It is important to note, however, that fatigue can be due to different diseases such as anemia, depression, sleep disorders, or a recent viral illness.

TSH tests are readily available and cheap. I don’t mind ordering the lab test again if it helps give the patient some reassurance. I also find that patients are relieved once they hear from their endocrinologist that their thyroid is unlikely to be the cause of their fatigue.

Some other endocrine causes we may consider additionally working up include adrenal insufficiency, vitamin D deficiency, and diabetes. A comprehensive metabolic panel and complete blood count is part of my workup to rule out any gross electrolyte abnormalities or any new diagnosis of anemia, liver disease, or chronic kidney disease.

Question: What are your criteria for recommending that someone see an endocrinologist?

Dr. Tsai: Our primary care colleagues can do a workup and interpretation of thyroid function tests in most cases. In the situations where the thyroid function test results are discordant (ie, elevated TSH and elevated free T4 levels or low TSH and low free T4 levels) or difficult to interpret, it would be appropriate to refer the patient to an endocrinologist.

One of the common referrals that we do get from the community is a patient’s thyroid function tests going from hyperthyroid to hypothyroid without a clear explanation or the patient is suboptimally controlled with levothyroxine or methimazole. In those circumstances, it would be worthwhile to send to an endocrinologist try to discern an underlying cause or for optimization of medication.

Dr. Leung and Dr. Tsai had no financial disclosures.
 

A version of this article appeared on Medscape.com.

The patient had been diagnosed with pemphigus vulgaris (PV) 1 year prior to presentation with erosions on the axilla. Biopsy at that time revealed intraepithelial acantholytic blistering with areas of suprabasilar and subcorneal clefting. Direct immunofluorescence was positive for linear/granular IgG deposition throughout the epithelial cell surfaces, as well as linear/granular C3 deposits of the lower two thirds of the epithelial strata, consistent for pemphigus vulgaris.

PV is a rare autoimmune bullous disease in which antibodies are directed against desmoglein 1 and 3 and less commonly, plakoglobin. There is likely a genetic predisposition. Medications that may induce pemphigus include penicillamine, nifedipine, or captopril.

Clinically, PV presents with flaccid blistering lesions that may be cutaneous and/or mucosal. Bullae can progress to erosions and crusting, which then heal with pigment alteration but not scarring. The most commonly affected sites are the mouth, intertriginous areas, face, and neck. Mucosal lesions can involve the lips, esophagus, conjunctiva, and genitals.

Biopsy for histology and direct immunofluorescence is important in distinguishing between PV and other blistering disorders. Up to 75% of patients with active disease also have a positive indirect immunofluorescence with circulating IgG.

There are numerous reports in the literature of PV occurring in previous surgical scars, and areas of friction or trauma. This so-called Koebner’s phenomenon is seen more commonly in several dermatologic conditions, such as psoriasis, lichen planus, verruca vulgaris, and vitiligo.

Treatment for PV is generally immunosuppressive. Systemic therapy usually begins with prednisone and then is transitioned to a steroid sparing agent such as mycophenolate mofetil. Other steroid sparing agents include azathioprine, methotrexate, cyclophosphamide, and intravenous immunoglobulin. Secondary infections are possible and should be treated. Topical therapies aimed at reducing pain, especially in mucosal lesions, can be beneficial.
 

Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Florida. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to [email protected].

References

Cerottini JP et al. Eur J Dermatol. 2000 Oct-Nov;10(7):546-7.

Reichert-Penetrat S et al. Eur J Dermatol. 1998 Jan-Feb;8(1):60-2.

Saini P et al. Skinmed. 2020 Aug 1;18(4):252-253.

The patient had been diagnosed with pemphigus vulgaris (PV) 1 year prior to presentation with erosions on the axilla. Biopsy at that time revealed intraepithelial acantholytic blistering with areas of suprabasilar and subcorneal clefting. Direct immunofluorescence was positive for linear/granular IgG deposition throughout the epithelial cell surfaces, as well as linear/granular C3 deposits of the lower two thirds of the epithelial strata, consistent for pemphigus vulgaris.

PV is a rare autoimmune bullous disease in which antibodies are directed against desmoglein 1 and 3 and less commonly, plakoglobin. There is likely a genetic predisposition. Medications that may induce pemphigus include penicillamine, nifedipine, or captopril.

Clinically, PV presents with flaccid blistering lesions that may be cutaneous and/or mucosal. Bullae can progress to erosions and crusting, which then heal with pigment alteration but not scarring. The most commonly affected sites are the mouth, intertriginous areas, face, and neck. Mucosal lesions can involve the lips, esophagus, conjunctiva, and genitals.

Biopsy for histology and direct immunofluorescence is important in distinguishing between PV and other blistering disorders. Up to 75% of patients with active disease also have a positive indirect immunofluorescence with circulating IgG.

There are numerous reports in the literature of PV occurring in previous surgical scars, and areas of friction or trauma. This so-called Koebner’s phenomenon is seen more commonly in several dermatologic conditions, such as psoriasis, lichen planus, verruca vulgaris, and vitiligo.

Treatment for PV is generally immunosuppressive. Systemic therapy usually begins with prednisone and then is transitioned to a steroid sparing agent such as mycophenolate mofetil. Other steroid sparing agents include azathioprine, methotrexate, cyclophosphamide, and intravenous immunoglobulin. Secondary infections are possible and should be treated. Topical therapies aimed at reducing pain, especially in mucosal lesions, can be beneficial.
 

Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Florida. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to [email protected].

References

Cerottini JP et al. Eur J Dermatol. 2000 Oct-Nov;10(7):546-7.

Reichert-Penetrat S et al. Eur J Dermatol. 1998 Jan-Feb;8(1):60-2.

Saini P et al. Skinmed. 2020 Aug 1;18(4):252-253.

The patient had been diagnosed with pemphigus vulgaris (PV) 1 year prior to presentation with erosions on the axilla. Biopsy at that time revealed intraepithelial acantholytic blistering with areas of suprabasilar and subcorneal clefting. Direct immunofluorescence was positive for linear/granular IgG deposition throughout the epithelial cell surfaces, as well as linear/granular C3 deposits of the lower two thirds of the epithelial strata, consistent for pemphigus vulgaris.

PV is a rare autoimmune bullous disease in which antibodies are directed against desmoglein 1 and 3 and less commonly, plakoglobin. There is likely a genetic predisposition. Medications that may induce pemphigus include penicillamine, nifedipine, or captopril.

Clinically, PV presents with flaccid blistering lesions that may be cutaneous and/or mucosal. Bullae can progress to erosions and crusting, which then heal with pigment alteration but not scarring. The most commonly affected sites are the mouth, intertriginous areas, face, and neck. Mucosal lesions can involve the lips, esophagus, conjunctiva, and genitals.

Biopsy for histology and direct immunofluorescence is important in distinguishing between PV and other blistering disorders. Up to 75% of patients with active disease also have a positive indirect immunofluorescence with circulating IgG.

There are numerous reports in the literature of PV occurring in previous surgical scars, and areas of friction or trauma. This so-called Koebner’s phenomenon is seen more commonly in several dermatologic conditions, such as psoriasis, lichen planus, verruca vulgaris, and vitiligo.

Treatment for PV is generally immunosuppressive. Systemic therapy usually begins with prednisone and then is transitioned to a steroid sparing agent such as mycophenolate mofetil. Other steroid sparing agents include azathioprine, methotrexate, cyclophosphamide, and intravenous immunoglobulin. Secondary infections are possible and should be treated. Topical therapies aimed at reducing pain, especially in mucosal lesions, can be beneficial.
 

Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Florida. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to [email protected].

References

Cerottini JP et al. Eur J Dermatol. 2000 Oct-Nov;10(7):546-7.

Reichert-Penetrat S et al. Eur J Dermatol. 1998 Jan-Feb;8(1):60-2.

Saini P et al. Skinmed. 2020 Aug 1;18(4):252-253.

This transcript has been edited for clarity. 

There’s a very interesting story in the medical press. A few years ago, a plastic surgeon named Edmond Cabbabe was preparing to do a follow-up cosmetic procedure on his wife at Mercy Hospital South, which is a big hospital in the St. Louis, Missouri, area.

He put her on the operating schedule, and he had done that when he had performed the original operation on her. On the day of the surgery, he got a call from the hospital saying the procedure was canceled. They said that the hospital’s policy, maybe a new one, would not allow doctors to operate on family members.

This physician was a past president of the Missouri State Medical Association. I think he was also on the board or president of the American Medical Association (AMA) Foundation. This was a physician not only in a skilled area where he felt confident he could take care of his wife, but also someone who was prominent in medical politics and medical policy.

The AMA forever has had a policy that says don’t treat relatives. This physician basically said, I think that policy is too restrictive, too cautious, and it doesn’t make much sense to continue to say that you can’t treat family and friends.

By implication, he was saying, I know exactly what I’m doing in my field and I know exactly what I’m doing with her procedure. I should have a right to perform it. I think I do a great job and I’d be best for her.

If you look at medical boards, every once in a while in some state, someone is brought up on a charge of doing different things with family members and saying that they’re going to get censured. They don’t usually lose their license, but they get a reprimand or get told that is just not ethical to do.

I think, in the long run, the policy about not treating your family and friends makes sense. The problem is, as is well known from the social sciences and psychology, people get biased when they deal with those they care about, love, and hold close to them.

It’s hard for the doctor to be objective when dealing with people that they really like or love. It’s also difficult for patients because they may not want to bring up something or they are uncomfortable talking with a doctor who’s a family member or close friend. They may not want to complain. They may be a little bit embarrassed about things. It just adds an emotional edge, I think, that’s difficult.

All that said, do I know doctors who regularly prescribe, say, an ointment for something that’s itchy or some kind of a pill when allergy season breaks out? I do. Do I think they’re acting in a horribly unethical manner? I don’t.

You need some judgment here. There are absolutely minor things where objectivity, fear, and anxiety are not in play. You’re going to be able to prescribe the routine thing for the routine itch without worrying too much about whether it’s a stranger, a friend, or your daughter.

What sorts of things am I really talking about when I say that minor variability ought to be allowed? It’s one thing when someone has poison ivy and they’re going to need some kind of standard medicine to treat it. A very different area that’s much more dangerous, and one I would avoid, is in the mental health field, and for that matter, the pain field.

It’s tempting to say: “Oh, my relative is just having a bad time. I’ll give her a little bit of antidepressant medicine,” or “They seem to be having pain after an operation or something, and I’m going to give them a little bit of pain meds just to get them through.”

Those areas are flying red flags. It’s easy to abuse and easy for someone to become a user and manipulate a friend or a doctor who’s a relative into getting things that another doctor wouldn’t be giving. I think that’s the space where you’ve got to exercise extreme caution.

Time and again, when those people get called up in front of the boards for treating relatives, it’s in those spaces of mental health, anxiety, and pain control. Again, when you know that there’s a likelihood of abuse, I think that’s the place where the line has to hold. Don’t treat the relative. Don’t treat the friend.

At the end of the day, I wouldn’t change the AMA policy. I think we should keep it in place and morally try to discourage doctors from caring for those they’re close to or they have emotional ties to.

At the same time, as with all ethical situations, there has to be a little bit of wiggle room for those super-minor cases where it just makes sense to say: “You don’t have to go find somebody else to do this. I can prescribe this ointment or this minor thing for you. No one’s objectivity is going to be soured, and you’re not going to feel in any way at risk because I’m going to prescribe this for you.”

Common sense ought to prevail. The default position is don’t do it; however, maybe with a tiny bit of space for what’s minor, what’s routine, and what really does just save people some inconvenience, there I might just give a little.

Dr. Caplan, Director, Division of Medical Ethics, New York University Langone Medical Center, New York City, has disclosed relationships with Johnson & Johnson’s Panel for Compassionate Drug Use and Medscape.

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

This transcript has been edited for clarity. 

There’s a very interesting story in the medical press. A few years ago, a plastic surgeon named Edmond Cabbabe was preparing to do a follow-up cosmetic procedure on his wife at Mercy Hospital South, which is a big hospital in the St. Louis, Missouri, area.

He put her on the operating schedule, and he had done that when he had performed the original operation on her. On the day of the surgery, he got a call from the hospital saying the procedure was canceled. They said that the hospital’s policy, maybe a new one, would not allow doctors to operate on family members.

This physician was a past president of the Missouri State Medical Association. I think he was also on the board or president of the American Medical Association (AMA) Foundation. This was a physician not only in a skilled area where he felt confident he could take care of his wife, but also someone who was prominent in medical politics and medical policy.

The AMA forever has had a policy that says don’t treat relatives. This physician basically said, I think that policy is too restrictive, too cautious, and it doesn’t make much sense to continue to say that you can’t treat family and friends.

By implication, he was saying, I know exactly what I’m doing in my field and I know exactly what I’m doing with her procedure. I should have a right to perform it. I think I do a great job and I’d be best for her.

If you look at medical boards, every once in a while in some state, someone is brought up on a charge of doing different things with family members and saying that they’re going to get censured. They don’t usually lose their license, but they get a reprimand or get told that is just not ethical to do.

I think, in the long run, the policy about not treating your family and friends makes sense. The problem is, as is well known from the social sciences and psychology, people get biased when they deal with those they care about, love, and hold close to them.

It’s hard for the doctor to be objective when dealing with people that they really like or love. It’s also difficult for patients because they may not want to bring up something or they are uncomfortable talking with a doctor who’s a family member or close friend. They may not want to complain. They may be a little bit embarrassed about things. It just adds an emotional edge, I think, that’s difficult.

All that said, do I know doctors who regularly prescribe, say, an ointment for something that’s itchy or some kind of a pill when allergy season breaks out? I do. Do I think they’re acting in a horribly unethical manner? I don’t.

You need some judgment here. There are absolutely minor things where objectivity, fear, and anxiety are not in play. You’re going to be able to prescribe the routine thing for the routine itch without worrying too much about whether it’s a stranger, a friend, or your daughter.

What sorts of things am I really talking about when I say that minor variability ought to be allowed? It’s one thing when someone has poison ivy and they’re going to need some kind of standard medicine to treat it. A very different area that’s much more dangerous, and one I would avoid, is in the mental health field, and for that matter, the pain field.

It’s tempting to say: “Oh, my relative is just having a bad time. I’ll give her a little bit of antidepressant medicine,” or “They seem to be having pain after an operation or something, and I’m going to give them a little bit of pain meds just to get them through.”

Those areas are flying red flags. It’s easy to abuse and easy for someone to become a user and manipulate a friend or a doctor who’s a relative into getting things that another doctor wouldn’t be giving. I think that’s the space where you’ve got to exercise extreme caution.

Time and again, when those people get called up in front of the boards for treating relatives, it’s in those spaces of mental health, anxiety, and pain control. Again, when you know that there’s a likelihood of abuse, I think that’s the place where the line has to hold. Don’t treat the relative. Don’t treat the friend.

At the end of the day, I wouldn’t change the AMA policy. I think we should keep it in place and morally try to discourage doctors from caring for those they’re close to or they have emotional ties to.

At the same time, as with all ethical situations, there has to be a little bit of wiggle room for those super-minor cases where it just makes sense to say: “You don’t have to go find somebody else to do this. I can prescribe this ointment or this minor thing for you. No one’s objectivity is going to be soured, and you’re not going to feel in any way at risk because I’m going to prescribe this for you.”

Common sense ought to prevail. The default position is don’t do it; however, maybe with a tiny bit of space for what’s minor, what’s routine, and what really does just save people some inconvenience, there I might just give a little.

Dr. Caplan, Director, Division of Medical Ethics, New York University Langone Medical Center, New York City, has disclosed relationships with Johnson & Johnson’s Panel for Compassionate Drug Use and Medscape.

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

This transcript has been edited for clarity. 

There’s a very interesting story in the medical press. A few years ago, a plastic surgeon named Edmond Cabbabe was preparing to do a follow-up cosmetic procedure on his wife at Mercy Hospital South, which is a big hospital in the St. Louis, Missouri, area.

He put her on the operating schedule, and he had done that when he had performed the original operation on her. On the day of the surgery, he got a call from the hospital saying the procedure was canceled. They said that the hospital’s policy, maybe a new one, would not allow doctors to operate on family members.

This physician was a past president of the Missouri State Medical Association. I think he was also on the board or president of the American Medical Association (AMA) Foundation. This was a physician not only in a skilled area where he felt confident he could take care of his wife, but also someone who was prominent in medical politics and medical policy.

The AMA forever has had a policy that says don’t treat relatives. This physician basically said, I think that policy is too restrictive, too cautious, and it doesn’t make much sense to continue to say that you can’t treat family and friends.

By implication, he was saying, I know exactly what I’m doing in my field and I know exactly what I’m doing with her procedure. I should have a right to perform it. I think I do a great job and I’d be best for her.

If you look at medical boards, every once in a while in some state, someone is brought up on a charge of doing different things with family members and saying that they’re going to get censured. They don’t usually lose their license, but they get a reprimand or get told that is just not ethical to do.

I think, in the long run, the policy about not treating your family and friends makes sense. The problem is, as is well known from the social sciences and psychology, people get biased when they deal with those they care about, love, and hold close to them.

It’s hard for the doctor to be objective when dealing with people that they really like or love. It’s also difficult for patients because they may not want to bring up something or they are uncomfortable talking with a doctor who’s a family member or close friend. They may not want to complain. They may be a little bit embarrassed about things. It just adds an emotional edge, I think, that’s difficult.

All that said, do I know doctors who regularly prescribe, say, an ointment for something that’s itchy or some kind of a pill when allergy season breaks out? I do. Do I think they’re acting in a horribly unethical manner? I don’t.

You need some judgment here. There are absolutely minor things where objectivity, fear, and anxiety are not in play. You’re going to be able to prescribe the routine thing for the routine itch without worrying too much about whether it’s a stranger, a friend, or your daughter.

What sorts of things am I really talking about when I say that minor variability ought to be allowed? It’s one thing when someone has poison ivy and they’re going to need some kind of standard medicine to treat it. A very different area that’s much more dangerous, and one I would avoid, is in the mental health field, and for that matter, the pain field.

It’s tempting to say: “Oh, my relative is just having a bad time. I’ll give her a little bit of antidepressant medicine,” or “They seem to be having pain after an operation or something, and I’m going to give them a little bit of pain meds just to get them through.”

Those areas are flying red flags. It’s easy to abuse and easy for someone to become a user and manipulate a friend or a doctor who’s a relative into getting things that another doctor wouldn’t be giving. I think that’s the space where you’ve got to exercise extreme caution.

Time and again, when those people get called up in front of the boards for treating relatives, it’s in those spaces of mental health, anxiety, and pain control. Again, when you know that there’s a likelihood of abuse, I think that’s the place where the line has to hold. Don’t treat the relative. Don’t treat the friend.

At the end of the day, I wouldn’t change the AMA policy. I think we should keep it in place and morally try to discourage doctors from caring for those they’re close to or they have emotional ties to.

At the same time, as with all ethical situations, there has to be a little bit of wiggle room for those super-minor cases where it just makes sense to say: “You don’t have to go find somebody else to do this. I can prescribe this ointment or this minor thing for you. No one’s objectivity is going to be soured, and you’re not going to feel in any way at risk because I’m going to prescribe this for you.”

Common sense ought to prevail. The default position is don’t do it; however, maybe with a tiny bit of space for what’s minor, what’s routine, and what really does just save people some inconvenience, there I might just give a little.

Dr. Caplan, Director, Division of Medical Ethics, New York University Langone Medical Center, New York City, has disclosed relationships with Johnson & Johnson’s Panel for Compassionate Drug Use and Medscape.

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

Primary care physicians frequently offer postexposure prophylaxis for various infections, including influenza, pertussis, tetanus, hepatitis, and Lyme disease, among others. However, the scope of postexposure prophylaxis in primary care is expanding, presenting an opportunity to further integrate it into patient care. As primary care providers, we have the unique advantage of being involved in both preventive care and immediate response, particularly in urgent care or triage scenarios. This dual role is crucial, as timely administration of postexposure prophylaxis can prevent infections from taking hold, especially following high-risk exposures.

Recently, the use of doxycycline as a form of postexposure prophylaxis for sexually transmitted infections (STIs) has gained attention. Traditionally, doxycycline has been used as preexposure or postexposure prophylaxis for conditions like malaria and Lyme disease but has not been widely employed for STI prevention until now. Doxycycline is a relatively common medication, generally safe with side effects that typically resolve upon discontinuation. Several open-label studies have shown that taking 200 mg of doxycycline within 72 hours of condomless sex significantly reduces the incidence of chlamydia, gonorrhea, and syphilis among gay, bisexual, and other men who have sex with men, as well as transgender women who have previously had a bacterial STI. However, these benefits have not been consistently observed among cisgender women and heterosexual men.

Given these findings, the Centers for Disease Control and Prevention now recommends that clinicians discuss the risks and benefits of doxycycline PEP (Doxy PEP) with gay, bisexual, and other men who have sex with men, as well as transgender women who have had a bacterial STI in the past 12 months. This discussion should be part of a shared decision-making process, advising the use of 200 mg of doxycycline within 72 hours of oral, vaginal, or anal sex, with the recommendation not to exceed 200 mg every 24 hours and to reassess the need for continued use every 3-6 months. Doxy PEP can be safely prescribed with preexposure prophylaxis for HIV (PrEP). Patients who receive PrEP may often be eligible for Doxy PEP, though the groups are not always the same.

The shared decision-making process is essential when considering Doxy PEP. While cost-effective and proven to reduce the risk of gonorrhea, chlamydia, and syphilis, its benefits vary among different populations. Moreover, some patients may experience side effects such as photosensitivity and gastrointestinal discomfort. Since the effectiveness of prophylaxis is closely tied to the timing of exposure and the patient’s current risk factors, it is important to regularly evaluate whether Doxy PEP remains beneficial. As there is not yet clear benefit to heterosexual men and cisgender women, opportunities still need to be explored for them.

Integrating Doxy PEP into a primary care practice can be done efficiently. A standing order protocol could be established for telehealth visits or nurse triage, allowing timely administration when patients report an exposure within 72 hours. It could also be incorporated into electronic medical records as part of a smart set for easy access to orders and as standard educational material in after-visit instructions. As this option is new, it is also important to discuss it with patients before they may need it so that they are aware should the need arise. While concerns about antibiotic resistance are valid, studies have not yet shown significant resistance issues related to Doxy PEP use, though ongoing monitoring is necessary.

You might wonder why primary care should prioritize this intervention. As the first point of contact, primary care providers are well-positioned to identify the need for prophylaxis, particularly since its effectiveness diminishes over time. Furthermore, the established, trusting relationships that primary care physicians often have with their patients create a nonjudgmental environment that encourages disclosure of potential exposures. This trust, combined with easier access to care, can make a significant difference in the timely provision of postexposure prophylaxis. By offering comprehensive, holistic care, including prophylaxis, primary care physicians can prevent infections and address conditions before they lead to serious complications. Therefore, family medicine physicians should consider incorporating Doxy PEP into their practices as a standard of care.
 

Dr. Wheat is vice chair of Diversity, Equity, and Inclusion, Department of Family and Community Medicine, and associate professor, Family and Community Medicine, at Northwestern University’s Feinberg School of Medicine, Chicago. She has no relevant financial disclosures.

References

Bachmann LH et al. CDC Clinical Guidelines on the Use of Doxycycline Postexposure Prophylaxis for Bacterial Sexually Transmitted Infection Prevention, United States, 2024. MMWR Recomm Rep 2024;73(No. RR-2):1-8.

Traeger MW et al. Potential Impact of Doxycycline Postexposure Prophylaxis Prescribing Strategies on Incidence of Bacterial Sexually Transmitted Infections. (Clin Infect Dis. 2023 Aug 18. doi: 10.1093/cid/ciad488).

Primary care physicians frequently offer postexposure prophylaxis for various infections, including influenza, pertussis, tetanus, hepatitis, and Lyme disease, among others. However, the scope of postexposure prophylaxis in primary care is expanding, presenting an opportunity to further integrate it into patient care. As primary care providers, we have the unique advantage of being involved in both preventive care and immediate response, particularly in urgent care or triage scenarios. This dual role is crucial, as timely administration of postexposure prophylaxis can prevent infections from taking hold, especially following high-risk exposures.

Recently, the use of doxycycline as a form of postexposure prophylaxis for sexually transmitted infections (STIs) has gained attention. Traditionally, doxycycline has been used as preexposure or postexposure prophylaxis for conditions like malaria and Lyme disease but has not been widely employed for STI prevention until now. Doxycycline is a relatively common medication, generally safe with side effects that typically resolve upon discontinuation. Several open-label studies have shown that taking 200 mg of doxycycline within 72 hours of condomless sex significantly reduces the incidence of chlamydia, gonorrhea, and syphilis among gay, bisexual, and other men who have sex with men, as well as transgender women who have previously had a bacterial STI. However, these benefits have not been consistently observed among cisgender women and heterosexual men.

Given these findings, the Centers for Disease Control and Prevention now recommends that clinicians discuss the risks and benefits of doxycycline PEP (Doxy PEP) with gay, bisexual, and other men who have sex with men, as well as transgender women who have had a bacterial STI in the past 12 months. This discussion should be part of a shared decision-making process, advising the use of 200 mg of doxycycline within 72 hours of oral, vaginal, or anal sex, with the recommendation not to exceed 200 mg every 24 hours and to reassess the need for continued use every 3-6 months. Doxy PEP can be safely prescribed with preexposure prophylaxis for HIV (PrEP). Patients who receive PrEP may often be eligible for Doxy PEP, though the groups are not always the same.

The shared decision-making process is essential when considering Doxy PEP. While cost-effective and proven to reduce the risk of gonorrhea, chlamydia, and syphilis, its benefits vary among different populations. Moreover, some patients may experience side effects such as photosensitivity and gastrointestinal discomfort. Since the effectiveness of prophylaxis is closely tied to the timing of exposure and the patient’s current risk factors, it is important to regularly evaluate whether Doxy PEP remains beneficial. As there is not yet clear benefit to heterosexual men and cisgender women, opportunities still need to be explored for them.

Integrating Doxy PEP into a primary care practice can be done efficiently. A standing order protocol could be established for telehealth visits or nurse triage, allowing timely administration when patients report an exposure within 72 hours. It could also be incorporated into electronic medical records as part of a smart set for easy access to orders and as standard educational material in after-visit instructions. As this option is new, it is also important to discuss it with patients before they may need it so that they are aware should the need arise. While concerns about antibiotic resistance are valid, studies have not yet shown significant resistance issues related to Doxy PEP use, though ongoing monitoring is necessary.

You might wonder why primary care should prioritize this intervention. As the first point of contact, primary care providers are well-positioned to identify the need for prophylaxis, particularly since its effectiveness diminishes over time. Furthermore, the established, trusting relationships that primary care physicians often have with their patients create a nonjudgmental environment that encourages disclosure of potential exposures. This trust, combined with easier access to care, can make a significant difference in the timely provision of postexposure prophylaxis. By offering comprehensive, holistic care, including prophylaxis, primary care physicians can prevent infections and address conditions before they lead to serious complications. Therefore, family medicine physicians should consider incorporating Doxy PEP into their practices as a standard of care.
 

Dr. Wheat is vice chair of Diversity, Equity, and Inclusion, Department of Family and Community Medicine, and associate professor, Family and Community Medicine, at Northwestern University’s Feinberg School of Medicine, Chicago. She has no relevant financial disclosures.

References

Bachmann LH et al. CDC Clinical Guidelines on the Use of Doxycycline Postexposure Prophylaxis for Bacterial Sexually Transmitted Infection Prevention, United States, 2024. MMWR Recomm Rep 2024;73(No. RR-2):1-8.

Traeger MW et al. Potential Impact of Doxycycline Postexposure Prophylaxis Prescribing Strategies on Incidence of Bacterial Sexually Transmitted Infections. (Clin Infect Dis. 2023 Aug 18. doi: 10.1093/cid/ciad488).

Primary care physicians frequently offer postexposure prophylaxis for various infections, including influenza, pertussis, tetanus, hepatitis, and Lyme disease, among others. However, the scope of postexposure prophylaxis in primary care is expanding, presenting an opportunity to further integrate it into patient care. As primary care providers, we have the unique advantage of being involved in both preventive care and immediate response, particularly in urgent care or triage scenarios. This dual role is crucial, as timely administration of postexposure prophylaxis can prevent infections from taking hold, especially following high-risk exposures.

Recently, the use of doxycycline as a form of postexposure prophylaxis for sexually transmitted infections (STIs) has gained attention. Traditionally, doxycycline has been used as preexposure or postexposure prophylaxis for conditions like malaria and Lyme disease but has not been widely employed for STI prevention until now. Doxycycline is a relatively common medication, generally safe with side effects that typically resolve upon discontinuation. Several open-label studies have shown that taking 200 mg of doxycycline within 72 hours of condomless sex significantly reduces the incidence of chlamydia, gonorrhea, and syphilis among gay, bisexual, and other men who have sex with men, as well as transgender women who have previously had a bacterial STI. However, these benefits have not been consistently observed among cisgender women and heterosexual men.

Given these findings, the Centers for Disease Control and Prevention now recommends that clinicians discuss the risks and benefits of doxycycline PEP (Doxy PEP) with gay, bisexual, and other men who have sex with men, as well as transgender women who have had a bacterial STI in the past 12 months. This discussion should be part of a shared decision-making process, advising the use of 200 mg of doxycycline within 72 hours of oral, vaginal, or anal sex, with the recommendation not to exceed 200 mg every 24 hours and to reassess the need for continued use every 3-6 months. Doxy PEP can be safely prescribed with preexposure prophylaxis for HIV (PrEP). Patients who receive PrEP may often be eligible for Doxy PEP, though the groups are not always the same.

The shared decision-making process is essential when considering Doxy PEP. While cost-effective and proven to reduce the risk of gonorrhea, chlamydia, and syphilis, its benefits vary among different populations. Moreover, some patients may experience side effects such as photosensitivity and gastrointestinal discomfort. Since the effectiveness of prophylaxis is closely tied to the timing of exposure and the patient’s current risk factors, it is important to regularly evaluate whether Doxy PEP remains beneficial. As there is not yet clear benefit to heterosexual men and cisgender women, opportunities still need to be explored for them.

Integrating Doxy PEP into a primary care practice can be done efficiently. A standing order protocol could be established for telehealth visits or nurse triage, allowing timely administration when patients report an exposure within 72 hours. It could also be incorporated into electronic medical records as part of a smart set for easy access to orders and as standard educational material in after-visit instructions. As this option is new, it is also important to discuss it with patients before they may need it so that they are aware should the need arise. While concerns about antibiotic resistance are valid, studies have not yet shown significant resistance issues related to Doxy PEP use, though ongoing monitoring is necessary.

You might wonder why primary care should prioritize this intervention. As the first point of contact, primary care providers are well-positioned to identify the need for prophylaxis, particularly since its effectiveness diminishes over time. Furthermore, the established, trusting relationships that primary care physicians often have with their patients create a nonjudgmental environment that encourages disclosure of potential exposures. This trust, combined with easier access to care, can make a significant difference in the timely provision of postexposure prophylaxis. By offering comprehensive, holistic care, including prophylaxis, primary care physicians can prevent infections and address conditions before they lead to serious complications. Therefore, family medicine physicians should consider incorporating Doxy PEP into their practices as a standard of care.
 

Dr. Wheat is vice chair of Diversity, Equity, and Inclusion, Department of Family and Community Medicine, and associate professor, Family and Community Medicine, at Northwestern University’s Feinberg School of Medicine, Chicago. She has no relevant financial disclosures.

References

Bachmann LH et al. CDC Clinical Guidelines on the Use of Doxycycline Postexposure Prophylaxis for Bacterial Sexually Transmitted Infection Prevention, United States, 2024. MMWR Recomm Rep 2024;73(No. RR-2):1-8.

Traeger MW et al. Potential Impact of Doxycycline Postexposure Prophylaxis Prescribing Strategies on Incidence of Bacterial Sexually Transmitted Infections. (Clin Infect Dis. 2023 Aug 18. doi: 10.1093/cid/ciad488).

Earlier this year, I wrote a Medscape commentary to explain my disagreement with the US Preventive Services Task Force (USPSTF)’s updated recommendation that all women at average risk for breast cancer start screening mammography at age 40. The bottom line is that when the evidence doesn’t change, the guidelines shouldn’t change. Since then, other screening experts have criticized the USPSTF guideline on similar grounds, and a national survey reported that nearly 4 out of 10 women in their 40s preferred to delay breast cancer screening after viewing a decision aid and a personalized breast cancer risk estimate.

The decision analysis performed for the USPSTF guideline estimated that compared with having mammography beginning at age 50, 1000 women who begin at age 40 experience 519 more false-positive results and 62 more benign breast biopsies. Another study suggested that anxiety and other psychosocial harms resulting from a false-positive test are similar between patients who require a biopsy vs additional imaging only. Of greater concern, women who have false-positive results are less likely to return for their next scheduled screening exam.

A recent analysis of 2005-2017 data from the US Breast Cancer Surveillance Consortium found that about 1 in 10 mammograms had a false-positive result. Sixty percent of these patients underwent immediate additional imaging, 27% were recalled for diagnostic imaging within the next few days to weeks, and 13% were advised to have a biopsy. While patients who had additional imaging at the same visit were only 1.9% less likely to return for screening mammography within 30 months compared with those with normal mammograms, women who were recalled for short-interval follow-up or recommended for biopsy were 15.9% and 10% less likely to return, respectively. For unclear reasons, women who identified as Asian or Hispanic had even lower rates of return screening after false-positive results.

These differences matter because women in their 40s, with the lowest incidence of breast cancer among those undergoing screening, have a lot of false positives. A patient who follows the USPSTF recommendation and starts screening at age 40 has a 42% chance of having at least one false positive with every-other-year screening, or a 61% chance with annual screening, by the time she turns 50. If some of these patients are so turned off by false positives that they don’t return for regular mammography in their 50s and 60s, when screening is the most likely to catch clinically significant cancers at treatable stages, then moving up the starting age may backfire and cause net harm.

The recently implemented FDA rule requiring mammography reports to include breast density could compound this problem. Because younger women are more likely to have dense breasts, more of them will probably decide to have supplemental imaging for cancer. I previously pointed out that we don’t know whether supplemental imaging with breast ultrasonography or MRI reduces cancer deaths, but we do know that it increases false-positive results.

I have personally cared for several patients who abandoned screening mammography for long stretches, or permanently, after having endured one or more benign biopsies prompted by a false-positive result. I vividly recall one woman in her 60s who was very reluctant to have screening tests in general, and mammography in particular, for that reason. After she had been my patient for a few years, I finally persuaded her to resume screening. We were both surprised when her first mammogram in more than a decade revealed an early-stage breast cancer. Fortunately, the tumor was successfully treated, but for her, an earlier false-positive result nearly ended up having critical health consequences.

Dr. Lin is associate director, Family Medicine Residency Program, Lancaster General Hospital, Lancaster, Pennsylvania. He blogs at Common Sense Family Doctor. He has no relevant financial relationships.

A version of this article appeared on Medscape.com.

Earlier this year, I wrote a Medscape commentary to explain my disagreement with the US Preventive Services Task Force (USPSTF)’s updated recommendation that all women at average risk for breast cancer start screening mammography at age 40. The bottom line is that when the evidence doesn’t change, the guidelines shouldn’t change. Since then, other screening experts have criticized the USPSTF guideline on similar grounds, and a national survey reported that nearly 4 out of 10 women in their 40s preferred to delay breast cancer screening after viewing a decision aid and a personalized breast cancer risk estimate.

The decision analysis performed for the USPSTF guideline estimated that compared with having mammography beginning at age 50, 1000 women who begin at age 40 experience 519 more false-positive results and 62 more benign breast biopsies. Another study suggested that anxiety and other psychosocial harms resulting from a false-positive test are similar between patients who require a biopsy vs additional imaging only. Of greater concern, women who have false-positive results are less likely to return for their next scheduled screening exam.

A recent analysis of 2005-2017 data from the US Breast Cancer Surveillance Consortium found that about 1 in 10 mammograms had a false-positive result. Sixty percent of these patients underwent immediate additional imaging, 27% were recalled for diagnostic imaging within the next few days to weeks, and 13% were advised to have a biopsy. While patients who had additional imaging at the same visit were only 1.9% less likely to return for screening mammography within 30 months compared with those with normal mammograms, women who were recalled for short-interval follow-up or recommended for biopsy were 15.9% and 10% less likely to return, respectively. For unclear reasons, women who identified as Asian or Hispanic had even lower rates of return screening after false-positive results.

These differences matter because women in their 40s, with the lowest incidence of breast cancer among those undergoing screening, have a lot of false positives. A patient who follows the USPSTF recommendation and starts screening at age 40 has a 42% chance of having at least one false positive with every-other-year screening, or a 61% chance with annual screening, by the time she turns 50. If some of these patients are so turned off by false positives that they don’t return for regular mammography in their 50s and 60s, when screening is the most likely to catch clinically significant cancers at treatable stages, then moving up the starting age may backfire and cause net harm.

The recently implemented FDA rule requiring mammography reports to include breast density could compound this problem. Because younger women are more likely to have dense breasts, more of them will probably decide to have supplemental imaging for cancer. I previously pointed out that we don’t know whether supplemental imaging with breast ultrasonography or MRI reduces cancer deaths, but we do know that it increases false-positive results.

I have personally cared for several patients who abandoned screening mammography for long stretches, or permanently, after having endured one or more benign biopsies prompted by a false-positive result. I vividly recall one woman in her 60s who was very reluctant to have screening tests in general, and mammography in particular, for that reason. After she had been my patient for a few years, I finally persuaded her to resume screening. We were both surprised when her first mammogram in more than a decade revealed an early-stage breast cancer. Fortunately, the tumor was successfully treated, but for her, an earlier false-positive result nearly ended up having critical health consequences.

Dr. Lin is associate director, Family Medicine Residency Program, Lancaster General Hospital, Lancaster, Pennsylvania. He blogs at Common Sense Family Doctor. He has no relevant financial relationships.

A version of this article appeared on Medscape.com.

Earlier this year, I wrote a Medscape commentary to explain my disagreement with the US Preventive Services Task Force (USPSTF)’s updated recommendation that all women at average risk for breast cancer start screening mammography at age 40. The bottom line is that when the evidence doesn’t change, the guidelines shouldn’t change. Since then, other screening experts have criticized the USPSTF guideline on similar grounds, and a national survey reported that nearly 4 out of 10 women in their 40s preferred to delay breast cancer screening after viewing a decision aid and a personalized breast cancer risk estimate.

The decision analysis performed for the USPSTF guideline estimated that compared with having mammography beginning at age 50, 1000 women who begin at age 40 experience 519 more false-positive results and 62 more benign breast biopsies. Another study suggested that anxiety and other psychosocial harms resulting from a false-positive test are similar between patients who require a biopsy vs additional imaging only. Of greater concern, women who have false-positive results are less likely to return for their next scheduled screening exam.

A recent analysis of 2005-2017 data from the US Breast Cancer Surveillance Consortium found that about 1 in 10 mammograms had a false-positive result. Sixty percent of these patients underwent immediate additional imaging, 27% were recalled for diagnostic imaging within the next few days to weeks, and 13% were advised to have a biopsy. While patients who had additional imaging at the same visit were only 1.9% less likely to return for screening mammography within 30 months compared with those with normal mammograms, women who were recalled for short-interval follow-up or recommended for biopsy were 15.9% and 10% less likely to return, respectively. For unclear reasons, women who identified as Asian or Hispanic had even lower rates of return screening after false-positive results.

These differences matter because women in their 40s, with the lowest incidence of breast cancer among those undergoing screening, have a lot of false positives. A patient who follows the USPSTF recommendation and starts screening at age 40 has a 42% chance of having at least one false positive with every-other-year screening, or a 61% chance with annual screening, by the time she turns 50. If some of these patients are so turned off by false positives that they don’t return for regular mammography in their 50s and 60s, when screening is the most likely to catch clinically significant cancers at treatable stages, then moving up the starting age may backfire and cause net harm.

The recently implemented FDA rule requiring mammography reports to include breast density could compound this problem. Because younger women are more likely to have dense breasts, more of them will probably decide to have supplemental imaging for cancer. I previously pointed out that we don’t know whether supplemental imaging with breast ultrasonography or MRI reduces cancer deaths, but we do know that it increases false-positive results.

I have personally cared for several patients who abandoned screening mammography for long stretches, or permanently, after having endured one or more benign biopsies prompted by a false-positive result. I vividly recall one woman in her 60s who was very reluctant to have screening tests in general, and mammography in particular, for that reason. After she had been my patient for a few years, I finally persuaded her to resume screening. We were both surprised when her first mammogram in more than a decade revealed an early-stage breast cancer. Fortunately, the tumor was successfully treated, but for her, an earlier false-positive result nearly ended up having critical health consequences.

Dr. Lin is associate director, Family Medicine Residency Program, Lancaster General Hospital, Lancaster, Pennsylvania. He blogs at Common Sense Family Doctor. He has no relevant financial relationships.

A version of this article appeared on Medscape.com.

This transcript has been edited for clarity. 

I’d like to pose a question: When should doctors retire? When, as practicing physicians or surgeons, do we become too old to deliver competent service? 

You will be amazed to hear, those of you who have listened to my videos before — and although it is a matter of public knowledge — that I’m 68. I know it’s impossible to imagine, due to this youthful appearance, visage, and so on, but I am. I’ve been a cancer doctor for 40 years; therefore, I need to think a little about retirement. 

There are two elements of this for me. I’m a university professor, and in Oxford we did vote, as a democracy of scholars, to have a mandatory retirement age around 68. This is so that we can bring new blood forward so that we can create the space to promote new professors, to bring youngsters in to make new ideas, and to get rid of us fusty old lot. 

The other argument would be, of course, that we are wise, we’re experienced, we are world-weary, and we’re successful — otherwise, we wouldn’t have lasted as academics as long. Nevertheless, we voted to do that. 

It’s possible to have a discussion with the university to extend this, and for those of us who are clinical academics, I have an honorary appointment as a consultant cancer physician in the hospital and my university professorial appointment, too.

I can extend it probably until I’m about 70. It feels like a nice, round number at which to retire — somewhat arbitrarily, one would admit. But does that feel right? 

In the United States, more than 25% of the physician workforce is over the age of 65. There are many studies showing that there is a 20% cognitive decline for most individuals between the ages of 45 and 65.

Are we as capable as an elderly workforce as once we were? Clearly, it’s hardly individualistic. It depends on each of our own health status, where we started from, and so on, but are there any general rules that we can apply? I think these are starting to creep in around the sense of revalidation.

In the United Kingdom, we have a General Medical Council (GMC). I need to have a license to practice from the GMC and a sense of fitness to practice. I have annual appraisals within the hospital system, in which I explore delivery of care, how I’m doing as a mentor, am I reaching the milestones I’ve set in terms of academic achievements, and so on.

This is a peer-to-peer process. We have senior physicians — people like myself — who act as appraisers to support our colleagues and to maintain that sense of fitness to practice. Every 5 years, I’m revalidated by the GMC. They take account of the annual appraisals and a report made by the senior physician within my hospital network who’s a so-called designated person.

These two elements come together with patient feedback, with 360-degree feedback from colleagues, and so on. This is quite a firmly regulated system that I think works. Our mandatory retirement age of 65 has gone. That was phased out by the government. In fact, our NHS is making an effort to retain older elders in the workforce.

They see the benefits of mentorship, experience, leadership, and networks. At a time when the majority of NHS are actively seeking to retire when 65, the NHS is trying to retain and pull back those of us who have been around for that wee bit longer and who still feel committed to doing it. 

I’d be really interested to see what you think. There’s variation from country to country. I know that, in Australia, they’re talking about annual appraisals of doctors over the age of 70. I’d be very interested to hear what you think is likely to happen in the United States. 

I think our system works pretty well, as long as you’re within the NHS and hospital system. If you wanted to still practice, but practice privately, you would still have to find somebody who’d be prepared to conduct appraisals and so on outside of the NHS. It’s an interesting area. 

For myself, I still feel competent. Patients seem to like me. That’s an objective assessment by this 360-degree thing in which patients reflected very positively, indeed, in my approach to the delivery of the care and so on, as did colleagues. I’m still publishing, I go to meetings, I cheer things, bits and bobs. I’d say I’m a wee bit unusual in terms of still having a strong academic profile in doing stuff.

It’s an interesting question. Richard Doll, one of the world’s great epidemiologists who, of course, was the dominant discoverer of the link between smoking and lung cancer, was attending seminars, sitting in the front row, and coming into university 3 days a week at age 90, continuing to be contributory with his extraordinarily sharp intellect and vast, vast experience.

When I think of experience, all young cancer doctors are now immunologists. When I was a young doctor, I was a clinical pharmacologist. There are many lessons and tricks that I learned which I do need to pass on to the younger generation of today. What do you think? Should there be a mandatory retirement age? How do we best measure, assess, and revalidate elderly physicians and surgeons? How can we continue to contribute to those who choose to do so? For the time being, as always, thanks for listening.
 

Dr. Kerr is professor, Nuffield Department of Clinical Laboratory Science, University of Oxford, and professor of cancer medicine, Oxford Cancer Centre, Oxford, United Kingdom. He has disclosed ties with Celleron Therapeutics, Oxford Cancer Biomarkers (Board of Directors); Afrox (charity; Trustee); GlaxoSmithKline and Bayer HealthCare Pharmaceuticals (Consultant), Genomic Health; Merck Serono, and Roche.

A version of this article appeared on Medscape.com.

This transcript has been edited for clarity. 

I’d like to pose a question: When should doctors retire? When, as practicing physicians or surgeons, do we become too old to deliver competent service? 

You will be amazed to hear, those of you who have listened to my videos before — and although it is a matter of public knowledge — that I’m 68. I know it’s impossible to imagine, due to this youthful appearance, visage, and so on, but I am. I’ve been a cancer doctor for 40 years; therefore, I need to think a little about retirement. 

There are two elements of this for me. I’m a university professor, and in Oxford we did vote, as a democracy of scholars, to have a mandatory retirement age around 68. This is so that we can bring new blood forward so that we can create the space to promote new professors, to bring youngsters in to make new ideas, and to get rid of us fusty old lot. 

The other argument would be, of course, that we are wise, we’re experienced, we are world-weary, and we’re successful — otherwise, we wouldn’t have lasted as academics as long. Nevertheless, we voted to do that. 

It’s possible to have a discussion with the university to extend this, and for those of us who are clinical academics, I have an honorary appointment as a consultant cancer physician in the hospital and my university professorial appointment, too.

I can extend it probably until I’m about 70. It feels like a nice, round number at which to retire — somewhat arbitrarily, one would admit. But does that feel right? 

In the United States, more than 25% of the physician workforce is over the age of 65. There are many studies showing that there is a 20% cognitive decline for most individuals between the ages of 45 and 65.

Are we as capable as an elderly workforce as once we were? Clearly, it’s hardly individualistic. It depends on each of our own health status, where we started from, and so on, but are there any general rules that we can apply? I think these are starting to creep in around the sense of revalidation.

In the United Kingdom, we have a General Medical Council (GMC). I need to have a license to practice from the GMC and a sense of fitness to practice. I have annual appraisals within the hospital system, in which I explore delivery of care, how I’m doing as a mentor, am I reaching the milestones I’ve set in terms of academic achievements, and so on.

This is a peer-to-peer process. We have senior physicians — people like myself — who act as appraisers to support our colleagues and to maintain that sense of fitness to practice. Every 5 years, I’m revalidated by the GMC. They take account of the annual appraisals and a report made by the senior physician within my hospital network who’s a so-called designated person.

These two elements come together with patient feedback, with 360-degree feedback from colleagues, and so on. This is quite a firmly regulated system that I think works. Our mandatory retirement age of 65 has gone. That was phased out by the government. In fact, our NHS is making an effort to retain older elders in the workforce.

They see the benefits of mentorship, experience, leadership, and networks. At a time when the majority of NHS are actively seeking to retire when 65, the NHS is trying to retain and pull back those of us who have been around for that wee bit longer and who still feel committed to doing it. 

I’d be really interested to see what you think. There’s variation from country to country. I know that, in Australia, they’re talking about annual appraisals of doctors over the age of 70. I’d be very interested to hear what you think is likely to happen in the United States. 

I think our system works pretty well, as long as you’re within the NHS and hospital system. If you wanted to still practice, but practice privately, you would still have to find somebody who’d be prepared to conduct appraisals and so on outside of the NHS. It’s an interesting area. 

For myself, I still feel competent. Patients seem to like me. That’s an objective assessment by this 360-degree thing in which patients reflected very positively, indeed, in my approach to the delivery of the care and so on, as did colleagues. I’m still publishing, I go to meetings, I cheer things, bits and bobs. I’d say I’m a wee bit unusual in terms of still having a strong academic profile in doing stuff.

It’s an interesting question. Richard Doll, one of the world’s great epidemiologists who, of course, was the dominant discoverer of the link between smoking and lung cancer, was attending seminars, sitting in the front row, and coming into university 3 days a week at age 90, continuing to be contributory with his extraordinarily sharp intellect and vast, vast experience.

When I think of experience, all young cancer doctors are now immunologists. When I was a young doctor, I was a clinical pharmacologist. There are many lessons and tricks that I learned which I do need to pass on to the younger generation of today. What do you think? Should there be a mandatory retirement age? How do we best measure, assess, and revalidate elderly physicians and surgeons? How can we continue to contribute to those who choose to do so? For the time being, as always, thanks for listening.
 

Dr. Kerr is professor, Nuffield Department of Clinical Laboratory Science, University of Oxford, and professor of cancer medicine, Oxford Cancer Centre, Oxford, United Kingdom. He has disclosed ties with Celleron Therapeutics, Oxford Cancer Biomarkers (Board of Directors); Afrox (charity; Trustee); GlaxoSmithKline and Bayer HealthCare Pharmaceuticals (Consultant), Genomic Health; Merck Serono, and Roche.

A version of this article appeared on Medscape.com.

This transcript has been edited for clarity. 

I’d like to pose a question: When should doctors retire? When, as practicing physicians or surgeons, do we become too old to deliver competent service? 

You will be amazed to hear, those of you who have listened to my videos before — and although it is a matter of public knowledge — that I’m 68. I know it’s impossible to imagine, due to this youthful appearance, visage, and so on, but I am. I’ve been a cancer doctor for 40 years; therefore, I need to think a little about retirement. 

There are two elements of this for me. I’m a university professor, and in Oxford we did vote, as a democracy of scholars, to have a mandatory retirement age around 68. This is so that we can bring new blood forward so that we can create the space to promote new professors, to bring youngsters in to make new ideas, and to get rid of us fusty old lot. 

The other argument would be, of course, that we are wise, we’re experienced, we are world-weary, and we’re successful — otherwise, we wouldn’t have lasted as academics as long. Nevertheless, we voted to do that. 

It’s possible to have a discussion with the university to extend this, and for those of us who are clinical academics, I have an honorary appointment as a consultant cancer physician in the hospital and my university professorial appointment, too.

I can extend it probably until I’m about 70. It feels like a nice, round number at which to retire — somewhat arbitrarily, one would admit. But does that feel right? 

In the United States, more than 25% of the physician workforce is over the age of 65. There are many studies showing that there is a 20% cognitive decline for most individuals between the ages of 45 and 65.

Are we as capable as an elderly workforce as once we were? Clearly, it’s hardly individualistic. It depends on each of our own health status, where we started from, and so on, but are there any general rules that we can apply? I think these are starting to creep in around the sense of revalidation.

In the United Kingdom, we have a General Medical Council (GMC). I need to have a license to practice from the GMC and a sense of fitness to practice. I have annual appraisals within the hospital system, in which I explore delivery of care, how I’m doing as a mentor, am I reaching the milestones I’ve set in terms of academic achievements, and so on.

This is a peer-to-peer process. We have senior physicians — people like myself — who act as appraisers to support our colleagues and to maintain that sense of fitness to practice. Every 5 years, I’m revalidated by the GMC. They take account of the annual appraisals and a report made by the senior physician within my hospital network who’s a so-called designated person.

These two elements come together with patient feedback, with 360-degree feedback from colleagues, and so on. This is quite a firmly regulated system that I think works. Our mandatory retirement age of 65 has gone. That was phased out by the government. In fact, our NHS is making an effort to retain older elders in the workforce.

They see the benefits of mentorship, experience, leadership, and networks. At a time when the majority of NHS are actively seeking to retire when 65, the NHS is trying to retain and pull back those of us who have been around for that wee bit longer and who still feel committed to doing it. 

I’d be really interested to see what you think. There’s variation from country to country. I know that, in Australia, they’re talking about annual appraisals of doctors over the age of 70. I’d be very interested to hear what you think is likely to happen in the United States. 

I think our system works pretty well, as long as you’re within the NHS and hospital system. If you wanted to still practice, but practice privately, you would still have to find somebody who’d be prepared to conduct appraisals and so on outside of the NHS. It’s an interesting area. 

For myself, I still feel competent. Patients seem to like me. That’s an objective assessment by this 360-degree thing in which patients reflected very positively, indeed, in my approach to the delivery of the care and so on, as did colleagues. I’m still publishing, I go to meetings, I cheer things, bits and bobs. I’d say I’m a wee bit unusual in terms of still having a strong academic profile in doing stuff.

It’s an interesting question. Richard Doll, one of the world’s great epidemiologists who, of course, was the dominant discoverer of the link between smoking and lung cancer, was attending seminars, sitting in the front row, and coming into university 3 days a week at age 90, continuing to be contributory with his extraordinarily sharp intellect and vast, vast experience.

When I think of experience, all young cancer doctors are now immunologists. When I was a young doctor, I was a clinical pharmacologist. There are many lessons and tricks that I learned which I do need to pass on to the younger generation of today. What do you think? Should there be a mandatory retirement age? How do we best measure, assess, and revalidate elderly physicians and surgeons? How can we continue to contribute to those who choose to do so? For the time being, as always, thanks for listening.
 

Dr. Kerr is professor, Nuffield Department of Clinical Laboratory Science, University of Oxford, and professor of cancer medicine, Oxford Cancer Centre, Oxford, United Kingdom. He has disclosed ties with Celleron Therapeutics, Oxford Cancer Biomarkers (Board of Directors); Afrox (charity; Trustee); GlaxoSmithKline and Bayer HealthCare Pharmaceuticals (Consultant), Genomic Health; Merck Serono, and Roche.

A version of this article appeared on Medscape.com.

Over the past few decades, researchers have developed a compelling case against ultraprocessed foods and beverages, linking them to several chronic diseases and adverse health conditions. Yet, even as this evidence mounted, these food items have become increasingly prominent in diets globally. 

Now, recent studies are unlocking why cutting back on ultraprocessed foods can be so challenging. In their ability to fuel intense cravings, loss of control, and even withdrawal symptoms, ultraprocessed foods appear as capable of triggering addiction as traditional culprits like tobacco and alcohol. 

This has driven efforts to better understand the addictive nature of these foods and identify strategies for combating it. 
 

The Key Role of the Food Industry

Some foods are more likely to trigger addictions than others. For instance, in our studies, participants frequently mention chocolate, pizza, French fries, potato chips, and soda as some of the most addictive foods. What these foods all share is an ability to deliver high doses of refined carbohydrates, fat, or salt at levels exceeding those found in natural foods (eg, fruits, vegetables, beans).

Furthermore, ultraprocessed foods are industrially mass-produced in a process that relies on the heavy use of flavor enhancers and additives, as well as preservatives and packaging that make them shelf-stable. This has flooded our food supply with cheap, accessible, hyperrewarding foods that our brains are not well equipped to resist.

To add to these already substantial effects, the food industry often employs strategies reminiscent of Big Tobacco. They engineer foods to hit our “bliss points,” maximizing craving and fostering brand loyalty from a young age. This product engineering, coupled with aggressive marketing, makes these foods both attractive and seemingly ubiquitous. 
 

How Many People Are Affected?

Addiction to ultraprocessed food is more common than you might think. According to the Yale Food Addiction Scale — a tool that uses the same criteria for diagnosing substance use disorders to assess ultraprocessed food addiction (UPFA) — about 14% of adults and 12% of children show clinically significant signs of addiction to such foods. This is quite similar to addiction rates among adults for legal substances like alcohol and tobacco. 

Research has shown that behaviors and brain mechanisms contributing to addictive disorders, such as cravings and impulsivity, also apply to UPFA. 

Many more people outside of those who meet the criteria for UPFA are influenced by their addictive properties. Picture a teenager craving a sugary drink after school, a child needing the morning cereal fix, or adults reaching for candy and fast food; these scenarios illustrate how addictive ultraprocessed foods permeate our daily lives. 

From a public health standpoint, this comes at a significant cost. Even experiencing one or two symptoms of UPFA, such as intense cravings or a feeling of loss of control over intake, can lead to consuming too many calories, sugar, fat, and sodium in a way that puts health at risk.
 

Clinical Implications

Numerous studies have found that individuals who exhibit UPFA have more severe mental and physical health challenges. For example, UPFA is associated with higher rates of diet-related diseases (like type 2 diabetes), greater overall mental health issues, and generally poorer outcomes in weight loss treatments.

Despite the growing understanding of UPFA’s relevance in clinical settings, research is still limited on how to best treat, manage, or prevent it. Most of the existing work has focused on investigating whether UPFA is indeed a real condition, with efforts to create clinical guidelines only just beginning.

Of note, UPFA isn’t officially recognized as a diagnosis — yet. If it were, it could spark much more research into how to handle it clinically.

There is some debate about whether we really need this new diagnosis, given that eating disorders are already recognized. However, the statistics tell a different story: Around 14% of people might have UPFA compared with about 1% for binge-type eating disorders. This suggests that many individuals with problematic eating habits are currently flying under the radar with our existing diagnostic categories. 

What’s even more concerning is that these individuals often suffer significant problems and exhibit distinct brain differences, even if they do not neatly fit into an existing eating disorder diagnosis. Officially recognizing UPFA could open up new avenues for support and lead to better treatments aimed at reducing compulsive eating patterns.
 

Treatment Options

Treatment options for UPFA are still being explored. Initial evidence suggests that medications used for treating substance addiction, such as naltrexone and bupropion, might help with highly processed food addiction as well. Newer drugs, like glucagon-like peptide-1 receptor agonists, which appear to curb food cravings and manage addictive behaviors, also look promising.

Psychosocial approaches can also be used to address UPFA. Strategies include:

• Helping individuals become more aware of their triggers for addictive patterns of intake. This often involves identifying certain types of food (eg, potato chips, candy), specific places or times of day (eg, sitting on the couch at night while watching TV), and particular emotional states (eg, anger, loneliness, boredom, sadness). Increasing awareness of personal triggers can help people minimize their exposure to these and develop coping strategies when they do arise.
• Many people use ultraprocessed foods to cope with challenging emotions. Helping individuals develop healthier strategies to regulate their emotions can be key. This may include seeking out social support, journaling, going for a walk, or practicing mindfulness.
• UPFA can be associated with erratic and inconsistent eating patterns. Stabilizing eating habits by consuming regular meals composed of more minimally processed foods (eg, vegetables, fruits, high-quality protein, beans) can help heal the body and reduce vulnerability to ultraprocessed food triggers.
• Many people with UPFA have other existing mental health conditions, including mood disorders, anxiety, substance use disorders, or trauma-related disorders. Addressing these co-occurring mental health conditions can help reduce reliance on ultraprocessed foods.

Public-policy interventions may also help safeguard vulnerable populations from developing UPFA. For instance, support exists for policies to protect children from cigarette marketing and to put clear addiction warning labels on cigarette packages. A similar approach could be applied to reduce the harms associated with ultraprocessed foods, particularly for children.

Combating this growing problem requires treating ultraprocessed foods like other addictive substances. By identifying the threat posed by these common food items, we can not only help patients with UPFA, but also potentially stave off the development of several diet-related conditions.
 

Dr. Gearhardt, professor of psychology, University of Michigan, Ann Arbor, has disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.

Over the past few decades, researchers have developed a compelling case against ultraprocessed foods and beverages, linking them to several chronic diseases and adverse health conditions. Yet, even as this evidence mounted, these food items have become increasingly prominent in diets globally. 

Now, recent studies are unlocking why cutting back on ultraprocessed foods can be so challenging. In their ability to fuel intense cravings, loss of control, and even withdrawal symptoms, ultraprocessed foods appear as capable of triggering addiction as traditional culprits like tobacco and alcohol. 

This has driven efforts to better understand the addictive nature of these foods and identify strategies for combating it. 
 

The Key Role of the Food Industry

Some foods are more likely to trigger addictions than others. For instance, in our studies, participants frequently mention chocolate, pizza, French fries, potato chips, and soda as some of the most addictive foods. What these foods all share is an ability to deliver high doses of refined carbohydrates, fat, or salt at levels exceeding those found in natural foods (eg, fruits, vegetables, beans).

Furthermore, ultraprocessed foods are industrially mass-produced in a process that relies on the heavy use of flavor enhancers and additives, as well as preservatives and packaging that make them shelf-stable. This has flooded our food supply with cheap, accessible, hyperrewarding foods that our brains are not well equipped to resist.

To add to these already substantial effects, the food industry often employs strategies reminiscent of Big Tobacco. They engineer foods to hit our “bliss points,” maximizing craving and fostering brand loyalty from a young age. This product engineering, coupled with aggressive marketing, makes these foods both attractive and seemingly ubiquitous. 
 

How Many People Are Affected?

Addiction to ultraprocessed food is more common than you might think. According to the Yale Food Addiction Scale — a tool that uses the same criteria for diagnosing substance use disorders to assess ultraprocessed food addiction (UPFA) — about 14% of adults and 12% of children show clinically significant signs of addiction to such foods. This is quite similar to addiction rates among adults for legal substances like alcohol and tobacco. 

Research has shown that behaviors and brain mechanisms contributing to addictive disorders, such as cravings and impulsivity, also apply to UPFA. 

Many more people outside of those who meet the criteria for UPFA are influenced by their addictive properties. Picture a teenager craving a sugary drink after school, a child needing the morning cereal fix, or adults reaching for candy and fast food; these scenarios illustrate how addictive ultraprocessed foods permeate our daily lives. 

From a public health standpoint, this comes at a significant cost. Even experiencing one or two symptoms of UPFA, such as intense cravings or a feeling of loss of control over intake, can lead to consuming too many calories, sugar, fat, and sodium in a way that puts health at risk.
 

Clinical Implications

Numerous studies have found that individuals who exhibit UPFA have more severe mental and physical health challenges. For example, UPFA is associated with higher rates of diet-related diseases (like type 2 diabetes), greater overall mental health issues, and generally poorer outcomes in weight loss treatments.

Despite the growing understanding of UPFA’s relevance in clinical settings, research is still limited on how to best treat, manage, or prevent it. Most of the existing work has focused on investigating whether UPFA is indeed a real condition, with efforts to create clinical guidelines only just beginning.

Of note, UPFA isn’t officially recognized as a diagnosis — yet. If it were, it could spark much more research into how to handle it clinically.

There is some debate about whether we really need this new diagnosis, given that eating disorders are already recognized. However, the statistics tell a different story: Around 14% of people might have UPFA compared with about 1% for binge-type eating disorders. This suggests that many individuals with problematic eating habits are currently flying under the radar with our existing diagnostic categories. 

What’s even more concerning is that these individuals often suffer significant problems and exhibit distinct brain differences, even if they do not neatly fit into an existing eating disorder diagnosis. Officially recognizing UPFA could open up new avenues for support and lead to better treatments aimed at reducing compulsive eating patterns.
 

Treatment Options

Treatment options for UPFA are still being explored. Initial evidence suggests that medications used for treating substance addiction, such as naltrexone and bupropion, might help with highly processed food addiction as well. Newer drugs, like glucagon-like peptide-1 receptor agonists, which appear to curb food cravings and manage addictive behaviors, also look promising.

Psychosocial approaches can also be used to address UPFA. Strategies include:

• Helping individuals become more aware of their triggers for addictive patterns of intake. This often involves identifying certain types of food (eg, potato chips, candy), specific places or times of day (eg, sitting on the couch at night while watching TV), and particular emotional states (eg, anger, loneliness, boredom, sadness). Increasing awareness of personal triggers can help people minimize their exposure to these and develop coping strategies when they do arise.
• Many people use ultraprocessed foods to cope with challenging emotions. Helping individuals develop healthier strategies to regulate their emotions can be key. This may include seeking out social support, journaling, going for a walk, or practicing mindfulness.
• UPFA can be associated with erratic and inconsistent eating patterns. Stabilizing eating habits by consuming regular meals composed of more minimally processed foods (eg, vegetables, fruits, high-quality protein, beans) can help heal the body and reduce vulnerability to ultraprocessed food triggers.
• Many people with UPFA have other existing mental health conditions, including mood disorders, anxiety, substance use disorders, or trauma-related disorders. Addressing these co-occurring mental health conditions can help reduce reliance on ultraprocessed foods.

Public-policy interventions may also help safeguard vulnerable populations from developing UPFA. For instance, support exists for policies to protect children from cigarette marketing and to put clear addiction warning labels on cigarette packages. A similar approach could be applied to reduce the harms associated with ultraprocessed foods, particularly for children.

Combating this growing problem requires treating ultraprocessed foods like other addictive substances. By identifying the threat posed by these common food items, we can not only help patients with UPFA, but also potentially stave off the development of several diet-related conditions.
 

Dr. Gearhardt, professor of psychology, University of Michigan, Ann Arbor, has disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.

Over the past few decades, researchers have developed a compelling case against ultraprocessed foods and beverages, linking them to several chronic diseases and adverse health conditions. Yet, even as this evidence mounted, these food items have become increasingly prominent in diets globally. 

Now, recent studies are unlocking why cutting back on ultraprocessed foods can be so challenging. In their ability to fuel intense cravings, loss of control, and even withdrawal symptoms, ultraprocessed foods appear as capable of triggering addiction as traditional culprits like tobacco and alcohol. 

This has driven efforts to better understand the addictive nature of these foods and identify strategies for combating it. 
 

The Key Role of the Food Industry

Some foods are more likely to trigger addictions than others. For instance, in our studies, participants frequently mention chocolate, pizza, French fries, potato chips, and soda as some of the most addictive foods. What these foods all share is an ability to deliver high doses of refined carbohydrates, fat, or salt at levels exceeding those found in natural foods (eg, fruits, vegetables, beans).

Furthermore, ultraprocessed foods are industrially mass-produced in a process that relies on the heavy use of flavor enhancers and additives, as well as preservatives and packaging that make them shelf-stable. This has flooded our food supply with cheap, accessible, hyperrewarding foods that our brains are not well equipped to resist.

To add to these already substantial effects, the food industry often employs strategies reminiscent of Big Tobacco. They engineer foods to hit our “bliss points,” maximizing craving and fostering brand loyalty from a young age. This product engineering, coupled with aggressive marketing, makes these foods both attractive and seemingly ubiquitous. 
 

How Many People Are Affected?

Addiction to ultraprocessed food is more common than you might think. According to the Yale Food Addiction Scale — a tool that uses the same criteria for diagnosing substance use disorders to assess ultraprocessed food addiction (UPFA) — about 14% of adults and 12% of children show clinically significant signs of addiction to such foods. This is quite similar to addiction rates among adults for legal substances like alcohol and tobacco. 

Research has shown that behaviors and brain mechanisms contributing to addictive disorders, such as cravings and impulsivity, also apply to UPFA. 

Many more people outside of those who meet the criteria for UPFA are influenced by their addictive properties. Picture a teenager craving a sugary drink after school, a child needing the morning cereal fix, or adults reaching for candy and fast food; these scenarios illustrate how addictive ultraprocessed foods permeate our daily lives. 

From a public health standpoint, this comes at a significant cost. Even experiencing one or two symptoms of UPFA, such as intense cravings or a feeling of loss of control over intake, can lead to consuming too many calories, sugar, fat, and sodium in a way that puts health at risk.
 

Clinical Implications

Numerous studies have found that individuals who exhibit UPFA have more severe mental and physical health challenges. For example, UPFA is associated with higher rates of diet-related diseases (like type 2 diabetes), greater overall mental health issues, and generally poorer outcomes in weight loss treatments.

Despite the growing understanding of UPFA’s relevance in clinical settings, research is still limited on how to best treat, manage, or prevent it. Most of the existing work has focused on investigating whether UPFA is indeed a real condition, with efforts to create clinical guidelines only just beginning.

Of note, UPFA isn’t officially recognized as a diagnosis — yet. If it were, it could spark much more research into how to handle it clinically.

There is some debate about whether we really need this new diagnosis, given that eating disorders are already recognized. However, the statistics tell a different story: Around 14% of people might have UPFA compared with about 1% for binge-type eating disorders. This suggests that many individuals with problematic eating habits are currently flying under the radar with our existing diagnostic categories. 

What’s even more concerning is that these individuals often suffer significant problems and exhibit distinct brain differences, even if they do not neatly fit into an existing eating disorder diagnosis. Officially recognizing UPFA could open up new avenues for support and lead to better treatments aimed at reducing compulsive eating patterns.
 

Treatment Options

Treatment options for UPFA are still being explored. Initial evidence suggests that medications used for treating substance addiction, such as naltrexone and bupropion, might help with highly processed food addiction as well. Newer drugs, like glucagon-like peptide-1 receptor agonists, which appear to curb food cravings and manage addictive behaviors, also look promising.

Psychosocial approaches can also be used to address UPFA. Strategies include:

• Helping individuals become more aware of their triggers for addictive patterns of intake. This often involves identifying certain types of food (eg, potato chips, candy), specific places or times of day (eg, sitting on the couch at night while watching TV), and particular emotional states (eg, anger, loneliness, boredom, sadness). Increasing awareness of personal triggers can help people minimize their exposure to these and develop coping strategies when they do arise.
• Many people use ultraprocessed foods to cope with challenging emotions. Helping individuals develop healthier strategies to regulate their emotions can be key. This may include seeking out social support, journaling, going for a walk, or practicing mindfulness.
• UPFA can be associated with erratic and inconsistent eating patterns. Stabilizing eating habits by consuming regular meals composed of more minimally processed foods (eg, vegetables, fruits, high-quality protein, beans) can help heal the body and reduce vulnerability to ultraprocessed food triggers.
• Many people with UPFA have other existing mental health conditions, including mood disorders, anxiety, substance use disorders, or trauma-related disorders. Addressing these co-occurring mental health conditions can help reduce reliance on ultraprocessed foods.

Public-policy interventions may also help safeguard vulnerable populations from developing UPFA. For instance, support exists for policies to protect children from cigarette marketing and to put clear addiction warning labels on cigarette packages. A similar approach could be applied to reduce the harms associated with ultraprocessed foods, particularly for children.

Combating this growing problem requires treating ultraprocessed foods like other addictive substances. By identifying the threat posed by these common food items, we can not only help patients with UPFA, but also potentially stave off the development of several diet-related conditions.
 

Dr. Gearhardt, professor of psychology, University of Michigan, Ann Arbor, has disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.

Each and every day, 1 billion people on this planet ingest a particular psychoactive substance. This chemical has fairly profound physiologic effects. It increases levels of nitric oxide in the blood, leads to vasodilation, and, of course, makes you feel more awake. The substance comes in many forms but almost always in a liquid medium. Do you have it yet? That’s right. The substance is caffeine, quite possibly the healthiest recreational drug that has ever been discovered.

This might be my New England upbringing speaking, but when it comes to lifestyle and health, one of the rules I’ve internalized is that things that are pleasurable are generally bad for you. I know, I know — some of you love to exercise. Some of you love doing crosswords. But you know what I mean. I’m talking French fries, smoked meats, drugs, smoking, alcohol, binge-watching Firefly. You’d be suspicious if a study came out suggesting that eating ice cream in bed reduces your risk for heart attack, and so would I. So I’m always on the lookout for those unicorns of lifestyle factors, those rare things that you want to do and are also good for you.

So far, the data are strong for three things: sleeping, (safe) sexual activity, and coffee. You’ll have to stay tuned for articles about the first two. Today, we’re brewing up some deeper insights about the power of java.

I was inspired to write this article because of a paper, “Habitual Coffee, Tea, and Caffeine Consumption, Circulating Metabolites, and the Risk of Cardiometabolic Multimorbidity,” appearing September 17 in The Journal of Clinical Endocrinology and Metabolism (JCEM). This study may be the most comprehensive study yet to go beyond the simple associations between caffeine intake and outcomes, to try to answer the question of how this miraculous substance does what it does.

This is not the first study to suggest that coffee intake may be beneficial. A 2013 meta-analysis summarized the results of 36 studies with more than a million participants and found a U-shaped relationship between coffee intake and cardiovascular risk. The sweet spot was at three to five cups a day; people drinking that much coffee had about a 15% reduced risk for cardiovascular disease compared with nondrinkers.

AHA/ASA Journals

Dr. F. Perry Wilson

The Journal of Clinical Endocrinology & Metabolism

The Journal of Clinical Endocrinology & Metabolism

The Journal of Clinical Endocrinology & Metabolism

The Journal of Clinical Endocrinology & Metabolism

Dr. Wilson, associate professor of medicine and public health and director of Yale’s Clinical and Translational Research Accelerator, reported no conflicts of interest.

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

Each and every day, 1 billion people on this planet ingest a particular psychoactive substance. This chemical has fairly profound physiologic effects. It increases levels of nitric oxide in the blood, leads to vasodilation, and, of course, makes you feel more awake. The substance comes in many forms but almost always in a liquid medium. Do you have it yet? That’s right. The substance is caffeine, quite possibly the healthiest recreational drug that has ever been discovered.

This might be my New England upbringing speaking, but when it comes to lifestyle and health, one of the rules I’ve internalized is that things that are pleasurable are generally bad for you. I know, I know — some of you love to exercise. Some of you love doing crosswords. But you know what I mean. I’m talking French fries, smoked meats, drugs, smoking, alcohol, binge-watching Firefly. You’d be suspicious if a study came out suggesting that eating ice cream in bed reduces your risk for heart attack, and so would I. So I’m always on the lookout for those unicorns of lifestyle factors, those rare things that you want to do and are also good for you.

So far, the data are strong for three things: sleeping, (safe) sexual activity, and coffee. You’ll have to stay tuned for articles about the first two. Today, we’re brewing up some deeper insights about the power of java.

I was inspired to write this article because of a paper, “Habitual Coffee, Tea, and Caffeine Consumption, Circulating Metabolites, and the Risk of Cardiometabolic Multimorbidity,” appearing September 17 in The Journal of Clinical Endocrinology and Metabolism (JCEM). This study may be the most comprehensive study yet to go beyond the simple associations between caffeine intake and outcomes, to try to answer the question of how this miraculous substance does what it does.

This is not the first study to suggest that coffee intake may be beneficial. A 2013 meta-analysis summarized the results of 36 studies with more than a million participants and found a U-shaped relationship between coffee intake and cardiovascular risk. The sweet spot was at three to five cups a day; people drinking that much coffee had about a 15% reduced risk for cardiovascular disease compared with nondrinkers.

AHA/ASA Journals

Dr. F. Perry Wilson

The Journal of Clinical Endocrinology & Metabolism

The Journal of Clinical Endocrinology & Metabolism

The Journal of Clinical Endocrinology & Metabolism

The Journal of Clinical Endocrinology & Metabolism

Dr. Wilson, associate professor of medicine and public health and director of Yale’s Clinical and Translational Research Accelerator, reported no conflicts of interest.

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

Each and every day, 1 billion people on this planet ingest a particular psychoactive substance. This chemical has fairly profound physiologic effects. It increases levels of nitric oxide in the blood, leads to vasodilation, and, of course, makes you feel more awake. The substance comes in many forms but almost always in a liquid medium. Do you have it yet? That’s right. The substance is caffeine, quite possibly the healthiest recreational drug that has ever been discovered.

This might be my New England upbringing speaking, but when it comes to lifestyle and health, one of the rules I’ve internalized is that things that are pleasurable are generally bad for you. I know, I know — some of you love to exercise. Some of you love doing crosswords. But you know what I mean. I’m talking French fries, smoked meats, drugs, smoking, alcohol, binge-watching Firefly. You’d be suspicious if a study came out suggesting that eating ice cream in bed reduces your risk for heart attack, and so would I. So I’m always on the lookout for those unicorns of lifestyle factors, those rare things that you want to do and are also good for you.

So far, the data are strong for three things: sleeping, (safe) sexual activity, and coffee. You’ll have to stay tuned for articles about the first two. Today, we’re brewing up some deeper insights about the power of java.

I was inspired to write this article because of a paper, “Habitual Coffee, Tea, and Caffeine Consumption, Circulating Metabolites, and the Risk of Cardiometabolic Multimorbidity,” appearing September 17 in The Journal of Clinical Endocrinology and Metabolism (JCEM). This study may be the most comprehensive study yet to go beyond the simple associations between caffeine intake and outcomes, to try to answer the question of how this miraculous substance does what it does.

This is not the first study to suggest that coffee intake may be beneficial. A 2013 meta-analysis summarized the results of 36 studies with more than a million participants and found a U-shaped relationship between coffee intake and cardiovascular risk. The sweet spot was at three to five cups a day; people drinking that much coffee had about a 15% reduced risk for cardiovascular disease compared with nondrinkers.

AHA/ASA Journals

Dr. F. Perry Wilson

The Journal of Clinical Endocrinology & Metabolism

The Journal of Clinical Endocrinology & Metabolism

The Journal of Clinical Endocrinology & Metabolism

The Journal of Clinical Endocrinology & Metabolism

Dr. Wilson, associate professor of medicine and public health and director of Yale’s Clinical and Translational Research Accelerator, reported no conflicts of interest.

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

In April 2022, the US Department of Veterans Affairs (VA) revised its behavioral health care eligibility policies to provide comprehensive mental and behavioral health care to former service members who received an Other Than Honorable (OTH) discharge characterization upon separation from military service.¹ This policy shift represents a marked expansion in eligibility practices (Table 1 includes amended eligibility criteria).

Since June 2017, eligibility policies allowed veterans with OTH discharges to receive “emergent mental health services” needed to stabilize acute mental health crises related to military service (eg, acute escalations in suicide risk).^2,3 Previously, veterans with OTH discharges were largely ineligible for VA-based health care; these individuals were only able to access Veterans Health Administration (VHA) mental and behavioral health care through limited channels of eligibility (eg, for treatment of military sexual trauma or psychosis or other mental illness within 2 years of discharge).^4,5 The impetus for expansions in eligibility stemmed from VA efforts to reduce the suicide rate among veterans.^6-8 Implications of such expansion extend beyond suicide prevention efforts, with notable promised effects on the care of veterans with criminal-legal involvement. This article highlights potential effects of recent eligibility expansions on veterans with criminal-legal involvement and makes specific recommendations for agencies and organizations serving these veterans.

OTHER THAN HONORABLE DISCHARGE

The US Department of Defense delineates 6 discharge characterizations provided to service members upon separation from military service: honorable, general under honorable conditions, OTH, bad conduct, dishonorable, and uncharacterized. Honorable discharge characterizations are considered to reflect general concordance between service member behavior and military standards; general discharge characterizations reflect some disparity between the service member’s behavior and military standards; OTH, bad conduct, and dishonorable discharge characterizations reflect serious disparities between the service member’s behavior and military standards; and uncharacterized discharge characterizations are given when other discharge characterizations are deemed inappropriate.^9,10 OTH discharge characterizations are typically issued under instances of misconduct, fraudulent entry, security reasons, or in lieu of trial by court martial.^9,10

Recent research suggests that about 85% of service members receive an honorable discharge characterization upon separation from military service, 8% receive general, 6% receive OTH, and 1% receive bad conduct or dishonorable discharges.11 In 2017, the VA estimated there were > 500,000 prior service members with OTH discharge characterizations, which has grown over time (1.9% during the Korean Conflict, 2.5% during the Vietnam War Era, 3.9% during the Cold War, 4.8% in the Persian Gulf War, and 5.8% in the post-9/11 era).^7,11

The OTH discharge characterization is 1 of 3 less than honorable discharges informally referred to as bad papers (ie, OTH, bad conduct, or dishonorable). Former service members receiving these discharge characterizations face significant social stigma and structural discrimination upon military discharge, including significant hurdles to employment and educational pursuits as well as notable social alienation.¹² Due to their discharge characterization, some are viewed as less deserving of the veteran title, and until recently, many did not qualify for the complex legal definition of veteran as established by the Congress.^11,13 Veterans with OTH discharge characterizations have also historically been excluded from services (eg, VHA care),³ benefits (eg, disability compensation),¹⁴ and protections (eg, Uniformed Services Employment and Reemployment Rights Act)¹⁵ offered to veterans with honorable or general discharge characterizations. However, eligibility policies have gradually expanded, providing veterans with OTH discharges with access to VHA-based mental and behavioral health services and VA supportive housing assistance.^1,3,16

Perhaps due to their historical exclusion from VA services, there is limited research available on the behavioral health and associated needs of veterans with OTH discharges. Some scholars argue that historical exclusions have exacerbated underlying difficulties faced by this population, thereby contributing to stark health and social disparities across discharge types.^14,15,17 Studies with large veteran samples, for example, reflect notable demographic and behavioral health differences across discharge types. Compared to routinely discharged veterans, veterans with OTH discharges are significantly more likely to be younger, have lower income, use substances, have a history of criminal-legal involvement, and have mental and physical health difficulties.^18,19

Substantial evidence also suggests a historical racial bias, with service members of color being disproportionately more likely to receive an OTH discharge.¹² Similarly, across all branches of military service, Black service members are significantly more likely to face general or special court martial in military justice proceedings when compared with White service members.²⁰ Service members from gender and sexual minorities are also disproportionately impacted by the OTH designation. Historically, many have been discharged with bad papers due to discriminatory policies, such as Don’t Ask Don’t Tell, which discriminated on the basis of sexual orientation between December 1993 and September 2011, and Directive-type Memorandum-19-004, which banned transgender persons from military service between April 2019 and January 2021.^21,22

There is also significant mental health bias in the provision of OTH discharges, such that OTH characterizations are disproportionately represented among individuals with mental health disorders.^18-20 Veterans discharged from military service due to behavioral misconduct are significantly more likely to meet diagnostic criteria for various behavioral health conditions and to experience homelessness, criminal-legal involvement, and suicidal ideation and behavior compared with routinely-discharged veterans.^23-28

Consistent with their comparatively higher rates of criminal-legal involvement relative to routinely discharged veterans, veterans with OTH discharges are disproportionately represented in criminal justice settings. While veterans with OTH discharges represent only 6% of discharging service members and 2.5% of community-based veterans, they represent 10% of incarcerated veterans.^11,18,23,29 Preliminary research suggests veterans with OTH discharges may be at higher risk for lifetime incarceration, though the association between OTH discharge and frequency of lifetime arrests remains unclear.^18,30

VETERANS TREATMENT COURTS

Given the overrepresentation of veterans with OTH discharges in criminal-legal settings, consideration for this subset of the veteran population and its unique needs is commonplace among problem-solving courts that service veterans. First conceptualized in 2004, Veterans Treatment Courts (VTCs) are specialized problem-solving courts that divert veterans away from traditional judicial court and penal systems and into community-based supervision and treatment (most commonly behavioral health services).^31-34 Although each VTC program is unique in structure, policies, and procedures, most VTCs can be characterized by certain key elements, including voluntary participation, plea requirements, delayed sentencing (often including reduced or dismissed charges), integration of military culture into court proceedings, a rehabilitative vs adversarial approach to decreasing risk of future criminal behavior, mandated treatment and supervision during participation, and use of veteran mentors to provide peer support.^32-35 Eligibility requirements vary; however, many restrict participation to veterans with honorable discharge types and charges for nonviolent offenses.^32,33,35-37

VTCs connect veterans within the criminal-legal system to needed behavioral health, community, and social services.^31-33,37 VTC participants are commonly connected to case management, behavioral health care, therapeutic journaling programs, and vocational rehabilitation.^38,39 Accordingly, the most common difficulties faced by veterans participating in these courts include substance use, mental health, family issues, anger management and/or aggressive behavior, and homelessness.^36,39 There is limited research on the effectiveness of VTCs. Evidence on their overall effectiveness is largely mixed, though some studies suggest VTC graduates tend to have lower recidivism rates than offenders more broadly or persons who terminate VTC programs prior to completion.^40,41 Other studies suggest that VTC participants are more likely to have jail sanctions, new arrests, and new incarcerations relative to nontreatment court participants.⁴² Notably, experimental designs (considered the gold standard in assessing effectiveness) to date have not been applied to evaluate the effectiveness of VTCs; as such, the effectiveness of these programs remains an area in need of continued empirical investigation.

Like all problem-solving courts, VTCs occasionally struggle to connect participating defendants with appropriate care, particularly when encountering structural barriers (eg, insurance, transportation) and/or complex behavioral health needs (eg, personality disorders).^34,43 As suicide rates among veterans experiencing criminal-legal involvement surge (about 150 per 100,000 in 2021, a 10% increase from 2020 to 2021 compared to about 40 per 100,000 and a 1.8% increase among other veterans), efficiency of adequate care coordination is vital.⁴⁴ Many VTCs rely on VTC-VA partnerships and collaborations to navigate these difficulties and facilitate connection of participating veterans to needed services.^32-34,45 For example, within the VHA, Veterans Justice Outreach (VJO) and Health Care for Re-Entry Veterans (HCRV) specialists assist and bridge the gap between the criminal-legal system (including, but not limited to VTCs) and VA services by engaging veterans involved in the criminal-legal system and connecting them to needed VA-based services (Table 2). Generally, VJO specialists support veterans involved with the front end of the criminallegal system (eg, arrest, pretrial incarceration, or participation in VTCs), while HCRV specialists tend to support veterans transitioning back into the community after a period of incarceration.^46,47 Specific to VTCs, VJO specialists typically serve as liaisons between the courts and VA, coordinating VA services for defendants to fulfill their terms of VTC participation.⁴⁶

The historical exclusion of veterans with OTH discharge characterizations from VA-based services has restricted many from accessing VTC programs.³² Of 17 VTC programs active in Pennsylvania in 2014, only 5 accepted veterans with OTstayH discharges, and 3 required application to and eligibility for VA benefits.³³ Similarly, in national surveys of VTC programs, about 1 in 3 report excluding veterans deemed ineligible for VA services.^35,36 When veterans with OTH discharges have accessed VTC programs, they have historically relied on non-VA, community-based programming to fulfill treatment mandates, which may be less suited to addressing the unique needs of veterans.⁴⁸

Veterans who utilize VTCs receive several benefits, namely peer support and mentorship, acceptance into a veteran-centric space, and connection with specially trained staff capable of supporting the veteran through applications for a range of VA benefits (eg, service connection, housing support).^31-33,37 Given the disparate prevalence of OTH discharge characterizations among service members from racial, sexual, and gender minorities and among service members with mental health disorders, exclusion of veterans with OTH discharges from VTCs solely based on the type of discharge likely contributes to structural inequities among these already underserved groups by restricting access to these potential benefits. Such structural inequity stands in direct conflict with VTC best practice standards, which admonish programs to adjust eligibility requirements to facilitate access to treatment court programs for historically marginalized groups.⁴⁹

ELIGIBILITY EXPANSIONS

Given the overrepresentation of veterans with OTH discharge characterizations within the criminal-legal system and historical barriers of these veterans to access needed mental and behavioral health care, expansions in VA eligibility policies could have immense implications for VTCs. First, these expansions could mitigate common barriers to connecting VTC-participating veterans with OTH discharges with needed behavioral health care by allowing these veterans to access established, VA-based services and programming. Expansion may also allow VTCs to serve as a key intercept point for identifying and engaging veterans with OTH discharges who may be unaware of their eligibility for VA-based behavioral health care.

Access to VA health care services is a major resource for VTC participants and a common requirement.³² Eligibility expansion should ease access barriers veterans with OTH discharges commonly face. By providing a potential source of treatment, expansions may also support OTH eligibility practices within VTCs, particularly practices that require participants to be eligible for VA health care.^33,35,36 Some VTCs may continue to determine eligibility on the basis of discharge status and remain inaccessible to veterans with OTH discharge characterizations without program-level policy changes.^32,36,37

Communicating changes in eligibility policies relevant to veterans with OTH discharges may be a challenge, because many of these individuals have no established channels of communication with the VA. Because veterans with OTH discharges are at increased risk for legal system involvement, VTCs may serve as a unique point of contact to help facilitate communication.¹⁸ For example, upon referral to a VTC, veterans with OTH discharges can be identified, VA health care eligibility can be verified, and veterans can connect to VA staff to facilitate enrollment in VA services and care.

VJO specialists are in a favorable position to serve a critical role in utilizing VTCs as a potential intercept point for engaging veterans with OTH discharge characterizations. As outlined in the STRONG Veterans Act of 2022, VJOs are mandated to “spread awareness and understanding of veteran eligibility for the [VJO] Program, including the eligibility of veterans who were discharged from service in the Armed Forces under conditions other than honorable.”50 The Act further requires VJOs to be annually trained in communicating eligibility changes as they arise. Accordingly, VJOs receive ongoing training in a wide variety of critical outreach topics, including changes in eligibility; while VJOs cannot make eligibility determinations, they are tasked with enrolling all veterans involved in the criminal-legal system with whom they interact into VHA services, whether through typical or special eligibility criteria (M. Stimmel, PhD, National Training Director for Veteran Justice Programming, oral communication, July 14, 2023). VJOs therefore routinely serve in this capacity of facilitating VA enrollment of veterans with OTH discharge characterizations.

Recommendations to Veteran-Servicing Judicial Programs

Considering these potential implications, professionals routinely interacting with veterans involved in the criminal-legal system should become familiarized with recent changes in VA eligibility policies. Such familiarization would support the identification of veterans previously considered ineligible for care; provision of education to these veterans regarding their new eligibility; and referral to appropriate VA-based behavioral health care options. Although conceptually simple, executing such an educational campaign may prove logistically difficult. Given their historical exclusion from VA services, veterans with OTH discharge characterizations are unlikely to seek VA-based services in times of need, instead relying on a broad swath of civilian community-based organizations and resources. Usual approaches to advertising VHA health care policy changes (eg, by notifying VA employees and/or departments providing corresponding services or by circulating information to veteran-focused mailing lists and organizations) likely would prove insufficient. Educational campaigns to disseminate information about recent OTH eligibility changes should instead consider partnering with traditionally civilian, communitybased organizations and institutions, such as state bar associations, legal aid networks, case management services, nonveteran treatment court programs (eg, drug courts, or domestic violence courts), or probation/ parole programs. Because national surveys suggest generally low military cultural competence among civilian populations, providing concurrent support in developing foundational veteran cultural competencies (eg, how to phrase questions about military service history, or understanding discharge characterizations) may be necessary to ensure effective identification and engagement of veteran clients.⁴⁸

Programs that serve veterans with criminal-legal involvement should also consider potential relevance of recent OTH eligibility changes to program operations. VTC program staff and key partners (eg, judges, case managers, district attorneys, or defense attorneys), should revisit policies and procedures surrounding the engagement of veterans with OTH discharges within VTC programs and strategies for connecting these veterans with needed services. VTC programs that have historically excluded veterans with OTH discharges due to associated difficulties in locating and connecting with needed services should consider expanding eligibility policies considering recent shifts in VA behavioral health care eligibility.^33,35,36 Within the VHA, VJO specialists can play a critical role in supporting these VTC eligibility and cultural shifts. Some evidence suggests a large proportion of VTC referrals are facilitated by VJO specialists and that many such referrals are identified when veterans involved with the criminal-legal system seek VA support and/or services.³³ Given the historical exclusion of veterans with OTH discharges from VA care, strategies used by VJO specialists to identify, connect, and engage veterans with OTH discharges with VTCs and other services may be beneficial.

Even with knowledge of VA eligibility changes and considerations of these changes on local operations, many forensic settings and programs struggle to identify veterans. These difficulties are likely amplified among veterans with OTH discharge characterizations, who may be hesitant to self-disclose their military service history due to fear of stigma and/or views of OTH discharge characterizations as undeserving of the veteran title.¹² The VA offers 2 tools to aid in identification of veterans for these settings: the Veterans Re-Entry Search Service (VRSS) and Status Query and Response Exchange System (SQUARES). For VRSS, correctional facilities, courts, and other criminal justice entities upload a simple spreadsheet that contains basic identifying information of inmates or defendants in their system. VRSS returns information about which inmates or defendants have a history of military service and alerts VA Veterans Justice Programs staff so they can conduct outreach. A pilot study conducted by the California Department of Corrections and Rehabilitation found that 2.7% of its inmate population self-identified as veterans, while VRSS identified 7.7% of inmates with a history of military service. This difference represented about 5000 previously unidentified veterans.⁵¹ Similarly, community entities that partner with the VA, such as law enforcement or homeless service programs, can be approved to become a SQUARES user and submit identifying information of individuals with whom they interact directly into the SQUARES search engine. SQUARES then directly returns information about the individual’s veteran status and eligibility for VA health care and homeless programs.

Other Eligibility Limitations

VTCs and other professionals looking to refer veterans with OTH discharge characterizations to VA-based behavioral health care should be aware of potential limitations in eligibility and access. Specifically, although veterans with OTH discharges are now broadly eligible for VA-based behavioral health care and homeless programs, they remain ineligible for other forms of health care, including primary care and nonbehavioral specialty care.1 Research has found a strong comorbidity between behavioral and nonbehavioral health concerns, particularly within historically marginalized demographic groups.^52-55 Because these historically marginalized groups are often overrepresented among persons with criminal-legal involvement, veterans with OTH discharges, and VTC participants, such comorbidities require consideration by services or programming designed to support veterans with criminal-legal involvement.^12,56-58 Connection with VA-based health care will therefore continue to fall short of addressing all health care needs of veterans with OTH discharges and effective case management will require considerable treatment coordination between VA behavioral health care practitioners (HCPs) and community-based HCPs (eg, primary care professionals or nonbehavioral HCPs).

Implications for VA Mental Health Care

Recent eligibility expansions will also have inevitable consequences for VA mental health care systems. For many years, these systems have been overburdened by high caseloads and clinician burnout.^59,60 Given the generally elevated rates of mental health and substance use concerns among veterans with OTH discharge characterizations, expansions hold the potential to further burden caseloads with clinically complex, high-risk, high-need clients. Nevertheless, these expansions are also structured in a way that forces existing systems to absorb the responsibilities of providing necessary care to these veterans. To mitigate detrimental effects of eligibility expansions on the broader VA mental health system, clinicians should be explicitly trained in identifying veterans with OTH discharge characterizations and the implications of discharge status on broader health care eligibility. Treatment of veterans with OTH discharges may also benefit from close coordination between mental health professionals and behavioral health care coordinators to ensure appropriate coordination of care between VA- and non–VA-based HCPs.

CONCLUSIONS

Recent changes to VA eligibility policies now allow comprehensive mental and behavioral health care services to be provided to veterans with OTH discharges.1 Compared to routinely discharged veterans, veterans with OTH discharges are more likely to be persons of color, sexual or gender minorities, and experiencing mental health-related difficulties. Given the disproportionate mental health burden often faced by veterans with OTH discharges and relative overrepresentation of these veterans in judicial and correctional systems, these changes have considerable implications for programs and services designed to support veterans with criminallegal involvement. Professionals within these systems, particularly VTC programs, are therefore encouraged to familiarize themselves with recent changes in VA eligibility policies and to revisit strategies, policies, and procedures surrounding the engagement and enrollment of veterans with OTH discharge characterizations. Doing so may ensure veterans with OTH discharges are effectively connected to needed behavioral health care services.

In April 2022, the US Department of Veterans Affairs (VA) revised its behavioral health care eligibility policies to provide comprehensive mental and behavioral health care to former service members who received an Other Than Honorable (OTH) discharge characterization upon separation from military service.¹ This policy shift represents a marked expansion in eligibility practices (Table 1 includes amended eligibility criteria).

Since June 2017, eligibility policies allowed veterans with OTH discharges to receive “emergent mental health services” needed to stabilize acute mental health crises related to military service (eg, acute escalations in suicide risk).^2,3 Previously, veterans with OTH discharges were largely ineligible for VA-based health care; these individuals were only able to access Veterans Health Administration (VHA) mental and behavioral health care through limited channels of eligibility (eg, for treatment of military sexual trauma or psychosis or other mental illness within 2 years of discharge).^4,5 The impetus for expansions in eligibility stemmed from VA efforts to reduce the suicide rate among veterans.^6-8 Implications of such expansion extend beyond suicide prevention efforts, with notable promised effects on the care of veterans with criminal-legal involvement. This article highlights potential effects of recent eligibility expansions on veterans with criminal-legal involvement and makes specific recommendations for agencies and organizations serving these veterans.

OTHER THAN HONORABLE DISCHARGE

The US Department of Defense delineates 6 discharge characterizations provided to service members upon separation from military service: honorable, general under honorable conditions, OTH, bad conduct, dishonorable, and uncharacterized. Honorable discharge characterizations are considered to reflect general concordance between service member behavior and military standards; general discharge characterizations reflect some disparity between the service member’s behavior and military standards; OTH, bad conduct, and dishonorable discharge characterizations reflect serious disparities between the service member’s behavior and military standards; and uncharacterized discharge characterizations are given when other discharge characterizations are deemed inappropriate.^9,10 OTH discharge characterizations are typically issued under instances of misconduct, fraudulent entry, security reasons, or in lieu of trial by court martial.^9,10

Recent research suggests that about 85% of service members receive an honorable discharge characterization upon separation from military service, 8% receive general, 6% receive OTH, and 1% receive bad conduct or dishonorable discharges.11 In 2017, the VA estimated there were > 500,000 prior service members with OTH discharge characterizations, which has grown over time (1.9% during the Korean Conflict, 2.5% during the Vietnam War Era, 3.9% during the Cold War, 4.8% in the Persian Gulf War, and 5.8% in the post-9/11 era).^7,11

The OTH discharge characterization is 1 of 3 less than honorable discharges informally referred to as bad papers (ie, OTH, bad conduct, or dishonorable). Former service members receiving these discharge characterizations face significant social stigma and structural discrimination upon military discharge, including significant hurdles to employment and educational pursuits as well as notable social alienation.¹² Due to their discharge characterization, some are viewed as less deserving of the veteran title, and until recently, many did not qualify for the complex legal definition of veteran as established by the Congress.^11,13 Veterans with OTH discharge characterizations have also historically been excluded from services (eg, VHA care),³ benefits (eg, disability compensation),¹⁴ and protections (eg, Uniformed Services Employment and Reemployment Rights Act)¹⁵ offered to veterans with honorable or general discharge characterizations. However, eligibility policies have gradually expanded, providing veterans with OTH discharges with access to VHA-based mental and behavioral health services and VA supportive housing assistance.^1,3,16

Perhaps due to their historical exclusion from VA services, there is limited research available on the behavioral health and associated needs of veterans with OTH discharges. Some scholars argue that historical exclusions have exacerbated underlying difficulties faced by this population, thereby contributing to stark health and social disparities across discharge types.^14,15,17 Studies with large veteran samples, for example, reflect notable demographic and behavioral health differences across discharge types. Compared to routinely discharged veterans, veterans with OTH discharges are significantly more likely to be younger, have lower income, use substances, have a history of criminal-legal involvement, and have mental and physical health difficulties.^18,19

Substantial evidence also suggests a historical racial bias, with service members of color being disproportionately more likely to receive an OTH discharge.¹² Similarly, across all branches of military service, Black service members are significantly more likely to face general or special court martial in military justice proceedings when compared with White service members.²⁰ Service members from gender and sexual minorities are also disproportionately impacted by the OTH designation. Historically, many have been discharged with bad papers due to discriminatory policies, such as Don’t Ask Don’t Tell, which discriminated on the basis of sexual orientation between December 1993 and September 2011, and Directive-type Memorandum-19-004, which banned transgender persons from military service between April 2019 and January 2021.^21,22

There is also significant mental health bias in the provision of OTH discharges, such that OTH characterizations are disproportionately represented among individuals with mental health disorders.^18-20 Veterans discharged from military service due to behavioral misconduct are significantly more likely to meet diagnostic criteria for various behavioral health conditions and to experience homelessness, criminal-legal involvement, and suicidal ideation and behavior compared with routinely-discharged veterans.^23-28

Consistent with their comparatively higher rates of criminal-legal involvement relative to routinely discharged veterans, veterans with OTH discharges are disproportionately represented in criminal justice settings. While veterans with OTH discharges represent only 6% of discharging service members and 2.5% of community-based veterans, they represent 10% of incarcerated veterans.^11,18,23,29 Preliminary research suggests veterans with OTH discharges may be at higher risk for lifetime incarceration, though the association between OTH discharge and frequency of lifetime arrests remains unclear.^18,30

VETERANS TREATMENT COURTS

Given the overrepresentation of veterans with OTH discharges in criminal-legal settings, consideration for this subset of the veteran population and its unique needs is commonplace among problem-solving courts that service veterans. First conceptualized in 2004, Veterans Treatment Courts (VTCs) are specialized problem-solving courts that divert veterans away from traditional judicial court and penal systems and into community-based supervision and treatment (most commonly behavioral health services).^31-34 Although each VTC program is unique in structure, policies, and procedures, most VTCs can be characterized by certain key elements, including voluntary participation, plea requirements, delayed sentencing (often including reduced or dismissed charges), integration of military culture into court proceedings, a rehabilitative vs adversarial approach to decreasing risk of future criminal behavior, mandated treatment and supervision during participation, and use of veteran mentors to provide peer support.^32-35 Eligibility requirements vary; however, many restrict participation to veterans with honorable discharge types and charges for nonviolent offenses.^32,33,35-37

VTCs connect veterans within the criminal-legal system to needed behavioral health, community, and social services.^31-33,37 VTC participants are commonly connected to case management, behavioral health care, therapeutic journaling programs, and vocational rehabilitation.^38,39 Accordingly, the most common difficulties faced by veterans participating in these courts include substance use, mental health, family issues, anger management and/or aggressive behavior, and homelessness.^36,39 There is limited research on the effectiveness of VTCs. Evidence on their overall effectiveness is largely mixed, though some studies suggest VTC graduates tend to have lower recidivism rates than offenders more broadly or persons who terminate VTC programs prior to completion.^40,41 Other studies suggest that VTC participants are more likely to have jail sanctions, new arrests, and new incarcerations relative to nontreatment court participants.⁴² Notably, experimental designs (considered the gold standard in assessing effectiveness) to date have not been applied to evaluate the effectiveness of VTCs; as such, the effectiveness of these programs remains an area in need of continued empirical investigation.

Like all problem-solving courts, VTCs occasionally struggle to connect participating defendants with appropriate care, particularly when encountering structural barriers (eg, insurance, transportation) and/or complex behavioral health needs (eg, personality disorders).^34,43 As suicide rates among veterans experiencing criminal-legal involvement surge (about 150 per 100,000 in 2021, a 10% increase from 2020 to 2021 compared to about 40 per 100,000 and a 1.8% increase among other veterans), efficiency of adequate care coordination is vital.⁴⁴ Many VTCs rely on VTC-VA partnerships and collaborations to navigate these difficulties and facilitate connection of participating veterans to needed services.^32-34,45 For example, within the VHA, Veterans Justice Outreach (VJO) and Health Care for Re-Entry Veterans (HCRV) specialists assist and bridge the gap between the criminal-legal system (including, but not limited to VTCs) and VA services by engaging veterans involved in the criminal-legal system and connecting them to needed VA-based services (Table 2). Generally, VJO specialists support veterans involved with the front end of the criminallegal system (eg, arrest, pretrial incarceration, or participation in VTCs), while HCRV specialists tend to support veterans transitioning back into the community after a period of incarceration.^46,47 Specific to VTCs, VJO specialists typically serve as liaisons between the courts and VA, coordinating VA services for defendants to fulfill their terms of VTC participation.⁴⁶

The historical exclusion of veterans with OTH discharge characterizations from VA-based services has restricted many from accessing VTC programs.³² Of 17 VTC programs active in Pennsylvania in 2014, only 5 accepted veterans with OTstayH discharges, and 3 required application to and eligibility for VA benefits.³³ Similarly, in national surveys of VTC programs, about 1 in 3 report excluding veterans deemed ineligible for VA services.^35,36 When veterans with OTH discharges have accessed VTC programs, they have historically relied on non-VA, community-based programming to fulfill treatment mandates, which may be less suited to addressing the unique needs of veterans.⁴⁸

Veterans who utilize VTCs receive several benefits, namely peer support and mentorship, acceptance into a veteran-centric space, and connection with specially trained staff capable of supporting the veteran through applications for a range of VA benefits (eg, service connection, housing support).^31-33,37 Given the disparate prevalence of OTH discharge characterizations among service members from racial, sexual, and gender minorities and among service members with mental health disorders, exclusion of veterans with OTH discharges from VTCs solely based on the type of discharge likely contributes to structural inequities among these already underserved groups by restricting access to these potential benefits. Such structural inequity stands in direct conflict with VTC best practice standards, which admonish programs to adjust eligibility requirements to facilitate access to treatment court programs for historically marginalized groups.⁴⁹

ELIGIBILITY EXPANSIONS

Given the overrepresentation of veterans with OTH discharge characterizations within the criminal-legal system and historical barriers of these veterans to access needed mental and behavioral health care, expansions in VA eligibility policies could have immense implications for VTCs. First, these expansions could mitigate common barriers to connecting VTC-participating veterans with OTH discharges with needed behavioral health care by allowing these veterans to access established, VA-based services and programming. Expansion may also allow VTCs to serve as a key intercept point for identifying and engaging veterans with OTH discharges who may be unaware of their eligibility for VA-based behavioral health care.

Access to VA health care services is a major resource for VTC participants and a common requirement.³² Eligibility expansion should ease access barriers veterans with OTH discharges commonly face. By providing a potential source of treatment, expansions may also support OTH eligibility practices within VTCs, particularly practices that require participants to be eligible for VA health care.^33,35,36 Some VTCs may continue to determine eligibility on the basis of discharge status and remain inaccessible to veterans with OTH discharge characterizations without program-level policy changes.^32,36,37

Communicating changes in eligibility policies relevant to veterans with OTH discharges may be a challenge, because many of these individuals have no established channels of communication with the VA. Because veterans with OTH discharges are at increased risk for legal system involvement, VTCs may serve as a unique point of contact to help facilitate communication.¹⁸ For example, upon referral to a VTC, veterans with OTH discharges can be identified, VA health care eligibility can be verified, and veterans can connect to VA staff to facilitate enrollment in VA services and care.

VJO specialists are in a favorable position to serve a critical role in utilizing VTCs as a potential intercept point for engaging veterans with OTH discharge characterizations. As outlined in the STRONG Veterans Act of 2022, VJOs are mandated to “spread awareness and understanding of veteran eligibility for the [VJO] Program, including the eligibility of veterans who were discharged from service in the Armed Forces under conditions other than honorable.”50 The Act further requires VJOs to be annually trained in communicating eligibility changes as they arise. Accordingly, VJOs receive ongoing training in a wide variety of critical outreach topics, including changes in eligibility; while VJOs cannot make eligibility determinations, they are tasked with enrolling all veterans involved in the criminal-legal system with whom they interact into VHA services, whether through typical or special eligibility criteria (M. Stimmel, PhD, National Training Director for Veteran Justice Programming, oral communication, July 14, 2023). VJOs therefore routinely serve in this capacity of facilitating VA enrollment of veterans with OTH discharge characterizations.

Recommendations to Veteran-Servicing Judicial Programs

Considering these potential implications, professionals routinely interacting with veterans involved in the criminal-legal system should become familiarized with recent changes in VA eligibility policies. Such familiarization would support the identification of veterans previously considered ineligible for care; provision of education to these veterans regarding their new eligibility; and referral to appropriate VA-based behavioral health care options. Although conceptually simple, executing such an educational campaign may prove logistically difficult. Given their historical exclusion from VA services, veterans with OTH discharge characterizations are unlikely to seek VA-based services in times of need, instead relying on a broad swath of civilian community-based organizations and resources. Usual approaches to advertising VHA health care policy changes (eg, by notifying VA employees and/or departments providing corresponding services or by circulating information to veteran-focused mailing lists and organizations) likely would prove insufficient. Educational campaigns to disseminate information about recent OTH eligibility changes should instead consider partnering with traditionally civilian, communitybased organizations and institutions, such as state bar associations, legal aid networks, case management services, nonveteran treatment court programs (eg, drug courts, or domestic violence courts), or probation/ parole programs. Because national surveys suggest generally low military cultural competence among civilian populations, providing concurrent support in developing foundational veteran cultural competencies (eg, how to phrase questions about military service history, or understanding discharge characterizations) may be necessary to ensure effective identification and engagement of veteran clients.⁴⁸

Programs that serve veterans with criminal-legal involvement should also consider potential relevance of recent OTH eligibility changes to program operations. VTC program staff and key partners (eg, judges, case managers, district attorneys, or defense attorneys), should revisit policies and procedures surrounding the engagement of veterans with OTH discharges within VTC programs and strategies for connecting these veterans with needed services. VTC programs that have historically excluded veterans with OTH discharges due to associated difficulties in locating and connecting with needed services should consider expanding eligibility policies considering recent shifts in VA behavioral health care eligibility.^33,35,36 Within the VHA, VJO specialists can play a critical role in supporting these VTC eligibility and cultural shifts. Some evidence suggests a large proportion of VTC referrals are facilitated by VJO specialists and that many such referrals are identified when veterans involved with the criminal-legal system seek VA support and/or services.³³ Given the historical exclusion of veterans with OTH discharges from VA care, strategies used by VJO specialists to identify, connect, and engage veterans with OTH discharges with VTCs and other services may be beneficial.

Even with knowledge of VA eligibility changes and considerations of these changes on local operations, many forensic settings and programs struggle to identify veterans. These difficulties are likely amplified among veterans with OTH discharge characterizations, who may be hesitant to self-disclose their military service history due to fear of stigma and/or views of OTH discharge characterizations as undeserving of the veteran title.¹² The VA offers 2 tools to aid in identification of veterans for these settings: the Veterans Re-Entry Search Service (VRSS) and Status Query and Response Exchange System (SQUARES). For VRSS, correctional facilities, courts, and other criminal justice entities upload a simple spreadsheet that contains basic identifying information of inmates or defendants in their system. VRSS returns information about which inmates or defendants have a history of military service and alerts VA Veterans Justice Programs staff so they can conduct outreach. A pilot study conducted by the California Department of Corrections and Rehabilitation found that 2.7% of its inmate population self-identified as veterans, while VRSS identified 7.7% of inmates with a history of military service. This difference represented about 5000 previously unidentified veterans.⁵¹ Similarly, community entities that partner with the VA, such as law enforcement or homeless service programs, can be approved to become a SQUARES user and submit identifying information of individuals with whom they interact directly into the SQUARES search engine. SQUARES then directly returns information about the individual’s veteran status and eligibility for VA health care and homeless programs.

Other Eligibility Limitations

VTCs and other professionals looking to refer veterans with OTH discharge characterizations to VA-based behavioral health care should be aware of potential limitations in eligibility and access. Specifically, although veterans with OTH discharges are now broadly eligible for VA-based behavioral health care and homeless programs, they remain ineligible for other forms of health care, including primary care and nonbehavioral specialty care.1 Research has found a strong comorbidity between behavioral and nonbehavioral health concerns, particularly within historically marginalized demographic groups.^52-55 Because these historically marginalized groups are often overrepresented among persons with criminal-legal involvement, veterans with OTH discharges, and VTC participants, such comorbidities require consideration by services or programming designed to support veterans with criminal-legal involvement.^12,56-58 Connection with VA-based health care will therefore continue to fall short of addressing all health care needs of veterans with OTH discharges and effective case management will require considerable treatment coordination between VA behavioral health care practitioners (HCPs) and community-based HCPs (eg, primary care professionals or nonbehavioral HCPs).

Implications for VA Mental Health Care

Recent eligibility expansions will also have inevitable consequences for VA mental health care systems. For many years, these systems have been overburdened by high caseloads and clinician burnout.^59,60 Given the generally elevated rates of mental health and substance use concerns among veterans with OTH discharge characterizations, expansions hold the potential to further burden caseloads with clinically complex, high-risk, high-need clients. Nevertheless, these expansions are also structured in a way that forces existing systems to absorb the responsibilities of providing necessary care to these veterans. To mitigate detrimental effects of eligibility expansions on the broader VA mental health system, clinicians should be explicitly trained in identifying veterans with OTH discharge characterizations and the implications of discharge status on broader health care eligibility. Treatment of veterans with OTH discharges may also benefit from close coordination between mental health professionals and behavioral health care coordinators to ensure appropriate coordination of care between VA- and non–VA-based HCPs.

CONCLUSIONS

Recent changes to VA eligibility policies now allow comprehensive mental and behavioral health care services to be provided to veterans with OTH discharges.1 Compared to routinely discharged veterans, veterans with OTH discharges are more likely to be persons of color, sexual or gender minorities, and experiencing mental health-related difficulties. Given the disproportionate mental health burden often faced by veterans with OTH discharges and relative overrepresentation of these veterans in judicial and correctional systems, these changes have considerable implications for programs and services designed to support veterans with criminallegal involvement. Professionals within these systems, particularly VTC programs, are therefore encouraged to familiarize themselves with recent changes in VA eligibility policies and to revisit strategies, policies, and procedures surrounding the engagement and enrollment of veterans with OTH discharge characterizations. Doing so may ensure veterans with OTH discharges are effectively connected to needed behavioral health care services.

In April 2022, the US Department of Veterans Affairs (VA) revised its behavioral health care eligibility policies to provide comprehensive mental and behavioral health care to former service members who received an Other Than Honorable (OTH) discharge characterization upon separation from military service.¹ This policy shift represents a marked expansion in eligibility practices (Table 1 includes amended eligibility criteria).

Since June 2017, eligibility policies allowed veterans with OTH discharges to receive “emergent mental health services” needed to stabilize acute mental health crises related to military service (eg, acute escalations in suicide risk).^2,3 Previously, veterans with OTH discharges were largely ineligible for VA-based health care; these individuals were only able to access Veterans Health Administration (VHA) mental and behavioral health care through limited channels of eligibility (eg, for treatment of military sexual trauma or psychosis or other mental illness within 2 years of discharge).^4,5 The impetus for expansions in eligibility stemmed from VA efforts to reduce the suicide rate among veterans.^6-8 Implications of such expansion extend beyond suicide prevention efforts, with notable promised effects on the care of veterans with criminal-legal involvement. This article highlights potential effects of recent eligibility expansions on veterans with criminal-legal involvement and makes specific recommendations for agencies and organizations serving these veterans.

OTHER THAN HONORABLE DISCHARGE

The US Department of Defense delineates 6 discharge characterizations provided to service members upon separation from military service: honorable, general under honorable conditions, OTH, bad conduct, dishonorable, and uncharacterized. Honorable discharge characterizations are considered to reflect general concordance between service member behavior and military standards; general discharge characterizations reflect some disparity between the service member’s behavior and military standards; OTH, bad conduct, and dishonorable discharge characterizations reflect serious disparities between the service member’s behavior and military standards; and uncharacterized discharge characterizations are given when other discharge characterizations are deemed inappropriate.^9,10 OTH discharge characterizations are typically issued under instances of misconduct, fraudulent entry, security reasons, or in lieu of trial by court martial.^9,10

Recent research suggests that about 85% of service members receive an honorable discharge characterization upon separation from military service, 8% receive general, 6% receive OTH, and 1% receive bad conduct or dishonorable discharges.11 In 2017, the VA estimated there were > 500,000 prior service members with OTH discharge characterizations, which has grown over time (1.9% during the Korean Conflict, 2.5% during the Vietnam War Era, 3.9% during the Cold War, 4.8% in the Persian Gulf War, and 5.8% in the post-9/11 era).^7,11

The OTH discharge characterization is 1 of 3 less than honorable discharges informally referred to as bad papers (ie, OTH, bad conduct, or dishonorable). Former service members receiving these discharge characterizations face significant social stigma and structural discrimination upon military discharge, including significant hurdles to employment and educational pursuits as well as notable social alienation.¹² Due to their discharge characterization, some are viewed as less deserving of the veteran title, and until recently, many did not qualify for the complex legal definition of veteran as established by the Congress.^11,13 Veterans with OTH discharge characterizations have also historically been excluded from services (eg, VHA care),³ benefits (eg, disability compensation),¹⁴ and protections (eg, Uniformed Services Employment and Reemployment Rights Act)¹⁵ offered to veterans with honorable or general discharge characterizations. However, eligibility policies have gradually expanded, providing veterans with OTH discharges with access to VHA-based mental and behavioral health services and VA supportive housing assistance.^1,3,16

Perhaps due to their historical exclusion from VA services, there is limited research available on the behavioral health and associated needs of veterans with OTH discharges. Some scholars argue that historical exclusions have exacerbated underlying difficulties faced by this population, thereby contributing to stark health and social disparities across discharge types.^14,15,17 Studies with large veteran samples, for example, reflect notable demographic and behavioral health differences across discharge types. Compared to routinely discharged veterans, veterans with OTH discharges are significantly more likely to be younger, have lower income, use substances, have a history of criminal-legal involvement, and have mental and physical health difficulties.^18,19

Substantial evidence also suggests a historical racial bias, with service members of color being disproportionately more likely to receive an OTH discharge.¹² Similarly, across all branches of military service, Black service members are significantly more likely to face general or special court martial in military justice proceedings when compared with White service members.²⁰ Service members from gender and sexual minorities are also disproportionately impacted by the OTH designation. Historically, many have been discharged with bad papers due to discriminatory policies, such as Don’t Ask Don’t Tell, which discriminated on the basis of sexual orientation between December 1993 and September 2011, and Directive-type Memorandum-19-004, which banned transgender persons from military service between April 2019 and January 2021.^21,22

There is also significant mental health bias in the provision of OTH discharges, such that OTH characterizations are disproportionately represented among individuals with mental health disorders.^18-20 Veterans discharged from military service due to behavioral misconduct are significantly more likely to meet diagnostic criteria for various behavioral health conditions and to experience homelessness, criminal-legal involvement, and suicidal ideation and behavior compared with routinely-discharged veterans.^23-28

Consistent with their comparatively higher rates of criminal-legal involvement relative to routinely discharged veterans, veterans with OTH discharges are disproportionately represented in criminal justice settings. While veterans with OTH discharges represent only 6% of discharging service members and 2.5% of community-based veterans, they represent 10% of incarcerated veterans.^11,18,23,29 Preliminary research suggests veterans with OTH discharges may be at higher risk for lifetime incarceration, though the association between OTH discharge and frequency of lifetime arrests remains unclear.^18,30

VETERANS TREATMENT COURTS

Given the overrepresentation of veterans with OTH discharges in criminal-legal settings, consideration for this subset of the veteran population and its unique needs is commonplace among problem-solving courts that service veterans. First conceptualized in 2004, Veterans Treatment Courts (VTCs) are specialized problem-solving courts that divert veterans away from traditional judicial court and penal systems and into community-based supervision and treatment (most commonly behavioral health services).^31-34 Although each VTC program is unique in structure, policies, and procedures, most VTCs can be characterized by certain key elements, including voluntary participation, plea requirements, delayed sentencing (often including reduced or dismissed charges), integration of military culture into court proceedings, a rehabilitative vs adversarial approach to decreasing risk of future criminal behavior, mandated treatment and supervision during participation, and use of veteran mentors to provide peer support.^32-35 Eligibility requirements vary; however, many restrict participation to veterans with honorable discharge types and charges for nonviolent offenses.^32,33,35-37

VTCs connect veterans within the criminal-legal system to needed behavioral health, community, and social services.^31-33,37 VTC participants are commonly connected to case management, behavioral health care, therapeutic journaling programs, and vocational rehabilitation.^38,39 Accordingly, the most common difficulties faced by veterans participating in these courts include substance use, mental health, family issues, anger management and/or aggressive behavior, and homelessness.^36,39 There is limited research on the effectiveness of VTCs. Evidence on their overall effectiveness is largely mixed, though some studies suggest VTC graduates tend to have lower recidivism rates than offenders more broadly or persons who terminate VTC programs prior to completion.^40,41 Other studies suggest that VTC participants are more likely to have jail sanctions, new arrests, and new incarcerations relative to nontreatment court participants.⁴² Notably, experimental designs (considered the gold standard in assessing effectiveness) to date have not been applied to evaluate the effectiveness of VTCs; as such, the effectiveness of these programs remains an area in need of continued empirical investigation.

Like all problem-solving courts, VTCs occasionally struggle to connect participating defendants with appropriate care, particularly when encountering structural barriers (eg, insurance, transportation) and/or complex behavioral health needs (eg, personality disorders).^34,43 As suicide rates among veterans experiencing criminal-legal involvement surge (about 150 per 100,000 in 2021, a 10% increase from 2020 to 2021 compared to about 40 per 100,000 and a 1.8% increase among other veterans), efficiency of adequate care coordination is vital.⁴⁴ Many VTCs rely on VTC-VA partnerships and collaborations to navigate these difficulties and facilitate connection of participating veterans to needed services.^32-34,45 For example, within the VHA, Veterans Justice Outreach (VJO) and Health Care for Re-Entry Veterans (HCRV) specialists assist and bridge the gap between the criminal-legal system (including, but not limited to VTCs) and VA services by engaging veterans involved in the criminal-legal system and connecting them to needed VA-based services (Table 2). Generally, VJO specialists support veterans involved with the front end of the criminallegal system (eg, arrest, pretrial incarceration, or participation in VTCs), while HCRV specialists tend to support veterans transitioning back into the community after a period of incarceration.^46,47 Specific to VTCs, VJO specialists typically serve as liaisons between the courts and VA, coordinating VA services for defendants to fulfill their terms of VTC participation.⁴⁶

The historical exclusion of veterans with OTH discharge characterizations from VA-based services has restricted many from accessing VTC programs.³² Of 17 VTC programs active in Pennsylvania in 2014, only 5 accepted veterans with OTstayH discharges, and 3 required application to and eligibility for VA benefits.³³ Similarly, in national surveys of VTC programs, about 1 in 3 report excluding veterans deemed ineligible for VA services.^35,36 When veterans with OTH discharges have accessed VTC programs, they have historically relied on non-VA, community-based programming to fulfill treatment mandates, which may be less suited to addressing the unique needs of veterans.⁴⁸

Veterans who utilize VTCs receive several benefits, namely peer support and mentorship, acceptance into a veteran-centric space, and connection with specially trained staff capable of supporting the veteran through applications for a range of VA benefits (eg, service connection, housing support).^31-33,37 Given the disparate prevalence of OTH discharge characterizations among service members from racial, sexual, and gender minorities and among service members with mental health disorders, exclusion of veterans with OTH discharges from VTCs solely based on the type of discharge likely contributes to structural inequities among these already underserved groups by restricting access to these potential benefits. Such structural inequity stands in direct conflict with VTC best practice standards, which admonish programs to adjust eligibility requirements to facilitate access to treatment court programs for historically marginalized groups.⁴⁹

ELIGIBILITY EXPANSIONS

Given the overrepresentation of veterans with OTH discharge characterizations within the criminal-legal system and historical barriers of these veterans to access needed mental and behavioral health care, expansions in VA eligibility policies could have immense implications for VTCs. First, these expansions could mitigate common barriers to connecting VTC-participating veterans with OTH discharges with needed behavioral health care by allowing these veterans to access established, VA-based services and programming. Expansion may also allow VTCs to serve as a key intercept point for identifying and engaging veterans with OTH discharges who may be unaware of their eligibility for VA-based behavioral health care.

Access to VA health care services is a major resource for VTC participants and a common requirement.³² Eligibility expansion should ease access barriers veterans with OTH discharges commonly face. By providing a potential source of treatment, expansions may also support OTH eligibility practices within VTCs, particularly practices that require participants to be eligible for VA health care.^33,35,36 Some VTCs may continue to determine eligibility on the basis of discharge status and remain inaccessible to veterans with OTH discharge characterizations without program-level policy changes.^32,36,37

Communicating changes in eligibility policies relevant to veterans with OTH discharges may be a challenge, because many of these individuals have no established channels of communication with the VA. Because veterans with OTH discharges are at increased risk for legal system involvement, VTCs may serve as a unique point of contact to help facilitate communication.¹⁸ For example, upon referral to a VTC, veterans with OTH discharges can be identified, VA health care eligibility can be verified, and veterans can connect to VA staff to facilitate enrollment in VA services and care.

VJO specialists are in a favorable position to serve a critical role in utilizing VTCs as a potential intercept point for engaging veterans with OTH discharge characterizations. As outlined in the STRONG Veterans Act of 2022, VJOs are mandated to “spread awareness and understanding of veteran eligibility for the [VJO] Program, including the eligibility of veterans who were discharged from service in the Armed Forces under conditions other than honorable.”50 The Act further requires VJOs to be annually trained in communicating eligibility changes as they arise. Accordingly, VJOs receive ongoing training in a wide variety of critical outreach topics, including changes in eligibility; while VJOs cannot make eligibility determinations, they are tasked with enrolling all veterans involved in the criminal-legal system with whom they interact into VHA services, whether through typical or special eligibility criteria (M. Stimmel, PhD, National Training Director for Veteran Justice Programming, oral communication, July 14, 2023). VJOs therefore routinely serve in this capacity of facilitating VA enrollment of veterans with OTH discharge characterizations.

Recommendations to Veteran-Servicing Judicial Programs

Considering these potential implications, professionals routinely interacting with veterans involved in the criminal-legal system should become familiarized with recent changes in VA eligibility policies. Such familiarization would support the identification of veterans previously considered ineligible for care; provision of education to these veterans regarding their new eligibility; and referral to appropriate VA-based behavioral health care options. Although conceptually simple, executing such an educational campaign may prove logistically difficult. Given their historical exclusion from VA services, veterans with OTH discharge characterizations are unlikely to seek VA-based services in times of need, instead relying on a broad swath of civilian community-based organizations and resources. Usual approaches to advertising VHA health care policy changes (eg, by notifying VA employees and/or departments providing corresponding services or by circulating information to veteran-focused mailing lists and organizations) likely would prove insufficient. Educational campaigns to disseminate information about recent OTH eligibility changes should instead consider partnering with traditionally civilian, communitybased organizations and institutions, such as state bar associations, legal aid networks, case management services, nonveteran treatment court programs (eg, drug courts, or domestic violence courts), or probation/ parole programs. Because national surveys suggest generally low military cultural competence among civilian populations, providing concurrent support in developing foundational veteran cultural competencies (eg, how to phrase questions about military service history, or understanding discharge characterizations) may be necessary to ensure effective identification and engagement of veteran clients.⁴⁸

Programs that serve veterans with criminal-legal involvement should also consider potential relevance of recent OTH eligibility changes to program operations. VTC program staff and key partners (eg, judges, case managers, district attorneys, or defense attorneys), should revisit policies and procedures surrounding the engagement of veterans with OTH discharges within VTC programs and strategies for connecting these veterans with needed services. VTC programs that have historically excluded veterans with OTH discharges due to associated difficulties in locating and connecting with needed services should consider expanding eligibility policies considering recent shifts in VA behavioral health care eligibility.^33,35,36 Within the VHA, VJO specialists can play a critical role in supporting these VTC eligibility and cultural shifts. Some evidence suggests a large proportion of VTC referrals are facilitated by VJO specialists and that many such referrals are identified when veterans involved with the criminal-legal system seek VA support and/or services.³³ Given the historical exclusion of veterans with OTH discharges from VA care, strategies used by VJO specialists to identify, connect, and engage veterans with OTH discharges with VTCs and other services may be beneficial.

Even with knowledge of VA eligibility changes and considerations of these changes on local operations, many forensic settings and programs struggle to identify veterans. These difficulties are likely amplified among veterans with OTH discharge characterizations, who may be hesitant to self-disclose their military service history due to fear of stigma and/or views of OTH discharge characterizations as undeserving of the veteran title.¹² The VA offers 2 tools to aid in identification of veterans for these settings: the Veterans Re-Entry Search Service (VRSS) and Status Query and Response Exchange System (SQUARES). For VRSS, correctional facilities, courts, and other criminal justice entities upload a simple spreadsheet that contains basic identifying information of inmates or defendants in their system. VRSS returns information about which inmates or defendants have a history of military service and alerts VA Veterans Justice Programs staff so they can conduct outreach. A pilot study conducted by the California Department of Corrections and Rehabilitation found that 2.7% of its inmate population self-identified as veterans, while VRSS identified 7.7% of inmates with a history of military service. This difference represented about 5000 previously unidentified veterans.⁵¹ Similarly, community entities that partner with the VA, such as law enforcement or homeless service programs, can be approved to become a SQUARES user and submit identifying information of individuals with whom they interact directly into the SQUARES search engine. SQUARES then directly returns information about the individual’s veteran status and eligibility for VA health care and homeless programs.

Other Eligibility Limitations

VTCs and other professionals looking to refer veterans with OTH discharge characterizations to VA-based behavioral health care should be aware of potential limitations in eligibility and access. Specifically, although veterans with OTH discharges are now broadly eligible for VA-based behavioral health care and homeless programs, they remain ineligible for other forms of health care, including primary care and nonbehavioral specialty care.1 Research has found a strong comorbidity between behavioral and nonbehavioral health concerns, particularly within historically marginalized demographic groups.^52-55 Because these historically marginalized groups are often overrepresented among persons with criminal-legal involvement, veterans with OTH discharges, and VTC participants, such comorbidities require consideration by services or programming designed to support veterans with criminal-legal involvement.^12,56-58 Connection with VA-based health care will therefore continue to fall short of addressing all health care needs of veterans with OTH discharges and effective case management will require considerable treatment coordination between VA behavioral health care practitioners (HCPs) and community-based HCPs (eg, primary care professionals or nonbehavioral HCPs).

Implications for VA Mental Health Care

Recent eligibility expansions will also have inevitable consequences for VA mental health care systems. For many years, these systems have been overburdened by high caseloads and clinician burnout.^59,60 Given the generally elevated rates of mental health and substance use concerns among veterans with OTH discharge characterizations, expansions hold the potential to further burden caseloads with clinically complex, high-risk, high-need clients. Nevertheless, these expansions are also structured in a way that forces existing systems to absorb the responsibilities of providing necessary care to these veterans. To mitigate detrimental effects of eligibility expansions on the broader VA mental health system, clinicians should be explicitly trained in identifying veterans with OTH discharge characterizations and the implications of discharge status on broader health care eligibility. Treatment of veterans with OTH discharges may also benefit from close coordination between mental health professionals and behavioral health care coordinators to ensure appropriate coordination of care between VA- and non–VA-based HCPs.

CONCLUSIONS

Recent changes to VA eligibility policies now allow comprehensive mental and behavioral health care services to be provided to veterans with OTH discharges.1 Compared to routinely discharged veterans, veterans with OTH discharges are more likely to be persons of color, sexual or gender minorities, and experiencing mental health-related difficulties. Given the disproportionate mental health burden often faced by veterans with OTH discharges and relative overrepresentation of these veterans in judicial and correctional systems, these changes have considerable implications for programs and services designed to support veterans with criminallegal involvement. Professionals within these systems, particularly VTC programs, are therefore encouraged to familiarize themselves with recent changes in VA eligibility policies and to revisit strategies, policies, and procedures surrounding the engagement and enrollment of veterans with OTH discharge characterizations. Doing so may ensure veterans with OTH discharges are effectively connected to needed behavioral health care services.

This transcript has been edited for clarity.

I’d like to talk about a recent report in the journal Menopause linking menopausal symptoms to increased risk for cognitive impairment. I’d also like to discuss some of the recent studies that have addressed whether hot flashes are linked to increased risk for heart disease and other forms of cardiovascular disease (CVD). 

Given that 75%-80% of perimenopausal and postmenopausal women have hot flashes and vasomotor symptoms, it’s undoubtedly a more complex relationship between hot flashes and these outcomes than a simple one-size-fits-all, yes-or-no question.

Increasing evidence shows that several additional factors are important, including the age at which the symptoms are occurring, the time since menopause, the severity of the symptoms, whether they co-occur with night sweats and sleep disruption, and the cardiovascular status of the woman.

Several studies suggest that women who have more severe hot flashes and vasomotor symptoms are more likely to have prevalent cardiovascular risk factors — hypertension, dyslipidemia, high body mass index, endothelial dysfunction — as measured by flow-mediated vasodilation and other measures.

It is quite plausible that hot flashes could be a marker for increased risk for cognitive impairment. But the question remains, are hot flashes associated with cognitive impairment independent of these other risk factors? It appears that the associations between hot flashes, vasomotor symptoms, and CVD, and other adverse outcomes, may be more likely when hot flashes persist after age 60 or are newly occurring in later menopause. In the Women’s Health Initiative observational study, the presence of hot flashes and vasomotor symptoms in early menopause was not linked to any increased risk for heart attack, stroke, total CVD, or all-cause mortality.

However, the onset of these symptoms, especially new onset of these symptoms after age 60 or in later menopause, was in fact linked to increased risk for CVD and all-cause mortality. With respect to cognitive impairment, if a woman is having hot flashes and night sweats with regular sleep disruption, performance on cognitive testing would not be as favorable as it would be in the absence of these symptoms.

This brings us to the new study in Menopause that included approximately 1300 Latino women in nine Latin American countries, with an average age of 55 years. Looking at the association between severe menopausal symptoms and cognitive impairment, researchers found that women with severe symptoms were more likely to have cognitive impairment.

Conversely, they found that the women who had a favorable CVD risk factor status (physically active, lower BMI, healthier) and were ever users of estrogen were less likely to have cognitive impairment.

Clearly, for estrogen therapy, we need randomized clinical trials of the presence or absence of vasomotor symptoms and cognitive and CVD outcomes. Such analyses are ongoing, and new randomized trials focused specifically on women in early menopause would be very beneficial.

At the present time, it’s important that we not alarm women about the associations seen in some of these studies because often they are not independent associations; they aren’t independent of other risk factors that are commonly linked to hot flashes and night sweats. There are many other complexities in the relationship between hot flashes and cognitive impairment.

We need to appreciate that women who have moderate to severe hot flashes (especially when associated with disrupted sleep) do have impaired quality of life. It’s important to treat these symptoms, especially in early menopause, and very effective hormonal and nonhormonal treatments are available.

For women with symptoms that persist into later menopause or who have new onset of symptoms in later menopause, it’s important to prioritize cardiovascular health. For example, be more vigilant about behavioral lifestyle counseling to lower risk, and be even more aggressive in treating dyslipidemia and diabetes.

JoAnn E. Manson, Professor of Medicine and the Michael and Lee Bell Professor of Women’s Health, Harvard Medical School; Chief, Division of Preventive Medicine, Brigham and Women’s Hospital, Boston, Massachusetts; and Past President, North American Menopause Society, 2011-2012, has disclosed the following relevant financial relationships: Received study pill donation and infrastructure support from Mars Symbioscience (for the COSMOS trial).

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

This transcript has been edited for clarity.

I’d like to talk about a recent report in the journal Menopause linking menopausal symptoms to increased risk for cognitive impairment. I’d also like to discuss some of the recent studies that have addressed whether hot flashes are linked to increased risk for heart disease and other forms of cardiovascular disease (CVD). 

Given that 75%-80% of perimenopausal and postmenopausal women have hot flashes and vasomotor symptoms, it’s undoubtedly a more complex relationship between hot flashes and these outcomes than a simple one-size-fits-all, yes-or-no question.

Increasing evidence shows that several additional factors are important, including the age at which the symptoms are occurring, the time since menopause, the severity of the symptoms, whether they co-occur with night sweats and sleep disruption, and the cardiovascular status of the woman.

Several studies suggest that women who have more severe hot flashes and vasomotor symptoms are more likely to have prevalent cardiovascular risk factors — hypertension, dyslipidemia, high body mass index, endothelial dysfunction — as measured by flow-mediated vasodilation and other measures.

It is quite plausible that hot flashes could be a marker for increased risk for cognitive impairment. But the question remains, are hot flashes associated with cognitive impairment independent of these other risk factors? It appears that the associations between hot flashes, vasomotor symptoms, and CVD, and other adverse outcomes, may be more likely when hot flashes persist after age 60 or are newly occurring in later menopause. In the Women’s Health Initiative observational study, the presence of hot flashes and vasomotor symptoms in early menopause was not linked to any increased risk for heart attack, stroke, total CVD, or all-cause mortality.

However, the onset of these symptoms, especially new onset of these symptoms after age 60 or in later menopause, was in fact linked to increased risk for CVD and all-cause mortality. With respect to cognitive impairment, if a woman is having hot flashes and night sweats with regular sleep disruption, performance on cognitive testing would not be as favorable as it would be in the absence of these symptoms.

This brings us to the new study in Menopause that included approximately 1300 Latino women in nine Latin American countries, with an average age of 55 years. Looking at the association between severe menopausal symptoms and cognitive impairment, researchers found that women with severe symptoms were more likely to have cognitive impairment.

Conversely, they found that the women who had a favorable CVD risk factor status (physically active, lower BMI, healthier) and were ever users of estrogen were less likely to have cognitive impairment.

Clearly, for estrogen therapy, we need randomized clinical trials of the presence or absence of vasomotor symptoms and cognitive and CVD outcomes. Such analyses are ongoing, and new randomized trials focused specifically on women in early menopause would be very beneficial.

At the present time, it’s important that we not alarm women about the associations seen in some of these studies because often they are not independent associations; they aren’t independent of other risk factors that are commonly linked to hot flashes and night sweats. There are many other complexities in the relationship between hot flashes and cognitive impairment.

We need to appreciate that women who have moderate to severe hot flashes (especially when associated with disrupted sleep) do have impaired quality of life. It’s important to treat these symptoms, especially in early menopause, and very effective hormonal and nonhormonal treatments are available.

For women with symptoms that persist into later menopause or who have new onset of symptoms in later menopause, it’s important to prioritize cardiovascular health. For example, be more vigilant about behavioral lifestyle counseling to lower risk, and be even more aggressive in treating dyslipidemia and diabetes.

JoAnn E. Manson, Professor of Medicine and the Michael and Lee Bell Professor of Women’s Health, Harvard Medical School; Chief, Division of Preventive Medicine, Brigham and Women’s Hospital, Boston, Massachusetts; and Past President, North American Menopause Society, 2011-2012, has disclosed the following relevant financial relationships: Received study pill donation and infrastructure support from Mars Symbioscience (for the COSMOS trial).

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

This transcript has been edited for clarity.

I’d like to talk about a recent report in the journal Menopause linking menopausal symptoms to increased risk for cognitive impairment. I’d also like to discuss some of the recent studies that have addressed whether hot flashes are linked to increased risk for heart disease and other forms of cardiovascular disease (CVD). 

Given that 75%-80% of perimenopausal and postmenopausal women have hot flashes and vasomotor symptoms, it’s undoubtedly a more complex relationship between hot flashes and these outcomes than a simple one-size-fits-all, yes-or-no question.

Increasing evidence shows that several additional factors are important, including the age at which the symptoms are occurring, the time since menopause, the severity of the symptoms, whether they co-occur with night sweats and sleep disruption, and the cardiovascular status of the woman.

Several studies suggest that women who have more severe hot flashes and vasomotor symptoms are more likely to have prevalent cardiovascular risk factors — hypertension, dyslipidemia, high body mass index, endothelial dysfunction — as measured by flow-mediated vasodilation and other measures.

It is quite plausible that hot flashes could be a marker for increased risk for cognitive impairment. But the question remains, are hot flashes associated with cognitive impairment independent of these other risk factors? It appears that the associations between hot flashes, vasomotor symptoms, and CVD, and other adverse outcomes, may be more likely when hot flashes persist after age 60 or are newly occurring in later menopause. In the Women’s Health Initiative observational study, the presence of hot flashes and vasomotor symptoms in early menopause was not linked to any increased risk for heart attack, stroke, total CVD, or all-cause mortality.

However, the onset of these symptoms, especially new onset of these symptoms after age 60 or in later menopause, was in fact linked to increased risk for CVD and all-cause mortality. With respect to cognitive impairment, if a woman is having hot flashes and night sweats with regular sleep disruption, performance on cognitive testing would not be as favorable as it would be in the absence of these symptoms.

This brings us to the new study in Menopause that included approximately 1300 Latino women in nine Latin American countries, with an average age of 55 years. Looking at the association between severe menopausal symptoms and cognitive impairment, researchers found that women with severe symptoms were more likely to have cognitive impairment.

Conversely, they found that the women who had a favorable CVD risk factor status (physically active, lower BMI, healthier) and were ever users of estrogen were less likely to have cognitive impairment.

Clearly, for estrogen therapy, we need randomized clinical trials of the presence or absence of vasomotor symptoms and cognitive and CVD outcomes. Such analyses are ongoing, and new randomized trials focused specifically on women in early menopause would be very beneficial.

At the present time, it’s important that we not alarm women about the associations seen in some of these studies because often they are not independent associations; they aren’t independent of other risk factors that are commonly linked to hot flashes and night sweats. There are many other complexities in the relationship between hot flashes and cognitive impairment.

We need to appreciate that women who have moderate to severe hot flashes (especially when associated with disrupted sleep) do have impaired quality of life. It’s important to treat these symptoms, especially in early menopause, and very effective hormonal and nonhormonal treatments are available.

For women with symptoms that persist into later menopause or who have new onset of symptoms in later menopause, it’s important to prioritize cardiovascular health. For example, be more vigilant about behavioral lifestyle counseling to lower risk, and be even more aggressive in treating dyslipidemia and diabetes.

JoAnn E. Manson, Professor of Medicine and the Michael and Lee Bell Professor of Women’s Health, Harvard Medical School; Chief, Division of Preventive Medicine, Brigham and Women’s Hospital, Boston, Massachusetts; and Past President, North American Menopause Society, 2011-2012, has disclosed the following relevant financial relationships: Received study pill donation and infrastructure support from Mars Symbioscience (for the COSMOS trial).

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