Depression

Middle-aged women with PTSD and comorbid depression have a nearly fourfold increased risk for early death from a variety of causes in comparison with their peers who do not have those conditions, new research shows.

“Women with more severe symptoms of depression and PTSD were more at risk, compared with those with fewer symptoms or women with symptoms of only PTSD or only depression,” lead investigator Andrea Roberts, PhD, Harvard School of Public Health, Boston, said in an interview.

Health care providers “should be aware that mental health is a critical component of overall health and is tightly entwined with physical health. Identifying and treating mental health issues should be a foundational part of general health practice,” said Dr. Roberts.

The study was published online Dec. 4 in JAMA Network Open.
 

Mental health fundamental to survival

The researchers studied more than 51,000 mostly White women from the Nurses Health Study II who were followed for 9 years (2008-2017). At baseline in 2008, the women were aged between 43 and 64 years (mean age, 53.3 years).

Women with high levels of PTSD (six or seven symptoms) and probable depression were nearly four times more likely to die during follow-up than their peers who did not have these conditions (hazard ratio, 3.8; 95% confidence interval, 2.65-5.45; P < .001).

With adjustment for health factors such as smoking and body mass index, women with a high level of PTSD and depression remained at increased risk for early death (HR, 3.11; 95% CI, 2.16-4.47; P < .001).

The risk for early death was also elevated among women with moderate PTSD (four or five symptoms) and depression (HR, 2.03; 95% CI, 1.35-3.03; P < .001) and women with subclinical PTSD and depression (HR, 2.85; 95% CI, 1.99-4.07; P < .001) compared with those who did not have PTSD or depression.

Among women with PTSD symptoms and depression, the incidence of death from nearly all major causes was increased, including death from cardiovascular disease, respiratory disease, type 2 diabetes, unintentional injury, suicide, and other causes.

“These findings provide further evidence that mental health is fundamental to physical health – and to our very survival. We ignore our emotional well-being at our peril,” senior author Karestan Koenen, PhD, said in a news release.
 

New knowledge

Commenting on the findings, Jennifer Sumner, PhD, said that it’s “critical to appreciate the physical health consequences of psychopathology in individuals who have experienced trauma. This study adds to a growing literature demonstrating that the impact extends far beyond emotional health.

“Furthermore, these results highlight the potential value of promoting healthy lifestyle changes in order to reduce the elevated mortality risk in trauma-exposed individuals with co-occurring PTSD and depression,” said Dr. Sumner, who is with the department of psychology, University of California, Los Angeles.

She noted that this study builds on other work that links PTSD to mortality in men.

“Most work on posttraumatic psychopathology and physical health has actually been conducted in predominantly male samples of veterans, so these findings in women exposed to a variety of traumatic experiences extend the literature in important ways,” said Dr. Sumner.

“It’s also important to note that PTSD and depression are more prevalent in women than in men, so demonstrating these associations in women is particularly relevant,” she added.

Funding for the study was provided by the National Institutes of Heath. The authors disclosed no relevant financial relationships. Dr. Sumner has collaborated with the study investigators on prior studies.

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

Middle-aged women with PTSD and comorbid depression have a nearly fourfold increased risk for early death from a variety of causes in comparison with their peers who do not have those conditions, new research shows.

“Women with more severe symptoms of depression and PTSD were more at risk, compared with those with fewer symptoms or women with symptoms of only PTSD or only depression,” lead investigator Andrea Roberts, PhD, Harvard School of Public Health, Boston, said in an interview.

Health care providers “should be aware that mental health is a critical component of overall health and is tightly entwined with physical health. Identifying and treating mental health issues should be a foundational part of general health practice,” said Dr. Roberts.

The study was published online Dec. 4 in JAMA Network Open.
 

Mental health fundamental to survival

The researchers studied more than 51,000 mostly White women from the Nurses Health Study II who were followed for 9 years (2008-2017). At baseline in 2008, the women were aged between 43 and 64 years (mean age, 53.3 years).

Women with high levels of PTSD (six or seven symptoms) and probable depression were nearly four times more likely to die during follow-up than their peers who did not have these conditions (hazard ratio, 3.8; 95% confidence interval, 2.65-5.45; P < .001).

With adjustment for health factors such as smoking and body mass index, women with a high level of PTSD and depression remained at increased risk for early death (HR, 3.11; 95% CI, 2.16-4.47; P < .001).

The risk for early death was also elevated among women with moderate PTSD (four or five symptoms) and depression (HR, 2.03; 95% CI, 1.35-3.03; P < .001) and women with subclinical PTSD and depression (HR, 2.85; 95% CI, 1.99-4.07; P < .001) compared with those who did not have PTSD or depression.

Among women with PTSD symptoms and depression, the incidence of death from nearly all major causes was increased, including death from cardiovascular disease, respiratory disease, type 2 diabetes, unintentional injury, suicide, and other causes.

“These findings provide further evidence that mental health is fundamental to physical health – and to our very survival. We ignore our emotional well-being at our peril,” senior author Karestan Koenen, PhD, said in a news release.
 

New knowledge

Commenting on the findings, Jennifer Sumner, PhD, said that it’s “critical to appreciate the physical health consequences of psychopathology in individuals who have experienced trauma. This study adds to a growing literature demonstrating that the impact extends far beyond emotional health.

“Furthermore, these results highlight the potential value of promoting healthy lifestyle changes in order to reduce the elevated mortality risk in trauma-exposed individuals with co-occurring PTSD and depression,” said Dr. Sumner, who is with the department of psychology, University of California, Los Angeles.

She noted that this study builds on other work that links PTSD to mortality in men.

“Most work on posttraumatic psychopathology and physical health has actually been conducted in predominantly male samples of veterans, so these findings in women exposed to a variety of traumatic experiences extend the literature in important ways,” said Dr. Sumner.

“It’s also important to note that PTSD and depression are more prevalent in women than in men, so demonstrating these associations in women is particularly relevant,” she added.

Funding for the study was provided by the National Institutes of Heath. The authors disclosed no relevant financial relationships. Dr. Sumner has collaborated with the study investigators on prior studies.

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

Middle-aged women with PTSD and comorbid depression have a nearly fourfold increased risk for early death from a variety of causes in comparison with their peers who do not have those conditions, new research shows.

“Women with more severe symptoms of depression and PTSD were more at risk, compared with those with fewer symptoms or women with symptoms of only PTSD or only depression,” lead investigator Andrea Roberts, PhD, Harvard School of Public Health, Boston, said in an interview.

Health care providers “should be aware that mental health is a critical component of overall health and is tightly entwined with physical health. Identifying and treating mental health issues should be a foundational part of general health practice,” said Dr. Roberts.

The study was published online Dec. 4 in JAMA Network Open.
 

Mental health fundamental to survival

The researchers studied more than 51,000 mostly White women from the Nurses Health Study II who were followed for 9 years (2008-2017). At baseline in 2008, the women were aged between 43 and 64 years (mean age, 53.3 years).

Women with high levels of PTSD (six or seven symptoms) and probable depression were nearly four times more likely to die during follow-up than their peers who did not have these conditions (hazard ratio, 3.8; 95% confidence interval, 2.65-5.45; P < .001).

With adjustment for health factors such as smoking and body mass index, women with a high level of PTSD and depression remained at increased risk for early death (HR, 3.11; 95% CI, 2.16-4.47; P < .001).

The risk for early death was also elevated among women with moderate PTSD (four or five symptoms) and depression (HR, 2.03; 95% CI, 1.35-3.03; P < .001) and women with subclinical PTSD and depression (HR, 2.85; 95% CI, 1.99-4.07; P < .001) compared with those who did not have PTSD or depression.

Among women with PTSD symptoms and depression, the incidence of death from nearly all major causes was increased, including death from cardiovascular disease, respiratory disease, type 2 diabetes, unintentional injury, suicide, and other causes.

“These findings provide further evidence that mental health is fundamental to physical health – and to our very survival. We ignore our emotional well-being at our peril,” senior author Karestan Koenen, PhD, said in a news release.
 

New knowledge

Commenting on the findings, Jennifer Sumner, PhD, said that it’s “critical to appreciate the physical health consequences of psychopathology in individuals who have experienced trauma. This study adds to a growing literature demonstrating that the impact extends far beyond emotional health.

“Furthermore, these results highlight the potential value of promoting healthy lifestyle changes in order to reduce the elevated mortality risk in trauma-exposed individuals with co-occurring PTSD and depression,” said Dr. Sumner, who is with the department of psychology, University of California, Los Angeles.

She noted that this study builds on other work that links PTSD to mortality in men.

“Most work on posttraumatic psychopathology and physical health has actually been conducted in predominantly male samples of veterans, so these findings in women exposed to a variety of traumatic experiences extend the literature in important ways,” said Dr. Sumner.

“It’s also important to note that PTSD and depression are more prevalent in women than in men, so demonstrating these associations in women is particularly relevant,” she added.

Funding for the study was provided by the National Institutes of Heath. The authors disclosed no relevant financial relationships. Dr. Sumner has collaborated with the study investigators on prior studies.

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

A public-private partnership, led by mental health advocate Patrick Kennedy and the head of the National Institute of Mental Health, Joshua Gordon, MD, PhD, want urgent action to address the wave of mental illness and suicide caused by COVID-19.

“Our country is in serious denial about the full impact of mental health in this country and certainly as part of this pandemic,” said former congressman Mr. Kennedy, cochair of the Action Alliance’s Mental Health & Suicide Prevention National Response to COVID-19, at a briefing unveiling the group’s new six-priority Action Plan.

“That’s reinforced when all we hear from is Dr. Fauci,” and only about the physical effects of the disease, said Mr. Kennedy, the founder of the Kennedy Forum, a nonprofit dedicated to changing the health system’s approach to mental health and substance use disorders.

“We’re seeing suffering on a whole new, unprecedented scale,” he said. Mr. Kennedy noted the huge effort to speed therapeutics and vaccines to the American public. “We need to bring that same sense of urgency to these deaths of despair hiding in plain sight.”

Dr. Gordon, NIMH’s director and a cochair of the National Response group, was also at the briefing.

“We know many people report experiencing symptoms of distress, including anxiety, sleep problems, depression, substance use, and suicidal thoughts at rates two to three times higher than we might expect in times before the pandemic. Just as the country has come together to mitigate the physical impacts of pandemic, we also have to identify how to mitigate the mental health impacts,” said Dr. Gordon.
 

Plan of action

Mr. Kennedy emphasized that it is crucial that federal lawmakers and regulators find a way to increase parity between mental and physical health.

Paramount in that effort would be ensuring stronger enforcement of the Mental Health Parity and Addiction Equity Act, he said.

That 1996 law requires health plans to ensure that benefits for physical and mental health were equivalent, but it has frequently been ignored. In 2019, a U.S. federal court found that one of the nation’s largest behavioral health insurers, United Behavioral Health, had been violating the law. Mr. Kennedy said he expects this decision to continue to have a positive impact on achieving parity.

In November, United was ordered by a federal judge to reprocess 67,000 claims that it illegally denied.

The Alliance’s Action Plan has six priorities:

• Change the national conversation about mental health and suicide.
• Increase access to evidence-based treatments for substance use and mental health disorders in specialty and primary care, and include better reimbursement for services and make permanent reimbursement for telehealth services.
• Increase the use of nonpunitive and supportive crisis intervention services, including keeping people out of the criminal justice system.
• Establish near real-time data collection systems to promptly identify changes in rates of suicide, overdose, and other key events, and of clusters or spikes.
• Ensure the equitable delivery of comprehensive and effective suicide prevention and mental health services for Black Americans, Latin Americans, American Indian/Alaskan Natives, LGBTQ individuals, and others disproportionately impacted by the pandemic.
• Invest in prevention and early intervention approaches that treat the root causes of suicide and mental health problems.

Uptick in distress

Dr. Gordon noted that recent data indicate that, although ED visits for children are still down in 2020, compared with previous years, mental health ED visits are back to prepandemic levels.

A September survey showed an increase in suicidal thoughts and attempts, anxiety, and depression pandemic in youth because of the pandemic. Almost one-quarter of those surveyed said they knew a peer who developed suicidal thoughts since the start of the pandemic and 5% reported making a suicide attempt themselves.

In early December, research reported in JAMA Psychiatry showed the overall rate of overdose-related cardiac arrests in 2020 was about 50% higher than trends in 2018 and 2019, and that all overdose-related incidents were about 17% above baseline in 2020.

COVID-19 also appears to be striking individuals who are living in behavioral health facilities, and some of those facilities are reducing inpatient care and other programs because they don’t have enough personal protective equipment, testing supplies, or staff to cope with the disease.

The facilities are not required to report infections to the federal government. Sen. Elizabeth Warren (D-Mass.), Rep. Carolyn Maloney (D-N.Y.), and Rep. Katie Porter (D-Calif.) issued a report based on their own offices’ survey of 10 large behavioral health program operators.

Eight of those operators – covering 376 facilities and more than 100,000 patients in 40 states and Puerto Rico – provided substantive responses.

More than half had at least one COVID case and 14% had large outbreaks of 10 or more cases. The infection rate for patients was in line with that of the general public.

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

A public-private partnership, led by mental health advocate Patrick Kennedy and the head of the National Institute of Mental Health, Joshua Gordon, MD, PhD, want urgent action to address the wave of mental illness and suicide caused by COVID-19.

“Our country is in serious denial about the full impact of mental health in this country and certainly as part of this pandemic,” said former congressman Mr. Kennedy, cochair of the Action Alliance’s Mental Health & Suicide Prevention National Response to COVID-19, at a briefing unveiling the group’s new six-priority Action Plan.

“That’s reinforced when all we hear from is Dr. Fauci,” and only about the physical effects of the disease, said Mr. Kennedy, the founder of the Kennedy Forum, a nonprofit dedicated to changing the health system’s approach to mental health and substance use disorders.

“We’re seeing suffering on a whole new, unprecedented scale,” he said. Mr. Kennedy noted the huge effort to speed therapeutics and vaccines to the American public. “We need to bring that same sense of urgency to these deaths of despair hiding in plain sight.”

Dr. Gordon, NIMH’s director and a cochair of the National Response group, was also at the briefing.

“We know many people report experiencing symptoms of distress, including anxiety, sleep problems, depression, substance use, and suicidal thoughts at rates two to three times higher than we might expect in times before the pandemic. Just as the country has come together to mitigate the physical impacts of pandemic, we also have to identify how to mitigate the mental health impacts,” said Dr. Gordon.
 

Plan of action

Mr. Kennedy emphasized that it is crucial that federal lawmakers and regulators find a way to increase parity between mental and physical health.

Paramount in that effort would be ensuring stronger enforcement of the Mental Health Parity and Addiction Equity Act, he said.

That 1996 law requires health plans to ensure that benefits for physical and mental health were equivalent, but it has frequently been ignored. In 2019, a U.S. federal court found that one of the nation’s largest behavioral health insurers, United Behavioral Health, had been violating the law. Mr. Kennedy said he expects this decision to continue to have a positive impact on achieving parity.

In November, United was ordered by a federal judge to reprocess 67,000 claims that it illegally denied.

The Alliance’s Action Plan has six priorities:

• Change the national conversation about mental health and suicide.
• Increase access to evidence-based treatments for substance use and mental health disorders in specialty and primary care, and include better reimbursement for services and make permanent reimbursement for telehealth services.
• Increase the use of nonpunitive and supportive crisis intervention services, including keeping people out of the criminal justice system.
• Establish near real-time data collection systems to promptly identify changes in rates of suicide, overdose, and other key events, and of clusters or spikes.
• Ensure the equitable delivery of comprehensive and effective suicide prevention and mental health services for Black Americans, Latin Americans, American Indian/Alaskan Natives, LGBTQ individuals, and others disproportionately impacted by the pandemic.
• Invest in prevention and early intervention approaches that treat the root causes of suicide and mental health problems.

Uptick in distress

Dr. Gordon noted that recent data indicate that, although ED visits for children are still down in 2020, compared with previous years, mental health ED visits are back to prepandemic levels.

A September survey showed an increase in suicidal thoughts and attempts, anxiety, and depression pandemic in youth because of the pandemic. Almost one-quarter of those surveyed said they knew a peer who developed suicidal thoughts since the start of the pandemic and 5% reported making a suicide attempt themselves.

In early December, research reported in JAMA Psychiatry showed the overall rate of overdose-related cardiac arrests in 2020 was about 50% higher than trends in 2018 and 2019, and that all overdose-related incidents were about 17% above baseline in 2020.

COVID-19 also appears to be striking individuals who are living in behavioral health facilities, and some of those facilities are reducing inpatient care and other programs because they don’t have enough personal protective equipment, testing supplies, or staff to cope with the disease.

The facilities are not required to report infections to the federal government. Sen. Elizabeth Warren (D-Mass.), Rep. Carolyn Maloney (D-N.Y.), and Rep. Katie Porter (D-Calif.) issued a report based on their own offices’ survey of 10 large behavioral health program operators.

Eight of those operators – covering 376 facilities and more than 100,000 patients in 40 states and Puerto Rico – provided substantive responses.

More than half had at least one COVID case and 14% had large outbreaks of 10 or more cases. The infection rate for patients was in line with that of the general public.

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

A public-private partnership, led by mental health advocate Patrick Kennedy and the head of the National Institute of Mental Health, Joshua Gordon, MD, PhD, want urgent action to address the wave of mental illness and suicide caused by COVID-19.

“Our country is in serious denial about the full impact of mental health in this country and certainly as part of this pandemic,” said former congressman Mr. Kennedy, cochair of the Action Alliance’s Mental Health & Suicide Prevention National Response to COVID-19, at a briefing unveiling the group’s new six-priority Action Plan.

“That’s reinforced when all we hear from is Dr. Fauci,” and only about the physical effects of the disease, said Mr. Kennedy, the founder of the Kennedy Forum, a nonprofit dedicated to changing the health system’s approach to mental health and substance use disorders.

“We’re seeing suffering on a whole new, unprecedented scale,” he said. Mr. Kennedy noted the huge effort to speed therapeutics and vaccines to the American public. “We need to bring that same sense of urgency to these deaths of despair hiding in plain sight.”

Dr. Gordon, NIMH’s director and a cochair of the National Response group, was also at the briefing.

“We know many people report experiencing symptoms of distress, including anxiety, sleep problems, depression, substance use, and suicidal thoughts at rates two to three times higher than we might expect in times before the pandemic. Just as the country has come together to mitigate the physical impacts of pandemic, we also have to identify how to mitigate the mental health impacts,” said Dr. Gordon.
 

Plan of action

Mr. Kennedy emphasized that it is crucial that federal lawmakers and regulators find a way to increase parity between mental and physical health.

Paramount in that effort would be ensuring stronger enforcement of the Mental Health Parity and Addiction Equity Act, he said.

That 1996 law requires health plans to ensure that benefits for physical and mental health were equivalent, but it has frequently been ignored. In 2019, a U.S. federal court found that one of the nation’s largest behavioral health insurers, United Behavioral Health, had been violating the law. Mr. Kennedy said he expects this decision to continue to have a positive impact on achieving parity.

In November, United was ordered by a federal judge to reprocess 67,000 claims that it illegally denied.

The Alliance’s Action Plan has six priorities:

• Change the national conversation about mental health and suicide.
• Increase access to evidence-based treatments for substance use and mental health disorders in specialty and primary care, and include better reimbursement for services and make permanent reimbursement for telehealth services.
• Increase the use of nonpunitive and supportive crisis intervention services, including keeping people out of the criminal justice system.
• Establish near real-time data collection systems to promptly identify changes in rates of suicide, overdose, and other key events, and of clusters or spikes.
• Ensure the equitable delivery of comprehensive and effective suicide prevention and mental health services for Black Americans, Latin Americans, American Indian/Alaskan Natives, LGBTQ individuals, and others disproportionately impacted by the pandemic.
• Invest in prevention and early intervention approaches that treat the root causes of suicide and mental health problems.

Uptick in distress

Dr. Gordon noted that recent data indicate that, although ED visits for children are still down in 2020, compared with previous years, mental health ED visits are back to prepandemic levels.

A September survey showed an increase in suicidal thoughts and attempts, anxiety, and depression pandemic in youth because of the pandemic. Almost one-quarter of those surveyed said they knew a peer who developed suicidal thoughts since the start of the pandemic and 5% reported making a suicide attempt themselves.

In early December, research reported in JAMA Psychiatry showed the overall rate of overdose-related cardiac arrests in 2020 was about 50% higher than trends in 2018 and 2019, and that all overdose-related incidents were about 17% above baseline in 2020.

COVID-19 also appears to be striking individuals who are living in behavioral health facilities, and some of those facilities are reducing inpatient care and other programs because they don’t have enough personal protective equipment, testing supplies, or staff to cope with the disease.

The facilities are not required to report infections to the federal government. Sen. Elizabeth Warren (D-Mass.), Rep. Carolyn Maloney (D-N.Y.), and Rep. Katie Porter (D-Calif.) issued a report based on their own offices’ survey of 10 large behavioral health program operators.

Eight of those operators – covering 376 facilities and more than 100,000 patients in 40 states and Puerto Rico – provided substantive responses.

More than half had at least one COVID case and 14% had large outbreaks of 10 or more cases. The infection rate for patients was in line with that of the general public.

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

In “Psychiatrist in the Chair,” authors Brendan Kelly and Muiris Houston tell the story of a fellow Irishman, Anthony Clare, MD, who brought intelligence and eloquence to psychiatry. They tell a well-measured, well-referenced story of Anthony Clare’s personal and professional life. They capture his eloquence, wit, charm, and success in psychiatry as well as alluding to Dr. Clare’s self-reported “some kind of Irish darkness.”

In 1983, I was a young Scottish psychiatrist entering a fusty profession. Suddenly, there was Dr. Anthony Clare on the BBC! In “In the Psychiatrist’s Chair,” Dr. Clare interviewed celebrities. In addition to describing his Irish darkness, Brendan Kelly, MD, PhD and Muiris Houston, MD, FRCGP, both of whom are affiliated with Trinity College Dublin, note that Dr. Clare said: “I’m better at destroying systems than I am at putting them together – I do rather look for people to interview who will not live up to the prediction; there’s an element of destructiveness that’s still in me.”

I still listen to his talks on YouTube. His delicate probing questioning of B.F. Skinner, PhD, is one of my favorites, as he expertly and in an ever-so-friendly manner, teases out Dr. Skinner’s views of his upbringing and tags them to his behavorialism. It is this skill as an interviewer that captured us; can psychiatrists really be this clever? Yes, we can. All of the young and hopeful psychiatrists could see a future.

Dr. Clare raised psychiatry up from the depths of the asylums. He showed that a psychiatrist can be kind, charming, and sophisticated – handsome and helpful, not the ghouls of old movies. He did what needed to be done to psychiatry at that time: He set us on a footing that was not scary to the public. His vision for psychiatry was to improve services to those in need, reduce stigma, and show the public that there is a continuum between health and illness. He also took on the push for diagnoses, which he felt separated the normal from the abnormal, us from them.

He wrote his seminal work 10 years after graduating from the University College of Dublin. “Psychiatry in Dissent: Controversial Issues in Thought and Practice” was published in 1976, and is still considered one of the most influential texts in psychiatry. Dr. Clare “legitimized psychiatry not only in the eyes of the public but in the eyes of psychiatrists too,” the authors wrote. He did not support psychoanalysis and eschewed the rigor attached to the learning of new psychotherapies. He took renowned experts to task, but in ever such an elegant way. He successfully took on Hans Eysenck, PhD, I think because Dr. Eysenck insulted the intelligence of the Irish. He had a measured response to the anti-psychiatrists Thomas Szasz, MD, and R.D. Laing, MD, incorporating their ideas into his view of psychiatry. Dr. Clare was a social psychiatrist who highlighted the role of poverty and lack of access to mental health services. He stated that psychiatry was a “shambles, a mess and at a very primitive level.”

I enjoyed learning about his fight to make the membership exam for entrance into the Royal College of Psychiatry worthy of its name. Dr. Clare helped found the Association of Psychiatrists in Training (APIT) and wrote eloquently about the difference between training and indoctrination, which he described as having people fit a predetermined paradigm of how psychiatry should be constructed and practiced, versus education, which he defined as forming the mind. He highlighted the lack of good training facilities, and teaching staff in many parts of the United Kingdom. When Dr. Clare studied candidates in Edinburgh, he found that 70% had no child, forensic, or intellectual disability training. By the time I did my training there, I was able to get experience in all three subspecialties. He opposed the granting of automatic membership to current consultants, many of whom he considered to be “dunderheads.” . I can attest to that!

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

In “Psychiatrist in the Chair,” authors Brendan Kelly and Muiris Houston tell the story of a fellow Irishman, Anthony Clare, MD, who brought intelligence and eloquence to psychiatry. They tell a well-measured, well-referenced story of Anthony Clare’s personal and professional life. They capture his eloquence, wit, charm, and success in psychiatry as well as alluding to Dr. Clare’s self-reported “some kind of Irish darkness.”

In 1983, I was a young Scottish psychiatrist entering a fusty profession. Suddenly, there was Dr. Anthony Clare on the BBC! In “In the Psychiatrist’s Chair,” Dr. Clare interviewed celebrities. In addition to describing his Irish darkness, Brendan Kelly, MD, PhD and Muiris Houston, MD, FRCGP, both of whom are affiliated with Trinity College Dublin, note that Dr. Clare said: “I’m better at destroying systems than I am at putting them together – I do rather look for people to interview who will not live up to the prediction; there’s an element of destructiveness that’s still in me.”

I still listen to his talks on YouTube. His delicate probing questioning of B.F. Skinner, PhD, is one of my favorites, as he expertly and in an ever-so-friendly manner, teases out Dr. Skinner’s views of his upbringing and tags them to his behavorialism. It is this skill as an interviewer that captured us; can psychiatrists really be this clever? Yes, we can. All of the young and hopeful psychiatrists could see a future.

Dr. Clare raised psychiatry up from the depths of the asylums. He showed that a psychiatrist can be kind, charming, and sophisticated – handsome and helpful, not the ghouls of old movies. He did what needed to be done to psychiatry at that time: He set us on a footing that was not scary to the public. His vision for psychiatry was to improve services to those in need, reduce stigma, and show the public that there is a continuum between health and illness. He also took on the push for diagnoses, which he felt separated the normal from the abnormal, us from them.

He wrote his seminal work 10 years after graduating from the University College of Dublin. “Psychiatry in Dissent: Controversial Issues in Thought and Practice” was published in 1976, and is still considered one of the most influential texts in psychiatry. Dr. Clare “legitimized psychiatry not only in the eyes of the public but in the eyes of psychiatrists too,” the authors wrote. He did not support psychoanalysis and eschewed the rigor attached to the learning of new psychotherapies. He took renowned experts to task, but in ever such an elegant way. He successfully took on Hans Eysenck, PhD, I think because Dr. Eysenck insulted the intelligence of the Irish. He had a measured response to the anti-psychiatrists Thomas Szasz, MD, and R.D. Laing, MD, incorporating their ideas into his view of psychiatry. Dr. Clare was a social psychiatrist who highlighted the role of poverty and lack of access to mental health services. He stated that psychiatry was a “shambles, a mess and at a very primitive level.”

I enjoyed learning about his fight to make the membership exam for entrance into the Royal College of Psychiatry worthy of its name. Dr. Clare helped found the Association of Psychiatrists in Training (APIT) and wrote eloquently about the difference between training and indoctrination, which he described as having people fit a predetermined paradigm of how psychiatry should be constructed and practiced, versus education, which he defined as forming the mind. He highlighted the lack of good training facilities, and teaching staff in many parts of the United Kingdom. When Dr. Clare studied candidates in Edinburgh, he found that 70% had no child, forensic, or intellectual disability training. By the time I did my training there, I was able to get experience in all three subspecialties. He opposed the granting of automatic membership to current consultants, many of whom he considered to be “dunderheads.” . I can attest to that!

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

In “Psychiatrist in the Chair,” authors Brendan Kelly and Muiris Houston tell the story of a fellow Irishman, Anthony Clare, MD, who brought intelligence and eloquence to psychiatry. They tell a well-measured, well-referenced story of Anthony Clare’s personal and professional life. They capture his eloquence, wit, charm, and success in psychiatry as well as alluding to Dr. Clare’s self-reported “some kind of Irish darkness.”

In 1983, I was a young Scottish psychiatrist entering a fusty profession. Suddenly, there was Dr. Anthony Clare on the BBC! In “In the Psychiatrist’s Chair,” Dr. Clare interviewed celebrities. In addition to describing his Irish darkness, Brendan Kelly, MD, PhD and Muiris Houston, MD, FRCGP, both of whom are affiliated with Trinity College Dublin, note that Dr. Clare said: “I’m better at destroying systems than I am at putting them together – I do rather look for people to interview who will not live up to the prediction; there’s an element of destructiveness that’s still in me.”

I still listen to his talks on YouTube. His delicate probing questioning of B.F. Skinner, PhD, is one of my favorites, as he expertly and in an ever-so-friendly manner, teases out Dr. Skinner’s views of his upbringing and tags them to his behavorialism. It is this skill as an interviewer that captured us; can psychiatrists really be this clever? Yes, we can. All of the young and hopeful psychiatrists could see a future.

Dr. Clare raised psychiatry up from the depths of the asylums. He showed that a psychiatrist can be kind, charming, and sophisticated – handsome and helpful, not the ghouls of old movies. He did what needed to be done to psychiatry at that time: He set us on a footing that was not scary to the public. His vision for psychiatry was to improve services to those in need, reduce stigma, and show the public that there is a continuum between health and illness. He also took on the push for diagnoses, which he felt separated the normal from the abnormal, us from them.

He wrote his seminal work 10 years after graduating from the University College of Dublin. “Psychiatry in Dissent: Controversial Issues in Thought and Practice” was published in 1976, and is still considered one of the most influential texts in psychiatry. Dr. Clare “legitimized psychiatry not only in the eyes of the public but in the eyes of psychiatrists too,” the authors wrote. He did not support psychoanalysis and eschewed the rigor attached to the learning of new psychotherapies. He took renowned experts to task, but in ever such an elegant way. He successfully took on Hans Eysenck, PhD, I think because Dr. Eysenck insulted the intelligence of the Irish. He had a measured response to the anti-psychiatrists Thomas Szasz, MD, and R.D. Laing, MD, incorporating their ideas into his view of psychiatry. Dr. Clare was a social psychiatrist who highlighted the role of poverty and lack of access to mental health services. He stated that psychiatry was a “shambles, a mess and at a very primitive level.”

I enjoyed learning about his fight to make the membership exam for entrance into the Royal College of Psychiatry worthy of its name. Dr. Clare helped found the Association of Psychiatrists in Training (APIT) and wrote eloquently about the difference between training and indoctrination, which he described as having people fit a predetermined paradigm of how psychiatry should be constructed and practiced, versus education, which he defined as forming the mind. He highlighted the lack of good training facilities, and teaching staff in many parts of the United Kingdom. When Dr. Clare studied candidates in Edinburgh, he found that 70% had no child, forensic, or intellectual disability training. By the time I did my training there, I was able to get experience in all three subspecialties. He opposed the granting of automatic membership to current consultants, many of whom he considered to be “dunderheads.” . I can attest to that!

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

Individuals experiencing a current episode of major depressive disorder (MDD) are significantly more likely to have insulin resistance (IR), research shows.

Investigators found patients with MDD were 51% more likely to have IR, compared with their counterparts without depressive disorder. In addition, in individuals experiencing current depression, IR was also associated with depression severity and depression chronicity.

“We learned two things from this study – first, that insulin resistance was associated with being in a depressive episode and with the severity of that episode,” Kathleen Watson, PhD, a postdoctoral research fellow in the department of psychiatry, Stanford (Calif.) University, told this news organization. “Second, we learned that we can estimate insulin resistance using a surrogate measure that is clinically accessible – the triglyceride/HDL ratio.”

The study was published online Dec. 2 in JAMA Psychiatry.
 

Targeted approach

Many studies have linked MDD and IR. However, said Dr. Watson, “We did not have much description of the nature of this relationship.” She added that her team wanted to gain a better understanding of how IR relates to depression characteristics, such as remission status, severity, and chronicity.

Characterizing these associations will “represent a critical step at better phenotyping, a prelude to longitudinal studies, and a more targeted approach to the treatment of MDD,” the authors note.

For the study, the researchers drew on data from the Netherlands Study of Depression and Anxiety, a longitudinal Dutch study of adults that “describes the course and consequences of depressive and anxiety disorders.”

The study included 1,269 study participants with current MDD (n = 536), remitted MDD (n = 394), and control participants without a history of MDD (n = 339).

In addition to investigating the association between MDD and IR, the researchers also wanted to understand “whether using different surrogate IR measures has consistent association with MDD.” IR was determined using two surrogate markers – the quantitative insulin sensitivity check index (QUICKI) and the triglyceride to high-density lipoprotein ratio. Participants in the bottom quartile of the QUICKI were categorized as IR, while all other participants were categorized as being “insulin sensitive.”

The second surrogate IR measure – the triglyceride-HDL ratio – is an index based on fasting blood sample measurements, in which the determination of IR was based on sex-specific cut points (female ratio, IR > 1.9; male ratio, IR > 2.8).

Depression was determined based on the Composite International Diagnostic Interview (version 2.1), while depression severity was based on the Inventory of Depression Symptomatology. “Chronicity” was defined as depression during the preceding 4 years and was measured using the life chart review.
 

State vs. trait

Insulin resistance was associated with current, but not with remitted, MDD (odds ratio, 1.51; 95% confidence interval, 1.08-2.12 and OR, 1.14; 95% CI, 0.79-1.64, respectively).

In a model adjusted for age, sex, education, partner status, smoking status, and alcohol consumption, IR, as assessed by both measures, was linked to depression severity – but only the triglyceride-HDL ratio yielded an association between IR and depression chronicity.

IR was not associated with depression severity or chronicity in remitted MDD on either measure.

The findings – specifically the association between current, but not remitted, MDD – suggest that “IR is a state, rather than a trait, biomarker of depression,” the authors note.

“There are many plausible mechanisms between IR and MDD,” said Dr. Watson. “Some hypotheses for the link include inflammations, alterations to the hypothalamic-pituitary-adrenal axis, and changes in health behavior.

“Understanding these nuances helped us to lay the foundation for future research, including asking whether IR can lead to the development of MDD,” she added.

Finally, Dr. Watson noted that her team is collaborating with neuroscientists to better identify the brain mechanisms at the genetic, molecular, and cellular level that link IR and MDD and ways to target them with potential treatments or interventions.
 

Shared biological mechanisms?

Commenting on the study in an interview, Roger McIntyre, MD, professor of psychiatry and pharmacology, University of Toronto and head of the Mood Disorders Psychopharmacology Unit, said the results “suggest that a subpopulation of people with depression have what might be referred to as ‘metabolic syndrome type II’ – the depression is a consequence of abnormal metabolic processes.”

The results also suggest “maybe metabolic markers can be used as biomarkers of disease presence vs. absence,” said Dr. McIntyre, who is also the chairman and executive director of the Brain and Cognition Discovery Foundation, Toronto, and was not involved with the study.

Also commenting on the study, Andrea Fagiolini, MD, professor of psychiatry, University of Siena (Italy), said depression, metabolic, and inflammatory diseases “likely share some common biological mechanism, as they share risk factors such as unhealthy diet, unhealthy lifestyles, and frequent exposure to physical and psychological distress.”

It is “possible that treatment of depression improves IR; conversely, it is possible that lifestyle programs or medications that are able to improve IR may improve depressive symptoms,” suggested Dr. Fagiolini, who was not involved with the study. “It remains to be established which symptoms of depression are most involved in this correlation and whether their improvement precedes or follows the improvement in IR,” he noted.

The Netherlands Study of Depression and Anxiety is funded through the Geestkracht program of the Netherlands Organisation for Health Research and Development and is supported by several participating universities and mental health care organizations. Dr. Watson has disclosed no relevant financial relationships. The other authors’ disclosures are listed on the original paper. Dr. McIntyre reported research grant support from CIHR/GACD/Chinese National Natural Research Foundation and speaker/consultation fees from multiple pharmaceutical companies. Dr. McIntyre is also CEO of AltMed. Dr. Fagiolini has served or is currently serving as consultant or speaker for or is a research grant recipient from multiple pharmaceutical companies.

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

Individuals experiencing a current episode of major depressive disorder (MDD) are significantly more likely to have insulin resistance (IR), research shows.

Investigators found patients with MDD were 51% more likely to have IR, compared with their counterparts without depressive disorder. In addition, in individuals experiencing current depression, IR was also associated with depression severity and depression chronicity.

“We learned two things from this study – first, that insulin resistance was associated with being in a depressive episode and with the severity of that episode,” Kathleen Watson, PhD, a postdoctoral research fellow in the department of psychiatry, Stanford (Calif.) University, told this news organization. “Second, we learned that we can estimate insulin resistance using a surrogate measure that is clinically accessible – the triglyceride/HDL ratio.”

The study was published online Dec. 2 in JAMA Psychiatry.
 

Targeted approach

Many studies have linked MDD and IR. However, said Dr. Watson, “We did not have much description of the nature of this relationship.” She added that her team wanted to gain a better understanding of how IR relates to depression characteristics, such as remission status, severity, and chronicity.

Characterizing these associations will “represent a critical step at better phenotyping, a prelude to longitudinal studies, and a more targeted approach to the treatment of MDD,” the authors note.

For the study, the researchers drew on data from the Netherlands Study of Depression and Anxiety, a longitudinal Dutch study of adults that “describes the course and consequences of depressive and anxiety disorders.”

The study included 1,269 study participants with current MDD (n = 536), remitted MDD (n = 394), and control participants without a history of MDD (n = 339).

In addition to investigating the association between MDD and IR, the researchers also wanted to understand “whether using different surrogate IR measures has consistent association with MDD.” IR was determined using two surrogate markers – the quantitative insulin sensitivity check index (QUICKI) and the triglyceride to high-density lipoprotein ratio. Participants in the bottom quartile of the QUICKI were categorized as IR, while all other participants were categorized as being “insulin sensitive.”

The second surrogate IR measure – the triglyceride-HDL ratio – is an index based on fasting blood sample measurements, in which the determination of IR was based on sex-specific cut points (female ratio, IR > 1.9; male ratio, IR > 2.8).

Depression was determined based on the Composite International Diagnostic Interview (version 2.1), while depression severity was based on the Inventory of Depression Symptomatology. “Chronicity” was defined as depression during the preceding 4 years and was measured using the life chart review.
 

State vs. trait

Insulin resistance was associated with current, but not with remitted, MDD (odds ratio, 1.51; 95% confidence interval, 1.08-2.12 and OR, 1.14; 95% CI, 0.79-1.64, respectively).

In a model adjusted for age, sex, education, partner status, smoking status, and alcohol consumption, IR, as assessed by both measures, was linked to depression severity – but only the triglyceride-HDL ratio yielded an association between IR and depression chronicity.

IR was not associated with depression severity or chronicity in remitted MDD on either measure.

The findings – specifically the association between current, but not remitted, MDD – suggest that “IR is a state, rather than a trait, biomarker of depression,” the authors note.

“There are many plausible mechanisms between IR and MDD,” said Dr. Watson. “Some hypotheses for the link include inflammations, alterations to the hypothalamic-pituitary-adrenal axis, and changes in health behavior.

“Understanding these nuances helped us to lay the foundation for future research, including asking whether IR can lead to the development of MDD,” she added.

Finally, Dr. Watson noted that her team is collaborating with neuroscientists to better identify the brain mechanisms at the genetic, molecular, and cellular level that link IR and MDD and ways to target them with potential treatments or interventions.
 

Shared biological mechanisms?

Commenting on the study in an interview, Roger McIntyre, MD, professor of psychiatry and pharmacology, University of Toronto and head of the Mood Disorders Psychopharmacology Unit, said the results “suggest that a subpopulation of people with depression have what might be referred to as ‘metabolic syndrome type II’ – the depression is a consequence of abnormal metabolic processes.”

The results also suggest “maybe metabolic markers can be used as biomarkers of disease presence vs. absence,” said Dr. McIntyre, who is also the chairman and executive director of the Brain and Cognition Discovery Foundation, Toronto, and was not involved with the study.

Also commenting on the study, Andrea Fagiolini, MD, professor of psychiatry, University of Siena (Italy), said depression, metabolic, and inflammatory diseases “likely share some common biological mechanism, as they share risk factors such as unhealthy diet, unhealthy lifestyles, and frequent exposure to physical and psychological distress.”

It is “possible that treatment of depression improves IR; conversely, it is possible that lifestyle programs or medications that are able to improve IR may improve depressive symptoms,” suggested Dr. Fagiolini, who was not involved with the study. “It remains to be established which symptoms of depression are most involved in this correlation and whether their improvement precedes or follows the improvement in IR,” he noted.

The Netherlands Study of Depression and Anxiety is funded through the Geestkracht program of the Netherlands Organisation for Health Research and Development and is supported by several participating universities and mental health care organizations. Dr. Watson has disclosed no relevant financial relationships. The other authors’ disclosures are listed on the original paper. Dr. McIntyre reported research grant support from CIHR/GACD/Chinese National Natural Research Foundation and speaker/consultation fees from multiple pharmaceutical companies. Dr. McIntyre is also CEO of AltMed. Dr. Fagiolini has served or is currently serving as consultant or speaker for or is a research grant recipient from multiple pharmaceutical companies.

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

Individuals experiencing a current episode of major depressive disorder (MDD) are significantly more likely to have insulin resistance (IR), research shows.

Investigators found patients with MDD were 51% more likely to have IR, compared with their counterparts without depressive disorder. In addition, in individuals experiencing current depression, IR was also associated with depression severity and depression chronicity.

“We learned two things from this study – first, that insulin resistance was associated with being in a depressive episode and with the severity of that episode,” Kathleen Watson, PhD, a postdoctoral research fellow in the department of psychiatry, Stanford (Calif.) University, told this news organization. “Second, we learned that we can estimate insulin resistance using a surrogate measure that is clinically accessible – the triglyceride/HDL ratio.”

The study was published online Dec. 2 in JAMA Psychiatry.
 

Targeted approach

Many studies have linked MDD and IR. However, said Dr. Watson, “We did not have much description of the nature of this relationship.” She added that her team wanted to gain a better understanding of how IR relates to depression characteristics, such as remission status, severity, and chronicity.

Characterizing these associations will “represent a critical step at better phenotyping, a prelude to longitudinal studies, and a more targeted approach to the treatment of MDD,” the authors note.

For the study, the researchers drew on data from the Netherlands Study of Depression and Anxiety, a longitudinal Dutch study of adults that “describes the course and consequences of depressive and anxiety disorders.”

The study included 1,269 study participants with current MDD (n = 536), remitted MDD (n = 394), and control participants without a history of MDD (n = 339).

In addition to investigating the association between MDD and IR, the researchers also wanted to understand “whether using different surrogate IR measures has consistent association with MDD.” IR was determined using two surrogate markers – the quantitative insulin sensitivity check index (QUICKI) and the triglyceride to high-density lipoprotein ratio. Participants in the bottom quartile of the QUICKI were categorized as IR, while all other participants were categorized as being “insulin sensitive.”

The second surrogate IR measure – the triglyceride-HDL ratio – is an index based on fasting blood sample measurements, in which the determination of IR was based on sex-specific cut points (female ratio, IR > 1.9; male ratio, IR > 2.8).

Depression was determined based on the Composite International Diagnostic Interview (version 2.1), while depression severity was based on the Inventory of Depression Symptomatology. “Chronicity” was defined as depression during the preceding 4 years and was measured using the life chart review.
 

State vs. trait

Insulin resistance was associated with current, but not with remitted, MDD (odds ratio, 1.51; 95% confidence interval, 1.08-2.12 and OR, 1.14; 95% CI, 0.79-1.64, respectively).

In a model adjusted for age, sex, education, partner status, smoking status, and alcohol consumption, IR, as assessed by both measures, was linked to depression severity – but only the triglyceride-HDL ratio yielded an association between IR and depression chronicity.

IR was not associated with depression severity or chronicity in remitted MDD on either measure.

The findings – specifically the association between current, but not remitted, MDD – suggest that “IR is a state, rather than a trait, biomarker of depression,” the authors note.

“There are many plausible mechanisms between IR and MDD,” said Dr. Watson. “Some hypotheses for the link include inflammations, alterations to the hypothalamic-pituitary-adrenal axis, and changes in health behavior.

“Understanding these nuances helped us to lay the foundation for future research, including asking whether IR can lead to the development of MDD,” she added.

Finally, Dr. Watson noted that her team is collaborating with neuroscientists to better identify the brain mechanisms at the genetic, molecular, and cellular level that link IR and MDD and ways to target them with potential treatments or interventions.
 

Shared biological mechanisms?

Commenting on the study in an interview, Roger McIntyre, MD, professor of psychiatry and pharmacology, University of Toronto and head of the Mood Disorders Psychopharmacology Unit, said the results “suggest that a subpopulation of people with depression have what might be referred to as ‘metabolic syndrome type II’ – the depression is a consequence of abnormal metabolic processes.”

The results also suggest “maybe metabolic markers can be used as biomarkers of disease presence vs. absence,” said Dr. McIntyre, who is also the chairman and executive director of the Brain and Cognition Discovery Foundation, Toronto, and was not involved with the study.

Also commenting on the study, Andrea Fagiolini, MD, professor of psychiatry, University of Siena (Italy), said depression, metabolic, and inflammatory diseases “likely share some common biological mechanism, as they share risk factors such as unhealthy diet, unhealthy lifestyles, and frequent exposure to physical and psychological distress.”

It is “possible that treatment of depression improves IR; conversely, it is possible that lifestyle programs or medications that are able to improve IR may improve depressive symptoms,” suggested Dr. Fagiolini, who was not involved with the study. “It remains to be established which symptoms of depression are most involved in this correlation and whether their improvement precedes or follows the improvement in IR,” he noted.

The Netherlands Study of Depression and Anxiety is funded through the Geestkracht program of the Netherlands Organisation for Health Research and Development and is supported by several participating universities and mental health care organizations. Dr. Watson has disclosed no relevant financial relationships. The other authors’ disclosures are listed on the original paper. Dr. McIntyre reported research grant support from CIHR/GACD/Chinese National Natural Research Foundation and speaker/consultation fees from multiple pharmaceutical companies. Dr. McIntyre is also CEO of AltMed. Dr. Fagiolini has served or is currently serving as consultant or speaker for or is a research grant recipient from multiple pharmaceutical companies.

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

References to mental health issues in popular rap music more than doubled in the period from 1998 to 2018, based on data from a review of 125 songs.

portishead1/Getty Images

Mental health distress is rising but often is undertreated among children and young adults in the United States, wrote Alex Kresovich, MA, of the University of North Carolina, Chapel Hill, and colleagues.

“Mental health risk especially is increasing among young Black/ African American male individuals (YBAAM), who are often disproportionately exposed to environmental, economic, and family stressors linked with depression and anxiety,” they said. Adolescents and young adults, especially YBAAM, make up a large part of the audience for rap music.

In recent years, more rap artists have disclosed mental health issues, and they have included mental health topics such as depression and suicidal thoughts into their music, the researchers said.

In a study published in JAMA Pediatrics, the researchers identified 125 songs from the period between 1998 and 2018, then assessed them for references to mental health. The song selections included the top 25 rap songs in 1998, 2003, 2008, 2013, and 2018, based on the Billboard music charts.

The majority of the songs (123) featured lead artists from North America, and 97 of them were Black/African American males. The average age of the artists was 28 years. “Prominent artists captured in the sample included 50 Cent, Drake, Eminem, Kanye West, Jay-Z, and Lil’Wayne, among others,” they said. The researchers divided mental health issues into four categories: anxiety or anxious thinking; depression or depressive thinking; metaphors (such as struggling with mental stability); and suicide or suicidal ideation.
 

Mental health references rise

Across the study period, 35 songs (28%) mentioned anxiety, 28 (22%) mentioned depression, 8 (6%) mentioned suicide, and 26 (21%) mentioned a mental health metaphor. The proportion of songs with a mental health reference increased in a significant linear trend across the study period for suicide (0%-12%), depression (16%-32%), and mental health metaphors (8%-44%).

All references to suicide or suicidal ideation were found in songs that were popular between 2013 and 2018, the researchers noted.

“This increase is important, given that rap artists serve as role models to their audience, which extends beyond YBAAM to include U.S. young people across strata, constituting a large group with increased risk of mental health issues and underuse of mental health services,” Mr. Kresovich and associates said.

In addition, the researchers found that stressors related to environmental conditions and love were significantly more likely to co-occur with mental health references (adjusted odds ratios 8.1 and 4.8, respectively).

The study findings were limited by several factors including the selection of songs only from the Billboard hot rap songs year-end charts, which “does not fully represent the population of rap music between 1998 and 2018,” the researchers said. In addition, they could not address causation or motivations for the increased mental health references over the study period. “We are also unable to ascertain how U.S. youth interact with this music or are positively or negatively affected by its messages.”

“For example, positively framed references to mental health awareness, treatment, or support may lead to reduced stigma and increased willingness to seek treatment,” Mr. Kresovich and associates wrote. “However, negatively framed references to mental health struggles might lead to negative outcomes, including copycat behavior in which listeners model harmful behavior, such as suicide attempts, if those behaviors are described in lyrics (i.e., the Werther effect),” they added.

Despite these limitations, the results support the need for more research on the impact of rap music as a way to reduce stigma and potentially reduce mental health risk in adolescents and young adults, Mr. Kresovich and associates concluded.
 

Music may help raise tough topics

The study is important because children and adolescents have more control than ever over the media they consume, Sarah Vinson, MD, founder of the Lorio Psych Group in Atlanta, said in an interview.

“With more and more children with access to their own devices, they spend a great amount of time consuming content, including music,” Dr. Vinson said. “The norms reflected in the lyrics they hear have an impact on their emerging view of themselves, others, and the world.”  

The increased recognition of mental health issues by rap musicians as a topic “certainly has the potential to have a positive impact; however, the way that it is discussed can influence [the] nature of that impact,” she explained.

“It is important for people who are dealing with the normal range of human emotions to know that they are not alone. It is even more important for people dealing with suicidality or mental illness to know that,” Dr. Vinson said.

“Validation and sense of connection are human needs, and stigma related to mental illness can be isolating,” she emphasized. “Rappers have a platform and are often people that children and adolescents look up to, for better or for worse.” Through their music, “the rappers are signaling that these topics are worthy of our attention and okay to talk about.”

Unfortunately, many barriers persist for adolescents in need of mental health treatment, said Dr. Vinson. “The children’s mental health workforce, quantitatively, is not enough to meet the current needs,” she said. “Mental health is not reimbursed at the same rate as other kinds of health care, which contributes to healthy systems not prioritizing these services. Additionally, the racial, ethnic, and socioeconomic background of those who are mental health providers is not reflective of the larger population, and mental health training insufficiently incorporates the cultural and structural humility needed to help professionals navigate those differences,” she explained.

“Children at increased risk are those who face many of those environmental barriers that the rappers reference in those lyrics. They are likely to have even poorer access because they are disproportionately impacted by residential segregation, transportation challenges, financial barriers, and structural racism in mental health care,” Dr. Vinson added. A take-home message for clinicians is to find out what their patients are listening to. “One way to understand what is on the hearts and minds of children is to ask them what’s in their playlist,” she said. 

Additional research is needed to examine “moderating factors for the impact, good or bad, of increased mental health content in hip hop for young listeners’ mental health awareness, symptoms and/or interest in seeking treatment,” Dr. Vinson concluded.

The study received no outside funding. The researchers had no financial conflicts to disclose.

Dr. Vinson served as chair for a workshop on mental health and hip-hop at the American Psychiatric Association annual meeting. She had no financial conflicts to disclose.

SOURCE: Kresovich A et al. JAMA Pediatr. 2020 Dec 7. doi: 10.1001/jamapediatrics.2020.5155.

This article was updated on December 21, 2020.

References to mental health issues in popular rap music more than doubled in the period from 1998 to 2018, based on data from a review of 125 songs.

portishead1/Getty Images

Mental health distress is rising but often is undertreated among children and young adults in the United States, wrote Alex Kresovich, MA, of the University of North Carolina, Chapel Hill, and colleagues.

“Mental health risk especially is increasing among young Black/ African American male individuals (YBAAM), who are often disproportionately exposed to environmental, economic, and family stressors linked with depression and anxiety,” they said. Adolescents and young adults, especially YBAAM, make up a large part of the audience for rap music.

In recent years, more rap artists have disclosed mental health issues, and they have included mental health topics such as depression and suicidal thoughts into their music, the researchers said.

In a study published in JAMA Pediatrics, the researchers identified 125 songs from the period between 1998 and 2018, then assessed them for references to mental health. The song selections included the top 25 rap songs in 1998, 2003, 2008, 2013, and 2018, based on the Billboard music charts.

The majority of the songs (123) featured lead artists from North America, and 97 of them were Black/African American males. The average age of the artists was 28 years. “Prominent artists captured in the sample included 50 Cent, Drake, Eminem, Kanye West, Jay-Z, and Lil’Wayne, among others,” they said. The researchers divided mental health issues into four categories: anxiety or anxious thinking; depression or depressive thinking; metaphors (such as struggling with mental stability); and suicide or suicidal ideation.
 

Mental health references rise

Across the study period, 35 songs (28%) mentioned anxiety, 28 (22%) mentioned depression, 8 (6%) mentioned suicide, and 26 (21%) mentioned a mental health metaphor. The proportion of songs with a mental health reference increased in a significant linear trend across the study period for suicide (0%-12%), depression (16%-32%), and mental health metaphors (8%-44%).

All references to suicide or suicidal ideation were found in songs that were popular between 2013 and 2018, the researchers noted.

“This increase is important, given that rap artists serve as role models to their audience, which extends beyond YBAAM to include U.S. young people across strata, constituting a large group with increased risk of mental health issues and underuse of mental health services,” Mr. Kresovich and associates said.

In addition, the researchers found that stressors related to environmental conditions and love were significantly more likely to co-occur with mental health references (adjusted odds ratios 8.1 and 4.8, respectively).

The study findings were limited by several factors including the selection of songs only from the Billboard hot rap songs year-end charts, which “does not fully represent the population of rap music between 1998 and 2018,” the researchers said. In addition, they could not address causation or motivations for the increased mental health references over the study period. “We are also unable to ascertain how U.S. youth interact with this music or are positively or negatively affected by its messages.”

“For example, positively framed references to mental health awareness, treatment, or support may lead to reduced stigma and increased willingness to seek treatment,” Mr. Kresovich and associates wrote. “However, negatively framed references to mental health struggles might lead to negative outcomes, including copycat behavior in which listeners model harmful behavior, such as suicide attempts, if those behaviors are described in lyrics (i.e., the Werther effect),” they added.

Despite these limitations, the results support the need for more research on the impact of rap music as a way to reduce stigma and potentially reduce mental health risk in adolescents and young adults, Mr. Kresovich and associates concluded.
 

Music may help raise tough topics

The study is important because children and adolescents have more control than ever over the media they consume, Sarah Vinson, MD, founder of the Lorio Psych Group in Atlanta, said in an interview.

“With more and more children with access to their own devices, they spend a great amount of time consuming content, including music,” Dr. Vinson said. “The norms reflected in the lyrics they hear have an impact on their emerging view of themselves, others, and the world.”  

The increased recognition of mental health issues by rap musicians as a topic “certainly has the potential to have a positive impact; however, the way that it is discussed can influence [the] nature of that impact,” she explained.

“It is important for people who are dealing with the normal range of human emotions to know that they are not alone. It is even more important for people dealing with suicidality or mental illness to know that,” Dr. Vinson said.

“Validation and sense of connection are human needs, and stigma related to mental illness can be isolating,” she emphasized. “Rappers have a platform and are often people that children and adolescents look up to, for better or for worse.” Through their music, “the rappers are signaling that these topics are worthy of our attention and okay to talk about.”

Unfortunately, many barriers persist for adolescents in need of mental health treatment, said Dr. Vinson. “The children’s mental health workforce, quantitatively, is not enough to meet the current needs,” she said. “Mental health is not reimbursed at the same rate as other kinds of health care, which contributes to healthy systems not prioritizing these services. Additionally, the racial, ethnic, and socioeconomic background of those who are mental health providers is not reflective of the larger population, and mental health training insufficiently incorporates the cultural and structural humility needed to help professionals navigate those differences,” she explained.

“Children at increased risk are those who face many of those environmental barriers that the rappers reference in those lyrics. They are likely to have even poorer access because they are disproportionately impacted by residential segregation, transportation challenges, financial barriers, and structural racism in mental health care,” Dr. Vinson added. A take-home message for clinicians is to find out what their patients are listening to. “One way to understand what is on the hearts and minds of children is to ask them what’s in their playlist,” she said. 

Additional research is needed to examine “moderating factors for the impact, good or bad, of increased mental health content in hip hop for young listeners’ mental health awareness, symptoms and/or interest in seeking treatment,” Dr. Vinson concluded.

The study received no outside funding. The researchers had no financial conflicts to disclose.

Dr. Vinson served as chair for a workshop on mental health and hip-hop at the American Psychiatric Association annual meeting. She had no financial conflicts to disclose.

SOURCE: Kresovich A et al. JAMA Pediatr. 2020 Dec 7. doi: 10.1001/jamapediatrics.2020.5155.

This article was updated on December 21, 2020.

References to mental health issues in popular rap music more than doubled in the period from 1998 to 2018, based on data from a review of 125 songs.

portishead1/Getty Images

Mental health distress is rising but often is undertreated among children and young adults in the United States, wrote Alex Kresovich, MA, of the University of North Carolina, Chapel Hill, and colleagues.

“Mental health risk especially is increasing among young Black/ African American male individuals (YBAAM), who are often disproportionately exposed to environmental, economic, and family stressors linked with depression and anxiety,” they said. Adolescents and young adults, especially YBAAM, make up a large part of the audience for rap music.

In recent years, more rap artists have disclosed mental health issues, and they have included mental health topics such as depression and suicidal thoughts into their music, the researchers said.

In a study published in JAMA Pediatrics, the researchers identified 125 songs from the period between 1998 and 2018, then assessed them for references to mental health. The song selections included the top 25 rap songs in 1998, 2003, 2008, 2013, and 2018, based on the Billboard music charts.

The majority of the songs (123) featured lead artists from North America, and 97 of them were Black/African American males. The average age of the artists was 28 years. “Prominent artists captured in the sample included 50 Cent, Drake, Eminem, Kanye West, Jay-Z, and Lil’Wayne, among others,” they said. The researchers divided mental health issues into four categories: anxiety or anxious thinking; depression or depressive thinking; metaphors (such as struggling with mental stability); and suicide or suicidal ideation.
 

Mental health references rise

Across the study period, 35 songs (28%) mentioned anxiety, 28 (22%) mentioned depression, 8 (6%) mentioned suicide, and 26 (21%) mentioned a mental health metaphor. The proportion of songs with a mental health reference increased in a significant linear trend across the study period for suicide (0%-12%), depression (16%-32%), and mental health metaphors (8%-44%).

All references to suicide or suicidal ideation were found in songs that were popular between 2013 and 2018, the researchers noted.

“This increase is important, given that rap artists serve as role models to their audience, which extends beyond YBAAM to include U.S. young people across strata, constituting a large group with increased risk of mental health issues and underuse of mental health services,” Mr. Kresovich and associates said.

In addition, the researchers found that stressors related to environmental conditions and love were significantly more likely to co-occur with mental health references (adjusted odds ratios 8.1 and 4.8, respectively).

The study findings were limited by several factors including the selection of songs only from the Billboard hot rap songs year-end charts, which “does not fully represent the population of rap music between 1998 and 2018,” the researchers said. In addition, they could not address causation or motivations for the increased mental health references over the study period. “We are also unable to ascertain how U.S. youth interact with this music or are positively or negatively affected by its messages.”

“For example, positively framed references to mental health awareness, treatment, or support may lead to reduced stigma and increased willingness to seek treatment,” Mr. Kresovich and associates wrote. “However, negatively framed references to mental health struggles might lead to negative outcomes, including copycat behavior in which listeners model harmful behavior, such as suicide attempts, if those behaviors are described in lyrics (i.e., the Werther effect),” they added.

Despite these limitations, the results support the need for more research on the impact of rap music as a way to reduce stigma and potentially reduce mental health risk in adolescents and young adults, Mr. Kresovich and associates concluded.
 

Music may help raise tough topics

The study is important because children and adolescents have more control than ever over the media they consume, Sarah Vinson, MD, founder of the Lorio Psych Group in Atlanta, said in an interview.

“With more and more children with access to their own devices, they spend a great amount of time consuming content, including music,” Dr. Vinson said. “The norms reflected in the lyrics they hear have an impact on their emerging view of themselves, others, and the world.”  

The increased recognition of mental health issues by rap musicians as a topic “certainly has the potential to have a positive impact; however, the way that it is discussed can influence [the] nature of that impact,” she explained.

“It is important for people who are dealing with the normal range of human emotions to know that they are not alone. It is even more important for people dealing with suicidality or mental illness to know that,” Dr. Vinson said.

“Validation and sense of connection are human needs, and stigma related to mental illness can be isolating,” she emphasized. “Rappers have a platform and are often people that children and adolescents look up to, for better or for worse.” Through their music, “the rappers are signaling that these topics are worthy of our attention and okay to talk about.”

Unfortunately, many barriers persist for adolescents in need of mental health treatment, said Dr. Vinson. “The children’s mental health workforce, quantitatively, is not enough to meet the current needs,” she said. “Mental health is not reimbursed at the same rate as other kinds of health care, which contributes to healthy systems not prioritizing these services. Additionally, the racial, ethnic, and socioeconomic background of those who are mental health providers is not reflective of the larger population, and mental health training insufficiently incorporates the cultural and structural humility needed to help professionals navigate those differences,” she explained.

“Children at increased risk are those who face many of those environmental barriers that the rappers reference in those lyrics. They are likely to have even poorer access because they are disproportionately impacted by residential segregation, transportation challenges, financial barriers, and structural racism in mental health care,” Dr. Vinson added. A take-home message for clinicians is to find out what their patients are listening to. “One way to understand what is on the hearts and minds of children is to ask them what’s in their playlist,” she said. 

Additional research is needed to examine “moderating factors for the impact, good or bad, of increased mental health content in hip hop for young listeners’ mental health awareness, symptoms and/or interest in seeking treatment,” Dr. Vinson concluded.

The study received no outside funding. The researchers had no financial conflicts to disclose.

Dr. Vinson served as chair for a workshop on mental health and hip-hop at the American Psychiatric Association annual meeting. She had no financial conflicts to disclose.

SOURCE: Kresovich A et al. JAMA Pediatr. 2020 Dec 7. doi: 10.1001/jamapediatrics.2020.5155.

This article was updated on December 21, 2020.

There has been a sharp increase in overdose-related cardiac arrests in the United States during the COVID-19 pandemic, a new analysis shows.

Overall rates in 2020 were elevated above the baseline from 2018 and 2019 by about 50%, the data show.

“Our results suggest that overdoses may be strongly on the rise in 2020, and efforts to combat the COVID-19 pandemic have not been effective at reducing overdoses,” Joseph Friedman, MPH, MD/PhD student, medical scientist training program, University of California, Los Angeles, said in an interview.

“We need to invest heavily in substance use treatment, harm reduction, and the structural drivers of overdose as core elements of the COVID-19 response,” said Mr. Friedman, who coauthored the study with UCLA colleague David Schriger, MD, MPH, and Leo Beletsky, JD, MPH, Northeastern University, Boston.

The study was published as a research letter Dec. 3 in JAMA Psychiatry.
 

Social isolation a key driver

Emergency medical services (EMS) data are available in near real time, providing a novel source of up-to-date information to monitor epidemiological shifts during the COVID-19 pandemic.

For the study, the researchers leveraged data from the National EMS Information System, a large registry of more than 10,000 EMS agencies in 47 states that represent over 80% of all EMS calls nationally in 2020. They used the data to track shifts in overdose-related cardiac arrests observed by EMS.

They found clear evidence of a large-scale uptick in overdose-related deaths during the COVID-19 pandemic.

The overall rate of overdose-related cardiac arrests in 2020 was about 50% higher than trends observed during 2018 and 2019, including a maximum peak of 123% above baseline reached in early May.

All overdose-related incidents (fatal and nonfatal) were elevated in 2020, by about 17% above baseline. However, there were larger increases in fatal overdose-related incidents, compared to all incidents, which may suggest a rising case fatality rate, the authors noted.

The observed trends line up in time with reductions in mobility (a metric of social interaction), as measured using cell phone data, they wrote.

“Many of the trends predicted by experts at the beginning of the pandemic could cause these shifts. Increases in social isolation likely play an important role, as people using [drugs] alone are less likely to receive help when they need it. Also shifts in the drug supply, and reduced access to healthcare and treatment,” said Mr. Friedman.

“We need to undertake short- and long-term strategies to combat the rising tide of overdose mortality in the United States,” he added.

In the short term, Mr. Friedman suggested reducing financial and logistical barriers for accessing a safe opioid supply. Such measures include allowing pharmacies to dispense methadone, allowing all physicians to prescribe buprenorphine without a special waiver, and releasing emergency funds to make these medications universally affordable.

“In the longer term, we should acknowledge that overdose is a symptom of structural problems in the U.S. We need to invest in making employment, housing, education, and health care accessible to all to address the upstream drivers of overdose,” he added.

The study had no commercial funding. The authors disclosed no relevant financial relationships.

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

There has been a sharp increase in overdose-related cardiac arrests in the United States during the COVID-19 pandemic, a new analysis shows.

Overall rates in 2020 were elevated above the baseline from 2018 and 2019 by about 50%, the data show.

“Our results suggest that overdoses may be strongly on the rise in 2020, and efforts to combat the COVID-19 pandemic have not been effective at reducing overdoses,” Joseph Friedman, MPH, MD/PhD student, medical scientist training program, University of California, Los Angeles, said in an interview.

“We need to invest heavily in substance use treatment, harm reduction, and the structural drivers of overdose as core elements of the COVID-19 response,” said Mr. Friedman, who coauthored the study with UCLA colleague David Schriger, MD, MPH, and Leo Beletsky, JD, MPH, Northeastern University, Boston.

The study was published as a research letter Dec. 3 in JAMA Psychiatry.
 

Social isolation a key driver

Emergency medical services (EMS) data are available in near real time, providing a novel source of up-to-date information to monitor epidemiological shifts during the COVID-19 pandemic.

For the study, the researchers leveraged data from the National EMS Information System, a large registry of more than 10,000 EMS agencies in 47 states that represent over 80% of all EMS calls nationally in 2020. They used the data to track shifts in overdose-related cardiac arrests observed by EMS.

They found clear evidence of a large-scale uptick in overdose-related deaths during the COVID-19 pandemic.

The overall rate of overdose-related cardiac arrests in 2020 was about 50% higher than trends observed during 2018 and 2019, including a maximum peak of 123% above baseline reached in early May.

All overdose-related incidents (fatal and nonfatal) were elevated in 2020, by about 17% above baseline. However, there were larger increases in fatal overdose-related incidents, compared to all incidents, which may suggest a rising case fatality rate, the authors noted.

The observed trends line up in time with reductions in mobility (a metric of social interaction), as measured using cell phone data, they wrote.

“Many of the trends predicted by experts at the beginning of the pandemic could cause these shifts. Increases in social isolation likely play an important role, as people using [drugs] alone are less likely to receive help when they need it. Also shifts in the drug supply, and reduced access to healthcare and treatment,” said Mr. Friedman.

“We need to undertake short- and long-term strategies to combat the rising tide of overdose mortality in the United States,” he added.

In the short term, Mr. Friedman suggested reducing financial and logistical barriers for accessing a safe opioid supply. Such measures include allowing pharmacies to dispense methadone, allowing all physicians to prescribe buprenorphine without a special waiver, and releasing emergency funds to make these medications universally affordable.

“In the longer term, we should acknowledge that overdose is a symptom of structural problems in the U.S. We need to invest in making employment, housing, education, and health care accessible to all to address the upstream drivers of overdose,” he added.

The study had no commercial funding. The authors disclosed no relevant financial relationships.

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

There has been a sharp increase in overdose-related cardiac arrests in the United States during the COVID-19 pandemic, a new analysis shows.

Overall rates in 2020 were elevated above the baseline from 2018 and 2019 by about 50%, the data show.

“Our results suggest that overdoses may be strongly on the rise in 2020, and efforts to combat the COVID-19 pandemic have not been effective at reducing overdoses,” Joseph Friedman, MPH, MD/PhD student, medical scientist training program, University of California, Los Angeles, said in an interview.

“We need to invest heavily in substance use treatment, harm reduction, and the structural drivers of overdose as core elements of the COVID-19 response,” said Mr. Friedman, who coauthored the study with UCLA colleague David Schriger, MD, MPH, and Leo Beletsky, JD, MPH, Northeastern University, Boston.

The study was published as a research letter Dec. 3 in JAMA Psychiatry.
 

Social isolation a key driver

Emergency medical services (EMS) data are available in near real time, providing a novel source of up-to-date information to monitor epidemiological shifts during the COVID-19 pandemic.

For the study, the researchers leveraged data from the National EMS Information System, a large registry of more than 10,000 EMS agencies in 47 states that represent over 80% of all EMS calls nationally in 2020. They used the data to track shifts in overdose-related cardiac arrests observed by EMS.

They found clear evidence of a large-scale uptick in overdose-related deaths during the COVID-19 pandemic.

The overall rate of overdose-related cardiac arrests in 2020 was about 50% higher than trends observed during 2018 and 2019, including a maximum peak of 123% above baseline reached in early May.

All overdose-related incidents (fatal and nonfatal) were elevated in 2020, by about 17% above baseline. However, there were larger increases in fatal overdose-related incidents, compared to all incidents, which may suggest a rising case fatality rate, the authors noted.

The observed trends line up in time with reductions in mobility (a metric of social interaction), as measured using cell phone data, they wrote.

“Many of the trends predicted by experts at the beginning of the pandemic could cause these shifts. Increases in social isolation likely play an important role, as people using [drugs] alone are less likely to receive help when they need it. Also shifts in the drug supply, and reduced access to healthcare and treatment,” said Mr. Friedman.

“We need to undertake short- and long-term strategies to combat the rising tide of overdose mortality in the United States,” he added.

In the short term, Mr. Friedman suggested reducing financial and logistical barriers for accessing a safe opioid supply. Such measures include allowing pharmacies to dispense methadone, allowing all physicians to prescribe buprenorphine without a special waiver, and releasing emergency funds to make these medications universally affordable.

“In the longer term, we should acknowledge that overdose is a symptom of structural problems in the U.S. We need to invest in making employment, housing, education, and health care accessible to all to address the upstream drivers of overdose,” he added.

The study had no commercial funding. The authors disclosed no relevant financial relationships.

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

Cases of poisoning – intentional and unintentional – from ingestion of alcohol-based hand sanitizer have soared during the COVID-19 pandemic.

In the United Kingdom alone, alcohol-based hand sanitizer poisonings reported to the National Poisons Information Service jumped 157% – from 155 between January 1 and September 16, 2019, to 398 between Jan. 1 and Sept. 14, 2020, new research shows.

More needs to be done to protect those at risk of unintentional and intentional swallowing of alcohol-based hand sanitizer, including children, people with dementia/confusion, and those with mental health issues, according to Georgia Richards, DPhil student, Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford (England).

“If providers are supplying alcohol-based hand sanitizers in the community to reduce the spread of SARS-CoV-2, the contents should be supplied in lockable and automated dispensers to reduce contamination and improve safety,” Ms. Richards said in an interview.

The study was published online Dec. 1 in BMJ Evidence-Based Medicine.
 

European, U.S. poisoning rates soar

In the paper Ms. Richards described two deaths that occurred in hospitals in England.

In one case, a 30-year-old woman, detained in a psychiatric unit who received the antidepressant venlafaxine was found dead in her hospital bed with a container of hand-sanitizing gel beside her.

“The gel was readily accessible to patients on the ward from a communal dispenser, and patients were allowed to fill cups or other containers with it to keep in their rooms,” Ms. Richards reported.

A postmortem analysis found a high level of alcohol in her blood (214 mg of alcohol in 100 mL of blood). The medical cause of death was listed as “ingestion of alcohol and venlafaxine.” The coroner concluded that the combination of these substances suppressed the patient’s breathing, leading to her death.

The other case involved a 76-year-old man who unintentionally swallowed an unknown quantity of alcohol-based hand-sanitizing foam attached to the foot of his hospital bed.

The patient had a history of agitation and depression and was treated with antidepressants. He had become increasingly confused over the preceding 9 months, possibly because of vascular dementia.

His blood ethanol concentration was 463 mg/dL (100 mmol/L) initially and 354 mg/dL (77mmol/L) 10 hours later. He was admitted to the ICU, where he received lorazepam and haloperidol and treated with ventilation, with a plan to allow the alcohol to be naturally metabolized.

The patient developed complications and died 6 days later. The primary causes of death were bronchopneumonia and acute alcohol toxicity, secondary to acute delirium and coronary artery disease.

Since COVID-19 started, alcohol-based hand sanitizers are among the most sought-after commodities around the world. The volume of these products – now found in homes, hospitals, schools, workplaces, and elsewhere – “may be a cause for concern,” Ms. Richards wrote.

Yet, warnings about the toxicity and lethality of intentional or unintentional ingestion of these products have not been widely disseminated, she noted.

To reduce the risk of harm, Ms. Richards suggested educating the public and health care professionals, improving warning labels on products, and increasing the awareness and reporting of such exposures to public health authorities.

“While governments and public health authorities have successfully heightened our awareness of, and need for, better hand hygiene during the COVID-19 outbreak, they must also make the public aware of the potential harms and encourage the reporting of such harms to poisons information centers,” she noted.

Increases in alcohol-based hand sanitizer poisoning during the pandemic have also been reported in the United States.

The American Association of Poison Control Centers reports that data from the National Poison Data System show 32,892 hand sanitizer exposure cases reported to the 55 U.S. poison control centers from Jan. 1 to Nov. 15, 2020 – an increase of 73%, compared with the same time period during the previous year.
 

An increase in self-harm

Weighing in on this issue, Robert Bassett, DO, associate medical director of the Poison Control Center at Children’s Hospital of Philadelphia, said in an interview that “cleaning agents and disinfectants have been around for eons and their potential for toxicity hasn’t changed.

“Now with COVID, and this hypervigilance when it comes to cleanliness, there is increased access and the exposure risk has gone up,” he said.

“One of the sad casualties of an overstressed health care system and a globally depressed environment is worsening behavioral health emergencies and, as part of that, the risk of self-harm goes up,” Dr. Bassett added.

“The consensus is that there has been an exacerbation of behavioral health emergencies and behavioral health needs since COVID started and hand sanitizers are readily accessible to someone who may be looking to self-harm,” he said.

This research had no specific funding. Ms. Richards is the editorial registrar of BMJ Evidence Based Medicine and is developing a website to track preventable deaths. Dr. Bassett disclosed no relevant financial relationships.

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

Cases of poisoning – intentional and unintentional – from ingestion of alcohol-based hand sanitizer have soared during the COVID-19 pandemic.

In the United Kingdom alone, alcohol-based hand sanitizer poisonings reported to the National Poisons Information Service jumped 157% – from 155 between January 1 and September 16, 2019, to 398 between Jan. 1 and Sept. 14, 2020, new research shows.

More needs to be done to protect those at risk of unintentional and intentional swallowing of alcohol-based hand sanitizer, including children, people with dementia/confusion, and those with mental health issues, according to Georgia Richards, DPhil student, Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford (England).

“If providers are supplying alcohol-based hand sanitizers in the community to reduce the spread of SARS-CoV-2, the contents should be supplied in lockable and automated dispensers to reduce contamination and improve safety,” Ms. Richards said in an interview.

The study was published online Dec. 1 in BMJ Evidence-Based Medicine.
 

European, U.S. poisoning rates soar

In the paper Ms. Richards described two deaths that occurred in hospitals in England.

In one case, a 30-year-old woman, detained in a psychiatric unit who received the antidepressant venlafaxine was found dead in her hospital bed with a container of hand-sanitizing gel beside her.

“The gel was readily accessible to patients on the ward from a communal dispenser, and patients were allowed to fill cups or other containers with it to keep in their rooms,” Ms. Richards reported.

A postmortem analysis found a high level of alcohol in her blood (214 mg of alcohol in 100 mL of blood). The medical cause of death was listed as “ingestion of alcohol and venlafaxine.” The coroner concluded that the combination of these substances suppressed the patient’s breathing, leading to her death.

The other case involved a 76-year-old man who unintentionally swallowed an unknown quantity of alcohol-based hand-sanitizing foam attached to the foot of his hospital bed.

The patient had a history of agitation and depression and was treated with antidepressants. He had become increasingly confused over the preceding 9 months, possibly because of vascular dementia.

His blood ethanol concentration was 463 mg/dL (100 mmol/L) initially and 354 mg/dL (77mmol/L) 10 hours later. He was admitted to the ICU, where he received lorazepam and haloperidol and treated with ventilation, with a plan to allow the alcohol to be naturally metabolized.

The patient developed complications and died 6 days later. The primary causes of death were bronchopneumonia and acute alcohol toxicity, secondary to acute delirium and coronary artery disease.

Since COVID-19 started, alcohol-based hand sanitizers are among the most sought-after commodities around the world. The volume of these products – now found in homes, hospitals, schools, workplaces, and elsewhere – “may be a cause for concern,” Ms. Richards wrote.

Yet, warnings about the toxicity and lethality of intentional or unintentional ingestion of these products have not been widely disseminated, she noted.

To reduce the risk of harm, Ms. Richards suggested educating the public and health care professionals, improving warning labels on products, and increasing the awareness and reporting of such exposures to public health authorities.

“While governments and public health authorities have successfully heightened our awareness of, and need for, better hand hygiene during the COVID-19 outbreak, they must also make the public aware of the potential harms and encourage the reporting of such harms to poisons information centers,” she noted.

Increases in alcohol-based hand sanitizer poisoning during the pandemic have also been reported in the United States.

The American Association of Poison Control Centers reports that data from the National Poison Data System show 32,892 hand sanitizer exposure cases reported to the 55 U.S. poison control centers from Jan. 1 to Nov. 15, 2020 – an increase of 73%, compared with the same time period during the previous year.
 

An increase in self-harm

Weighing in on this issue, Robert Bassett, DO, associate medical director of the Poison Control Center at Children’s Hospital of Philadelphia, said in an interview that “cleaning agents and disinfectants have been around for eons and their potential for toxicity hasn’t changed.

“Now with COVID, and this hypervigilance when it comes to cleanliness, there is increased access and the exposure risk has gone up,” he said.

“One of the sad casualties of an overstressed health care system and a globally depressed environment is worsening behavioral health emergencies and, as part of that, the risk of self-harm goes up,” Dr. Bassett added.

“The consensus is that there has been an exacerbation of behavioral health emergencies and behavioral health needs since COVID started and hand sanitizers are readily accessible to someone who may be looking to self-harm,” he said.

This research had no specific funding. Ms. Richards is the editorial registrar of BMJ Evidence Based Medicine and is developing a website to track preventable deaths. Dr. Bassett disclosed no relevant financial relationships.

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

Cases of poisoning – intentional and unintentional – from ingestion of alcohol-based hand sanitizer have soared during the COVID-19 pandemic.

In the United Kingdom alone, alcohol-based hand sanitizer poisonings reported to the National Poisons Information Service jumped 157% – from 155 between January 1 and September 16, 2019, to 398 between Jan. 1 and Sept. 14, 2020, new research shows.

More needs to be done to protect those at risk of unintentional and intentional swallowing of alcohol-based hand sanitizer, including children, people with dementia/confusion, and those with mental health issues, according to Georgia Richards, DPhil student, Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford (England).

“If providers are supplying alcohol-based hand sanitizers in the community to reduce the spread of SARS-CoV-2, the contents should be supplied in lockable and automated dispensers to reduce contamination and improve safety,” Ms. Richards said in an interview.

The study was published online Dec. 1 in BMJ Evidence-Based Medicine.
 

European, U.S. poisoning rates soar

In the paper Ms. Richards described two deaths that occurred in hospitals in England.

In one case, a 30-year-old woman, detained in a psychiatric unit who received the antidepressant venlafaxine was found dead in her hospital bed with a container of hand-sanitizing gel beside her.

“The gel was readily accessible to patients on the ward from a communal dispenser, and patients were allowed to fill cups or other containers with it to keep in their rooms,” Ms. Richards reported.

A postmortem analysis found a high level of alcohol in her blood (214 mg of alcohol in 100 mL of blood). The medical cause of death was listed as “ingestion of alcohol and venlafaxine.” The coroner concluded that the combination of these substances suppressed the patient’s breathing, leading to her death.

The other case involved a 76-year-old man who unintentionally swallowed an unknown quantity of alcohol-based hand-sanitizing foam attached to the foot of his hospital bed.

The patient had a history of agitation and depression and was treated with antidepressants. He had become increasingly confused over the preceding 9 months, possibly because of vascular dementia.

His blood ethanol concentration was 463 mg/dL (100 mmol/L) initially and 354 mg/dL (77mmol/L) 10 hours later. He was admitted to the ICU, where he received lorazepam and haloperidol and treated with ventilation, with a plan to allow the alcohol to be naturally metabolized.

The patient developed complications and died 6 days later. The primary causes of death were bronchopneumonia and acute alcohol toxicity, secondary to acute delirium and coronary artery disease.

Since COVID-19 started, alcohol-based hand sanitizers are among the most sought-after commodities around the world. The volume of these products – now found in homes, hospitals, schools, workplaces, and elsewhere – “may be a cause for concern,” Ms. Richards wrote.

Yet, warnings about the toxicity and lethality of intentional or unintentional ingestion of these products have not been widely disseminated, she noted.

To reduce the risk of harm, Ms. Richards suggested educating the public and health care professionals, improving warning labels on products, and increasing the awareness and reporting of such exposures to public health authorities.

“While governments and public health authorities have successfully heightened our awareness of, and need for, better hand hygiene during the COVID-19 outbreak, they must also make the public aware of the potential harms and encourage the reporting of such harms to poisons information centers,” she noted.

Increases in alcohol-based hand sanitizer poisoning during the pandemic have also been reported in the United States.

The American Association of Poison Control Centers reports that data from the National Poison Data System show 32,892 hand sanitizer exposure cases reported to the 55 U.S. poison control centers from Jan. 1 to Nov. 15, 2020 – an increase of 73%, compared with the same time period during the previous year.
 

An increase in self-harm

Weighing in on this issue, Robert Bassett, DO, associate medical director of the Poison Control Center at Children’s Hospital of Philadelphia, said in an interview that “cleaning agents and disinfectants have been around for eons and their potential for toxicity hasn’t changed.

“Now with COVID, and this hypervigilance when it comes to cleanliness, there is increased access and the exposure risk has gone up,” he said.

“One of the sad casualties of an overstressed health care system and a globally depressed environment is worsening behavioral health emergencies and, as part of that, the risk of self-harm goes up,” Dr. Bassett added.

“The consensus is that there has been an exacerbation of behavioral health emergencies and behavioral health needs since COVID started and hand sanitizers are readily accessible to someone who may be looking to self-harm,” he said.

This research had no specific funding. Ms. Richards is the editorial registrar of BMJ Evidence Based Medicine and is developing a website to track preventable deaths. Dr. Bassett disclosed no relevant financial relationships.

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

If you have been faithfully following the COVID-19 stay-at-home restrictive orders, you may have become a victim of “COVID-15,” the additional, unexpected, unwanted 10- to 15-pound weight gain that is making your clothes not fit so well any more.

dulezidar/Thinkstock

A change in routine; being home in comfy, stretchable clothing in front of the TV; and having unhealthy, processed foods ready to grab have set us up to lose the battle with COVID-15. We are set up to gain the weight because of excessive or unhealthful eating, taking an extra daily shot of alcohol, and being inactive, bored, depressed, anxious, and isolated from coworkers and family. Beware – weight gain can be “catching”; we tend to adopt the same poor eating habits and eat the same junk foods as those around us.

Since psychiatry can be a sedentary profession, I’ve (R.W.C.) kept myself very active and physically fit. Prior to the pandemic, I played tennis and ran every day. I was obese only once in my life. I had not realized that I had gained a lot of weight.

Thankfully, a physician called me “obese.” Initially, I was angry at the doctor, however, I realized that he did me the biggest favor of my life. I changed my diet and eating habits, and for the past 20 years, kept my weight between 135-140 pounds and my BMI at 23 consistently – until the pandemic stress caused me to fall into the same bad eating habits that have caused many others to gain the COVID-15.

I was surprised to see that when I weighed myself, and I had gained 12 pounds! I immediately modified my diet and increased my physical activity. I have now lost the extra 12 pounds and will offer suggestions that may help you and your patients exceed your prepandemic physical condition.
 

Possible solutions

1. Keep a food journal. Write down what you eat, the amount of food you eat, the time you are eating, and your mood at that moment. Keeping a small notebook to record what and when you eat is important because upon review, it will make you face reality and be accountable for what you put in your mouth. Until you review your journal, you may have underestimated the amount, as well as the kinds, of food and drinks you actually consume. A food journal can show your areas of struggle and unhealthy eating habits and help you make necessary changes in your habits and diet to eventually lose weight. You will be less likely to eat junk food or have an extra serving of food. If you do not want to use paper and pencil, you can download an app on your phone, such as myplate tracker to keep track of your food and calorie intake. Do your journaling immediately after you eat and include snacks; do not wait until night time to record your food and journal. Include your mood or how you felt during your meal or snack (for example, were you bored, sad, or anxious) since this information will indicate why you may be overeating.

2. Develop healthful eating habits. Eat a maximum of three meals and three snacks per day but eat only when you are hungry (that is, when your stomach growls or you feel light headed). Limiting yourself to eating only when you are hungry will help eliminate emotional eating to fill a loss in your life or to deal with feelings of stress, anxiety, sadness, or isolation, which have been exacerbated by the pandemic. Buy eat only healthful foods and not items with empty calories, such as chips, cake, and items with sugar. When you are eating, devote yourself to that activity only, eat slowly, and savor each bite. Do not watch television during your meal time.

3. Record the amount and type of exercise you engage in each day and determine the number of calories burned. Walk, run, or bicycle outside, or exercise inside with stretching, weights, or an exercycle. You may use a website, such as diet tool on WebMD.com to calculate daily calories burned. To lose weight, calories burned during a day must exceed caloric intake. You may want to invest in a Fitbit or an Apple Watch and use the health section to determine your caloric intake versus output. Analyzing your caloric data will provide a concrete measure of your progress.

4. Do not overconsume calories or underconsume protein. Protein plays a key role in the creation and maintenance of every cell of your body, and because the body does not store protein, it is important to consume it every day. To meet basic protein requirements, the DRI (Dietary Reference Intake) recommends 0.36 grams of protein per pound (0.8 grams per kg) of body weight. This amounts to: 56 grams per day for the average sedentary man, and 46 grams per day for the average sedentary woman. There is also an app entitled the Protein Tracker that can simplify your calculations.

5. Drink water. It is important to be hydrated to regulate body temperature, keep joints lubricated, prevent infections, deliver nutrients to cells, and keep organs functioning properly. Being well hydrated also improves sleep, cognition, and mood. Your daily water intake by ounce should be equal to your weight in pounds multiplied by two-thirds (or 67%) to determine the amount of water to drink daily. For example, if you weigh 175 pounds, you would multiply 175 by two-thirds and learn that you should be drinking about 117 ounces of water every day. You can also meet some of your daily water requirements by consuming fruits and vegetables, such as tomatoes, watermelon, lettuce, etc.

Also, drink 2 cups (16 oz.) of water before every meal: Often when you feel hungry, it is because your body simply needs water. Science has proven that drinking 2 cups of water before every meal helps you to eat less during meal time and lose weight. If you do this three times daily – at breakfast, lunch, and dinner – you have already consumed 48 ounces of water.
 

6. Keep track of your progress. In addition to keeping and analyzing your food journal, weigh yourself once or twice a week. Do not weigh yourself every day; you will not see any results on a day-to-day basis, but once a week gives your body time to regulate and show progress. Always calibrate/zero your scale before each use, and weigh yourself at the same time of the day (preferably after you first wake up in the morning) while wearing the same type of clothing. Keep a record of your weight in your journal to track your progress. Do not panic if the scale indicates you gained 1, 2, or 3 pounds, your weight can fluctuate because of glycogen storage, sodium retention, human bias, reporting or recall errors, and home scales can have a plus or minus 3 pound margin of error. Look at your weight trend over time. You may prefer buying a scale that indicates both weight and body mass index.

7. Celebrate and reward yourself with nonfood items. A healthful fitness and diet regime requires energy and dedication, so if you are able to follow a healthful routine, reward yourself with nonfood rewards for your good choices and new habits as an incentive to maintain your healthful behavior.

8. Don’t buy it if you can’t stop eating it. The biggest decision you make is when you decide what you are going to buy. Don’t lie to yourself in the store that you will only eat one at a time. Only buy what you can afford to binge eat if you can’t stop yourself from eating any particular type of food.

9. Have someone hide the food you can’t resist. You can’t eat what you can’t find. If you can’t avoid having irresistible food around, ask another adult to hide the food from you.

10. Learn what harm foods can cause in your body. Read about the effects of high blood sugar and high blood pressure can cause in your body. Find out which foods boost your immune system. Demonize the bad foods in your mind. Make up your mind before you go into the store that you are going to read food labels and find the best quality food with the lowest amount of sugar or saturated fat. Appreciate the flavor of vegetables and fruit. Gaining weight will suppress your immune system and make you more susceptible to COVID-19.

11. Treat sugar as if it were an addictive drug. You can’t have just one. If you reduce your craving for sugar by slowly reducing your intake of sugar, you will find that you don’t crave sugar any more. This won’t be easy, but once it is done, you will be preventing many of the ravages that sugar takes on your body over time. But you can’t have one piece of pie because the craving will come back. At some point, it may be more likely that you find that piece of pie too sweet.

Here are a few other ideas: Buy a gift for yourself or new clothes, makeup, a plant or flowers, running shoes, exercise clothes, fitness tracker, water bottle, book, movie or network subscription. Improve your home décor. Or treat yourself to online lessons for painting, music, and so on. Or you might adopt a dog, donate food to a shelter or food bank; or organize and declutter your home since staying busy will give you a reason not to eat. In nice weather, enjoy the outdoors by going for a walk, run, bikeride or by gardening.

We are all worried about getting COVID-19. Preventing COVID-15 will go a long way toward boosting our immune systems to help protect us from the coronavirus.
 

Dr. Cohen is board-certified in psychiatry and has had a private practice in Philadelphia for more than 35 years. His areas of specialty include sports psychiatry, agoraphobia, depression, and substance abuse. In addition, Dr. Cohen is a former professor of psychiatry, family medicine, and otolaryngology at Thomas Jefferson University in Philadelphia. He has no conflicts of interest. Ms. Cohen holds an MBA from Temple University in Philadelphia with a focus on health care administration. Previously, Ms. Cohen was an associate administrator at Hahnemann University Hospital and an executive at the Health Services Council, both in Philadelphia. She currently writes biographical summaries of notable 18th- and 19th-century women. Ms. Cohen has no conflicts of interest.

If you have been faithfully following the COVID-19 stay-at-home restrictive orders, you may have become a victim of “COVID-15,” the additional, unexpected, unwanted 10- to 15-pound weight gain that is making your clothes not fit so well any more.

dulezidar/Thinkstock

A change in routine; being home in comfy, stretchable clothing in front of the TV; and having unhealthy, processed foods ready to grab have set us up to lose the battle with COVID-15. We are set up to gain the weight because of excessive or unhealthful eating, taking an extra daily shot of alcohol, and being inactive, bored, depressed, anxious, and isolated from coworkers and family. Beware – weight gain can be “catching”; we tend to adopt the same poor eating habits and eat the same junk foods as those around us.

Since psychiatry can be a sedentary profession, I’ve (R.W.C.) kept myself very active and physically fit. Prior to the pandemic, I played tennis and ran every day. I was obese only once in my life. I had not realized that I had gained a lot of weight.

Thankfully, a physician called me “obese.” Initially, I was angry at the doctor, however, I realized that he did me the biggest favor of my life. I changed my diet and eating habits, and for the past 20 years, kept my weight between 135-140 pounds and my BMI at 23 consistently – until the pandemic stress caused me to fall into the same bad eating habits that have caused many others to gain the COVID-15.

I was surprised to see that when I weighed myself, and I had gained 12 pounds! I immediately modified my diet and increased my physical activity. I have now lost the extra 12 pounds and will offer suggestions that may help you and your patients exceed your prepandemic physical condition.
 

Possible solutions

1. Keep a food journal. Write down what you eat, the amount of food you eat, the time you are eating, and your mood at that moment. Keeping a small notebook to record what and when you eat is important because upon review, it will make you face reality and be accountable for what you put in your mouth. Until you review your journal, you may have underestimated the amount, as well as the kinds, of food and drinks you actually consume. A food journal can show your areas of struggle and unhealthy eating habits and help you make necessary changes in your habits and diet to eventually lose weight. You will be less likely to eat junk food or have an extra serving of food. If you do not want to use paper and pencil, you can download an app on your phone, such as myplate tracker to keep track of your food and calorie intake. Do your journaling immediately after you eat and include snacks; do not wait until night time to record your food and journal. Include your mood or how you felt during your meal or snack (for example, were you bored, sad, or anxious) since this information will indicate why you may be overeating.

2. Develop healthful eating habits. Eat a maximum of three meals and three snacks per day but eat only when you are hungry (that is, when your stomach growls or you feel light headed). Limiting yourself to eating only when you are hungry will help eliminate emotional eating to fill a loss in your life or to deal with feelings of stress, anxiety, sadness, or isolation, which have been exacerbated by the pandemic. Buy eat only healthful foods and not items with empty calories, such as chips, cake, and items with sugar. When you are eating, devote yourself to that activity only, eat slowly, and savor each bite. Do not watch television during your meal time.

3. Record the amount and type of exercise you engage in each day and determine the number of calories burned. Walk, run, or bicycle outside, or exercise inside with stretching, weights, or an exercycle. You may use a website, such as diet tool on WebMD.com to calculate daily calories burned. To lose weight, calories burned during a day must exceed caloric intake. You may want to invest in a Fitbit or an Apple Watch and use the health section to determine your caloric intake versus output. Analyzing your caloric data will provide a concrete measure of your progress.

4. Do not overconsume calories or underconsume protein. Protein plays a key role in the creation and maintenance of every cell of your body, and because the body does not store protein, it is important to consume it every day. To meet basic protein requirements, the DRI (Dietary Reference Intake) recommends 0.36 grams of protein per pound (0.8 grams per kg) of body weight. This amounts to: 56 grams per day for the average sedentary man, and 46 grams per day for the average sedentary woman. There is also an app entitled the Protein Tracker that can simplify your calculations.

5. Drink water. It is important to be hydrated to regulate body temperature, keep joints lubricated, prevent infections, deliver nutrients to cells, and keep organs functioning properly. Being well hydrated also improves sleep, cognition, and mood. Your daily water intake by ounce should be equal to your weight in pounds multiplied by two-thirds (or 67%) to determine the amount of water to drink daily. For example, if you weigh 175 pounds, you would multiply 175 by two-thirds and learn that you should be drinking about 117 ounces of water every day. You can also meet some of your daily water requirements by consuming fruits and vegetables, such as tomatoes, watermelon, lettuce, etc.

Also, drink 2 cups (16 oz.) of water before every meal: Often when you feel hungry, it is because your body simply needs water. Science has proven that drinking 2 cups of water before every meal helps you to eat less during meal time and lose weight. If you do this three times daily – at breakfast, lunch, and dinner – you have already consumed 48 ounces of water.
 

6. Keep track of your progress. In addition to keeping and analyzing your food journal, weigh yourself once or twice a week. Do not weigh yourself every day; you will not see any results on a day-to-day basis, but once a week gives your body time to regulate and show progress. Always calibrate/zero your scale before each use, and weigh yourself at the same time of the day (preferably after you first wake up in the morning) while wearing the same type of clothing. Keep a record of your weight in your journal to track your progress. Do not panic if the scale indicates you gained 1, 2, or 3 pounds, your weight can fluctuate because of glycogen storage, sodium retention, human bias, reporting or recall errors, and home scales can have a plus or minus 3 pound margin of error. Look at your weight trend over time. You may prefer buying a scale that indicates both weight and body mass index.

7. Celebrate and reward yourself with nonfood items. A healthful fitness and diet regime requires energy and dedication, so if you are able to follow a healthful routine, reward yourself with nonfood rewards for your good choices and new habits as an incentive to maintain your healthful behavior.

8. Don’t buy it if you can’t stop eating it. The biggest decision you make is when you decide what you are going to buy. Don’t lie to yourself in the store that you will only eat one at a time. Only buy what you can afford to binge eat if you can’t stop yourself from eating any particular type of food.

9. Have someone hide the food you can’t resist. You can’t eat what you can’t find. If you can’t avoid having irresistible food around, ask another adult to hide the food from you.

10. Learn what harm foods can cause in your body. Read about the effects of high blood sugar and high blood pressure can cause in your body. Find out which foods boost your immune system. Demonize the bad foods in your mind. Make up your mind before you go into the store that you are going to read food labels and find the best quality food with the lowest amount of sugar or saturated fat. Appreciate the flavor of vegetables and fruit. Gaining weight will suppress your immune system and make you more susceptible to COVID-19.

11. Treat sugar as if it were an addictive drug. You can’t have just one. If you reduce your craving for sugar by slowly reducing your intake of sugar, you will find that you don’t crave sugar any more. This won’t be easy, but once it is done, you will be preventing many of the ravages that sugar takes on your body over time. But you can’t have one piece of pie because the craving will come back. At some point, it may be more likely that you find that piece of pie too sweet.

Here are a few other ideas: Buy a gift for yourself or new clothes, makeup, a plant or flowers, running shoes, exercise clothes, fitness tracker, water bottle, book, movie or network subscription. Improve your home décor. Or treat yourself to online lessons for painting, music, and so on. Or you might adopt a dog, donate food to a shelter or food bank; or organize and declutter your home since staying busy will give you a reason not to eat. In nice weather, enjoy the outdoors by going for a walk, run, bikeride or by gardening.

We are all worried about getting COVID-19. Preventing COVID-15 will go a long way toward boosting our immune systems to help protect us from the coronavirus.
 

Dr. Cohen is board-certified in psychiatry and has had a private practice in Philadelphia for more than 35 years. His areas of specialty include sports psychiatry, agoraphobia, depression, and substance abuse. In addition, Dr. Cohen is a former professor of psychiatry, family medicine, and otolaryngology at Thomas Jefferson University in Philadelphia. He has no conflicts of interest. Ms. Cohen holds an MBA from Temple University in Philadelphia with a focus on health care administration. Previously, Ms. Cohen was an associate administrator at Hahnemann University Hospital and an executive at the Health Services Council, both in Philadelphia. She currently writes biographical summaries of notable 18th- and 19th-century women. Ms. Cohen has no conflicts of interest.

If you have been faithfully following the COVID-19 stay-at-home restrictive orders, you may have become a victim of “COVID-15,” the additional, unexpected, unwanted 10- to 15-pound weight gain that is making your clothes not fit so well any more.

dulezidar/Thinkstock

A change in routine; being home in comfy, stretchable clothing in front of the TV; and having unhealthy, processed foods ready to grab have set us up to lose the battle with COVID-15. We are set up to gain the weight because of excessive or unhealthful eating, taking an extra daily shot of alcohol, and being inactive, bored, depressed, anxious, and isolated from coworkers and family. Beware – weight gain can be “catching”; we tend to adopt the same poor eating habits and eat the same junk foods as those around us.

Since psychiatry can be a sedentary profession, I’ve (R.W.C.) kept myself very active and physically fit. Prior to the pandemic, I played tennis and ran every day. I was obese only once in my life. I had not realized that I had gained a lot of weight.

Thankfully, a physician called me “obese.” Initially, I was angry at the doctor, however, I realized that he did me the biggest favor of my life. I changed my diet and eating habits, and for the past 20 years, kept my weight between 135-140 pounds and my BMI at 23 consistently – until the pandemic stress caused me to fall into the same bad eating habits that have caused many others to gain the COVID-15.

I was surprised to see that when I weighed myself, and I had gained 12 pounds! I immediately modified my diet and increased my physical activity. I have now lost the extra 12 pounds and will offer suggestions that may help you and your patients exceed your prepandemic physical condition.
 

Possible solutions

1. Keep a food journal. Write down what you eat, the amount of food you eat, the time you are eating, and your mood at that moment. Keeping a small notebook to record what and when you eat is important because upon review, it will make you face reality and be accountable for what you put in your mouth. Until you review your journal, you may have underestimated the amount, as well as the kinds, of food and drinks you actually consume. A food journal can show your areas of struggle and unhealthy eating habits and help you make necessary changes in your habits and diet to eventually lose weight. You will be less likely to eat junk food or have an extra serving of food. If you do not want to use paper and pencil, you can download an app on your phone, such as myplate tracker to keep track of your food and calorie intake. Do your journaling immediately after you eat and include snacks; do not wait until night time to record your food and journal. Include your mood or how you felt during your meal or snack (for example, were you bored, sad, or anxious) since this information will indicate why you may be overeating.

2. Develop healthful eating habits. Eat a maximum of three meals and three snacks per day but eat only when you are hungry (that is, when your stomach growls or you feel light headed). Limiting yourself to eating only when you are hungry will help eliminate emotional eating to fill a loss in your life or to deal with feelings of stress, anxiety, sadness, or isolation, which have been exacerbated by the pandemic. Buy eat only healthful foods and not items with empty calories, such as chips, cake, and items with sugar. When you are eating, devote yourself to that activity only, eat slowly, and savor each bite. Do not watch television during your meal time.

3. Record the amount and type of exercise you engage in each day and determine the number of calories burned. Walk, run, or bicycle outside, or exercise inside with stretching, weights, or an exercycle. You may use a website, such as diet tool on WebMD.com to calculate daily calories burned. To lose weight, calories burned during a day must exceed caloric intake. You may want to invest in a Fitbit or an Apple Watch and use the health section to determine your caloric intake versus output. Analyzing your caloric data will provide a concrete measure of your progress.

4. Do not overconsume calories or underconsume protein. Protein plays a key role in the creation and maintenance of every cell of your body, and because the body does not store protein, it is important to consume it every day. To meet basic protein requirements, the DRI (Dietary Reference Intake) recommends 0.36 grams of protein per pound (0.8 grams per kg) of body weight. This amounts to: 56 grams per day for the average sedentary man, and 46 grams per day for the average sedentary woman. There is also an app entitled the Protein Tracker that can simplify your calculations.

5. Drink water. It is important to be hydrated to regulate body temperature, keep joints lubricated, prevent infections, deliver nutrients to cells, and keep organs functioning properly. Being well hydrated also improves sleep, cognition, and mood. Your daily water intake by ounce should be equal to your weight in pounds multiplied by two-thirds (or 67%) to determine the amount of water to drink daily. For example, if you weigh 175 pounds, you would multiply 175 by two-thirds and learn that you should be drinking about 117 ounces of water every day. You can also meet some of your daily water requirements by consuming fruits and vegetables, such as tomatoes, watermelon, lettuce, etc.

Also, drink 2 cups (16 oz.) of water before every meal: Often when you feel hungry, it is because your body simply needs water. Science has proven that drinking 2 cups of water before every meal helps you to eat less during meal time and lose weight. If you do this three times daily – at breakfast, lunch, and dinner – you have already consumed 48 ounces of water.
 

6. Keep track of your progress. In addition to keeping and analyzing your food journal, weigh yourself once or twice a week. Do not weigh yourself every day; you will not see any results on a day-to-day basis, but once a week gives your body time to regulate and show progress. Always calibrate/zero your scale before each use, and weigh yourself at the same time of the day (preferably after you first wake up in the morning) while wearing the same type of clothing. Keep a record of your weight in your journal to track your progress. Do not panic if the scale indicates you gained 1, 2, or 3 pounds, your weight can fluctuate because of glycogen storage, sodium retention, human bias, reporting or recall errors, and home scales can have a plus or minus 3 pound margin of error. Look at your weight trend over time. You may prefer buying a scale that indicates both weight and body mass index.

7. Celebrate and reward yourself with nonfood items. A healthful fitness and diet regime requires energy and dedication, so if you are able to follow a healthful routine, reward yourself with nonfood rewards for your good choices and new habits as an incentive to maintain your healthful behavior.

8. Don’t buy it if you can’t stop eating it. The biggest decision you make is when you decide what you are going to buy. Don’t lie to yourself in the store that you will only eat one at a time. Only buy what you can afford to binge eat if you can’t stop yourself from eating any particular type of food.

9. Have someone hide the food you can’t resist. You can’t eat what you can’t find. If you can’t avoid having irresistible food around, ask another adult to hide the food from you.

10. Learn what harm foods can cause in your body. Read about the effects of high blood sugar and high blood pressure can cause in your body. Find out which foods boost your immune system. Demonize the bad foods in your mind. Make up your mind before you go into the store that you are going to read food labels and find the best quality food with the lowest amount of sugar or saturated fat. Appreciate the flavor of vegetables and fruit. Gaining weight will suppress your immune system and make you more susceptible to COVID-19.

11. Treat sugar as if it were an addictive drug. You can’t have just one. If you reduce your craving for sugar by slowly reducing your intake of sugar, you will find that you don’t crave sugar any more. This won’t be easy, but once it is done, you will be preventing many of the ravages that sugar takes on your body over time. But you can’t have one piece of pie because the craving will come back. At some point, it may be more likely that you find that piece of pie too sweet.

Here are a few other ideas: Buy a gift for yourself or new clothes, makeup, a plant or flowers, running shoes, exercise clothes, fitness tracker, water bottle, book, movie or network subscription. Improve your home décor. Or treat yourself to online lessons for painting, music, and so on. Or you might adopt a dog, donate food to a shelter or food bank; or organize and declutter your home since staying busy will give you a reason not to eat. In nice weather, enjoy the outdoors by going for a walk, run, bikeride or by gardening.

We are all worried about getting COVID-19. Preventing COVID-15 will go a long way toward boosting our immune systems to help protect us from the coronavirus.
 

Dr. Cohen is board-certified in psychiatry and has had a private practice in Philadelphia for more than 35 years. His areas of specialty include sports psychiatry, agoraphobia, depression, and substance abuse. In addition, Dr. Cohen is a former professor of psychiatry, family medicine, and otolaryngology at Thomas Jefferson University in Philadelphia. He has no conflicts of interest. Ms. Cohen holds an MBA from Temple University in Philadelphia with a focus on health care administration. Previously, Ms. Cohen was an associate administrator at Hahnemann University Hospital and an executive at the Health Services Council, both in Philadelphia. She currently writes biographical summaries of notable 18th- and 19th-century women. Ms. Cohen has no conflicts of interest.

CASE A passive wish to die

Ms. M, age 76, has a history of major depressive disorder, unspecified anxiety disorder, and severe chronic obstructive pulmonary disease (COPD), for which she requires supplemental oxygen. She is admitted to a psychiatric hospital after several months of increased dysphoria, rumination, anhedonia, and a passive wish to die. She also has a decreased appetite and has lost 10 lb, experiences frequent daily episodes of shortness of breath and associated racing thoughts, and has a rapid heart rate.

HISTORY Past medication trials

In addition to COPD, Ms. M’s medical history includes hypertension. Past psychotropic medication trials used to treat her depression and anxiety have included aripiprazole, 5 mg/d; duloxetine, 60 mg/d; fluoxetine, 40 mg/d; mirtazapine, 30 mg nightly; buspirone, 10 mg twice daily; and clonazepam, 0.5 mg twice daily. She has no history of psychotherapy, and because of her uncontrolled anxiety and depression, she has never completed a pulmonary rehabilitation program.

Her current medications include salmeterol, 50 mcg inhaled twice daily, for COPD; amlodipine, 10 mg/d, for hypertension; buspirone, 10 mg twice daily, for anxiety; and duloxetine, 60 mg/d, for depression.

EXAMINATION No evidence of dementia

On examination, Ms. M is alert and oriented to person, place, date, and situation. Overall, she has mild difficulty with attention and short-term recall, which appears to be due to poor effort; intact long-term memory; and is able to abstract appropriately. There is no evidence of dementia.

A mental status exam reveals a frail, elderly woman with fair-to-poor hygiene, cooperative behavior, slowed motor activity, slowed speech with low volume, low mood, and depressed affect with constricted range. Her thought process is linear, her thought content includes passive death wishes, and she does not have hallucinations.

Bitemporal electroconvulsive therapy (ECT), 1.0 ms pulse width at 1.5 times Ms. M’s seizure threshold 3 times weekly, is initiated to treat her depression, with seizure duration averaging 45 seconds for each session. She receives a total of 8 treatments over the course of admission. Buspirone, 10 mg twice daily, is stopped shortly after admission, but she continues to receive duloxetine, 60 mg/d. Ms. M continues to have shortness of breath, palpitations, fearful ruminations about the future, and difficulty falling asleep.

[polldaddy:10673878]

The authors’ observations

The treatment team explores other options, such as benzodiazepines, psychotherapy modalities, and mindfulness exercises, to treat Ms. M’s anxiety and comorbid COPD. Lorazepam, 0.5 mg twice daily, was chosen to treat her acute anxiety. Due to Ms. M’s need for supplemental oxygen, the treatment team attempted to mitigate the risk of using a benzodiazepine by limiting its use to the minimum effective dose. The teams also looked for alternative therapies.

Continue to: Evalution of anxiety...

Evaluation of anxiety and depression in a patient with COPD is complicated by a high degree of symptom overlap. Patients with COPD may experience anxiety symptoms such as shortness of breath, rapid heart rate, numbness/tingling, and racing thoughts, and/or depressive symptoms such as decreased energy, impaired sleep, and impaired concentration. It can therefore be difficult to discern if a symptom is attributable to the physical diagnosis, the psychiatric diagnosis, or a combination of both. Catastrophic thinking about mild physical symptoms is common in patients with COPD. This can lead to hyperventilation and hypocapnia (manifested by lightheadedness, dizziness, paresthesia, and altered consciousness), with a reciprocally escalating cascade of anxiety and somatic symptoms.¹

First-line therapy for anxiety disorders with comorbid COPD is CBT and other nonpharmacologic interventions.^2,3However, access to CBT-trained psychotherapists is limited due to the cost and a shortage of qualified professionals.⁴ One randomized clinical trial evaluated improving accessibility to this therapy by training respiratory therapists to perform CBT sessions for COPD patients who were anxious and depressed.⁴ This method was as successful as using CBT-trained psychotherapists, and also reduced emergency room visits and hospitalizations in this population.⁴ Respiratory therapists often intuitively use CBT concepts in coaching patients and generally have the knowledge and background to be able to help patients identify symptoms caused by anxiety vs when to seek additional medical support. Furthermore, these interventions have been shown to increase quality-adjusted life years,⁴ improve physical performance, and reduce symptoms of anxiety and depression as reported on the Beck Anxiety Inventory and Beck Depression Inventory.⁵ In addition to relaxation/imagery training, cognitive restructuring, breathing retraining, and maintaining daily symptom logs, CBT for COPD may include interoceptive exposure therapy. This technique involves deliberately inducing hyperventilation, followed by desensitization exercises to uncouple any uncomfortable physical sensations with the conditioned fear response.¹

Although there is little evidence that traditional pharmacologic treatments (eg, antidepressants, benzodiazepines) have a statistically significant effect on anxiety and depression in COPD, studies have found that they have some clinical benefit.³ Risks, however, limit the utility of certain agents. Sedative-hypnotics potentially decrease respiratory drive and, particularly in older patients, antidepressants’ sedating effects can increase the risk of falls³ leading to increased morbidity, hospitalization, and mortality.

TREATMENT Mindfulness techniques and meditation

Ms. M’s symptoms show no improvement with the addition of lorazepam, 0.5 mg twice daily. A clinician teaches Ms. M mindfulness techniques, and she begins a trial of daily, individual, guided meditation using a meditation app. Respiratory therapists also instruct her on controlled breathing techniques such as pursed-lips breathing, diaphragmatic breathing, and deep breathing. They also encourage Ms. M to participate in the daily exercise group while on the unit.

[polldaddy:10673881]

The authors’ observations

Research indicates that low doses of opioids are safe and effective for refractory breathlessness in patients with severe COPD(those with an arterial partial pressure of oxygen ≤55 mm Hg or arterial oxygen saturation ≤88%).^6,7 Patients at this advanced stage of illness have likely been started on oxygen therapy to improve survival but may need additional palliative measures to alleviate the discomfort associated with the severe breathlessness experienced at this stage.⁸ In such situations, low-dose opioids, such as immediate-release morphine, 1 mg/d given as 0.5 mg twice daily, can be started.⁸ The dose can be increased by 0.5 mg until a therapeutic dose is achieved.⁸ Alternately, 24-hour extended-release morphine, 20 mg/d, or an equivalent dose of oxycodone or hydromorphone, can be prescribed.⁸ The proposed therapeutic mechanisms of low-dose opioids for these patients include decreasing one’s sense of effort, altering central perception, altering activity of peripheral opioid receptors located in the lung, and decreasing anxiety.⁸

Continue to: The current opioid crisis...

The current opioid crisis prompts additional caution in prescribing, especially when considering using short-acting, immediate-release opioids such as morphine, which have a greater potential for abuse and dependence. The Table lists safeguards that should be implemented when prescribing opioids.

Many patients with COPD in the end-of-life phase and in severe pain or discomfort due to the advanced stages of their illness receive opioids as part of palliative care. Patients with COPD whose medical care is predominantly palliative may benefit greatly from being prescribed opioids. Most patients with COPD who find relief from low-dose opioids usually have 6 to 12 months to live, and low-dose opioids may help them obtain the best possible quality of life.

Choosing opioids as a treatment involves the risk of physiologic dependence and opioid use disorder. For Ms. M, the potential benefits were thought to outweigh such risks.

OUTCOME Breathlessness improves, anxiety decreases

Ms. M’s lorazepam is discontinued, and immediate-release morphine is prescribed at a low dose of 1 mg/d on an as-needed basis for anxiety with good effect. Ms. M’s breathlessness improves, leading to an overall decrease in anxiety. She does not experience sedation, confusion, or adverse respiratory effects.

Ms. M’s anxiety and depression improve over the course of the hospitalization with this regimen. On hospital Day 25, she is discharged with a plan to continue duloxetine, 60 mg/d, ECT twice weekly, and low-dose morphine, 1 mg/d, as needed for anxiety. She is referred for pulmonary rehabilitation and CBT to maintain remission.

[polldaddy:10673882]

Continue to: The authors' observations

Ms. M’s case highlights several challenges associated with treating psychiatric illness in a patient with a chronic medical illness. The relationship between COPD, anxiety, and depression is complex, and is associated with reduced quality of life, increasing severity of pulmonary disease, increased dyspnea, a sense of loss and inability to cope, and decreased self-efficacy and adherence to treatment.^9-11Adding supplemental oxygen has been shown to improve longevity, and may help boost mood and lessen anxiety in some patients, whereas others find its restrictions burdensome and demoralizing.⁸ Pulmonary rehabilitation programs are a key component of both secondary prevention and treatment in improving overall health outcomes in patients with COPD,¹² and can be started at any stage of the illness. However, patients with comorbid anxiety and depression are often the least likely to engage in these programs.^4,13 One program that offered management of depression and COPD care with a focus on misconceptions about treatment and obstacles to treatment engagement reduced depressive symptoms and dyspnea-related disability, which led to greater remission of depression.^14,15 Exercise training in such programs also helps manage avoidance of physical activity due to fear of dyspnea by allowing patients to experience feared symptoms in the presence of medical professionals, similar to the CBT interoceptive exposure technique described earlier.¹ Several traditional treatment modalities used to target Ms. M’s anxiety disorder were unsuccessful. Low-dose, as-needed opioids are a safe and useful pharmacologic option worth considering for patients with refractory anxiety and depression and comorbid COPD.

Bottom Line

When traditional antidepressant and anxiolytic therapies have not sufficiently helped, consider low-dose, once-daily opioids to address refractory breathlessness in a patient with COPD with comorbid anxiety and depression. This treatment can lead patients to participate in rehabilitation therapies and improve their quality of life.

Related Resources

• Alexopoulos G, Kiosses D, Sirey J, et al. Untangling therapeutic ingredients of a personalized intervention for patients with depression and severe COPD. Am J Geriatr Psychiatry. 2014;22(11):1316-1324.
• Jackson D, Banerjee S, Sirey J, et al. Two interventions for patients with major depression and severe chronic obstructive pulmonary disease: impact on quality of life. Am J Geriatr Psychiatry. 2018;27(5):502-511.

Drug Brand Names

Amlodipine • Norvasc
Aripiprazole • Abilify
Buspirone • Buspar
Clonazepam • Klonopin
Duloxetine • Cymbalta
Fluoxetine • Prozac
Hydromorphone • Dilaudid
Levodopa • Sinemet
Lorazepam • Ativan
Mirtazapine • Remeron
Morphine • MS Contin
Naloxone • Narcan
Oxycodone • Oxycontin
Salmeterol • Serevent Diskus

CASE A passive wish to die

Ms. M, age 76, has a history of major depressive disorder, unspecified anxiety disorder, and severe chronic obstructive pulmonary disease (COPD), for which she requires supplemental oxygen. She is admitted to a psychiatric hospital after several months of increased dysphoria, rumination, anhedonia, and a passive wish to die. She also has a decreased appetite and has lost 10 lb, experiences frequent daily episodes of shortness of breath and associated racing thoughts, and has a rapid heart rate.

HISTORY Past medication trials

In addition to COPD, Ms. M’s medical history includes hypertension. Past psychotropic medication trials used to treat her depression and anxiety have included aripiprazole, 5 mg/d; duloxetine, 60 mg/d; fluoxetine, 40 mg/d; mirtazapine, 30 mg nightly; buspirone, 10 mg twice daily; and clonazepam, 0.5 mg twice daily. She has no history of psychotherapy, and because of her uncontrolled anxiety and depression, she has never completed a pulmonary rehabilitation program.

Her current medications include salmeterol, 50 mcg inhaled twice daily, for COPD; amlodipine, 10 mg/d, for hypertension; buspirone, 10 mg twice daily, for anxiety; and duloxetine, 60 mg/d, for depression.

EXAMINATION No evidence of dementia

On examination, Ms. M is alert and oriented to person, place, date, and situation. Overall, she has mild difficulty with attention and short-term recall, which appears to be due to poor effort; intact long-term memory; and is able to abstract appropriately. There is no evidence of dementia.

A mental status exam reveals a frail, elderly woman with fair-to-poor hygiene, cooperative behavior, slowed motor activity, slowed speech with low volume, low mood, and depressed affect with constricted range. Her thought process is linear, her thought content includes passive death wishes, and she does not have hallucinations.

Bitemporal electroconvulsive therapy (ECT), 1.0 ms pulse width at 1.5 times Ms. M’s seizure threshold 3 times weekly, is initiated to treat her depression, with seizure duration averaging 45 seconds for each session. She receives a total of 8 treatments over the course of admission. Buspirone, 10 mg twice daily, is stopped shortly after admission, but she continues to receive duloxetine, 60 mg/d. Ms. M continues to have shortness of breath, palpitations, fearful ruminations about the future, and difficulty falling asleep.

[polldaddy:10673878]

The authors’ observations

The treatment team explores other options, such as benzodiazepines, psychotherapy modalities, and mindfulness exercises, to treat Ms. M’s anxiety and comorbid COPD. Lorazepam, 0.5 mg twice daily, was chosen to treat her acute anxiety. Due to Ms. M’s need for supplemental oxygen, the treatment team attempted to mitigate the risk of using a benzodiazepine by limiting its use to the minimum effective dose. The teams also looked for alternative therapies.

Continue to: Evalution of anxiety...

Evaluation of anxiety and depression in a patient with COPD is complicated by a high degree of symptom overlap. Patients with COPD may experience anxiety symptoms such as shortness of breath, rapid heart rate, numbness/tingling, and racing thoughts, and/or depressive symptoms such as decreased energy, impaired sleep, and impaired concentration. It can therefore be difficult to discern if a symptom is attributable to the physical diagnosis, the psychiatric diagnosis, or a combination of both. Catastrophic thinking about mild physical symptoms is common in patients with COPD. This can lead to hyperventilation and hypocapnia (manifested by lightheadedness, dizziness, paresthesia, and altered consciousness), with a reciprocally escalating cascade of anxiety and somatic symptoms.¹

First-line therapy for anxiety disorders with comorbid COPD is CBT and other nonpharmacologic interventions.^2,3However, access to CBT-trained psychotherapists is limited due to the cost and a shortage of qualified professionals.⁴ One randomized clinical trial evaluated improving accessibility to this therapy by training respiratory therapists to perform CBT sessions for COPD patients who were anxious and depressed.⁴ This method was as successful as using CBT-trained psychotherapists, and also reduced emergency room visits and hospitalizations in this population.⁴ Respiratory therapists often intuitively use CBT concepts in coaching patients and generally have the knowledge and background to be able to help patients identify symptoms caused by anxiety vs when to seek additional medical support. Furthermore, these interventions have been shown to increase quality-adjusted life years,⁴ improve physical performance, and reduce symptoms of anxiety and depression as reported on the Beck Anxiety Inventory and Beck Depression Inventory.⁵ In addition to relaxation/imagery training, cognitive restructuring, breathing retraining, and maintaining daily symptom logs, CBT for COPD may include interoceptive exposure therapy. This technique involves deliberately inducing hyperventilation, followed by desensitization exercises to uncouple any uncomfortable physical sensations with the conditioned fear response.¹

Although there is little evidence that traditional pharmacologic treatments (eg, antidepressants, benzodiazepines) have a statistically significant effect on anxiety and depression in COPD, studies have found that they have some clinical benefit.³ Risks, however, limit the utility of certain agents. Sedative-hypnotics potentially decrease respiratory drive and, particularly in older patients, antidepressants’ sedating effects can increase the risk of falls³ leading to increased morbidity, hospitalization, and mortality.

TREATMENT Mindfulness techniques and meditation

Ms. M’s symptoms show no improvement with the addition of lorazepam, 0.5 mg twice daily. A clinician teaches Ms. M mindfulness techniques, and she begins a trial of daily, individual, guided meditation using a meditation app. Respiratory therapists also instruct her on controlled breathing techniques such as pursed-lips breathing, diaphragmatic breathing, and deep breathing. They also encourage Ms. M to participate in the daily exercise group while on the unit.

[polldaddy:10673881]

The authors’ observations

Research indicates that low doses of opioids are safe and effective for refractory breathlessness in patients with severe COPD(those with an arterial partial pressure of oxygen ≤55 mm Hg or arterial oxygen saturation ≤88%).^6,7 Patients at this advanced stage of illness have likely been started on oxygen therapy to improve survival but may need additional palliative measures to alleviate the discomfort associated with the severe breathlessness experienced at this stage.⁸ In such situations, low-dose opioids, such as immediate-release morphine, 1 mg/d given as 0.5 mg twice daily, can be started.⁸ The dose can be increased by 0.5 mg until a therapeutic dose is achieved.⁸ Alternately, 24-hour extended-release morphine, 20 mg/d, or an equivalent dose of oxycodone or hydromorphone, can be prescribed.⁸ The proposed therapeutic mechanisms of low-dose opioids for these patients include decreasing one’s sense of effort, altering central perception, altering activity of peripheral opioid receptors located in the lung, and decreasing anxiety.⁸

Continue to: The current opioid crisis...

The current opioid crisis prompts additional caution in prescribing, especially when considering using short-acting, immediate-release opioids such as morphine, which have a greater potential for abuse and dependence. The Table lists safeguards that should be implemented when prescribing opioids.

Many patients with COPD in the end-of-life phase and in severe pain or discomfort due to the advanced stages of their illness receive opioids as part of palliative care. Patients with COPD whose medical care is predominantly palliative may benefit greatly from being prescribed opioids. Most patients with COPD who find relief from low-dose opioids usually have 6 to 12 months to live, and low-dose opioids may help them obtain the best possible quality of life.

Choosing opioids as a treatment involves the risk of physiologic dependence and opioid use disorder. For Ms. M, the potential benefits were thought to outweigh such risks.

OUTCOME Breathlessness improves, anxiety decreases

Ms. M’s lorazepam is discontinued, and immediate-release morphine is prescribed at a low dose of 1 mg/d on an as-needed basis for anxiety with good effect. Ms. M’s breathlessness improves, leading to an overall decrease in anxiety. She does not experience sedation, confusion, or adverse respiratory effects.

Ms. M’s anxiety and depression improve over the course of the hospitalization with this regimen. On hospital Day 25, she is discharged with a plan to continue duloxetine, 60 mg/d, ECT twice weekly, and low-dose morphine, 1 mg/d, as needed for anxiety. She is referred for pulmonary rehabilitation and CBT to maintain remission.

[polldaddy:10673882]

Continue to: The authors' observations

Ms. M’s case highlights several challenges associated with treating psychiatric illness in a patient with a chronic medical illness. The relationship between COPD, anxiety, and depression is complex, and is associated with reduced quality of life, increasing severity of pulmonary disease, increased dyspnea, a sense of loss and inability to cope, and decreased self-efficacy and adherence to treatment.^9-11Adding supplemental oxygen has been shown to improve longevity, and may help boost mood and lessen anxiety in some patients, whereas others find its restrictions burdensome and demoralizing.⁸ Pulmonary rehabilitation programs are a key component of both secondary prevention and treatment in improving overall health outcomes in patients with COPD,¹² and can be started at any stage of the illness. However, patients with comorbid anxiety and depression are often the least likely to engage in these programs.^4,13 One program that offered management of depression and COPD care with a focus on misconceptions about treatment and obstacles to treatment engagement reduced depressive symptoms and dyspnea-related disability, which led to greater remission of depression.^14,15 Exercise training in such programs also helps manage avoidance of physical activity due to fear of dyspnea by allowing patients to experience feared symptoms in the presence of medical professionals, similar to the CBT interoceptive exposure technique described earlier.¹ Several traditional treatment modalities used to target Ms. M’s anxiety disorder were unsuccessful. Low-dose, as-needed opioids are a safe and useful pharmacologic option worth considering for patients with refractory anxiety and depression and comorbid COPD.

Bottom Line

When traditional antidepressant and anxiolytic therapies have not sufficiently helped, consider low-dose, once-daily opioids to address refractory breathlessness in a patient with COPD with comorbid anxiety and depression. This treatment can lead patients to participate in rehabilitation therapies and improve their quality of life.

Related Resources

• Alexopoulos G, Kiosses D, Sirey J, et al. Untangling therapeutic ingredients of a personalized intervention for patients with depression and severe COPD. Am J Geriatr Psychiatry. 2014;22(11):1316-1324.
• Jackson D, Banerjee S, Sirey J, et al. Two interventions for patients with major depression and severe chronic obstructive pulmonary disease: impact on quality of life. Am J Geriatr Psychiatry. 2018;27(5):502-511.

Drug Brand Names

Amlodipine • Norvasc
Aripiprazole • Abilify
Buspirone • Buspar
Clonazepam • Klonopin
Duloxetine • Cymbalta
Fluoxetine • Prozac
Hydromorphone • Dilaudid
Levodopa • Sinemet
Lorazepam • Ativan
Mirtazapine • Remeron
Morphine • MS Contin
Naloxone • Narcan
Oxycodone • Oxycontin
Salmeterol • Serevent Diskus

CASE A passive wish to die

Ms. M, age 76, has a history of major depressive disorder, unspecified anxiety disorder, and severe chronic obstructive pulmonary disease (COPD), for which she requires supplemental oxygen. She is admitted to a psychiatric hospital after several months of increased dysphoria, rumination, anhedonia, and a passive wish to die. She also has a decreased appetite and has lost 10 lb, experiences frequent daily episodes of shortness of breath and associated racing thoughts, and has a rapid heart rate.

HISTORY Past medication trials

In addition to COPD, Ms. M’s medical history includes hypertension. Past psychotropic medication trials used to treat her depression and anxiety have included aripiprazole, 5 mg/d; duloxetine, 60 mg/d; fluoxetine, 40 mg/d; mirtazapine, 30 mg nightly; buspirone, 10 mg twice daily; and clonazepam, 0.5 mg twice daily. She has no history of psychotherapy, and because of her uncontrolled anxiety and depression, she has never completed a pulmonary rehabilitation program.

Her current medications include salmeterol, 50 mcg inhaled twice daily, for COPD; amlodipine, 10 mg/d, for hypertension; buspirone, 10 mg twice daily, for anxiety; and duloxetine, 60 mg/d, for depression.

EXAMINATION No evidence of dementia

On examination, Ms. M is alert and oriented to person, place, date, and situation. Overall, she has mild difficulty with attention and short-term recall, which appears to be due to poor effort; intact long-term memory; and is able to abstract appropriately. There is no evidence of dementia.

A mental status exam reveals a frail, elderly woman with fair-to-poor hygiene, cooperative behavior, slowed motor activity, slowed speech with low volume, low mood, and depressed affect with constricted range. Her thought process is linear, her thought content includes passive death wishes, and she does not have hallucinations.

Bitemporal electroconvulsive therapy (ECT), 1.0 ms pulse width at 1.5 times Ms. M’s seizure threshold 3 times weekly, is initiated to treat her depression, with seizure duration averaging 45 seconds for each session. She receives a total of 8 treatments over the course of admission. Buspirone, 10 mg twice daily, is stopped shortly after admission, but she continues to receive duloxetine, 60 mg/d. Ms. M continues to have shortness of breath, palpitations, fearful ruminations about the future, and difficulty falling asleep.

[polldaddy:10673878]

The authors’ observations

The treatment team explores other options, such as benzodiazepines, psychotherapy modalities, and mindfulness exercises, to treat Ms. M’s anxiety and comorbid COPD. Lorazepam, 0.5 mg twice daily, was chosen to treat her acute anxiety. Due to Ms. M’s need for supplemental oxygen, the treatment team attempted to mitigate the risk of using a benzodiazepine by limiting its use to the minimum effective dose. The teams also looked for alternative therapies.

Continue to: Evalution of anxiety...

Evaluation of anxiety and depression in a patient with COPD is complicated by a high degree of symptom overlap. Patients with COPD may experience anxiety symptoms such as shortness of breath, rapid heart rate, numbness/tingling, and racing thoughts, and/or depressive symptoms such as decreased energy, impaired sleep, and impaired concentration. It can therefore be difficult to discern if a symptom is attributable to the physical diagnosis, the psychiatric diagnosis, or a combination of both. Catastrophic thinking about mild physical symptoms is common in patients with COPD. This can lead to hyperventilation and hypocapnia (manifested by lightheadedness, dizziness, paresthesia, and altered consciousness), with a reciprocally escalating cascade of anxiety and somatic symptoms.¹

First-line therapy for anxiety disorders with comorbid COPD is CBT and other nonpharmacologic interventions.^2,3However, access to CBT-trained psychotherapists is limited due to the cost and a shortage of qualified professionals.⁴ One randomized clinical trial evaluated improving accessibility to this therapy by training respiratory therapists to perform CBT sessions for COPD patients who were anxious and depressed.⁴ This method was as successful as using CBT-trained psychotherapists, and also reduced emergency room visits and hospitalizations in this population.⁴ Respiratory therapists often intuitively use CBT concepts in coaching patients and generally have the knowledge and background to be able to help patients identify symptoms caused by anxiety vs when to seek additional medical support. Furthermore, these interventions have been shown to increase quality-adjusted life years,⁴ improve physical performance, and reduce symptoms of anxiety and depression as reported on the Beck Anxiety Inventory and Beck Depression Inventory.⁵ In addition to relaxation/imagery training, cognitive restructuring, breathing retraining, and maintaining daily symptom logs, CBT for COPD may include interoceptive exposure therapy. This technique involves deliberately inducing hyperventilation, followed by desensitization exercises to uncouple any uncomfortable physical sensations with the conditioned fear response.¹

Although there is little evidence that traditional pharmacologic treatments (eg, antidepressants, benzodiazepines) have a statistically significant effect on anxiety and depression in COPD, studies have found that they have some clinical benefit.³ Risks, however, limit the utility of certain agents. Sedative-hypnotics potentially decrease respiratory drive and, particularly in older patients, antidepressants’ sedating effects can increase the risk of falls³ leading to increased morbidity, hospitalization, and mortality.

TREATMENT Mindfulness techniques and meditation

Ms. M’s symptoms show no improvement with the addition of lorazepam, 0.5 mg twice daily. A clinician teaches Ms. M mindfulness techniques, and she begins a trial of daily, individual, guided meditation using a meditation app. Respiratory therapists also instruct her on controlled breathing techniques such as pursed-lips breathing, diaphragmatic breathing, and deep breathing. They also encourage Ms. M to participate in the daily exercise group while on the unit.

[polldaddy:10673881]

The authors’ observations

Research indicates that low doses of opioids are safe and effective for refractory breathlessness in patients with severe COPD(those with an arterial partial pressure of oxygen ≤55 mm Hg or arterial oxygen saturation ≤88%).^6,7 Patients at this advanced stage of illness have likely been started on oxygen therapy to improve survival but may need additional palliative measures to alleviate the discomfort associated with the severe breathlessness experienced at this stage.⁸ In such situations, low-dose opioids, such as immediate-release morphine, 1 mg/d given as 0.5 mg twice daily, can be started.⁸ The dose can be increased by 0.5 mg until a therapeutic dose is achieved.⁸ Alternately, 24-hour extended-release morphine, 20 mg/d, or an equivalent dose of oxycodone or hydromorphone, can be prescribed.⁸ The proposed therapeutic mechanisms of low-dose opioids for these patients include decreasing one’s sense of effort, altering central perception, altering activity of peripheral opioid receptors located in the lung, and decreasing anxiety.⁸

Continue to: The current opioid crisis...

The current opioid crisis prompts additional caution in prescribing, especially when considering using short-acting, immediate-release opioids such as morphine, which have a greater potential for abuse and dependence. The Table lists safeguards that should be implemented when prescribing opioids.

Many patients with COPD in the end-of-life phase and in severe pain or discomfort due to the advanced stages of their illness receive opioids as part of palliative care. Patients with COPD whose medical care is predominantly palliative may benefit greatly from being prescribed opioids. Most patients with COPD who find relief from low-dose opioids usually have 6 to 12 months to live, and low-dose opioids may help them obtain the best possible quality of life.

Choosing opioids as a treatment involves the risk of physiologic dependence and opioid use disorder. For Ms. M, the potential benefits were thought to outweigh such risks.

OUTCOME Breathlessness improves, anxiety decreases

Ms. M’s lorazepam is discontinued, and immediate-release morphine is prescribed at a low dose of 1 mg/d on an as-needed basis for anxiety with good effect. Ms. M’s breathlessness improves, leading to an overall decrease in anxiety. She does not experience sedation, confusion, or adverse respiratory effects.

Ms. M’s anxiety and depression improve over the course of the hospitalization with this regimen. On hospital Day 25, she is discharged with a plan to continue duloxetine, 60 mg/d, ECT twice weekly, and low-dose morphine, 1 mg/d, as needed for anxiety. She is referred for pulmonary rehabilitation and CBT to maintain remission.

[polldaddy:10673882]

Continue to: The authors' observations

Ms. M’s case highlights several challenges associated with treating psychiatric illness in a patient with a chronic medical illness. The relationship between COPD, anxiety, and depression is complex, and is associated with reduced quality of life, increasing severity of pulmonary disease, increased dyspnea, a sense of loss and inability to cope, and decreased self-efficacy and adherence to treatment.^9-11Adding supplemental oxygen has been shown to improve longevity, and may help boost mood and lessen anxiety in some patients, whereas others find its restrictions burdensome and demoralizing.⁸ Pulmonary rehabilitation programs are a key component of both secondary prevention and treatment in improving overall health outcomes in patients with COPD,¹² and can be started at any stage of the illness. However, patients with comorbid anxiety and depression are often the least likely to engage in these programs.^4,13 One program that offered management of depression and COPD care with a focus on misconceptions about treatment and obstacles to treatment engagement reduced depressive symptoms and dyspnea-related disability, which led to greater remission of depression.^14,15 Exercise training in such programs also helps manage avoidance of physical activity due to fear of dyspnea by allowing patients to experience feared symptoms in the presence of medical professionals, similar to the CBT interoceptive exposure technique described earlier.¹ Several traditional treatment modalities used to target Ms. M’s anxiety disorder were unsuccessful. Low-dose, as-needed opioids are a safe and useful pharmacologic option worth considering for patients with refractory anxiety and depression and comorbid COPD.

Bottom Line

When traditional antidepressant and anxiolytic therapies have not sufficiently helped, consider low-dose, once-daily opioids to address refractory breathlessness in a patient with COPD with comorbid anxiety and depression. This treatment can lead patients to participate in rehabilitation therapies and improve their quality of life.

Related Resources

• Alexopoulos G, Kiosses D, Sirey J, et al. Untangling therapeutic ingredients of a personalized intervention for patients with depression and severe COPD. Am J Geriatr Psychiatry. 2014;22(11):1316-1324.
• Jackson D, Banerjee S, Sirey J, et al. Two interventions for patients with major depression and severe chronic obstructive pulmonary disease: impact on quality of life. Am J Geriatr Psychiatry. 2018;27(5):502-511.

Drug Brand Names

Amlodipine • Norvasc
Aripiprazole • Abilify
Buspirone • Buspar
Clonazepam • Klonopin
Duloxetine • Cymbalta
Fluoxetine • Prozac
Hydromorphone • Dilaudid
Levodopa • Sinemet
Lorazepam • Ativan
Mirtazapine • Remeron
Morphine • MS Contin
Naloxone • Narcan
Oxycodone • Oxycontin
Salmeterol • Serevent Diskus

On Nov. 9, the Biden-Harris administration announced the members of its COVID-19 Advisory Board. Among them were many esteemed infectious disease and public health experts – encouraging, given that, for now, the COVID-19 pandemic shows no signs of slowing down. Not among them was a mental health professional.

As psychiatrists, we did not find this omission surprising, given the sidelined role our specialty too often plays among medical professionals. But we did find it disappointing. Not having a single behavioral health provider on the advisory board will prove to be a mistake that could affect millions of Americans.

Studies continue to roll in showing that patients with COVID-19 can present during and after infection with neuropsychiatric symptoms, including delirium, psychosis, and anxiety. In July, a meta-analysis published in The Lancet regarding the neuropsychological outcomes of earlier diseases caused by coronaviruses – severe acute respiratory syndrome and Middle East respiratory syndrome – suggested that, in the short term, close to one-quarter of patients experienced confusion representative of delirium. In the long term, following recovery, respondents frequently reported emotional lability, impaired concentration, and traumatic memories. Additionally, more recent research published in The Lancet suggests that rates of psychiatric disorders, dementia, and insomnia are significantly higher among survivors of COVID-19. This study echoes the findings of an article in JAMA from September that reported that, among patients who were hospitalized for COVID-19, mortality rates were higher for those who had previously been diagnosed with a psychiatric condition. And overall, the pandemic has been associated with significantly increased rates of anxiety and depression symptoms.

Although this research is preliminary, it would be irresponsible – and at the very least myopic — not to take seriously the downstream consequences of the damage to the American people’s psyches when planning how our system can adapt to ensure that there is access to care and treatment.

This is especially true when you consider the following:

• It is very difficult to diagnose and treat mental health symptoms in a primary care setting that is already overburdened. Doing so results in delayed treatment and increased costs.
• In the long term, COVID-19 survivors will overburden the already underfunded mental healthcare system.
• Additional unforeseen psychological outcomes stem from the myriad traumas of events in 2020 (eg, racial unrest, children out of school, loss of jobs, the recent election).

Psychiatric disorders are notoriously difficult to diagnose and treat in the outpatient primary care setting, which is why mental health professionals will need to be a more integral part of the postpandemic treatment model and should be represented on the advisory board. Each year in the United States, there are more than 8 million doctors’ visits for depression, and more than half of these are in the primary care setting. Yet fewer than half of those patients leave with a diagnosis of depression or are treated for it.

Historically, screening for depression in the primary care setting is difficult given its broad presentation of symptoms, which include nonspecific physical complaints, such as digestive problems, headaches, insomnia, or general aches and pains. These shortcomings exist despite multiple changes in guidelines, such as regarding the use of self-screening tools and general screening for specific populations, such as postpartum women.

But screening alone has not been an effective strategy, especially when certain groups are less likely to be screened. These include older adults, Black persons, and men, all of whom are at higher risk for mortality after COVID-19. There is a failure to consistently apply standards of universal screening across all patient groups, and even if it occurs, there is a failure to establish reliable treatment and follow-up regimens. As clinicians, imagine how challenging diagnosis and treatment of more complicated psychiatric syndromes, such as somatoform disorder, will be in the primary care setting after the pandemic.

When almost two-thirds of symptoms in primary care are already “medically unexplained,” how do we expect primary care doctors to differentiate between those presenting with vague coronavirus-related “brain fog,” the run of the mill worrywart, and the 16%-34% with legitimate hypochondriasis of somatoform disorder who won’t improve without the involvement of a mental health provider?
 

A specialty in short supply

The mental health system we have now is inadequate for those who are currently diagnosed with mental disorders. Before the pandemic, emergency departments were boarding increasing numbers of patients with psychiatric illness because beds on inpatient units were unavailable. Individuals with insurance faced difficulty finding psychiatrists or psychotherapists who took insurance or who were availabile to accept new patients, given the growing shortage of providers in general. Community health centers continued to grapple with decreases in federal and state funding despite public political support for parity. Individuals with substance use faced few options for the outpatient, residential, or pharmacologic treatment that many needed to maintain sobriety.

Since the pandemic, we have seen rates of anxiety, depression, and suicidal thinking increase among adults and youth while many clinics have been forced to lay off employees, reduce services, or close their doors. As psychiatrists, we not only see the lack of treatment options for our patients but are forced to find creative solutions to meet their needs. How are we supposed to adapt (or feel confident) when individuals with or without previous mental illness face downstream consequences after COVID-19 when not one of our own is represented in the advisory board? How can we feel confident that downstream solutions acknowledge and address the intricacy of the behavioral health system that we, as mental health providers, know so intimately?

And what about the cumulative impact of everything else that has happened in 2020 in addition to the pandemic?! Although cataloging the various negative events that have happened this year is beyond the scope of this discussion, such lists have been compiled by the mainstream media and include the Australian brush fires, the crisis in Armenia, racial protests, economic uncertainties, and the run-up to and occurrence of the 2020 presidential election. Research is solid in its assertion that chronic stress can disturb our immune and cardiovascular systems, as well as mental health, leading to depression or anxiety. As a result of the pandemic itself, plus the events of this year, mental health providers are already warning not only of the current trauma underlying our day-to-day lives but also that of years to come.

More importantly, healthcare providers, both those represented by members of the advisory board and those who are not, are not immune to these issues. Before the pandemic, rates of suicide among doctors were already above average compared with other professions. After witnessing death repeatedly, self-isolation, the risk for infection to family, and dealing with the continued resistance to wearing masks, who knows what the eventual psychological toll our medical workforce will be?

Mental health providers have stepped up to the plate to provide care outside of traditional models to meet the needs that patients have now. One survey found that 81% of behavioral health providers began using telehealth for the first time in the past 6 months, owing to the COVID-19 pandemic. If not for the sake of the mental health of the Biden-Harris advisory board members themselves, who as doctors are likely to downplay the impact when struggling with mental health concerns in their own lives, a mental health provider deserves a seat at the table.

Plus, the outcomes speak for themselves when behavioral health providers collaborate with primary care providers to give treatment or when mental health experts are members of health crisis teams. Why wouldn’t the same be true for the Biden-Harris advisory board?


Kali Cyrus, MD, MPH, is an assistant professor of psychiatry and behavioral medicine at the Johns Hopkins School of Medicine, Baltimore, Maryland. She sees patients in private practice and offers consultation services in diversity strategy. Ranna Parekh, MD, MPH, is past deputy medical director and director of diversity and health equity for the American Psychiatric Association. She is currently a consultant psychiatrist at the Massachusetts General Hospital, Boston, and the chief diversity and inclusion officer at the American College of Cardiology.
 

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

On Nov. 9, the Biden-Harris administration announced the members of its COVID-19 Advisory Board. Among them were many esteemed infectious disease and public health experts – encouraging, given that, for now, the COVID-19 pandemic shows no signs of slowing down. Not among them was a mental health professional.

As psychiatrists, we did not find this omission surprising, given the sidelined role our specialty too often plays among medical professionals. But we did find it disappointing. Not having a single behavioral health provider on the advisory board will prove to be a mistake that could affect millions of Americans.

Studies continue to roll in showing that patients with COVID-19 can present during and after infection with neuropsychiatric symptoms, including delirium, psychosis, and anxiety. In July, a meta-analysis published in The Lancet regarding the neuropsychological outcomes of earlier diseases caused by coronaviruses – severe acute respiratory syndrome and Middle East respiratory syndrome – suggested that, in the short term, close to one-quarter of patients experienced confusion representative of delirium. In the long term, following recovery, respondents frequently reported emotional lability, impaired concentration, and traumatic memories. Additionally, more recent research published in The Lancet suggests that rates of psychiatric disorders, dementia, and insomnia are significantly higher among survivors of COVID-19. This study echoes the findings of an article in JAMA from September that reported that, among patients who were hospitalized for COVID-19, mortality rates were higher for those who had previously been diagnosed with a psychiatric condition. And overall, the pandemic has been associated with significantly increased rates of anxiety and depression symptoms.

Although this research is preliminary, it would be irresponsible – and at the very least myopic — not to take seriously the downstream consequences of the damage to the American people’s psyches when planning how our system can adapt to ensure that there is access to care and treatment.

This is especially true when you consider the following:

• It is very difficult to diagnose and treat mental health symptoms in a primary care setting that is already overburdened. Doing so results in delayed treatment and increased costs.
• In the long term, COVID-19 survivors will overburden the already underfunded mental healthcare system.
• Additional unforeseen psychological outcomes stem from the myriad traumas of events in 2020 (eg, racial unrest, children out of school, loss of jobs, the recent election).

Psychiatric disorders are notoriously difficult to diagnose and treat in the outpatient primary care setting, which is why mental health professionals will need to be a more integral part of the postpandemic treatment model and should be represented on the advisory board. Each year in the United States, there are more than 8 million doctors’ visits for depression, and more than half of these are in the primary care setting. Yet fewer than half of those patients leave with a diagnosis of depression or are treated for it.

Historically, screening for depression in the primary care setting is difficult given its broad presentation of symptoms, which include nonspecific physical complaints, such as digestive problems, headaches, insomnia, or general aches and pains. These shortcomings exist despite multiple changes in guidelines, such as regarding the use of self-screening tools and general screening for specific populations, such as postpartum women.

But screening alone has not been an effective strategy, especially when certain groups are less likely to be screened. These include older adults, Black persons, and men, all of whom are at higher risk for mortality after COVID-19. There is a failure to consistently apply standards of universal screening across all patient groups, and even if it occurs, there is a failure to establish reliable treatment and follow-up regimens. As clinicians, imagine how challenging diagnosis and treatment of more complicated psychiatric syndromes, such as somatoform disorder, will be in the primary care setting after the pandemic.

When almost two-thirds of symptoms in primary care are already “medically unexplained,” how do we expect primary care doctors to differentiate between those presenting with vague coronavirus-related “brain fog,” the run of the mill worrywart, and the 16%-34% with legitimate hypochondriasis of somatoform disorder who won’t improve without the involvement of a mental health provider?
 

A specialty in short supply

The mental health system we have now is inadequate for those who are currently diagnosed with mental disorders. Before the pandemic, emergency departments were boarding increasing numbers of patients with psychiatric illness because beds on inpatient units were unavailable. Individuals with insurance faced difficulty finding psychiatrists or psychotherapists who took insurance or who were availabile to accept new patients, given the growing shortage of providers in general. Community health centers continued to grapple with decreases in federal and state funding despite public political support for parity. Individuals with substance use faced few options for the outpatient, residential, or pharmacologic treatment that many needed to maintain sobriety.

Since the pandemic, we have seen rates of anxiety, depression, and suicidal thinking increase among adults and youth while many clinics have been forced to lay off employees, reduce services, or close their doors. As psychiatrists, we not only see the lack of treatment options for our patients but are forced to find creative solutions to meet their needs. How are we supposed to adapt (or feel confident) when individuals with or without previous mental illness face downstream consequences after COVID-19 when not one of our own is represented in the advisory board? How can we feel confident that downstream solutions acknowledge and address the intricacy of the behavioral health system that we, as mental health providers, know so intimately?

And what about the cumulative impact of everything else that has happened in 2020 in addition to the pandemic?! Although cataloging the various negative events that have happened this year is beyond the scope of this discussion, such lists have been compiled by the mainstream media and include the Australian brush fires, the crisis in Armenia, racial protests, economic uncertainties, and the run-up to and occurrence of the 2020 presidential election. Research is solid in its assertion that chronic stress can disturb our immune and cardiovascular systems, as well as mental health, leading to depression or anxiety. As a result of the pandemic itself, plus the events of this year, mental health providers are already warning not only of the current trauma underlying our day-to-day lives but also that of years to come.

More importantly, healthcare providers, both those represented by members of the advisory board and those who are not, are not immune to these issues. Before the pandemic, rates of suicide among doctors were already above average compared with other professions. After witnessing death repeatedly, self-isolation, the risk for infection to family, and dealing with the continued resistance to wearing masks, who knows what the eventual psychological toll our medical workforce will be?

Mental health providers have stepped up to the plate to provide care outside of traditional models to meet the needs that patients have now. One survey found that 81% of behavioral health providers began using telehealth for the first time in the past 6 months, owing to the COVID-19 pandemic. If not for the sake of the mental health of the Biden-Harris advisory board members themselves, who as doctors are likely to downplay the impact when struggling with mental health concerns in their own lives, a mental health provider deserves a seat at the table.

Plus, the outcomes speak for themselves when behavioral health providers collaborate with primary care providers to give treatment or when mental health experts are members of health crisis teams. Why wouldn’t the same be true for the Biden-Harris advisory board?


Kali Cyrus, MD, MPH, is an assistant professor of psychiatry and behavioral medicine at the Johns Hopkins School of Medicine, Baltimore, Maryland. She sees patients in private practice and offers consultation services in diversity strategy. Ranna Parekh, MD, MPH, is past deputy medical director and director of diversity and health equity for the American Psychiatric Association. She is currently a consultant psychiatrist at the Massachusetts General Hospital, Boston, and the chief diversity and inclusion officer at the American College of Cardiology.
 

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

On Nov. 9, the Biden-Harris administration announced the members of its COVID-19 Advisory Board. Among them were many esteemed infectious disease and public health experts – encouraging, given that, for now, the COVID-19 pandemic shows no signs of slowing down. Not among them was a mental health professional.

As psychiatrists, we did not find this omission surprising, given the sidelined role our specialty too often plays among medical professionals. But we did find it disappointing. Not having a single behavioral health provider on the advisory board will prove to be a mistake that could affect millions of Americans.

Studies continue to roll in showing that patients with COVID-19 can present during and after infection with neuropsychiatric symptoms, including delirium, psychosis, and anxiety. In July, a meta-analysis published in The Lancet regarding the neuropsychological outcomes of earlier diseases caused by coronaviruses – severe acute respiratory syndrome and Middle East respiratory syndrome – suggested that, in the short term, close to one-quarter of patients experienced confusion representative of delirium. In the long term, following recovery, respondents frequently reported emotional lability, impaired concentration, and traumatic memories. Additionally, more recent research published in The Lancet suggests that rates of psychiatric disorders, dementia, and insomnia are significantly higher among survivors of COVID-19. This study echoes the findings of an article in JAMA from September that reported that, among patients who were hospitalized for COVID-19, mortality rates were higher for those who had previously been diagnosed with a psychiatric condition. And overall, the pandemic has been associated with significantly increased rates of anxiety and depression symptoms.

Although this research is preliminary, it would be irresponsible – and at the very least myopic — not to take seriously the downstream consequences of the damage to the American people’s psyches when planning how our system can adapt to ensure that there is access to care and treatment.

This is especially true when you consider the following:

• It is very difficult to diagnose and treat mental health symptoms in a primary care setting that is already overburdened. Doing so results in delayed treatment and increased costs.
• In the long term, COVID-19 survivors will overburden the already underfunded mental healthcare system.
• Additional unforeseen psychological outcomes stem from the myriad traumas of events in 2020 (eg, racial unrest, children out of school, loss of jobs, the recent election).

Psychiatric disorders are notoriously difficult to diagnose and treat in the outpatient primary care setting, which is why mental health professionals will need to be a more integral part of the postpandemic treatment model and should be represented on the advisory board. Each year in the United States, there are more than 8 million doctors’ visits for depression, and more than half of these are in the primary care setting. Yet fewer than half of those patients leave with a diagnosis of depression or are treated for it.

Historically, screening for depression in the primary care setting is difficult given its broad presentation of symptoms, which include nonspecific physical complaints, such as digestive problems, headaches, insomnia, or general aches and pains. These shortcomings exist despite multiple changes in guidelines, such as regarding the use of self-screening tools and general screening for specific populations, such as postpartum women.

But screening alone has not been an effective strategy, especially when certain groups are less likely to be screened. These include older adults, Black persons, and men, all of whom are at higher risk for mortality after COVID-19. There is a failure to consistently apply standards of universal screening across all patient groups, and even if it occurs, there is a failure to establish reliable treatment and follow-up regimens. As clinicians, imagine how challenging diagnosis and treatment of more complicated psychiatric syndromes, such as somatoform disorder, will be in the primary care setting after the pandemic.

When almost two-thirds of symptoms in primary care are already “medically unexplained,” how do we expect primary care doctors to differentiate between those presenting with vague coronavirus-related “brain fog,” the run of the mill worrywart, and the 16%-34% with legitimate hypochondriasis of somatoform disorder who won’t improve without the involvement of a mental health provider?
 

A specialty in short supply

The mental health system we have now is inadequate for those who are currently diagnosed with mental disorders. Before the pandemic, emergency departments were boarding increasing numbers of patients with psychiatric illness because beds on inpatient units were unavailable. Individuals with insurance faced difficulty finding psychiatrists or psychotherapists who took insurance or who were availabile to accept new patients, given the growing shortage of providers in general. Community health centers continued to grapple with decreases in federal and state funding despite public political support for parity. Individuals with substance use faced few options for the outpatient, residential, or pharmacologic treatment that many needed to maintain sobriety.

Since the pandemic, we have seen rates of anxiety, depression, and suicidal thinking increase among adults and youth while many clinics have been forced to lay off employees, reduce services, or close their doors. As psychiatrists, we not only see the lack of treatment options for our patients but are forced to find creative solutions to meet their needs. How are we supposed to adapt (or feel confident) when individuals with or without previous mental illness face downstream consequences after COVID-19 when not one of our own is represented in the advisory board? How can we feel confident that downstream solutions acknowledge and address the intricacy of the behavioral health system that we, as mental health providers, know so intimately?

And what about the cumulative impact of everything else that has happened in 2020 in addition to the pandemic?! Although cataloging the various negative events that have happened this year is beyond the scope of this discussion, such lists have been compiled by the mainstream media and include the Australian brush fires, the crisis in Armenia, racial protests, economic uncertainties, and the run-up to and occurrence of the 2020 presidential election. Research is solid in its assertion that chronic stress can disturb our immune and cardiovascular systems, as well as mental health, leading to depression or anxiety. As a result of the pandemic itself, plus the events of this year, mental health providers are already warning not only of the current trauma underlying our day-to-day lives but also that of years to come.

More importantly, healthcare providers, both those represented by members of the advisory board and those who are not, are not immune to these issues. Before the pandemic, rates of suicide among doctors were already above average compared with other professions. After witnessing death repeatedly, self-isolation, the risk for infection to family, and dealing with the continued resistance to wearing masks, who knows what the eventual psychological toll our medical workforce will be?

Mental health providers have stepped up to the plate to provide care outside of traditional models to meet the needs that patients have now. One survey found that 81% of behavioral health providers began using telehealth for the first time in the past 6 months, owing to the COVID-19 pandemic. If not for the sake of the mental health of the Biden-Harris advisory board members themselves, who as doctors are likely to downplay the impact when struggling with mental health concerns in their own lives, a mental health provider deserves a seat at the table.

Plus, the outcomes speak for themselves when behavioral health providers collaborate with primary care providers to give treatment or when mental health experts are members of health crisis teams. Why wouldn’t the same be true for the Biden-Harris advisory board?


Kali Cyrus, MD, MPH, is an assistant professor of psychiatry and behavioral medicine at the Johns Hopkins School of Medicine, Baltimore, Maryland. She sees patients in private practice and offers consultation services in diversity strategy. Ranna Parekh, MD, MPH, is past deputy medical director and director of diversity and health equity for the American Psychiatric Association. She is currently a consultant psychiatrist at the Massachusetts General Hospital, Boston, and the chief diversity and inclusion officer at the American College of Cardiology.
 

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