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Probiotic, prebiotic, and postbiotic skin care
A decade ago, I gave my senior expert talk at the University of California, San Francisco, department of dermatology on skin care and brought up the controversial topic that sterile or clean skin is bad. At the time, I initiated the conversation on the Today, I not only preach this message to my patients, but I also practice the “less-is-more” philosophy every day. It is my hope that this brief summary of the skin microbiome and the importance of skin bacteria will affect the development of the next generation of skin care products.
The normal human skin is a microbiome colonized by 10,000-1,000,000 bacteria units/cm2 that prevent the growth of pathogenic organisms and maintain the immunity of the skin. The diversity and type of skin bacteria (that is, Staphylococcus or Propionibacterium acnes), as well as their concentration, varies by person, body location, and environment. Symbiotic with bacteria on the skin are yeasts, such as Malassezia, and parasites, such as Demodex. When the composition and diversity of microorganisms are disrupted, the skin can no longer protect its barrier functions, leading to pathogenic bacterial infections, altered skin pH, decreased production of antimicrobial peptides, and increased inflammation. The microbiome also serves to shield the skin from environmental stressors, such as free radicals, UV radiation, and pollution.
What can lead to disruption of our skin is hygiene. Over-washing; stripping of the skin with lathering cleaner; overexfoliation; long, hot showers; and the use of products with antibacterial properties have increased over the last 50 years, and so has skin disease. The removal of these microorganisms, either by overcleansing or with antibiotic use, disrupts the microflora and leads to pH-imbalanced and inflamed skin. Our microflora contains prebiotics, probiotics, and postbiotics. Prebiotics are the “fertilizer” or “food,” so to speak, that encourages these essential microorganisms to grow; probiotics are the microorganisms themselves; and postbiotics are the chemical byproducts of bacteria, such as antimicrobial peptides and fragments of dead bacterial cells that remain on the skin.
Skin care tailored to our unique microbiome is in its infancy. On the frontier of microflora-rich skin care are organisms like Bifidobacterium longum, which increases the skin’s resistance to temperature and product-related irritation. Streptococcus thermophilus has been shown to increase the production of ceramides in the skin, which could help atopic dermatitis. Lactobacillus paracasei has been shown to inhibit the neuropeptide substance P, which increases inflammation and oil production. Enterococcus faecalis, Streptococcus salivarius, and Lactobacillus plantarum have all been shown to decrease Propionibacterium acnes. Bacillus coagulans and Bifidobacterium breve have been shown to decrease free radicals and protect against UV rays.
Probiotic, prebiotic, and postbiotic skin care, however, does have its challenges. Probiotics are live bacteria, and thus need refrigeration. These products are also not intended for use in anyone who is immunosuppressed or neutropenic. Another complexity in the development of probiotic, prebiotic, and postbiotic skin care is that each person may have a different need in terms of their skin microflora and that microflora is inherently different in different body parts. Furthermore, people with skin inflammation may require a different concentration or population of that flora.
In 2007, the National Institutes of Health initiated the Human Microbiome Project, and in 2016, the White House announced the creation of a new National Microbiome Initiative (NMI). Through this research, the identification and importance of our gut bacteria has led to a vast increase in development and near obsession with probiotic supplements, foods, and drinks (examples include Kombucha tea, kimchi, miso, and Kefir). Although oral consumption of prebiotics and probiotics may prove to be helpful, the skin does have its own unique flora and will benefit from targeted skin care. In the meantime, fostering the skins’s microflora is as important or more important than the replacement of it. My recommendations include using “microflora friendly” products that are lather-free, cream- or oil-based cleansers with acidic pH’s, and moisturizing heavily and consistently. I recommend staying away from antibacterial wipes, antibacterial soaps, and sanitizers.
Fostering this bacterial rich environment will help maintain your skin integrity. Squeaky clean skin is damaged skin.
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Talakoub. Write to them at [email protected]. They had no relevant disclosures.
References
Al-Ghazzewi F et al. Benef Microbes. 2014 Jun 1;5(2):99-107.
Baquerizo Nole K et al. J Am Acad Dermatol. 2014 Oct;71(4):814-21.
Chen Y et al. J Am Acad Dermatol. 2013 Jul;69(1):143-55.e3.
Grice E et al. Nat Rev Microbiol. 2011 Apr;9(4):244-53.
Kong H et al. J Invest Dermatol. 2012 Mar;132(3, part 2):933-9.
Hutkins R et al. Curr Opin Biotechnol. 2016 Feb;37:1-7.
Kober MM et al. Int J Womens Dermatol. 2015 Apr 6;1(2):85-9.
Maquire M. et al. Arch Dermatol Res. 2017 Aug;309(6):411-421.
Sugimoto S. et al. Photodermatol. Photoimmunol. Photomed. 2012 Dec;28(6): 312-9.
A decade ago, I gave my senior expert talk at the University of California, San Francisco, department of dermatology on skin care and brought up the controversial topic that sterile or clean skin is bad. At the time, I initiated the conversation on the Today, I not only preach this message to my patients, but I also practice the “less-is-more” philosophy every day. It is my hope that this brief summary of the skin microbiome and the importance of skin bacteria will affect the development of the next generation of skin care products.
The normal human skin is a microbiome colonized by 10,000-1,000,000 bacteria units/cm2 that prevent the growth of pathogenic organisms and maintain the immunity of the skin. The diversity and type of skin bacteria (that is, Staphylococcus or Propionibacterium acnes), as well as their concentration, varies by person, body location, and environment. Symbiotic with bacteria on the skin are yeasts, such as Malassezia, and parasites, such as Demodex. When the composition and diversity of microorganisms are disrupted, the skin can no longer protect its barrier functions, leading to pathogenic bacterial infections, altered skin pH, decreased production of antimicrobial peptides, and increased inflammation. The microbiome also serves to shield the skin from environmental stressors, such as free radicals, UV radiation, and pollution.
What can lead to disruption of our skin is hygiene. Over-washing; stripping of the skin with lathering cleaner; overexfoliation; long, hot showers; and the use of products with antibacterial properties have increased over the last 50 years, and so has skin disease. The removal of these microorganisms, either by overcleansing or with antibiotic use, disrupts the microflora and leads to pH-imbalanced and inflamed skin. Our microflora contains prebiotics, probiotics, and postbiotics. Prebiotics are the “fertilizer” or “food,” so to speak, that encourages these essential microorganisms to grow; probiotics are the microorganisms themselves; and postbiotics are the chemical byproducts of bacteria, such as antimicrobial peptides and fragments of dead bacterial cells that remain on the skin.
Skin care tailored to our unique microbiome is in its infancy. On the frontier of microflora-rich skin care are organisms like Bifidobacterium longum, which increases the skin’s resistance to temperature and product-related irritation. Streptococcus thermophilus has been shown to increase the production of ceramides in the skin, which could help atopic dermatitis. Lactobacillus paracasei has been shown to inhibit the neuropeptide substance P, which increases inflammation and oil production. Enterococcus faecalis, Streptococcus salivarius, and Lactobacillus plantarum have all been shown to decrease Propionibacterium acnes. Bacillus coagulans and Bifidobacterium breve have been shown to decrease free radicals and protect against UV rays.
Probiotic, prebiotic, and postbiotic skin care, however, does have its challenges. Probiotics are live bacteria, and thus need refrigeration. These products are also not intended for use in anyone who is immunosuppressed or neutropenic. Another complexity in the development of probiotic, prebiotic, and postbiotic skin care is that each person may have a different need in terms of their skin microflora and that microflora is inherently different in different body parts. Furthermore, people with skin inflammation may require a different concentration or population of that flora.
In 2007, the National Institutes of Health initiated the Human Microbiome Project, and in 2016, the White House announced the creation of a new National Microbiome Initiative (NMI). Through this research, the identification and importance of our gut bacteria has led to a vast increase in development and near obsession with probiotic supplements, foods, and drinks (examples include Kombucha tea, kimchi, miso, and Kefir). Although oral consumption of prebiotics and probiotics may prove to be helpful, the skin does have its own unique flora and will benefit from targeted skin care. In the meantime, fostering the skins’s microflora is as important or more important than the replacement of it. My recommendations include using “microflora friendly” products that are lather-free, cream- or oil-based cleansers with acidic pH’s, and moisturizing heavily and consistently. I recommend staying away from antibacterial wipes, antibacterial soaps, and sanitizers.
Fostering this bacterial rich environment will help maintain your skin integrity. Squeaky clean skin is damaged skin.
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Talakoub. Write to them at [email protected]. They had no relevant disclosures.
References
Al-Ghazzewi F et al. Benef Microbes. 2014 Jun 1;5(2):99-107.
Baquerizo Nole K et al. J Am Acad Dermatol. 2014 Oct;71(4):814-21.
Chen Y et al. J Am Acad Dermatol. 2013 Jul;69(1):143-55.e3.
Grice E et al. Nat Rev Microbiol. 2011 Apr;9(4):244-53.
Kong H et al. J Invest Dermatol. 2012 Mar;132(3, part 2):933-9.
Hutkins R et al. Curr Opin Biotechnol. 2016 Feb;37:1-7.
Kober MM et al. Int J Womens Dermatol. 2015 Apr 6;1(2):85-9.
Maquire M. et al. Arch Dermatol Res. 2017 Aug;309(6):411-421.
Sugimoto S. et al. Photodermatol. Photoimmunol. Photomed. 2012 Dec;28(6): 312-9.
A decade ago, I gave my senior expert talk at the University of California, San Francisco, department of dermatology on skin care and brought up the controversial topic that sterile or clean skin is bad. At the time, I initiated the conversation on the Today, I not only preach this message to my patients, but I also practice the “less-is-more” philosophy every day. It is my hope that this brief summary of the skin microbiome and the importance of skin bacteria will affect the development of the next generation of skin care products.
The normal human skin is a microbiome colonized by 10,000-1,000,000 bacteria units/cm2 that prevent the growth of pathogenic organisms and maintain the immunity of the skin. The diversity and type of skin bacteria (that is, Staphylococcus or Propionibacterium acnes), as well as their concentration, varies by person, body location, and environment. Symbiotic with bacteria on the skin are yeasts, such as Malassezia, and parasites, such as Demodex. When the composition and diversity of microorganisms are disrupted, the skin can no longer protect its barrier functions, leading to pathogenic bacterial infections, altered skin pH, decreased production of antimicrobial peptides, and increased inflammation. The microbiome also serves to shield the skin from environmental stressors, such as free radicals, UV radiation, and pollution.
What can lead to disruption of our skin is hygiene. Over-washing; stripping of the skin with lathering cleaner; overexfoliation; long, hot showers; and the use of products with antibacterial properties have increased over the last 50 years, and so has skin disease. The removal of these microorganisms, either by overcleansing or with antibiotic use, disrupts the microflora and leads to pH-imbalanced and inflamed skin. Our microflora contains prebiotics, probiotics, and postbiotics. Prebiotics are the “fertilizer” or “food,” so to speak, that encourages these essential microorganisms to grow; probiotics are the microorganisms themselves; and postbiotics are the chemical byproducts of bacteria, such as antimicrobial peptides and fragments of dead bacterial cells that remain on the skin.
Skin care tailored to our unique microbiome is in its infancy. On the frontier of microflora-rich skin care are organisms like Bifidobacterium longum, which increases the skin’s resistance to temperature and product-related irritation. Streptococcus thermophilus has been shown to increase the production of ceramides in the skin, which could help atopic dermatitis. Lactobacillus paracasei has been shown to inhibit the neuropeptide substance P, which increases inflammation and oil production. Enterococcus faecalis, Streptococcus salivarius, and Lactobacillus plantarum have all been shown to decrease Propionibacterium acnes. Bacillus coagulans and Bifidobacterium breve have been shown to decrease free radicals and protect against UV rays.
Probiotic, prebiotic, and postbiotic skin care, however, does have its challenges. Probiotics are live bacteria, and thus need refrigeration. These products are also not intended for use in anyone who is immunosuppressed or neutropenic. Another complexity in the development of probiotic, prebiotic, and postbiotic skin care is that each person may have a different need in terms of their skin microflora and that microflora is inherently different in different body parts. Furthermore, people with skin inflammation may require a different concentration or population of that flora.
In 2007, the National Institutes of Health initiated the Human Microbiome Project, and in 2016, the White House announced the creation of a new National Microbiome Initiative (NMI). Through this research, the identification and importance of our gut bacteria has led to a vast increase in development and near obsession with probiotic supplements, foods, and drinks (examples include Kombucha tea, kimchi, miso, and Kefir). Although oral consumption of prebiotics and probiotics may prove to be helpful, the skin does have its own unique flora and will benefit from targeted skin care. In the meantime, fostering the skins’s microflora is as important or more important than the replacement of it. My recommendations include using “microflora friendly” products that are lather-free, cream- or oil-based cleansers with acidic pH’s, and moisturizing heavily and consistently. I recommend staying away from antibacterial wipes, antibacterial soaps, and sanitizers.
Fostering this bacterial rich environment will help maintain your skin integrity. Squeaky clean skin is damaged skin.
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Talakoub. Write to them at [email protected]. They had no relevant disclosures.
References
Al-Ghazzewi F et al. Benef Microbes. 2014 Jun 1;5(2):99-107.
Baquerizo Nole K et al. J Am Acad Dermatol. 2014 Oct;71(4):814-21.
Chen Y et al. J Am Acad Dermatol. 2013 Jul;69(1):143-55.e3.
Grice E et al. Nat Rev Microbiol. 2011 Apr;9(4):244-53.
Kong H et al. J Invest Dermatol. 2012 Mar;132(3, part 2):933-9.
Hutkins R et al. Curr Opin Biotechnol. 2016 Feb;37:1-7.
Kober MM et al. Int J Womens Dermatol. 2015 Apr 6;1(2):85-9.
Maquire M. et al. Arch Dermatol Res. 2017 Aug;309(6):411-421.
Sugimoto S. et al. Photodermatol. Photoimmunol. Photomed. 2012 Dec;28(6): 312-9.
Medical students and psychiatry
I have the unfortunate task of trying to teach medical students about psychiatry. I say “unfortunate,” as most of them find psychiatry a difficult art to understand, and they seem reluctant to classify psychiatry as a branch of medicine.
In my efforts to keep things simple, I tell that them psychiatry is one of the most difficult branches of medicine as there are very few objective measures we can rely on to make sense of people’s behavior. Regrettably, the American Psychiatric Association’s Diagnostic and Statistical Manual only seems to confuse them more. So, I remind them that, in medicine, 90%-95% of diagnoses can be obtained from doing a good history, and, if we are lucky a drug level will show drugs in the system, a CT scan without contrast will show cerebral atrophy, or there will be a lab result that will be abnormal and point to a diagnosis. But mostly what they will be seeing is unusual behavior they are unable to classify.
So I identifiable brain damage, psychosis, affective disorders, anxiety disorders, and personality disorders. Under the brain damage category, I include the short- and long-term effects of drugs, major neurocognitive disorders (called dementia before DSM-5), cerebrovascular infarcts, traumatic brain injury, and neurodevelopmental disorders. For their exams and, if they are interested in psychiatry, I tell them to study the DSM. I explain to them that when I was in medical school my dermatology professor told us that if we could recognize the 10 most common dermatologic disorders, we would be able to recognize 90% of the skin disorders we would see. It is similar in psychiatry – thus, my five categories.
However, because I do not want them thinking that only schizophrenia causes psychosis, I let them know that at least 40 different factors cause people to be psychotic indicated by auditory hallucinations. Those 40 factors are: 1) acute alcohol intoxication, 2) alcohol withdrawal, 3) alcoholism, 4) Alzheimer’s disease, 5) benzodiazepine withdrawal, 6) cocaine abuse and addiction, 7) chemical poisoning, 8) dehydration, 9) delirium, 10) dissociative disorders, 11) electrolyte imbalances, 12) encephalopathy of various forms, 13) ecstasy, 14) extreme fatigue, 15) falling asleep, 16) fetal alcohol exposure, 17) grief, 18) hallucinogen use, 19) heroin abuse and dependence, 20) high fever, 21) hyperglycemia, 22) hypoglycemia, 23) intellectual disability, 24) lupus, 25) major depression, 26) mania, 27) methamphetamine use, 28) Parkinson’s disease, 29) phencyclidine, 30) postictal states, 31) posttraumatic stress disorder, 32) schizoid or schizotypal personality disorder, 33) schizophrenia, 34) sleep deprivation, 35) sleep paralysis, 36) solvent abuse, 37) traumatic brain injury, 38) temporal lobe epilepsy, 39) uremia. Lastly, I ask them about No. 40 – “normal” (For example, have you ever been walking down the street and thought you heard someone calling your name, but when you turned around no one was there?). Of course, there are many more causes of psychosis, but keeping it simple makes the principle easier to remember.
Regarding affective disorders, I point out to them, as I did in a previous column, that there is a huge difference between major depressive disorders, unhappiness, or sadness, grief, and demoralization. Regarding anxiety disorders, I let the medical students know that, like personality disorders, there is a lot of comorbidity. Yet, if they can distinguish brain damage, psychosis, and affective disorders from anxiety and personality disorders, that will be good enough.
In keeping with trying to help medical students not make assumptions, I always ask them what’s wrong with people who wash their hands 30 times a day. Invariably, the answer is obsessive-compulsive disorder. So, next I ask: Isn’t it possible that the person who washes his hands 30 times a day is a surgeon – or perhaps a patient with schizophrenia who thinks that Martians are beaming germs to his hands?
I guess I raise this issue because I am concerned with the future of psychiatry, and I think that my approach to medical school education provides a framework that can help students learn how to think about and provide care for psychiatric patients.
Dr. Bell is a staff psychiatrist at Jackson Park Hospital’s Medical/Surgical-Psychiatry Inpatient Unit in Chicago, clinical psychiatrist emeritus in the department of psychiatry at the University of Illinois at Chicago, former president/CEO of the Community Mental Health Council, and former director of the Institute for Juvenile Research (birthplace of child psychiatry), also in Chicago. If you have tricks of the medical school teaching trade that you would like to share, email Dr. Bell at [email protected].
I have the unfortunate task of trying to teach medical students about psychiatry. I say “unfortunate,” as most of them find psychiatry a difficult art to understand, and they seem reluctant to classify psychiatry as a branch of medicine.
In my efforts to keep things simple, I tell that them psychiatry is one of the most difficult branches of medicine as there are very few objective measures we can rely on to make sense of people’s behavior. Regrettably, the American Psychiatric Association’s Diagnostic and Statistical Manual only seems to confuse them more. So, I remind them that, in medicine, 90%-95% of diagnoses can be obtained from doing a good history, and, if we are lucky a drug level will show drugs in the system, a CT scan without contrast will show cerebral atrophy, or there will be a lab result that will be abnormal and point to a diagnosis. But mostly what they will be seeing is unusual behavior they are unable to classify.
So I identifiable brain damage, psychosis, affective disorders, anxiety disorders, and personality disorders. Under the brain damage category, I include the short- and long-term effects of drugs, major neurocognitive disorders (called dementia before DSM-5), cerebrovascular infarcts, traumatic brain injury, and neurodevelopmental disorders. For their exams and, if they are interested in psychiatry, I tell them to study the DSM. I explain to them that when I was in medical school my dermatology professor told us that if we could recognize the 10 most common dermatologic disorders, we would be able to recognize 90% of the skin disorders we would see. It is similar in psychiatry – thus, my five categories.
However, because I do not want them thinking that only schizophrenia causes psychosis, I let them know that at least 40 different factors cause people to be psychotic indicated by auditory hallucinations. Those 40 factors are: 1) acute alcohol intoxication, 2) alcohol withdrawal, 3) alcoholism, 4) Alzheimer’s disease, 5) benzodiazepine withdrawal, 6) cocaine abuse and addiction, 7) chemical poisoning, 8) dehydration, 9) delirium, 10) dissociative disorders, 11) electrolyte imbalances, 12) encephalopathy of various forms, 13) ecstasy, 14) extreme fatigue, 15) falling asleep, 16) fetal alcohol exposure, 17) grief, 18) hallucinogen use, 19) heroin abuse and dependence, 20) high fever, 21) hyperglycemia, 22) hypoglycemia, 23) intellectual disability, 24) lupus, 25) major depression, 26) mania, 27) methamphetamine use, 28) Parkinson’s disease, 29) phencyclidine, 30) postictal states, 31) posttraumatic stress disorder, 32) schizoid or schizotypal personality disorder, 33) schizophrenia, 34) sleep deprivation, 35) sleep paralysis, 36) solvent abuse, 37) traumatic brain injury, 38) temporal lobe epilepsy, 39) uremia. Lastly, I ask them about No. 40 – “normal” (For example, have you ever been walking down the street and thought you heard someone calling your name, but when you turned around no one was there?). Of course, there are many more causes of psychosis, but keeping it simple makes the principle easier to remember.
Regarding affective disorders, I point out to them, as I did in a previous column, that there is a huge difference between major depressive disorders, unhappiness, or sadness, grief, and demoralization. Regarding anxiety disorders, I let the medical students know that, like personality disorders, there is a lot of comorbidity. Yet, if they can distinguish brain damage, psychosis, and affective disorders from anxiety and personality disorders, that will be good enough.
In keeping with trying to help medical students not make assumptions, I always ask them what’s wrong with people who wash their hands 30 times a day. Invariably, the answer is obsessive-compulsive disorder. So, next I ask: Isn’t it possible that the person who washes his hands 30 times a day is a surgeon – or perhaps a patient with schizophrenia who thinks that Martians are beaming germs to his hands?
I guess I raise this issue because I am concerned with the future of psychiatry, and I think that my approach to medical school education provides a framework that can help students learn how to think about and provide care for psychiatric patients.
Dr. Bell is a staff psychiatrist at Jackson Park Hospital’s Medical/Surgical-Psychiatry Inpatient Unit in Chicago, clinical psychiatrist emeritus in the department of psychiatry at the University of Illinois at Chicago, former president/CEO of the Community Mental Health Council, and former director of the Institute for Juvenile Research (birthplace of child psychiatry), also in Chicago. If you have tricks of the medical school teaching trade that you would like to share, email Dr. Bell at [email protected].
I have the unfortunate task of trying to teach medical students about psychiatry. I say “unfortunate,” as most of them find psychiatry a difficult art to understand, and they seem reluctant to classify psychiatry as a branch of medicine.
In my efforts to keep things simple, I tell that them psychiatry is one of the most difficult branches of medicine as there are very few objective measures we can rely on to make sense of people’s behavior. Regrettably, the American Psychiatric Association’s Diagnostic and Statistical Manual only seems to confuse them more. So, I remind them that, in medicine, 90%-95% of diagnoses can be obtained from doing a good history, and, if we are lucky a drug level will show drugs in the system, a CT scan without contrast will show cerebral atrophy, or there will be a lab result that will be abnormal and point to a diagnosis. But mostly what they will be seeing is unusual behavior they are unable to classify.
So I identifiable brain damage, psychosis, affective disorders, anxiety disorders, and personality disorders. Under the brain damage category, I include the short- and long-term effects of drugs, major neurocognitive disorders (called dementia before DSM-5), cerebrovascular infarcts, traumatic brain injury, and neurodevelopmental disorders. For their exams and, if they are interested in psychiatry, I tell them to study the DSM. I explain to them that when I was in medical school my dermatology professor told us that if we could recognize the 10 most common dermatologic disorders, we would be able to recognize 90% of the skin disorders we would see. It is similar in psychiatry – thus, my five categories.
However, because I do not want them thinking that only schizophrenia causes psychosis, I let them know that at least 40 different factors cause people to be psychotic indicated by auditory hallucinations. Those 40 factors are: 1) acute alcohol intoxication, 2) alcohol withdrawal, 3) alcoholism, 4) Alzheimer’s disease, 5) benzodiazepine withdrawal, 6) cocaine abuse and addiction, 7) chemical poisoning, 8) dehydration, 9) delirium, 10) dissociative disorders, 11) electrolyte imbalances, 12) encephalopathy of various forms, 13) ecstasy, 14) extreme fatigue, 15) falling asleep, 16) fetal alcohol exposure, 17) grief, 18) hallucinogen use, 19) heroin abuse and dependence, 20) high fever, 21) hyperglycemia, 22) hypoglycemia, 23) intellectual disability, 24) lupus, 25) major depression, 26) mania, 27) methamphetamine use, 28) Parkinson’s disease, 29) phencyclidine, 30) postictal states, 31) posttraumatic stress disorder, 32) schizoid or schizotypal personality disorder, 33) schizophrenia, 34) sleep deprivation, 35) sleep paralysis, 36) solvent abuse, 37) traumatic brain injury, 38) temporal lobe epilepsy, 39) uremia. Lastly, I ask them about No. 40 – “normal” (For example, have you ever been walking down the street and thought you heard someone calling your name, but when you turned around no one was there?). Of course, there are many more causes of psychosis, but keeping it simple makes the principle easier to remember.
Regarding affective disorders, I point out to them, as I did in a previous column, that there is a huge difference between major depressive disorders, unhappiness, or sadness, grief, and demoralization. Regarding anxiety disorders, I let the medical students know that, like personality disorders, there is a lot of comorbidity. Yet, if they can distinguish brain damage, psychosis, and affective disorders from anxiety and personality disorders, that will be good enough.
In keeping with trying to help medical students not make assumptions, I always ask them what’s wrong with people who wash their hands 30 times a day. Invariably, the answer is obsessive-compulsive disorder. So, next I ask: Isn’t it possible that the person who washes his hands 30 times a day is a surgeon – or perhaps a patient with schizophrenia who thinks that Martians are beaming germs to his hands?
I guess I raise this issue because I am concerned with the future of psychiatry, and I think that my approach to medical school education provides a framework that can help students learn how to think about and provide care for psychiatric patients.
Dr. Bell is a staff psychiatrist at Jackson Park Hospital’s Medical/Surgical-Psychiatry Inpatient Unit in Chicago, clinical psychiatrist emeritus in the department of psychiatry at the University of Illinois at Chicago, former president/CEO of the Community Mental Health Council, and former director of the Institute for Juvenile Research (birthplace of child psychiatry), also in Chicago. If you have tricks of the medical school teaching trade that you would like to share, email Dr. Bell at [email protected].
Failure to launch can happen to college students
March often is the time of year when college freshmen truly begin to feel comfortable in their new settings. Many students report feeling excited to get back to campus after the long winter break, and once into their second semester, they feel more comfortable with the independence from family and high school supports. It also is a time for some college freshmen to return home after failing to manage this major transition.
Of the latter group, many will have had difficult months of depression, anxiety, or substance use, and most will be suffering from a deep sense of shame after failing to navigate this long-anticipated transition. Asking detailed questions about their academic challenges, social lives, self-care, and sleep while they were on campus will help you make thoughtful recommendations to your patients and their parents about how they might best get back on track.
Some students will report a great social experience, but academic struggles. They will report some normal ups and downs emotionally, but most of their distress will have been focused on their academic performance. Many 18-year-olds have not had to organize their time and effort around homework without the attention and support of parents and teachers. College often has much bigger classes, with less personal attention. There is a lot of assigned reading, but no regular incremental homework, only a major midterm and final exam, or a substantial paper. For a student who gets anxious about performance, or one with organizational challenges, this can lead to procrastination and poor performance.
Find out details about how they did academically. Did they fail one class or many classes? Did they receive some incompletes in their first semester and then struggle to catch up with them while keeping up with their second semester work? Did they have tutoring or support? Were they unrealistic about their course load? Or did they have their first serious relationship and not spend enough time on homework? Did they spend too much time partying with their new friends and not enough time sleeping and getting their homework done?
It is important to dig deeper if patients report regular or binge drug and alcohol use that interfered with their academic performance, as they may need more substantial substance use disorder treatment. Most students, though, will not have a substance use disorder. Instead, their academic failure could represent something as simple as the need for more academic support and time management support. Many schools have such programs to help students learn how to better manage their time and effort as they take fuller responsibility than they had for it in high school.
For other students, you will learn that their emotional distress preceded their academic troubles. The stress of the transition to college may be enough to trigger an episode of depression or to exacerbate a mood or anxiety disorder that was subclinical or in remission before school started. These students usually will report that sadness, intense anxiety, or loss of interest came early in their semester; perhaps they were even doing well academically when these problems started.
Ask about how their sleep was. Often they had difficulty falling asleep or woke up often at night, unlike most college students, whose sleep is compromised because they stay up late with new friends or because they are hard at work, but could easily sleep at any time.
Find out about their eating habits. Did they lose their appetite? Lose weight? Did they become preoccupied with weight or body image issues and begin restricting their intake? Eating disorders can begin in college when vulnerable students are stressed and have more control over their diet. While weight gain is more common in freshman year, it often is connected to poor stress management skills, and is more often a marker of a student who was struggling academically and then managing stress by overeating.
In the case where the distress came first, it is critical that your patients have a thorough psychiatric evaluation and treatment. It may be possible for them to return to school quickly, but it is most important that they are engaged in effective treatment and in at last partial remission before adding to their stress by attempting to return to school. Often, ambitious students and their parents need to hear this message very clearly from a pediatrician. A rushed return to school may be a set-up for a more protracted and difficult course of illness. For these students, it may be better to have a fresh start in a new semester. Help them (and their parents) to understand that they should use their time off to focus on treatment and good self-care so they might benefit from the many opportunities of college.
For a small minority of college students who do not succeed at college, their social withdrawal, academic deterioration, anxiety, and loss of interest in previous passions may occur alongside more serious psychiatric symptoms such as auditory hallucinations, paranoia, or grandiosity. Any time there is a suggestion of psychotic symptoms in a previously healthy person in the late teens or early 20s, a prompt comprehensive psychiatric evaluation is critical. These years are when most chronic psychotic disorders, such as schizophrenia, are likely to emerge. These patients require a thorough evaluation to distinguish these disorders from other illnesses, especially when they occur with substance use. And these patients require specialized care.
If your patient appears to have any psychotic symptoms, it is critical that you help the family find an excellent psychiatrist, or even a clinic that specializes in thought disorders so that he or she may get the best possible care early.
There is another class of students who withdraw from college who will need more comprehensive remediation, but not connected to any psychiatric diagnosis. Some young people may not be developmentally ready for college. These are your patients who often were excellent performers in high school, perhaps academically and athletically, but whose performance was more connected to pleasing important adults than to genuine motivating passions or sense of purpose. These young adults may have been drawn into the intense, results-oriented forces that are powerful in many of our high schools. If they did not have enough time or space to explore a host of interests, and to then manage the routine failures, setbacks, and disappointments that are essential to healthy adolescent development, they are going to run out of fuel in college. Such students often are quite dependent on their parents, and struggle with the independence college offers.
If your patients report that they could not muster the same intense work ethic they previously had, without any evidence of a psychiatric illness interfering with motivation, they may need time to finish the developmental work of cultivating a deep and rich sense of their own identity. Some students can do this at college, provided they, their parents and their school offer them adequate time before they have to declare a major. Other students will need to get a job and explore interests with a few courses at a community college, cultivating independence while learning about their own strengths and weaknesses and their genuine interests. This way, when they return to school, they will be motivated by a genuine sense of purpose and self-knowledge.
“Failure to launch” is a critical symptom at a key transitional moment. Pediatric providers can be essential to their patients and families by clarifying the nature of the difficulty and coordinating a reasonable plan to get these young adults back on track to healthy adulthood.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].
March often is the time of year when college freshmen truly begin to feel comfortable in their new settings. Many students report feeling excited to get back to campus after the long winter break, and once into their second semester, they feel more comfortable with the independence from family and high school supports. It also is a time for some college freshmen to return home after failing to manage this major transition.
Of the latter group, many will have had difficult months of depression, anxiety, or substance use, and most will be suffering from a deep sense of shame after failing to navigate this long-anticipated transition. Asking detailed questions about their academic challenges, social lives, self-care, and sleep while they were on campus will help you make thoughtful recommendations to your patients and their parents about how they might best get back on track.
Some students will report a great social experience, but academic struggles. They will report some normal ups and downs emotionally, but most of their distress will have been focused on their academic performance. Many 18-year-olds have not had to organize their time and effort around homework without the attention and support of parents and teachers. College often has much bigger classes, with less personal attention. There is a lot of assigned reading, but no regular incremental homework, only a major midterm and final exam, or a substantial paper. For a student who gets anxious about performance, or one with organizational challenges, this can lead to procrastination and poor performance.
Find out details about how they did academically. Did they fail one class or many classes? Did they receive some incompletes in their first semester and then struggle to catch up with them while keeping up with their second semester work? Did they have tutoring or support? Were they unrealistic about their course load? Or did they have their first serious relationship and not spend enough time on homework? Did they spend too much time partying with their new friends and not enough time sleeping and getting their homework done?
It is important to dig deeper if patients report regular or binge drug and alcohol use that interfered with their academic performance, as they may need more substantial substance use disorder treatment. Most students, though, will not have a substance use disorder. Instead, their academic failure could represent something as simple as the need for more academic support and time management support. Many schools have such programs to help students learn how to better manage their time and effort as they take fuller responsibility than they had for it in high school.
For other students, you will learn that their emotional distress preceded their academic troubles. The stress of the transition to college may be enough to trigger an episode of depression or to exacerbate a mood or anxiety disorder that was subclinical or in remission before school started. These students usually will report that sadness, intense anxiety, or loss of interest came early in their semester; perhaps they were even doing well academically when these problems started.
Ask about how their sleep was. Often they had difficulty falling asleep or woke up often at night, unlike most college students, whose sleep is compromised because they stay up late with new friends or because they are hard at work, but could easily sleep at any time.
Find out about their eating habits. Did they lose their appetite? Lose weight? Did they become preoccupied with weight or body image issues and begin restricting their intake? Eating disorders can begin in college when vulnerable students are stressed and have more control over their diet. While weight gain is more common in freshman year, it often is connected to poor stress management skills, and is more often a marker of a student who was struggling academically and then managing stress by overeating.
In the case where the distress came first, it is critical that your patients have a thorough psychiatric evaluation and treatment. It may be possible for them to return to school quickly, but it is most important that they are engaged in effective treatment and in at last partial remission before adding to their stress by attempting to return to school. Often, ambitious students and their parents need to hear this message very clearly from a pediatrician. A rushed return to school may be a set-up for a more protracted and difficult course of illness. For these students, it may be better to have a fresh start in a new semester. Help them (and their parents) to understand that they should use their time off to focus on treatment and good self-care so they might benefit from the many opportunities of college.
For a small minority of college students who do not succeed at college, their social withdrawal, academic deterioration, anxiety, and loss of interest in previous passions may occur alongside more serious psychiatric symptoms such as auditory hallucinations, paranoia, or grandiosity. Any time there is a suggestion of psychotic symptoms in a previously healthy person in the late teens or early 20s, a prompt comprehensive psychiatric evaluation is critical. These years are when most chronic psychotic disorders, such as schizophrenia, are likely to emerge. These patients require a thorough evaluation to distinguish these disorders from other illnesses, especially when they occur with substance use. And these patients require specialized care.
If your patient appears to have any psychotic symptoms, it is critical that you help the family find an excellent psychiatrist, or even a clinic that specializes in thought disorders so that he or she may get the best possible care early.
There is another class of students who withdraw from college who will need more comprehensive remediation, but not connected to any psychiatric diagnosis. Some young people may not be developmentally ready for college. These are your patients who often were excellent performers in high school, perhaps academically and athletically, but whose performance was more connected to pleasing important adults than to genuine motivating passions or sense of purpose. These young adults may have been drawn into the intense, results-oriented forces that are powerful in many of our high schools. If they did not have enough time or space to explore a host of interests, and to then manage the routine failures, setbacks, and disappointments that are essential to healthy adolescent development, they are going to run out of fuel in college. Such students often are quite dependent on their parents, and struggle with the independence college offers.
If your patients report that they could not muster the same intense work ethic they previously had, without any evidence of a psychiatric illness interfering with motivation, they may need time to finish the developmental work of cultivating a deep and rich sense of their own identity. Some students can do this at college, provided they, their parents and their school offer them adequate time before they have to declare a major. Other students will need to get a job and explore interests with a few courses at a community college, cultivating independence while learning about their own strengths and weaknesses and their genuine interests. This way, when they return to school, they will be motivated by a genuine sense of purpose and self-knowledge.
“Failure to launch” is a critical symptom at a key transitional moment. Pediatric providers can be essential to their patients and families by clarifying the nature of the difficulty and coordinating a reasonable plan to get these young adults back on track to healthy adulthood.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].
March often is the time of year when college freshmen truly begin to feel comfortable in their new settings. Many students report feeling excited to get back to campus after the long winter break, and once into their second semester, they feel more comfortable with the independence from family and high school supports. It also is a time for some college freshmen to return home after failing to manage this major transition.
Of the latter group, many will have had difficult months of depression, anxiety, or substance use, and most will be suffering from a deep sense of shame after failing to navigate this long-anticipated transition. Asking detailed questions about their academic challenges, social lives, self-care, and sleep while they were on campus will help you make thoughtful recommendations to your patients and their parents about how they might best get back on track.
Some students will report a great social experience, but academic struggles. They will report some normal ups and downs emotionally, but most of their distress will have been focused on their academic performance. Many 18-year-olds have not had to organize their time and effort around homework without the attention and support of parents and teachers. College often has much bigger classes, with less personal attention. There is a lot of assigned reading, but no regular incremental homework, only a major midterm and final exam, or a substantial paper. For a student who gets anxious about performance, or one with organizational challenges, this can lead to procrastination and poor performance.
Find out details about how they did academically. Did they fail one class or many classes? Did they receive some incompletes in their first semester and then struggle to catch up with them while keeping up with their second semester work? Did they have tutoring or support? Were they unrealistic about their course load? Or did they have their first serious relationship and not spend enough time on homework? Did they spend too much time partying with their new friends and not enough time sleeping and getting their homework done?
It is important to dig deeper if patients report regular or binge drug and alcohol use that interfered with their academic performance, as they may need more substantial substance use disorder treatment. Most students, though, will not have a substance use disorder. Instead, their academic failure could represent something as simple as the need for more academic support and time management support. Many schools have such programs to help students learn how to better manage their time and effort as they take fuller responsibility than they had for it in high school.
For other students, you will learn that their emotional distress preceded their academic troubles. The stress of the transition to college may be enough to trigger an episode of depression or to exacerbate a mood or anxiety disorder that was subclinical or in remission before school started. These students usually will report that sadness, intense anxiety, or loss of interest came early in their semester; perhaps they were even doing well academically when these problems started.
Ask about how their sleep was. Often they had difficulty falling asleep or woke up often at night, unlike most college students, whose sleep is compromised because they stay up late with new friends or because they are hard at work, but could easily sleep at any time.
Find out about their eating habits. Did they lose their appetite? Lose weight? Did they become preoccupied with weight or body image issues and begin restricting their intake? Eating disorders can begin in college when vulnerable students are stressed and have more control over their diet. While weight gain is more common in freshman year, it often is connected to poor stress management skills, and is more often a marker of a student who was struggling academically and then managing stress by overeating.
In the case where the distress came first, it is critical that your patients have a thorough psychiatric evaluation and treatment. It may be possible for them to return to school quickly, but it is most important that they are engaged in effective treatment and in at last partial remission before adding to their stress by attempting to return to school. Often, ambitious students and their parents need to hear this message very clearly from a pediatrician. A rushed return to school may be a set-up for a more protracted and difficult course of illness. For these students, it may be better to have a fresh start in a new semester. Help them (and their parents) to understand that they should use their time off to focus on treatment and good self-care so they might benefit from the many opportunities of college.
For a small minority of college students who do not succeed at college, their social withdrawal, academic deterioration, anxiety, and loss of interest in previous passions may occur alongside more serious psychiatric symptoms such as auditory hallucinations, paranoia, or grandiosity. Any time there is a suggestion of psychotic symptoms in a previously healthy person in the late teens or early 20s, a prompt comprehensive psychiatric evaluation is critical. These years are when most chronic psychotic disorders, such as schizophrenia, are likely to emerge. These patients require a thorough evaluation to distinguish these disorders from other illnesses, especially when they occur with substance use. And these patients require specialized care.
If your patient appears to have any psychotic symptoms, it is critical that you help the family find an excellent psychiatrist, or even a clinic that specializes in thought disorders so that he or she may get the best possible care early.
There is another class of students who withdraw from college who will need more comprehensive remediation, but not connected to any psychiatric diagnosis. Some young people may not be developmentally ready for college. These are your patients who often were excellent performers in high school, perhaps academically and athletically, but whose performance was more connected to pleasing important adults than to genuine motivating passions or sense of purpose. These young adults may have been drawn into the intense, results-oriented forces that are powerful in many of our high schools. If they did not have enough time or space to explore a host of interests, and to then manage the routine failures, setbacks, and disappointments that are essential to healthy adolescent development, they are going to run out of fuel in college. Such students often are quite dependent on their parents, and struggle with the independence college offers.
If your patients report that they could not muster the same intense work ethic they previously had, without any evidence of a psychiatric illness interfering with motivation, they may need time to finish the developmental work of cultivating a deep and rich sense of their own identity. Some students can do this at college, provided they, their parents and their school offer them adequate time before they have to declare a major. Other students will need to get a job and explore interests with a few courses at a community college, cultivating independence while learning about their own strengths and weaknesses and their genuine interests. This way, when they return to school, they will be motivated by a genuine sense of purpose and self-knowledge.
“Failure to launch” is a critical symptom at a key transitional moment. Pediatric providers can be essential to their patients and families by clarifying the nature of the difficulty and coordinating a reasonable plan to get these young adults back on track to healthy adulthood.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].
Adenovirus: More than just another viral illness
The mother of three looked tired and little worried. She wasn’t one to bring her kids to the pediatrician’s office with every minor illness, but her youngest had 3 days of fever, runny nose, cough, and little of her normal energy.
The pediatrician entered the room and smiled sympathetically.
“We ran tests for flu and RSV [respiratory syncytial virus] and it’s neither of those so. ...”
“So it’s just a virus that we don’t routinely test for and it’s going to need to run its course,” the mother finished his sentence. She knew the drill.
Before the doctor could leave the room though, the mother had one more question. “You don’t think it could be adenovirus do you?”
Most years, influenza and RSV command center stage, and adenovirus is relegated to the wings. It is not so much lack of disease or morbidity, but rather lack of recognition. Yes, we all learned in medical school that it is a cause of epidemic keratoconjunctivitis, but many adenoviral infections are clinically indistinguishable from infections caused by other viruses. Common symptoms – fever, cough, sore throat, and malaise – overlap with those caused by influenza. Like rhinovirus, adenovirus can cause common cold symptoms. Like RSV, it can cause bronchiolitis. Just like parainfluenza, it can cause croup. It can cause a pertussislike syndrome with prolonged cough, and enteric adenoviruses, especially types 40 and 41, cause gastroenteritis that mimics norovirus or rotavirus infection.
Testing for adenovirus is not readily available or routine in most pediatricians’ offices, and while many hospitals and reference labs offer adenovirus polymerase chain reaction testing as part of a comprehensive respiratory virus panel, the test can be expensive and unlikely to change management in most ambulatory patients. This makes it difficult to count the number of adenoviruses annually.
This winter though, adenovirus was in the news ... repeatedly. In November 2018, CBS News reported that a University of Maryland freshman had died of an adenovirus-related illness. The family of Olivia Paregol told reporters that she was being treated for Crohn’s disease. Immune suppression is one recognized risk factor for more severe adenoviral disease; underlying heart and lung disease are others. Testing at the Centers for Disease Control and Prevention revealed that the student and several others on campus were infected with adenovirus type 7, a strain that has been associated with outbreaks of acute, severe respiratory illness in military recruits. As of Jan. 24, 2019, university officials reported 42 confirmed cases of adenovirus in University of Maryland students, 13 of which were confirmed as adenovirus 7.
Adenovirus type 7 also caused an outbreak at a pediatric long-term care facility in New Jersey late last year. Between Sept. 26 and Nov. 11, 2018, 36 residents and 1 staff member became ill. Eleven individuals died. In an unrelated outbreak at a second pediatric long-term care facility, 17 residents were affected between Oct. 20 and Dec. 10, 2018. Adenovirus 3 was identified and all children recovered.
Between October 2013 and July 2014, public health officials in Oregon identified an increase in adenoviral infections in people with respiratory illness. Sixty-nine percent were hospitalized (136/198), 31% needed intensive care, and 18% were mechanically ventilated. Multiple types of adenovirus were recovered but the most common was adenovirus 7 (Emerg Infect Dis. 2016. doi: 10.3201/eid2206.151898).
Depending on your perspective, measures to prevent the spread of adenovirus are elegantly simple, evidence-based, public health intervention or maddeningly little more than common sense. Wash your hands often with soap and water. Avoid touching your eyes, mouth, and nose with unwashed hands. Avoid close contact with people who are sick. The latter is easier if those who are sick stay home. Prior to the start of the most recent academic semester at the University of Maryland, university officials urged students who were sick not to return to campus but to stay at home to rest and recover. Those who fell ill on campus were urged to return home via nonpublic transportation if possible. Those who stayed on campus were advised to stay in their living spaces and clean high-touch surfaces with bleach. Like other nonenveloped viruses, adenovirus is not easily destroyed by many commonly used disinfectants. Under ideal conditions, it can survive on surfaces – remaining infectious – for up to 3 months.
Back at the pediatrician’s office, “We need an adenovirus vaccine,” the mother said as she picked up her child and headed for the door.
There is, in fact, a live oral vaccine that protects against adenovirus types 4 and 7. It is only approved for use in United States military personnel aged 17-50 years and it is given to all recruits as soon as they enter basic training. It works too. Before vaccine was available, up to 80% of recruits became infected during their initial training, half of those developing significant illness and a quarter being hospitalized. When the current vaccine was introduced in 2011, there was a 100-fold decrease in adenovirus-related disease burden (from 5.8 to 0.02 cases per 1,000 person-weeks, P less than .0001). That translates to 1 death, 1,100-2,700 hospitalizations and 13,000 febrile illnesses prevented each year (Clin Infect Dis. 2014 Oct 1. doi: 10.1093/cid/ciu507).
Some experts have suggested that adenovirus vaccine could be useful in civilian populations, too, but I question what the public reception would be. We have safe influenza vaccines that reduce the need for hospitalization and reduce mortality from influenza, but we still can’t convince some people to immunize themselves and their children. In the last 4 years, flu vaccination rates among children have remained just shy of 60% and adult rates are even lower. Collectively, we don’t seem to be ready to relinquish – or at least diminish – the annual suffering that goes with flu. I have to wonder if the same would be true for adenovirus.
Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She said she had no relevant financial disclosures. Email her at [email protected].
The mother of three looked tired and little worried. She wasn’t one to bring her kids to the pediatrician’s office with every minor illness, but her youngest had 3 days of fever, runny nose, cough, and little of her normal energy.
The pediatrician entered the room and smiled sympathetically.
“We ran tests for flu and RSV [respiratory syncytial virus] and it’s neither of those so. ...”
“So it’s just a virus that we don’t routinely test for and it’s going to need to run its course,” the mother finished his sentence. She knew the drill.
Before the doctor could leave the room though, the mother had one more question. “You don’t think it could be adenovirus do you?”
Most years, influenza and RSV command center stage, and adenovirus is relegated to the wings. It is not so much lack of disease or morbidity, but rather lack of recognition. Yes, we all learned in medical school that it is a cause of epidemic keratoconjunctivitis, but many adenoviral infections are clinically indistinguishable from infections caused by other viruses. Common symptoms – fever, cough, sore throat, and malaise – overlap with those caused by influenza. Like rhinovirus, adenovirus can cause common cold symptoms. Like RSV, it can cause bronchiolitis. Just like parainfluenza, it can cause croup. It can cause a pertussislike syndrome with prolonged cough, and enteric adenoviruses, especially types 40 and 41, cause gastroenteritis that mimics norovirus or rotavirus infection.
Testing for adenovirus is not readily available or routine in most pediatricians’ offices, and while many hospitals and reference labs offer adenovirus polymerase chain reaction testing as part of a comprehensive respiratory virus panel, the test can be expensive and unlikely to change management in most ambulatory patients. This makes it difficult to count the number of adenoviruses annually.
This winter though, adenovirus was in the news ... repeatedly. In November 2018, CBS News reported that a University of Maryland freshman had died of an adenovirus-related illness. The family of Olivia Paregol told reporters that she was being treated for Crohn’s disease. Immune suppression is one recognized risk factor for more severe adenoviral disease; underlying heart and lung disease are others. Testing at the Centers for Disease Control and Prevention revealed that the student and several others on campus were infected with adenovirus type 7, a strain that has been associated with outbreaks of acute, severe respiratory illness in military recruits. As of Jan. 24, 2019, university officials reported 42 confirmed cases of adenovirus in University of Maryland students, 13 of which were confirmed as adenovirus 7.
Adenovirus type 7 also caused an outbreak at a pediatric long-term care facility in New Jersey late last year. Between Sept. 26 and Nov. 11, 2018, 36 residents and 1 staff member became ill. Eleven individuals died. In an unrelated outbreak at a second pediatric long-term care facility, 17 residents were affected between Oct. 20 and Dec. 10, 2018. Adenovirus 3 was identified and all children recovered.
Between October 2013 and July 2014, public health officials in Oregon identified an increase in adenoviral infections in people with respiratory illness. Sixty-nine percent were hospitalized (136/198), 31% needed intensive care, and 18% were mechanically ventilated. Multiple types of adenovirus were recovered but the most common was adenovirus 7 (Emerg Infect Dis. 2016. doi: 10.3201/eid2206.151898).
Depending on your perspective, measures to prevent the spread of adenovirus are elegantly simple, evidence-based, public health intervention or maddeningly little more than common sense. Wash your hands often with soap and water. Avoid touching your eyes, mouth, and nose with unwashed hands. Avoid close contact with people who are sick. The latter is easier if those who are sick stay home. Prior to the start of the most recent academic semester at the University of Maryland, university officials urged students who were sick not to return to campus but to stay at home to rest and recover. Those who fell ill on campus were urged to return home via nonpublic transportation if possible. Those who stayed on campus were advised to stay in their living spaces and clean high-touch surfaces with bleach. Like other nonenveloped viruses, adenovirus is not easily destroyed by many commonly used disinfectants. Under ideal conditions, it can survive on surfaces – remaining infectious – for up to 3 months.
Back at the pediatrician’s office, “We need an adenovirus vaccine,” the mother said as she picked up her child and headed for the door.
There is, in fact, a live oral vaccine that protects against adenovirus types 4 and 7. It is only approved for use in United States military personnel aged 17-50 years and it is given to all recruits as soon as they enter basic training. It works too. Before vaccine was available, up to 80% of recruits became infected during their initial training, half of those developing significant illness and a quarter being hospitalized. When the current vaccine was introduced in 2011, there was a 100-fold decrease in adenovirus-related disease burden (from 5.8 to 0.02 cases per 1,000 person-weeks, P less than .0001). That translates to 1 death, 1,100-2,700 hospitalizations and 13,000 febrile illnesses prevented each year (Clin Infect Dis. 2014 Oct 1. doi: 10.1093/cid/ciu507).
Some experts have suggested that adenovirus vaccine could be useful in civilian populations, too, but I question what the public reception would be. We have safe influenza vaccines that reduce the need for hospitalization and reduce mortality from influenza, but we still can’t convince some people to immunize themselves and their children. In the last 4 years, flu vaccination rates among children have remained just shy of 60% and adult rates are even lower. Collectively, we don’t seem to be ready to relinquish – or at least diminish – the annual suffering that goes with flu. I have to wonder if the same would be true for adenovirus.
Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She said she had no relevant financial disclosures. Email her at [email protected].
The mother of three looked tired and little worried. She wasn’t one to bring her kids to the pediatrician’s office with every minor illness, but her youngest had 3 days of fever, runny nose, cough, and little of her normal energy.
The pediatrician entered the room and smiled sympathetically.
“We ran tests for flu and RSV [respiratory syncytial virus] and it’s neither of those so. ...”
“So it’s just a virus that we don’t routinely test for and it’s going to need to run its course,” the mother finished his sentence. She knew the drill.
Before the doctor could leave the room though, the mother had one more question. “You don’t think it could be adenovirus do you?”
Most years, influenza and RSV command center stage, and adenovirus is relegated to the wings. It is not so much lack of disease or morbidity, but rather lack of recognition. Yes, we all learned in medical school that it is a cause of epidemic keratoconjunctivitis, but many adenoviral infections are clinically indistinguishable from infections caused by other viruses. Common symptoms – fever, cough, sore throat, and malaise – overlap with those caused by influenza. Like rhinovirus, adenovirus can cause common cold symptoms. Like RSV, it can cause bronchiolitis. Just like parainfluenza, it can cause croup. It can cause a pertussislike syndrome with prolonged cough, and enteric adenoviruses, especially types 40 and 41, cause gastroenteritis that mimics norovirus or rotavirus infection.
Testing for adenovirus is not readily available or routine in most pediatricians’ offices, and while many hospitals and reference labs offer adenovirus polymerase chain reaction testing as part of a comprehensive respiratory virus panel, the test can be expensive and unlikely to change management in most ambulatory patients. This makes it difficult to count the number of adenoviruses annually.
This winter though, adenovirus was in the news ... repeatedly. In November 2018, CBS News reported that a University of Maryland freshman had died of an adenovirus-related illness. The family of Olivia Paregol told reporters that she was being treated for Crohn’s disease. Immune suppression is one recognized risk factor for more severe adenoviral disease; underlying heart and lung disease are others. Testing at the Centers for Disease Control and Prevention revealed that the student and several others on campus were infected with adenovirus type 7, a strain that has been associated with outbreaks of acute, severe respiratory illness in military recruits. As of Jan. 24, 2019, university officials reported 42 confirmed cases of adenovirus in University of Maryland students, 13 of which were confirmed as adenovirus 7.
Adenovirus type 7 also caused an outbreak at a pediatric long-term care facility in New Jersey late last year. Between Sept. 26 and Nov. 11, 2018, 36 residents and 1 staff member became ill. Eleven individuals died. In an unrelated outbreak at a second pediatric long-term care facility, 17 residents were affected between Oct. 20 and Dec. 10, 2018. Adenovirus 3 was identified and all children recovered.
Between October 2013 and July 2014, public health officials in Oregon identified an increase in adenoviral infections in people with respiratory illness. Sixty-nine percent were hospitalized (136/198), 31% needed intensive care, and 18% were mechanically ventilated. Multiple types of adenovirus were recovered but the most common was adenovirus 7 (Emerg Infect Dis. 2016. doi: 10.3201/eid2206.151898).
Depending on your perspective, measures to prevent the spread of adenovirus are elegantly simple, evidence-based, public health intervention or maddeningly little more than common sense. Wash your hands often with soap and water. Avoid touching your eyes, mouth, and nose with unwashed hands. Avoid close contact with people who are sick. The latter is easier if those who are sick stay home. Prior to the start of the most recent academic semester at the University of Maryland, university officials urged students who were sick not to return to campus but to stay at home to rest and recover. Those who fell ill on campus were urged to return home via nonpublic transportation if possible. Those who stayed on campus were advised to stay in their living spaces and clean high-touch surfaces with bleach. Like other nonenveloped viruses, adenovirus is not easily destroyed by many commonly used disinfectants. Under ideal conditions, it can survive on surfaces – remaining infectious – for up to 3 months.
Back at the pediatrician’s office, “We need an adenovirus vaccine,” the mother said as she picked up her child and headed for the door.
There is, in fact, a live oral vaccine that protects against adenovirus types 4 and 7. It is only approved for use in United States military personnel aged 17-50 years and it is given to all recruits as soon as they enter basic training. It works too. Before vaccine was available, up to 80% of recruits became infected during their initial training, half of those developing significant illness and a quarter being hospitalized. When the current vaccine was introduced in 2011, there was a 100-fold decrease in adenovirus-related disease burden (from 5.8 to 0.02 cases per 1,000 person-weeks, P less than .0001). That translates to 1 death, 1,100-2,700 hospitalizations and 13,000 febrile illnesses prevented each year (Clin Infect Dis. 2014 Oct 1. doi: 10.1093/cid/ciu507).
Some experts have suggested that adenovirus vaccine could be useful in civilian populations, too, but I question what the public reception would be. We have safe influenza vaccines that reduce the need for hospitalization and reduce mortality from influenza, but we still can’t convince some people to immunize themselves and their children. In the last 4 years, flu vaccination rates among children have remained just shy of 60% and adult rates are even lower. Collectively, we don’t seem to be ready to relinquish – or at least diminish – the annual suffering that goes with flu. I have to wonder if the same would be true for adenovirus.
Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She said she had no relevant financial disclosures. Email her at [email protected].
A 60-year-old white woman presented with a 3-month history of a painful, nonhealing ulceration on her left lateral lower leg
It is a vasculopathy rather than a vasculitis as the former is caused by occlusion of blood vessels and the latter results from inflammation of the vessels. Middle-aged women tend to be affected more frequently. Although the exact cause is unclear, systemic diseases, such as hypercoagulable states, may predispose vessels to develop occlusion. Associated disorders include antiphospholipid syndrome, protein C deficiency, factor V mutation, arteriosclerosis, hyperhomocysteinemia, and hepatitis C.
Typically, lesions begin as painful purpura or reticulated macules on the lower extremities that ulcerate and heal very slowly. Ankles, particularly malleoli, are more frequently affected. When they heal, they form painless white stellate scars typical of atrophie blanche. Surrounding erythema, telangiectasias, and sclerosis may be present; livedo reticularis may be seen as well.
Histologically, the epidermis may be atrophic or necrotic. Hyaline thickening of the blood vessel walls is seen. Thrombi may be present. Direct immunofluorescence of perilesional skin may be positive for complement C3 and immunoglobulin (IgM) in dermal blood vessels.
Livedoid vasculopathy can be difficult to treat. Treatment is aimed at reducing clotting and improving blood flow and includes antiplatelet drugs (low-dose aspirin, dipyridamole), anticoagulants, and vasodilating agents (nifedipine). Pentoxifylline two or three times daily may help by altering blood viscosity. A recent literature search reports success in topical dapsone applied to lesions twice daily under occlusion. Leg elevation and compression stockings help healing. Livedoid vasculopathy may have periods of activity and remission.
The case and photo were submitted by Dr. Bilu Martin.
Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/edermatologynews.com. To submit a case for possible publication, send an email to [email protected]
It is a vasculopathy rather than a vasculitis as the former is caused by occlusion of blood vessels and the latter results from inflammation of the vessels. Middle-aged women tend to be affected more frequently. Although the exact cause is unclear, systemic diseases, such as hypercoagulable states, may predispose vessels to develop occlusion. Associated disorders include antiphospholipid syndrome, protein C deficiency, factor V mutation, arteriosclerosis, hyperhomocysteinemia, and hepatitis C.
Typically, lesions begin as painful purpura or reticulated macules on the lower extremities that ulcerate and heal very slowly. Ankles, particularly malleoli, are more frequently affected. When they heal, they form painless white stellate scars typical of atrophie blanche. Surrounding erythema, telangiectasias, and sclerosis may be present; livedo reticularis may be seen as well.
Histologically, the epidermis may be atrophic or necrotic. Hyaline thickening of the blood vessel walls is seen. Thrombi may be present. Direct immunofluorescence of perilesional skin may be positive for complement C3 and immunoglobulin (IgM) in dermal blood vessels.
Livedoid vasculopathy can be difficult to treat. Treatment is aimed at reducing clotting and improving blood flow and includes antiplatelet drugs (low-dose aspirin, dipyridamole), anticoagulants, and vasodilating agents (nifedipine). Pentoxifylline two or three times daily may help by altering blood viscosity. A recent literature search reports success in topical dapsone applied to lesions twice daily under occlusion. Leg elevation and compression stockings help healing. Livedoid vasculopathy may have periods of activity and remission.
The case and photo were submitted by Dr. Bilu Martin.
Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/edermatologynews.com. To submit a case for possible publication, send an email to [email protected]
It is a vasculopathy rather than a vasculitis as the former is caused by occlusion of blood vessels and the latter results from inflammation of the vessels. Middle-aged women tend to be affected more frequently. Although the exact cause is unclear, systemic diseases, such as hypercoagulable states, may predispose vessels to develop occlusion. Associated disorders include antiphospholipid syndrome, protein C deficiency, factor V mutation, arteriosclerosis, hyperhomocysteinemia, and hepatitis C.
Typically, lesions begin as painful purpura or reticulated macules on the lower extremities that ulcerate and heal very slowly. Ankles, particularly malleoli, are more frequently affected. When they heal, they form painless white stellate scars typical of atrophie blanche. Surrounding erythema, telangiectasias, and sclerosis may be present; livedo reticularis may be seen as well.
Histologically, the epidermis may be atrophic or necrotic. Hyaline thickening of the blood vessel walls is seen. Thrombi may be present. Direct immunofluorescence of perilesional skin may be positive for complement C3 and immunoglobulin (IgM) in dermal blood vessels.
Livedoid vasculopathy can be difficult to treat. Treatment is aimed at reducing clotting and improving blood flow and includes antiplatelet drugs (low-dose aspirin, dipyridamole), anticoagulants, and vasodilating agents (nifedipine). Pentoxifylline two or three times daily may help by altering blood viscosity. A recent literature search reports success in topical dapsone applied to lesions twice daily under occlusion. Leg elevation and compression stockings help healing. Livedoid vasculopathy may have periods of activity and remission.
The case and photo were submitted by Dr. Bilu Martin.
Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/edermatologynews.com. To submit a case for possible publication, send an email to [email protected]
Terminating an employee
I’ve written more than once about the private practitioner’s least favorite task. Now, new federal worker protection laws are making terminations even more difficult, even when they’re justified; however, that’s still no excuse for keeping an employee that should be replaced.
Once you make the decision to replace an employee, be sure that you have legitimate grounds and assemble as much documentation as you can. Record all terminable transgressions in the employee’s permanent record and document all verbal and written warnings. This is essential; you must be prepared to prove that your reasons for termination were legal.
Former employees will sometimes charge that any of a number of their civil rights were violated. For example, federal law prohibits you from firing anyone because of race, gender, national origin, disability, religion, or age – if the employee is over 40. You cannot fire a woman because she is pregnant or recently gave birth. Other illegal reasons include assertion of antidiscrimination rights, refusing to take a lie detector test, and reporting Occupational Safety and Health Administration violations.
You also can’t terminate someone for refusing to commit an illegal act – such as filing false insurance claims – or for exercising a legal right – such as voting or participating in a political demonstration.
While you cannot fire an alcohol abuser unless he or she is caught drinking at work, many forms of illegal drug use are legitimate causes for termination. Other laws may apply, depending on where you live. When in doubt, contact your attorney, state labor department, or fair employment office.
If a fired employee alleges that he or she was fired for any of these illegal reasons and you do not have convincing documentation to counter the charge, you may find yourself defending your actions in court. If you anticipate such problems, you can ask the employee to sign a waiver of future litigation in exchange for a concession from you – such as extra severance pay or a promise not to contest an unemployment application. Also, consider adding employment practices liability insurance – which I covered in detail a few months ago – to your umbrella policy, since lawsuits are always a possibility, despite all efforts to prevent them.
Once you have all your legal ducks in a row, don’t procrastinate. Get it over with first thing on Monday morning. If you wait until Friday afternoon, you will worry about the dreaded task all week long, and the fired employee will stew about it all weekend. Ask your manager or another trusted employee to be present to reduce the risk of subsequent disputes over what was discussed.
I’ve been asked to share exactly what I say; so for what it’s worth, here it is: “We have called you in to discuss a difficult issue. You know that we have not been happy with your performance. We are still not happy with it, despite all the discussions we have had, and we feel that you can do better elsewhere. So today we will part company, and I wish you the best of luck in your future endeavors. Here is your severance check. I hope there are no hard feelings.”
There will, of course, be hard feelings, despite all your “hopes,” but that cannot be helped. The point is to be quick, firm, and decisive. Get it over with and allow everyone to move on. Make it clear, when necessary, that the decision has already been made, so arguing or pleading will change nothing.
Be sure to get all your office keys back – or change the locks if you cannot. Back up all important computer files and change all your passwords. Most employees know more of them than you would ever suspect.
Finally, call the staff together and explain everything. They should hear it from you, not some distorted version via the rumor mill. You don’t have to divulge every detail, but do explain how the termination will affect everyone else. Responsibilities will need to be shifted until a replacement can be hired, and all employees should understand that.
If you are asked in the future to give a reference or write a letter of recommendation for the terminated employee, be sure that everything you say is truthful and well documented.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
I’ve written more than once about the private practitioner’s least favorite task. Now, new federal worker protection laws are making terminations even more difficult, even when they’re justified; however, that’s still no excuse for keeping an employee that should be replaced.
Once you make the decision to replace an employee, be sure that you have legitimate grounds and assemble as much documentation as you can. Record all terminable transgressions in the employee’s permanent record and document all verbal and written warnings. This is essential; you must be prepared to prove that your reasons for termination were legal.
Former employees will sometimes charge that any of a number of their civil rights were violated. For example, federal law prohibits you from firing anyone because of race, gender, national origin, disability, religion, or age – if the employee is over 40. You cannot fire a woman because she is pregnant or recently gave birth. Other illegal reasons include assertion of antidiscrimination rights, refusing to take a lie detector test, and reporting Occupational Safety and Health Administration violations.
You also can’t terminate someone for refusing to commit an illegal act – such as filing false insurance claims – or for exercising a legal right – such as voting or participating in a political demonstration.
While you cannot fire an alcohol abuser unless he or she is caught drinking at work, many forms of illegal drug use are legitimate causes for termination. Other laws may apply, depending on where you live. When in doubt, contact your attorney, state labor department, or fair employment office.
If a fired employee alleges that he or she was fired for any of these illegal reasons and you do not have convincing documentation to counter the charge, you may find yourself defending your actions in court. If you anticipate such problems, you can ask the employee to sign a waiver of future litigation in exchange for a concession from you – such as extra severance pay or a promise not to contest an unemployment application. Also, consider adding employment practices liability insurance – which I covered in detail a few months ago – to your umbrella policy, since lawsuits are always a possibility, despite all efforts to prevent them.
Once you have all your legal ducks in a row, don’t procrastinate. Get it over with first thing on Monday morning. If you wait until Friday afternoon, you will worry about the dreaded task all week long, and the fired employee will stew about it all weekend. Ask your manager or another trusted employee to be present to reduce the risk of subsequent disputes over what was discussed.
I’ve been asked to share exactly what I say; so for what it’s worth, here it is: “We have called you in to discuss a difficult issue. You know that we have not been happy with your performance. We are still not happy with it, despite all the discussions we have had, and we feel that you can do better elsewhere. So today we will part company, and I wish you the best of luck in your future endeavors. Here is your severance check. I hope there are no hard feelings.”
There will, of course, be hard feelings, despite all your “hopes,” but that cannot be helped. The point is to be quick, firm, and decisive. Get it over with and allow everyone to move on. Make it clear, when necessary, that the decision has already been made, so arguing or pleading will change nothing.
Be sure to get all your office keys back – or change the locks if you cannot. Back up all important computer files and change all your passwords. Most employees know more of them than you would ever suspect.
Finally, call the staff together and explain everything. They should hear it from you, not some distorted version via the rumor mill. You don’t have to divulge every detail, but do explain how the termination will affect everyone else. Responsibilities will need to be shifted until a replacement can be hired, and all employees should understand that.
If you are asked in the future to give a reference or write a letter of recommendation for the terminated employee, be sure that everything you say is truthful and well documented.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
I’ve written more than once about the private practitioner’s least favorite task. Now, new federal worker protection laws are making terminations even more difficult, even when they’re justified; however, that’s still no excuse for keeping an employee that should be replaced.
Once you make the decision to replace an employee, be sure that you have legitimate grounds and assemble as much documentation as you can. Record all terminable transgressions in the employee’s permanent record and document all verbal and written warnings. This is essential; you must be prepared to prove that your reasons for termination were legal.
Former employees will sometimes charge that any of a number of their civil rights were violated. For example, federal law prohibits you from firing anyone because of race, gender, national origin, disability, religion, or age – if the employee is over 40. You cannot fire a woman because she is pregnant or recently gave birth. Other illegal reasons include assertion of antidiscrimination rights, refusing to take a lie detector test, and reporting Occupational Safety and Health Administration violations.
You also can’t terminate someone for refusing to commit an illegal act – such as filing false insurance claims – or for exercising a legal right – such as voting or participating in a political demonstration.
While you cannot fire an alcohol abuser unless he or she is caught drinking at work, many forms of illegal drug use are legitimate causes for termination. Other laws may apply, depending on where you live. When in doubt, contact your attorney, state labor department, or fair employment office.
If a fired employee alleges that he or she was fired for any of these illegal reasons and you do not have convincing documentation to counter the charge, you may find yourself defending your actions in court. If you anticipate such problems, you can ask the employee to sign a waiver of future litigation in exchange for a concession from you – such as extra severance pay or a promise not to contest an unemployment application. Also, consider adding employment practices liability insurance – which I covered in detail a few months ago – to your umbrella policy, since lawsuits are always a possibility, despite all efforts to prevent them.
Once you have all your legal ducks in a row, don’t procrastinate. Get it over with first thing on Monday morning. If you wait until Friday afternoon, you will worry about the dreaded task all week long, and the fired employee will stew about it all weekend. Ask your manager or another trusted employee to be present to reduce the risk of subsequent disputes over what was discussed.
I’ve been asked to share exactly what I say; so for what it’s worth, here it is: “We have called you in to discuss a difficult issue. You know that we have not been happy with your performance. We are still not happy with it, despite all the discussions we have had, and we feel that you can do better elsewhere. So today we will part company, and I wish you the best of luck in your future endeavors. Here is your severance check. I hope there are no hard feelings.”
There will, of course, be hard feelings, despite all your “hopes,” but that cannot be helped. The point is to be quick, firm, and decisive. Get it over with and allow everyone to move on. Make it clear, when necessary, that the decision has already been made, so arguing or pleading will change nothing.
Be sure to get all your office keys back – or change the locks if you cannot. Back up all important computer files and change all your passwords. Most employees know more of them than you would ever suspect.
Finally, call the staff together and explain everything. They should hear it from you, not some distorted version via the rumor mill. You don’t have to divulge every detail, but do explain how the termination will affect everyone else. Responsibilities will need to be shifted until a replacement can be hired, and all employees should understand that.
If you are asked in the future to give a reference or write a letter of recommendation for the terminated employee, be sure that everything you say is truthful and well documented.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].
In search of an ear
On our way up north to go backcountry skiing with another couple, we stopped at a roadside restaurant/tavern for lunch. We seated ourselves and, after a long 10 minutes, our waitperson arrived like a tornado, looking frazzled. She offered an apology and the first installment of her tale of woe. Before taking our order, she explained it all began when her car wouldn’t start, and then her day care provider called to say that she was sick and our server would have to find some other arrangement for the day. When our meal finally arrived, it looked appetizing but didn’t quite match our order. Again, our waitperson apologized, adding that it has been a particularly hard week because her husband was out of town and not around to help with her three children.
Had we been dining at a high-end restaurant with a white tablecloth and a candle, we would have considered our server’s behavior unprofessional and off-putting. However, we were in no hurry as the light snow had turned to a ski-unfriendly drizzle. While our original intent had been to simply have lunch, we accepted our role as a sympathetic audience for this unfortunate woman. In fact, we asked a few open-ended questions to help the cathartic process along.
The need to share one’s troubles seems to be a universal human trait. Our server had no illusions that we were going to provide any solutions to her problems. Nor was she seeking any expression of sympathy beyond our patience. However, I’m sure that unburdening herself by telling the story made her feel better, at least temporarily. Hopefully, there would be additional understanding diners to help her through the day.
For many people, the workplace serves as a therapeutic outlet where they can share their troubles and concerns. At times, the whining can be annoying to coworkers but in general, woe sharing is a harmless and valuable perk of having a job. Unless, of course, one’s job is primarily serving the public.
As physicians we are accustomed listening to our patients’ troubles. However, our job is not one of those that affords much opportunity to unburden ourselves of our own concerns. The patients assume that we are the problem solvers and don’t have any of our own. Or, if we do have some troubles, their office visit is not the time for us to share them.
The occasional sharing, such as that we are running late because we’ve had a flat on the way to the office, is harmless and can remind patients that we are human. But one must be careful stay off the slippery slope that leads to unprofessional oversharing.
Without that luxury of a workplace that allows for occasional catharsis, physicians have an additional risk for burnout. There are no easy solutions. Sharing with patients is unprofessional. Our peers are as busy as we are and probably don’t have the time to listen. Or at least they don’t seem to have the time. And then there is that ego-vulnerability issue where we are hesitant to reveal to anyone, be they staff or peers, that we have a soft underbelly.
I don’t have any easy answers to the problem beyond the usual suggestion that, Personally, I have to admit that, when my bad day was the result of an accumulation of minor bumps, I would follow our waitperson’s example and share them selectively with patients whom I deluded myself into believing had the time and concern to listen. It probably was unprofessional, but it made me feel better.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
On our way up north to go backcountry skiing with another couple, we stopped at a roadside restaurant/tavern for lunch. We seated ourselves and, after a long 10 minutes, our waitperson arrived like a tornado, looking frazzled. She offered an apology and the first installment of her tale of woe. Before taking our order, she explained it all began when her car wouldn’t start, and then her day care provider called to say that she was sick and our server would have to find some other arrangement for the day. When our meal finally arrived, it looked appetizing but didn’t quite match our order. Again, our waitperson apologized, adding that it has been a particularly hard week because her husband was out of town and not around to help with her three children.
Had we been dining at a high-end restaurant with a white tablecloth and a candle, we would have considered our server’s behavior unprofessional and off-putting. However, we were in no hurry as the light snow had turned to a ski-unfriendly drizzle. While our original intent had been to simply have lunch, we accepted our role as a sympathetic audience for this unfortunate woman. In fact, we asked a few open-ended questions to help the cathartic process along.
The need to share one’s troubles seems to be a universal human trait. Our server had no illusions that we were going to provide any solutions to her problems. Nor was she seeking any expression of sympathy beyond our patience. However, I’m sure that unburdening herself by telling the story made her feel better, at least temporarily. Hopefully, there would be additional understanding diners to help her through the day.
For many people, the workplace serves as a therapeutic outlet where they can share their troubles and concerns. At times, the whining can be annoying to coworkers but in general, woe sharing is a harmless and valuable perk of having a job. Unless, of course, one’s job is primarily serving the public.
As physicians we are accustomed listening to our patients’ troubles. However, our job is not one of those that affords much opportunity to unburden ourselves of our own concerns. The patients assume that we are the problem solvers and don’t have any of our own. Or, if we do have some troubles, their office visit is not the time for us to share them.
The occasional sharing, such as that we are running late because we’ve had a flat on the way to the office, is harmless and can remind patients that we are human. But one must be careful stay off the slippery slope that leads to unprofessional oversharing.
Without that luxury of a workplace that allows for occasional catharsis, physicians have an additional risk for burnout. There are no easy solutions. Sharing with patients is unprofessional. Our peers are as busy as we are and probably don’t have the time to listen. Or at least they don’t seem to have the time. And then there is that ego-vulnerability issue where we are hesitant to reveal to anyone, be they staff or peers, that we have a soft underbelly.
I don’t have any easy answers to the problem beyond the usual suggestion that, Personally, I have to admit that, when my bad day was the result of an accumulation of minor bumps, I would follow our waitperson’s example and share them selectively with patients whom I deluded myself into believing had the time and concern to listen. It probably was unprofessional, but it made me feel better.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
On our way up north to go backcountry skiing with another couple, we stopped at a roadside restaurant/tavern for lunch. We seated ourselves and, after a long 10 minutes, our waitperson arrived like a tornado, looking frazzled. She offered an apology and the first installment of her tale of woe. Before taking our order, she explained it all began when her car wouldn’t start, and then her day care provider called to say that she was sick and our server would have to find some other arrangement for the day. When our meal finally arrived, it looked appetizing but didn’t quite match our order. Again, our waitperson apologized, adding that it has been a particularly hard week because her husband was out of town and not around to help with her three children.
Had we been dining at a high-end restaurant with a white tablecloth and a candle, we would have considered our server’s behavior unprofessional and off-putting. However, we were in no hurry as the light snow had turned to a ski-unfriendly drizzle. While our original intent had been to simply have lunch, we accepted our role as a sympathetic audience for this unfortunate woman. In fact, we asked a few open-ended questions to help the cathartic process along.
The need to share one’s troubles seems to be a universal human trait. Our server had no illusions that we were going to provide any solutions to her problems. Nor was she seeking any expression of sympathy beyond our patience. However, I’m sure that unburdening herself by telling the story made her feel better, at least temporarily. Hopefully, there would be additional understanding diners to help her through the day.
For many people, the workplace serves as a therapeutic outlet where they can share their troubles and concerns. At times, the whining can be annoying to coworkers but in general, woe sharing is a harmless and valuable perk of having a job. Unless, of course, one’s job is primarily serving the public.
As physicians we are accustomed listening to our patients’ troubles. However, our job is not one of those that affords much opportunity to unburden ourselves of our own concerns. The patients assume that we are the problem solvers and don’t have any of our own. Or, if we do have some troubles, their office visit is not the time for us to share them.
The occasional sharing, such as that we are running late because we’ve had a flat on the way to the office, is harmless and can remind patients that we are human. But one must be careful stay off the slippery slope that leads to unprofessional oversharing.
Without that luxury of a workplace that allows for occasional catharsis, physicians have an additional risk for burnout. There are no easy solutions. Sharing with patients is unprofessional. Our peers are as busy as we are and probably don’t have the time to listen. Or at least they don’t seem to have the time. And then there is that ego-vulnerability issue where we are hesitant to reveal to anyone, be they staff or peers, that we have a soft underbelly.
I don’t have any easy answers to the problem beyond the usual suggestion that, Personally, I have to admit that, when my bad day was the result of an accumulation of minor bumps, I would follow our waitperson’s example and share them selectively with patients whom I deluded myself into believing had the time and concern to listen. It probably was unprofessional, but it made me feel better.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].
What is your diagnosis?
It most commonly affects young girls. The pathogenesis of LAHS is thought to involve a sporadic, autosomal dominant mutation that leads to a defect between the hair cuticle and the inner root sheath.1 This defect results in the hair being poorly anchored to the scalp, and therefore easily and painlessly plucked or lost during normal hair care.
The classic presentation of LAHS is that of hair thinning and hair that may be unruly and/or lackluster; the hair rarely, if ever, requires cutting.2 The key feature is the ability to easily and painlessly pluck hairs from the patient’s scalp. The affected area is limited to the scalp, and loss of eyebrows, eyelashes, and body hair should not be seen.
Diagnosis and consideration of the differential
The diagnosis of LAHS can in some cases be made on history and physical exam alone. Patients with LAHS typically will show hair thinning with or without dullness or unruliness. They lack evidence of scalp inflammation, such as erythema, scale, pruritus, and pain. Areas of hair thinning or aberration are typically not well demarcated, and there are typically not areas of complete hair loss. There is no scarring or atrophy of the scalp itself.
Diagnostic tests include the “hair pull test,” as well as trichogram testing. In the “hair pull test” a provider grasps a set of hair at the proximal shaft near the scalp. The traction applied should result in the painless and easy extraction of more than 10% of grasped hairs in a patient with LAHS. Removal of less than 10% of hair is a normal finding, as patients without LAHS typically have about 10% of their scalp hair in the telogen phase at any given time, which would result in removal during the hair pull test.3 In trichography, plucked hairs are examined under magnification, with or without the use of selective dyes. Cinnamaldehyde is a dye that stains citrulline, which is abundant in the inner root sheath, and can be a tool in identifying its presence and/or aberrations.4 A trichogram of the pulled hairs in a patient with LAHS may classically show ruffled appearance of the cuticle, misshapen anagen hair bulbs, and absence of the inner root sheath.5 Examination under magnification also allows providers to better identify telogen versus anagen hairs, which aids in the diagnosis. By carefully considering the patient history, physical exam, and results of additional hair tests, providers can make the diagnosis of LAHS and avoid unnecessary blood work and invasive procedures like scalp biopsies.
The differential diagnosis of hair loss frequently includes alopecia areata. However, in alopecia areata, patients typically have sharply demarcated areas of hair loss, which may involve the eyebrows, eyelids, and body hairs. In alopecia areata, providers may be able to identify the “exclamation point sign” in which the hair shaft thins proximally, leading to the appearance of more pigmented, thicker hairs floating above the scalp.
Telogen effluvium is a condition in which a medical illness or stress, such as systemic illness, surgery, severe emotional distress, childbirth, dietary changes, or another traumatic event, causes a disruption in the natural cycle of hair growth such that the percentage of hairs in the telogen phase increases from about 10% to up to 70%.6 Unlike in LAHS, in which shed hairs are in the anagen phase, the hair that is shed in telogen effluvium is in the telogen phase and will have a different appearance when magnified.
Anagen effluvium, loss of hairs in their growing phase, is typically associated with chemotherapy. The hairs become broken and fractured at the shaft leading to breakage at different points throughout the scalp. Affected areas can include the eyebrows, eyelashes, and body hair. In the absence of a history of administration of a chemotherapy agent (or other drug known to trigger hair loss), the diagnosis of anagen effluvium should not be made.
Patients with trichotillosis (also known as trichotillomania) present with areas of hair loss caused by intentional or subconscious hair pulling. It is considered a psychological condition that can be associated with obsessive compulsive disorder, although the presence of a secondary psychological diagnosis is not required. Providers may see irregular geometric shapes of hair loss, and on close inspection see broken hair shafts of different lengths. Patients most often pull hair from their scalps (over 70% of patients), but also can pull eyelashes, eyebrow hairs, and pubic hairs.7
Treatment
LAHS is self-limited and does not necessitate treatment. However, if patients or parents feel there is significant disease burden, perhaps with poor effects on quality of life or with psychosocial impairment, treatment with minoxidil 5% solution has been studied with some success reported in the literature.1,8,9
Ms. Natsis is a medical student at the University of California, San Diego. Dr. Eichenfield is chief of pediatric and adolescent dermatology at Rady Children’s Hospital-San Diego. He is vice chair of the department of dermatology and professor of dermatology and pediatrics at the University of California, San Diego. Ms. Natsis and Dr. Eichenfield had no relevant financial disclosures. Email them at [email protected].
References
1. Arch Dermatol. 2002;138(4):501-6.
2. Int J Trichology. 2010;2(2):96-100.
3. Pediatric Dermatol. 2016:33(50):507-10.
4. Dermatol Clin. 1986;14:745-51.
5. Arch Dermatol. 2009;145(10):1123-8.
6. J Clin Diagn Res. 2015;9(9):WE01-3.
7. Am J Psychiatry. 2016;173(9):868-74.
8. Australas J Dermatol. 2018;59:e286-e287.
9. Pediatr Dermatol. 2014;31:389-90.
It most commonly affects young girls. The pathogenesis of LAHS is thought to involve a sporadic, autosomal dominant mutation that leads to a defect between the hair cuticle and the inner root sheath.1 This defect results in the hair being poorly anchored to the scalp, and therefore easily and painlessly plucked or lost during normal hair care.
The classic presentation of LAHS is that of hair thinning and hair that may be unruly and/or lackluster; the hair rarely, if ever, requires cutting.2 The key feature is the ability to easily and painlessly pluck hairs from the patient’s scalp. The affected area is limited to the scalp, and loss of eyebrows, eyelashes, and body hair should not be seen.
Diagnosis and consideration of the differential
The diagnosis of LAHS can in some cases be made on history and physical exam alone. Patients with LAHS typically will show hair thinning with or without dullness or unruliness. They lack evidence of scalp inflammation, such as erythema, scale, pruritus, and pain. Areas of hair thinning or aberration are typically not well demarcated, and there are typically not areas of complete hair loss. There is no scarring or atrophy of the scalp itself.
Diagnostic tests include the “hair pull test,” as well as trichogram testing. In the “hair pull test” a provider grasps a set of hair at the proximal shaft near the scalp. The traction applied should result in the painless and easy extraction of more than 10% of grasped hairs in a patient with LAHS. Removal of less than 10% of hair is a normal finding, as patients without LAHS typically have about 10% of their scalp hair in the telogen phase at any given time, which would result in removal during the hair pull test.3 In trichography, plucked hairs are examined under magnification, with or without the use of selective dyes. Cinnamaldehyde is a dye that stains citrulline, which is abundant in the inner root sheath, and can be a tool in identifying its presence and/or aberrations.4 A trichogram of the pulled hairs in a patient with LAHS may classically show ruffled appearance of the cuticle, misshapen anagen hair bulbs, and absence of the inner root sheath.5 Examination under magnification also allows providers to better identify telogen versus anagen hairs, which aids in the diagnosis. By carefully considering the patient history, physical exam, and results of additional hair tests, providers can make the diagnosis of LAHS and avoid unnecessary blood work and invasive procedures like scalp biopsies.
The differential diagnosis of hair loss frequently includes alopecia areata. However, in alopecia areata, patients typically have sharply demarcated areas of hair loss, which may involve the eyebrows, eyelids, and body hairs. In alopecia areata, providers may be able to identify the “exclamation point sign” in which the hair shaft thins proximally, leading to the appearance of more pigmented, thicker hairs floating above the scalp.
Telogen effluvium is a condition in which a medical illness or stress, such as systemic illness, surgery, severe emotional distress, childbirth, dietary changes, or another traumatic event, causes a disruption in the natural cycle of hair growth such that the percentage of hairs in the telogen phase increases from about 10% to up to 70%.6 Unlike in LAHS, in which shed hairs are in the anagen phase, the hair that is shed in telogen effluvium is in the telogen phase and will have a different appearance when magnified.
Anagen effluvium, loss of hairs in their growing phase, is typically associated with chemotherapy. The hairs become broken and fractured at the shaft leading to breakage at different points throughout the scalp. Affected areas can include the eyebrows, eyelashes, and body hair. In the absence of a history of administration of a chemotherapy agent (or other drug known to trigger hair loss), the diagnosis of anagen effluvium should not be made.
Patients with trichotillosis (also known as trichotillomania) present with areas of hair loss caused by intentional or subconscious hair pulling. It is considered a psychological condition that can be associated with obsessive compulsive disorder, although the presence of a secondary psychological diagnosis is not required. Providers may see irregular geometric shapes of hair loss, and on close inspection see broken hair shafts of different lengths. Patients most often pull hair from their scalps (over 70% of patients), but also can pull eyelashes, eyebrow hairs, and pubic hairs.7
Treatment
LAHS is self-limited and does not necessitate treatment. However, if patients or parents feel there is significant disease burden, perhaps with poor effects on quality of life or with psychosocial impairment, treatment with minoxidil 5% solution has been studied with some success reported in the literature.1,8,9
Ms. Natsis is a medical student at the University of California, San Diego. Dr. Eichenfield is chief of pediatric and adolescent dermatology at Rady Children’s Hospital-San Diego. He is vice chair of the department of dermatology and professor of dermatology and pediatrics at the University of California, San Diego. Ms. Natsis and Dr. Eichenfield had no relevant financial disclosures. Email them at [email protected].
References
1. Arch Dermatol. 2002;138(4):501-6.
2. Int J Trichology. 2010;2(2):96-100.
3. Pediatric Dermatol. 2016:33(50):507-10.
4. Dermatol Clin. 1986;14:745-51.
5. Arch Dermatol. 2009;145(10):1123-8.
6. J Clin Diagn Res. 2015;9(9):WE01-3.
7. Am J Psychiatry. 2016;173(9):868-74.
8. Australas J Dermatol. 2018;59:e286-e287.
9. Pediatr Dermatol. 2014;31:389-90.
It most commonly affects young girls. The pathogenesis of LAHS is thought to involve a sporadic, autosomal dominant mutation that leads to a defect between the hair cuticle and the inner root sheath.1 This defect results in the hair being poorly anchored to the scalp, and therefore easily and painlessly plucked or lost during normal hair care.
The classic presentation of LAHS is that of hair thinning and hair that may be unruly and/or lackluster; the hair rarely, if ever, requires cutting.2 The key feature is the ability to easily and painlessly pluck hairs from the patient’s scalp. The affected area is limited to the scalp, and loss of eyebrows, eyelashes, and body hair should not be seen.
Diagnosis and consideration of the differential
The diagnosis of LAHS can in some cases be made on history and physical exam alone. Patients with LAHS typically will show hair thinning with or without dullness or unruliness. They lack evidence of scalp inflammation, such as erythema, scale, pruritus, and pain. Areas of hair thinning or aberration are typically not well demarcated, and there are typically not areas of complete hair loss. There is no scarring or atrophy of the scalp itself.
Diagnostic tests include the “hair pull test,” as well as trichogram testing. In the “hair pull test” a provider grasps a set of hair at the proximal shaft near the scalp. The traction applied should result in the painless and easy extraction of more than 10% of grasped hairs in a patient with LAHS. Removal of less than 10% of hair is a normal finding, as patients without LAHS typically have about 10% of their scalp hair in the telogen phase at any given time, which would result in removal during the hair pull test.3 In trichography, plucked hairs are examined under magnification, with or without the use of selective dyes. Cinnamaldehyde is a dye that stains citrulline, which is abundant in the inner root sheath, and can be a tool in identifying its presence and/or aberrations.4 A trichogram of the pulled hairs in a patient with LAHS may classically show ruffled appearance of the cuticle, misshapen anagen hair bulbs, and absence of the inner root sheath.5 Examination under magnification also allows providers to better identify telogen versus anagen hairs, which aids in the diagnosis. By carefully considering the patient history, physical exam, and results of additional hair tests, providers can make the diagnosis of LAHS and avoid unnecessary blood work and invasive procedures like scalp biopsies.
The differential diagnosis of hair loss frequently includes alopecia areata. However, in alopecia areata, patients typically have sharply demarcated areas of hair loss, which may involve the eyebrows, eyelids, and body hairs. In alopecia areata, providers may be able to identify the “exclamation point sign” in which the hair shaft thins proximally, leading to the appearance of more pigmented, thicker hairs floating above the scalp.
Telogen effluvium is a condition in which a medical illness or stress, such as systemic illness, surgery, severe emotional distress, childbirth, dietary changes, or another traumatic event, causes a disruption in the natural cycle of hair growth such that the percentage of hairs in the telogen phase increases from about 10% to up to 70%.6 Unlike in LAHS, in which shed hairs are in the anagen phase, the hair that is shed in telogen effluvium is in the telogen phase and will have a different appearance when magnified.
Anagen effluvium, loss of hairs in their growing phase, is typically associated with chemotherapy. The hairs become broken and fractured at the shaft leading to breakage at different points throughout the scalp. Affected areas can include the eyebrows, eyelashes, and body hair. In the absence of a history of administration of a chemotherapy agent (or other drug known to trigger hair loss), the diagnosis of anagen effluvium should not be made.
Patients with trichotillosis (also known as trichotillomania) present with areas of hair loss caused by intentional or subconscious hair pulling. It is considered a psychological condition that can be associated with obsessive compulsive disorder, although the presence of a secondary psychological diagnosis is not required. Providers may see irregular geometric shapes of hair loss, and on close inspection see broken hair shafts of different lengths. Patients most often pull hair from their scalps (over 70% of patients), but also can pull eyelashes, eyebrow hairs, and pubic hairs.7
Treatment
LAHS is self-limited and does not necessitate treatment. However, if patients or parents feel there is significant disease burden, perhaps with poor effects on quality of life or with psychosocial impairment, treatment with minoxidil 5% solution has been studied with some success reported in the literature.1,8,9
Ms. Natsis is a medical student at the University of California, San Diego. Dr. Eichenfield is chief of pediatric and adolescent dermatology at Rady Children’s Hospital-San Diego. He is vice chair of the department of dermatology and professor of dermatology and pediatrics at the University of California, San Diego. Ms. Natsis and Dr. Eichenfield had no relevant financial disclosures. Email them at [email protected].
References
1. Arch Dermatol. 2002;138(4):501-6.
2. Int J Trichology. 2010;2(2):96-100.
3. Pediatric Dermatol. 2016:33(50):507-10.
4. Dermatol Clin. 1986;14:745-51.
5. Arch Dermatol. 2009;145(10):1123-8.
6. J Clin Diagn Res. 2015;9(9):WE01-3.
7. Am J Psychiatry. 2016;173(9):868-74.
8. Australas J Dermatol. 2018;59:e286-e287.
9. Pediatr Dermatol. 2014;31:389-90.
A 5-year-old female is brought to clinic for hair loss. The mother reports that when styling her daughter's hair, she has noticed areas of hair thinning, especially at the temples and at the occiput. The mother denies scale, pruritus, and erythema. The patient reports that her scalp does not hurt. She has never had a haircut because her hair hasn't grown long enough to cut. There is no history of specific bald spots. The patient has no personal history of psoriasis, seborrheic dermatitis, or autoimmune disease. No picking has been noted, and there is no history of compulsive behaviors or anxiety. The patient's mother has a history of Graves disease. The mother reports that the patient's older sister may have had hair thinning when she was younger as well, but no longer has thin hair.
The patient was previously seen by another provider who prescribed hydrocortisone 2.5% ointment, which the mother has been applying nightly without improvement.
The child is otherwise medically well and thriving, with no recent change in activity level and with growth parameters consistently around the 75th percentile for height and weight. On physical exam, the patient has blondish, fine hair with areas of poorly demarcated hair thinning at the left temple and at the occiput. The hair remaining at the occiput is normal in texture. There are no areas of complete hair loss. There is no scale, erythema, or abnormal pigmentation, and no cervical or occipital adenopathy. The patient has intact eyebrows and eyelashes.
Obstetric hospitalists can screen for postpartum depression
Postpartum depression (PPD) is the most common complication of pregnancy, and onset can occur at any time from pregnancy until up to 1 year post partum.1,2 The immediate postpartum period is a time during which care is shared among multiple providers for both mother and child, and the transition from inpatient to outpatient postpartum care can impede communication between those caring for the patient in each setting. In 2018, the American College of Obstetricians and Gynecologists published a committee opinion emphasizing the importance of the “fourth trimester” and calling for health care providers to assist women in navigating the transition from pre- to postpartum care.3 An important consideration of perinatal care is mental health care for the mother, including screening and care for postpartum depression; however, the optimal role for the obstetric hospitalist in providing such services has been unclear.
Estimates of the prevalence of PPD in new mothers in the United States varied by state from 8% to 20% in 2012, with an overall average of 12%.2 Left untreated, PPD may result in significant negative outcomes for women, their children, and families. The depressive symptoms of PPD may persist for months or years afterward,4 with one study finding elevated depressive symptoms in women up to 11 years post partum.5 Suicide is also a leading cause of pregnancy-related mortality associated with depressive symptoms.6-9 In addition, maternal postpartum depression symptoms have been associated with impaired mother-infant bonding at 6 months of age10 and decreased cognitive and fine motor development of children at 18 months.11
Importance of screening
Evidence from the literature shows that, without proper screening, approximately 50% of cases of PPD go undiagnosed, and that increasing the number of women being screened by perinatal providers is an important first step to improving outcomes.12-18 Current recommendations for the timing and frequency of screening for PPD vary among the published guidelines. ACOG recommends screening at least once during the perinatal period for depression and anxiety using a standardized, validated tool; an update of the ACOG committee opinion in 2018 also states: “It is recommended that all obstetrician-gynecologists and other obstetric care providers complete a full assessment of mood and emotional well-being (including screening for PPD and anxiety with a validated instrument) during the comprehensive postpartum visit for each patient.”19 The American Medical Association adopted new policies in 2017 promoting the implementation of a routine protocol for depression screening of perinatal women.20 The American Academy of Pediatrics recommends more frequent screening, with assessments at the 1-, 2-, 4-, and 6-month visits.21 Finally, the U.S. Preventive Services Task Force recommends screening for depression in the general population including pregnant and postpartum women.22
Multiple standardized, validated screening instruments are available for detecting possible symptoms of PPD, including the most widely used tools: the Edinburgh Postnatal Depression Scale (EPDS)19,23 and the Patient Health Questionnaire (PHQ-9).24 Two recent studies have shown that screening women for symptoms of PPD with a validated tool may reduce the duration or severity of depressive symptoms,25,26 further reinforcing the need to ensure that women experiencing symptoms of PPD are identified and treated early.
The inpatient hospitalization for labor, delivery, and birth of a child has not traditionally been viewed as an opportunity for PPD screening. While private practitioners and obstetric medical group practices typically have inquired about and documented the individual patient’s mental health history and risk factors for PPD, the obstetric hospitalist is most commonly meeting a patient in labor or in a postpartum encounter for the first time. As obstetric practices grow ever more consolidated, and as obstetric hospitalist care is implemented for a variety of reasons including, but not limited to, preventing burnout among private practitioners, serving as a safety net for all inpatient obstetric services, and increasing standardization in obstetric triage and obstetric emergency departments,
Barriers remain
Despite the need for early detection of PPD, screening practices remain inconsistent. A literature review of health care provider practices showed only one in four physicians reported using screening tools; obstetrician-gynecologists were most likely (36%) to use screening tools, followed by family practitioners (31%), with pediatricians the least likely (7%).27 This low rate is at least partially the result of perceived barriers to screening among health care providers, which contributes to underdiagnosis. A survey of more than 200 physicians who were members of ACOG showed that the top three barriers restricting screening practices were time constraints, inadequate training, and a lack of knowledge of the diagnostic criteria.28
Since 2017, Dignity Health has instituted routine screening of all inpatient postpartum patients at its 29 birth centers in Arizona, California, and Nevada. In this program, of which I am a physician participant, more than 30,000 women have been screened with the EPDS. In addition to providing screening, Dignity Health staff (physicians, certified nurse midwives, nurse practitioners, registered nurses, social workers, mental health therapists, lactation consultants, health educators, and others) have received in-person Perinatal Mental Health training. In this way, the entire care team coordinates inpatient screening and referral to outpatient care providers – thus bridging the gap in postpartum mental health care. For those patients who screen positive while an inpatient, a psychiatric telemedicine appointment is provided and, if necessary, short-course medications can be prescribed until the patient has outpatient follow-up and continuity of care. While we as obstetric hospitalists and community obstetrician-gynecologists recognize that inpatient postpartum screening may be limited in its sensitivity for capturing all women who will go on to develop PPD, there is definitely a benefit to having a discussion about PPD and maternal mental health early and often throughout the postpartum period. For many women suffering in silence, a 6-week postpartum outpatient visit is too late, especially given that approximately one-third of women are lost to postpartum follow-up.29,30
Addressing barriers
A growing number of states have enacted policies to address the challenge of peripartum behavioral health needs, and several states – Illinois, Massachusetts, New Jersey, and West Virginia – now mandate routine PPD screening by health care providers.31 However, few of these laws or policies contain specific guidance, such as the optimal timing for screening, instead leaving the details to providers.32 The proper identification and management of PPD cannot be achieved by state-level policy mandates alone, but must include clinician buy-in and participation.
Obstetricians play an essential role in the identification and treatment of PPD. Among nonpsychiatric specialists, obstetrician-gynecologists are the most likely providers to see and screen during the perinatal period.33 In addition, women prefer to receive help for PPD from either their obstetric practitioners or a mental-health specialists located at the obstetric clinic, and are more likely to receive mental-health services if they are provided at the same location as that of the obstetric provider.34,35 According to ACOG’s new guidance on the fourth trimester, obstetricians are encouraged to take responsibility for women’s care immediately after birth, and this care would include contact with all mothers within the first 3 weeks post partum, at follow-up visits as needed, and for a comprehensive postpartum visit at 12 weeks.3
Our specialty has and will continue to evolve, and obstetric hospitalists will play an ever more essential role in the care of women during their inpatient obstetric admission. Whether we are a patient’s primary inpatient obstetric provider or a practice extender for single or multigroup practice, we are in a unique role to screen, begin treatment for, and offer anticipatory guidance for maternal mental health and postpartum depression disorders. Obstetric hospitalists can be a bridge between inpatient and outpatient follow-up and catalysts for implementing universal inpatient PPD screening. Our role presents an opportunity to start the discussion early and often in the fourth trimester and to make a significant difference in addressing this critical unmet need in postnatal care.
Dr. van Dis is the medical director of the Ob Hospitalist Group in Burbank, Calif. She disclosed she received editorial assistance from Erik MacLaren, PhD, of Boston Strategic Partners Inc., with funding support from Sage Therapeutics Inc. E-mail [email protected].
References
1. Centers for Disease Control and Prevention. Postpartum Depression. 2017.
2. Morb Mortal Wkly Rep. 2017;66(6):153-8.
3. Obstet Gynecol. 2018;131(5):e140-e150.
4. Harv Rev Psychiatry. 2014;22(1):1-22.
5. JAMA Psychiatry. 2018;75(3):247-53.
6. J Womens Health (Larchmt). 2016;25(12):1219-24.
7. J Psychiatr Res. 2017;84:284-91.
8. Br J Psychiatry. 2003;183:279-81.
9. Obstet Gynecol Surv. 2005;60(3):183-90.
10. Arch Womens Ment Health. 2016;19(1):87-94.
11. Soc Psychiatry Psychiatr Epidemiol. 2013;48(8):1335-45.
12. J Reprod Med. 1999;44(4):351-8.
13. J Behav Health Serv Res. 2004;31(2):117-33.
14. J Clin Psychiatry. 2016;77(9):1189-200.
15. Am J Obstet Gynecol. 2000;182(5):1080-2.
16. J Fam Pract. 2001;50(2):117-22.
17. Obstet Gynecol. 1999;93(5 Pt 1):653-7.
18. J Womens Health (Larchmt). 2010;19(3):477-90.
19. Obstet Gynecol. 2018;132:e208-12.
20. “Physicians back programs to address maternal mortality, depression,” AMA, Nov. 15, 2017
21. Pediatrics. 2019 Jan 1;143(1):e20183260.
22. JAMA. 2016;315(4):380-7.
23. Br J Psychiatry. 1987;150:782-6.
24. Ann Fam Med. 2009;7(1):63-70.
25. Obstet Gynecol. 2016;127(5):917-25.
26. Pediatrics. 2017 Oct;140(4). pii: e20170110.
27. Womens Health Issues. 2015;25(6):703-10.
28. J Psychosom Obstet Gynaecol. 2011;32(1):27-34.
29. Matern Child Health J. 2016;20(Suppl 1):22-7.
30. National Committee for Quality Assurance. Prenatal and Postpartum Care (PPC). 2018.
31. Psychiatr Serv. 2015;66(3):324-8.
32. Postpartum Support International. Legislation. 2018.
33. American Academy of Pediatrics, American College of Obstetricians and Gynecologists, eds. Guidelines for Perinatal Care. 7th ed. (Elk Grove Village, IL: Washington, DC: American Academy of Pediatrics; American College of Obstetricians and Gynecologists; Oct 2012.)
34. Birth. 2009;36(1):60-9.
35. Gen Hosp Psychiatry. 2009;31(2):155-62.
Postpartum depression (PPD) is the most common complication of pregnancy, and onset can occur at any time from pregnancy until up to 1 year post partum.1,2 The immediate postpartum period is a time during which care is shared among multiple providers for both mother and child, and the transition from inpatient to outpatient postpartum care can impede communication between those caring for the patient in each setting. In 2018, the American College of Obstetricians and Gynecologists published a committee opinion emphasizing the importance of the “fourth trimester” and calling for health care providers to assist women in navigating the transition from pre- to postpartum care.3 An important consideration of perinatal care is mental health care for the mother, including screening and care for postpartum depression; however, the optimal role for the obstetric hospitalist in providing such services has been unclear.
Estimates of the prevalence of PPD in new mothers in the United States varied by state from 8% to 20% in 2012, with an overall average of 12%.2 Left untreated, PPD may result in significant negative outcomes for women, their children, and families. The depressive symptoms of PPD may persist for months or years afterward,4 with one study finding elevated depressive symptoms in women up to 11 years post partum.5 Suicide is also a leading cause of pregnancy-related mortality associated with depressive symptoms.6-9 In addition, maternal postpartum depression symptoms have been associated with impaired mother-infant bonding at 6 months of age10 and decreased cognitive and fine motor development of children at 18 months.11
Importance of screening
Evidence from the literature shows that, without proper screening, approximately 50% of cases of PPD go undiagnosed, and that increasing the number of women being screened by perinatal providers is an important first step to improving outcomes.12-18 Current recommendations for the timing and frequency of screening for PPD vary among the published guidelines. ACOG recommends screening at least once during the perinatal period for depression and anxiety using a standardized, validated tool; an update of the ACOG committee opinion in 2018 also states: “It is recommended that all obstetrician-gynecologists and other obstetric care providers complete a full assessment of mood and emotional well-being (including screening for PPD and anxiety with a validated instrument) during the comprehensive postpartum visit for each patient.”19 The American Medical Association adopted new policies in 2017 promoting the implementation of a routine protocol for depression screening of perinatal women.20 The American Academy of Pediatrics recommends more frequent screening, with assessments at the 1-, 2-, 4-, and 6-month visits.21 Finally, the U.S. Preventive Services Task Force recommends screening for depression in the general population including pregnant and postpartum women.22
Multiple standardized, validated screening instruments are available for detecting possible symptoms of PPD, including the most widely used tools: the Edinburgh Postnatal Depression Scale (EPDS)19,23 and the Patient Health Questionnaire (PHQ-9).24 Two recent studies have shown that screening women for symptoms of PPD with a validated tool may reduce the duration or severity of depressive symptoms,25,26 further reinforcing the need to ensure that women experiencing symptoms of PPD are identified and treated early.
The inpatient hospitalization for labor, delivery, and birth of a child has not traditionally been viewed as an opportunity for PPD screening. While private practitioners and obstetric medical group practices typically have inquired about and documented the individual patient’s mental health history and risk factors for PPD, the obstetric hospitalist is most commonly meeting a patient in labor or in a postpartum encounter for the first time. As obstetric practices grow ever more consolidated, and as obstetric hospitalist care is implemented for a variety of reasons including, but not limited to, preventing burnout among private practitioners, serving as a safety net for all inpatient obstetric services, and increasing standardization in obstetric triage and obstetric emergency departments,
Barriers remain
Despite the need for early detection of PPD, screening practices remain inconsistent. A literature review of health care provider practices showed only one in four physicians reported using screening tools; obstetrician-gynecologists were most likely (36%) to use screening tools, followed by family practitioners (31%), with pediatricians the least likely (7%).27 This low rate is at least partially the result of perceived barriers to screening among health care providers, which contributes to underdiagnosis. A survey of more than 200 physicians who were members of ACOG showed that the top three barriers restricting screening practices were time constraints, inadequate training, and a lack of knowledge of the diagnostic criteria.28
Since 2017, Dignity Health has instituted routine screening of all inpatient postpartum patients at its 29 birth centers in Arizona, California, and Nevada. In this program, of which I am a physician participant, more than 30,000 women have been screened with the EPDS. In addition to providing screening, Dignity Health staff (physicians, certified nurse midwives, nurse practitioners, registered nurses, social workers, mental health therapists, lactation consultants, health educators, and others) have received in-person Perinatal Mental Health training. In this way, the entire care team coordinates inpatient screening and referral to outpatient care providers – thus bridging the gap in postpartum mental health care. For those patients who screen positive while an inpatient, a psychiatric telemedicine appointment is provided and, if necessary, short-course medications can be prescribed until the patient has outpatient follow-up and continuity of care. While we as obstetric hospitalists and community obstetrician-gynecologists recognize that inpatient postpartum screening may be limited in its sensitivity for capturing all women who will go on to develop PPD, there is definitely a benefit to having a discussion about PPD and maternal mental health early and often throughout the postpartum period. For many women suffering in silence, a 6-week postpartum outpatient visit is too late, especially given that approximately one-third of women are lost to postpartum follow-up.29,30
Addressing barriers
A growing number of states have enacted policies to address the challenge of peripartum behavioral health needs, and several states – Illinois, Massachusetts, New Jersey, and West Virginia – now mandate routine PPD screening by health care providers.31 However, few of these laws or policies contain specific guidance, such as the optimal timing for screening, instead leaving the details to providers.32 The proper identification and management of PPD cannot be achieved by state-level policy mandates alone, but must include clinician buy-in and participation.
Obstetricians play an essential role in the identification and treatment of PPD. Among nonpsychiatric specialists, obstetrician-gynecologists are the most likely providers to see and screen during the perinatal period.33 In addition, women prefer to receive help for PPD from either their obstetric practitioners or a mental-health specialists located at the obstetric clinic, and are more likely to receive mental-health services if they are provided at the same location as that of the obstetric provider.34,35 According to ACOG’s new guidance on the fourth trimester, obstetricians are encouraged to take responsibility for women’s care immediately after birth, and this care would include contact with all mothers within the first 3 weeks post partum, at follow-up visits as needed, and for a comprehensive postpartum visit at 12 weeks.3
Our specialty has and will continue to evolve, and obstetric hospitalists will play an ever more essential role in the care of women during their inpatient obstetric admission. Whether we are a patient’s primary inpatient obstetric provider or a practice extender for single or multigroup practice, we are in a unique role to screen, begin treatment for, and offer anticipatory guidance for maternal mental health and postpartum depression disorders. Obstetric hospitalists can be a bridge between inpatient and outpatient follow-up and catalysts for implementing universal inpatient PPD screening. Our role presents an opportunity to start the discussion early and often in the fourth trimester and to make a significant difference in addressing this critical unmet need in postnatal care.
Dr. van Dis is the medical director of the Ob Hospitalist Group in Burbank, Calif. She disclosed she received editorial assistance from Erik MacLaren, PhD, of Boston Strategic Partners Inc., with funding support from Sage Therapeutics Inc. E-mail [email protected].
References
1. Centers for Disease Control and Prevention. Postpartum Depression. 2017.
2. Morb Mortal Wkly Rep. 2017;66(6):153-8.
3. Obstet Gynecol. 2018;131(5):e140-e150.
4. Harv Rev Psychiatry. 2014;22(1):1-22.
5. JAMA Psychiatry. 2018;75(3):247-53.
6. J Womens Health (Larchmt). 2016;25(12):1219-24.
7. J Psychiatr Res. 2017;84:284-91.
8. Br J Psychiatry. 2003;183:279-81.
9. Obstet Gynecol Surv. 2005;60(3):183-90.
10. Arch Womens Ment Health. 2016;19(1):87-94.
11. Soc Psychiatry Psychiatr Epidemiol. 2013;48(8):1335-45.
12. J Reprod Med. 1999;44(4):351-8.
13. J Behav Health Serv Res. 2004;31(2):117-33.
14. J Clin Psychiatry. 2016;77(9):1189-200.
15. Am J Obstet Gynecol. 2000;182(5):1080-2.
16. J Fam Pract. 2001;50(2):117-22.
17. Obstet Gynecol. 1999;93(5 Pt 1):653-7.
18. J Womens Health (Larchmt). 2010;19(3):477-90.
19. Obstet Gynecol. 2018;132:e208-12.
20. “Physicians back programs to address maternal mortality, depression,” AMA, Nov. 15, 2017
21. Pediatrics. 2019 Jan 1;143(1):e20183260.
22. JAMA. 2016;315(4):380-7.
23. Br J Psychiatry. 1987;150:782-6.
24. Ann Fam Med. 2009;7(1):63-70.
25. Obstet Gynecol. 2016;127(5):917-25.
26. Pediatrics. 2017 Oct;140(4). pii: e20170110.
27. Womens Health Issues. 2015;25(6):703-10.
28. J Psychosom Obstet Gynaecol. 2011;32(1):27-34.
29. Matern Child Health J. 2016;20(Suppl 1):22-7.
30. National Committee for Quality Assurance. Prenatal and Postpartum Care (PPC). 2018.
31. Psychiatr Serv. 2015;66(3):324-8.
32. Postpartum Support International. Legislation. 2018.
33. American Academy of Pediatrics, American College of Obstetricians and Gynecologists, eds. Guidelines for Perinatal Care. 7th ed. (Elk Grove Village, IL: Washington, DC: American Academy of Pediatrics; American College of Obstetricians and Gynecologists; Oct 2012.)
34. Birth. 2009;36(1):60-9.
35. Gen Hosp Psychiatry. 2009;31(2):155-62.
Postpartum depression (PPD) is the most common complication of pregnancy, and onset can occur at any time from pregnancy until up to 1 year post partum.1,2 The immediate postpartum period is a time during which care is shared among multiple providers for both mother and child, and the transition from inpatient to outpatient postpartum care can impede communication between those caring for the patient in each setting. In 2018, the American College of Obstetricians and Gynecologists published a committee opinion emphasizing the importance of the “fourth trimester” and calling for health care providers to assist women in navigating the transition from pre- to postpartum care.3 An important consideration of perinatal care is mental health care for the mother, including screening and care for postpartum depression; however, the optimal role for the obstetric hospitalist in providing such services has been unclear.
Estimates of the prevalence of PPD in new mothers in the United States varied by state from 8% to 20% in 2012, with an overall average of 12%.2 Left untreated, PPD may result in significant negative outcomes for women, their children, and families. The depressive symptoms of PPD may persist for months or years afterward,4 with one study finding elevated depressive symptoms in women up to 11 years post partum.5 Suicide is also a leading cause of pregnancy-related mortality associated with depressive symptoms.6-9 In addition, maternal postpartum depression symptoms have been associated with impaired mother-infant bonding at 6 months of age10 and decreased cognitive and fine motor development of children at 18 months.11
Importance of screening
Evidence from the literature shows that, without proper screening, approximately 50% of cases of PPD go undiagnosed, and that increasing the number of women being screened by perinatal providers is an important first step to improving outcomes.12-18 Current recommendations for the timing and frequency of screening for PPD vary among the published guidelines. ACOG recommends screening at least once during the perinatal period for depression and anxiety using a standardized, validated tool; an update of the ACOG committee opinion in 2018 also states: “It is recommended that all obstetrician-gynecologists and other obstetric care providers complete a full assessment of mood and emotional well-being (including screening for PPD and anxiety with a validated instrument) during the comprehensive postpartum visit for each patient.”19 The American Medical Association adopted new policies in 2017 promoting the implementation of a routine protocol for depression screening of perinatal women.20 The American Academy of Pediatrics recommends more frequent screening, with assessments at the 1-, 2-, 4-, and 6-month visits.21 Finally, the U.S. Preventive Services Task Force recommends screening for depression in the general population including pregnant and postpartum women.22
Multiple standardized, validated screening instruments are available for detecting possible symptoms of PPD, including the most widely used tools: the Edinburgh Postnatal Depression Scale (EPDS)19,23 and the Patient Health Questionnaire (PHQ-9).24 Two recent studies have shown that screening women for symptoms of PPD with a validated tool may reduce the duration or severity of depressive symptoms,25,26 further reinforcing the need to ensure that women experiencing symptoms of PPD are identified and treated early.
The inpatient hospitalization for labor, delivery, and birth of a child has not traditionally been viewed as an opportunity for PPD screening. While private practitioners and obstetric medical group practices typically have inquired about and documented the individual patient’s mental health history and risk factors for PPD, the obstetric hospitalist is most commonly meeting a patient in labor or in a postpartum encounter for the first time. As obstetric practices grow ever more consolidated, and as obstetric hospitalist care is implemented for a variety of reasons including, but not limited to, preventing burnout among private practitioners, serving as a safety net for all inpatient obstetric services, and increasing standardization in obstetric triage and obstetric emergency departments,
Barriers remain
Despite the need for early detection of PPD, screening practices remain inconsistent. A literature review of health care provider practices showed only one in four physicians reported using screening tools; obstetrician-gynecologists were most likely (36%) to use screening tools, followed by family practitioners (31%), with pediatricians the least likely (7%).27 This low rate is at least partially the result of perceived barriers to screening among health care providers, which contributes to underdiagnosis. A survey of more than 200 physicians who were members of ACOG showed that the top three barriers restricting screening practices were time constraints, inadequate training, and a lack of knowledge of the diagnostic criteria.28
Since 2017, Dignity Health has instituted routine screening of all inpatient postpartum patients at its 29 birth centers in Arizona, California, and Nevada. In this program, of which I am a physician participant, more than 30,000 women have been screened with the EPDS. In addition to providing screening, Dignity Health staff (physicians, certified nurse midwives, nurse practitioners, registered nurses, social workers, mental health therapists, lactation consultants, health educators, and others) have received in-person Perinatal Mental Health training. In this way, the entire care team coordinates inpatient screening and referral to outpatient care providers – thus bridging the gap in postpartum mental health care. For those patients who screen positive while an inpatient, a psychiatric telemedicine appointment is provided and, if necessary, short-course medications can be prescribed until the patient has outpatient follow-up and continuity of care. While we as obstetric hospitalists and community obstetrician-gynecologists recognize that inpatient postpartum screening may be limited in its sensitivity for capturing all women who will go on to develop PPD, there is definitely a benefit to having a discussion about PPD and maternal mental health early and often throughout the postpartum period. For many women suffering in silence, a 6-week postpartum outpatient visit is too late, especially given that approximately one-third of women are lost to postpartum follow-up.29,30
Addressing barriers
A growing number of states have enacted policies to address the challenge of peripartum behavioral health needs, and several states – Illinois, Massachusetts, New Jersey, and West Virginia – now mandate routine PPD screening by health care providers.31 However, few of these laws or policies contain specific guidance, such as the optimal timing for screening, instead leaving the details to providers.32 The proper identification and management of PPD cannot be achieved by state-level policy mandates alone, but must include clinician buy-in and participation.
Obstetricians play an essential role in the identification and treatment of PPD. Among nonpsychiatric specialists, obstetrician-gynecologists are the most likely providers to see and screen during the perinatal period.33 In addition, women prefer to receive help for PPD from either their obstetric practitioners or a mental-health specialists located at the obstetric clinic, and are more likely to receive mental-health services if they are provided at the same location as that of the obstetric provider.34,35 According to ACOG’s new guidance on the fourth trimester, obstetricians are encouraged to take responsibility for women’s care immediately after birth, and this care would include contact with all mothers within the first 3 weeks post partum, at follow-up visits as needed, and for a comprehensive postpartum visit at 12 weeks.3
Our specialty has and will continue to evolve, and obstetric hospitalists will play an ever more essential role in the care of women during their inpatient obstetric admission. Whether we are a patient’s primary inpatient obstetric provider or a practice extender for single or multigroup practice, we are in a unique role to screen, begin treatment for, and offer anticipatory guidance for maternal mental health and postpartum depression disorders. Obstetric hospitalists can be a bridge between inpatient and outpatient follow-up and catalysts for implementing universal inpatient PPD screening. Our role presents an opportunity to start the discussion early and often in the fourth trimester and to make a significant difference in addressing this critical unmet need in postnatal care.
Dr. van Dis is the medical director of the Ob Hospitalist Group in Burbank, Calif. She disclosed she received editorial assistance from Erik MacLaren, PhD, of Boston Strategic Partners Inc., with funding support from Sage Therapeutics Inc. E-mail [email protected].
References
1. Centers for Disease Control and Prevention. Postpartum Depression. 2017.
2. Morb Mortal Wkly Rep. 2017;66(6):153-8.
3. Obstet Gynecol. 2018;131(5):e140-e150.
4. Harv Rev Psychiatry. 2014;22(1):1-22.
5. JAMA Psychiatry. 2018;75(3):247-53.
6. J Womens Health (Larchmt). 2016;25(12):1219-24.
7. J Psychiatr Res. 2017;84:284-91.
8. Br J Psychiatry. 2003;183:279-81.
9. Obstet Gynecol Surv. 2005;60(3):183-90.
10. Arch Womens Ment Health. 2016;19(1):87-94.
11. Soc Psychiatry Psychiatr Epidemiol. 2013;48(8):1335-45.
12. J Reprod Med. 1999;44(4):351-8.
13. J Behav Health Serv Res. 2004;31(2):117-33.
14. J Clin Psychiatry. 2016;77(9):1189-200.
15. Am J Obstet Gynecol. 2000;182(5):1080-2.
16. J Fam Pract. 2001;50(2):117-22.
17. Obstet Gynecol. 1999;93(5 Pt 1):653-7.
18. J Womens Health (Larchmt). 2010;19(3):477-90.
19. Obstet Gynecol. 2018;132:e208-12.
20. “Physicians back programs to address maternal mortality, depression,” AMA, Nov. 15, 2017
21. Pediatrics. 2019 Jan 1;143(1):e20183260.
22. JAMA. 2016;315(4):380-7.
23. Br J Psychiatry. 1987;150:782-6.
24. Ann Fam Med. 2009;7(1):63-70.
25. Obstet Gynecol. 2016;127(5):917-25.
26. Pediatrics. 2017 Oct;140(4). pii: e20170110.
27. Womens Health Issues. 2015;25(6):703-10.
28. J Psychosom Obstet Gynaecol. 2011;32(1):27-34.
29. Matern Child Health J. 2016;20(Suppl 1):22-7.
30. National Committee for Quality Assurance. Prenatal and Postpartum Care (PPC). 2018.
31. Psychiatr Serv. 2015;66(3):324-8.
32. Postpartum Support International. Legislation. 2018.
33. American Academy of Pediatrics, American College of Obstetricians and Gynecologists, eds. Guidelines for Perinatal Care. 7th ed. (Elk Grove Village, IL: Washington, DC: American Academy of Pediatrics; American College of Obstetricians and Gynecologists; Oct 2012.)
34. Birth. 2009;36(1):60-9.
35. Gen Hosp Psychiatry. 2009;31(2):155-62.
ADHD: When and how do we choose to start medications?
- A 9-year-old boy has poor impulse control, throws things in class, and cannot sit still. Teachers ask: Is this ADHD and should we start a medication?
- A 9-year-old girl is an inattentive daydreamer with poor class performance and trouble turning in homework. Her parents and teachers ask: Is this ADHD and should we start a medication?
- A 17-year-old boy who is a high achiever is taking the upcoming SATs and does poorly on timed tests because of poor focus and is now wondering: Do I have ADHD and would a medication help me perform better?
- A 17-year-old boy had poor grades for much of his early school years, but his parents always thought he was just a “lazy kid” although he insists he is trying his best. His parents now ask: Is this ADHD and has it been all along?
The above cases may sound familiar to you. They are an oversimplification of the patients who may come to you with two questions: Do I or someone I care about have ADHD and should they have medication for it? What may matter even more is how they are doing with that inattentiveness and how much it impacts their lives.
Sigmund Freud was known to think about goals for treatment as “liebe und arbeit” translated into “to love and to work.” As in, can someone live, love, and work or are their psychiatric symptoms impairing those functionalities? For a child, to live, work, and play (well with others) is most apt here. It is often more helpful to think in terms of childhood daily life when choosing to begin a medication or not. With inattention, a child can range from having a parent hoping for performance enhancement to having a severe impairment in their day-to-day functioning in a classroom. In the above case examples, each child or adolescent has varying impairments in performance – one is a high academic performer with very few issues outside of testing and another is a young child who can’t even sit still in a classroom to learn. Who should be prescribed a stimulant? Any or all of the above? It’s not as easy an answer as you may suspect, and there may not be one “right” answer either.
We know that stimulants can help a great deal of patients. They have the highest effect size for ADHD in that about 80% of children can benefit from stimulant treatment for ADHD. Specifically, “a high response rate of 70%-85% has been noted with methylphenidate and amphetamine formulations. The response rate is lower for atomoxetine [60%-65%] and guanfacine [30%-40%]” (Venkat B, Hechtman L. Considerations in selecting pharmacological treatments for attention deficit hyperactivity disorder. Clinical Pharmacist. 2016 Feb 11). In thinking about when to prescribe, we want to balance offering nonpharmacologic means to address symptoms of inattention (like mindfulness, exercise, and school supports such as individualized learning plans where applicable). We also do not want to withhold helpful treatments such as stimulants or other nonstimulant medications or trend toward overprescribing potentially habit-forming and imperfect medications.
It is important to make that distinction between impairment and the desire for medications to “enhance” life and optimize performance rather than treating symptoms of a disorder. It is most helpful to gain skills to navigate those challenges simultaneously to ultimately help our patients live, learn, love, and play to the best of their abilities.
Where to begin
When I was in training, I had difficulty teasing out the various ADHD stimulant formations. There were and are so many Ritalin preparations! Mostly there is a variation in shorter-acting to longer-acting effects. If the diagnosis is highly suspected and uncomplicated ADHD, I usually choose to start with Concerta 18 mg daily (a long-acting methylphenidate) for children aged over 6 years. Many times I don’t see the need to titrate that upwards much further toward the maximum clinically used dose of 54 mg daily (despite guidelines saying otherwise up to 72 mg daily, which I have found unnecessary usually and poorly tolerated). Concerta has an immediate effect (20%) and then slowly peaks until 12 p.m. (80%) and then is out of system by about 3 p.m. (for a total of 7 hours duration of action). There also are shorter-acting preparations (Ritalin, Methylin) which are “on/off” in 4 hours and use of these is more consistent with an antiquated way of prescribing, often up to twice daily and three times daily dosing schedules with the risk of the harder to tolerate “drop-off” effects with stimulants. And, if there is not an effect, I often reconsider the diagnosis and any co-occurring anxiety disorder, stressful life events, or depression or other illness with the knowledge that these medications so often are effective.
Anxiety + ADHD
If there is prominent anxiety, anxiety disorder, or tics, I often consider Strattera 10-20 mg daily up to around 40 mg. I tend to dose this lower than as written for tolerability and in a “dose low and go slow” approach with kids, which often results in better experiences with the medication. This medication also is recommended to be dosed by weight; this should be taken into account as well. Atomoxetine is a selective serotonin and norepinephrine reuptake inhibitor which is likely similar to Cymbalta (duloxetine). It may have a lower effect size of around less than 60% but this also is around the reported effect sizes for selective serotonin reuptake inhibitors (SSRIs) for depression. If a patient has both ADHD and an anxiety disorder, I often consider an SSRI alternatively first to manage attention issues associated with anxiety and then would add on a stimulant if attention issues persist once anxiety is better treated.
Second/third line ADHD treatments
As a second-line approach to long-acting Ritalin and if there is not a response to it, I would consider extended-release Adderall preparations such as Vyvanse, which is an amphetamine preparation supposedly less abusable than Adderall (one can’t snort it), but I also caution that it releases dopamine, peaks faster, and does not reduce to zero stimulant in 24 hours because of a variable half-life.
In this way, I always have imagined that these amphetamines may be more theoretically concerning than Ritalin/methylphenidate because they increase dopamine dumping into the synapse (which is a different and extra mechanism than just reuptake). For a third line, I may consider guanfacine depending on weight daily, which is an Food and Drug Administration–approved, nonstimulant alpha-2 agonist, which also acts longer than clonidine and may be better for hyperactivity symptoms. I may begin with doses as low as 0.25-0.5 mg in the evening for concerns with sedation or groggy aftereffects in the morning.
Throughout all treatment with medication, I emphasize the importance of assertively managing ADHD symptoms which may be in the form of “behavioral treatment,” like cognitive behavioral therapy, organizational coaching available at some educational centers, or even finding ways to train one’s focus with athletics or practices such as yoga and mindfulness. In addition to this combined approach to treatment, stimulants are not perfect medications. All stimulants have a “drop-off effect” and were made to work during a school day lasting from 8 a.m. to 3 p.m. Some patients and families complain about the drop-off effect and may want to “dose” around a medication more frequently, in the late afternoon and in the evening, which can lead to poor appetite at dinner and insomnia.
My answers to the cases above would be that all the patients could have ADHD, but they also may have anxiety or stress-related disorders, depression, worries about performance, or poor skills to manage inattention. They may not yet have received school supports, coaching, or found ways to manage these symptoms either. Because stimulants can improve and enhance performance but also have their own drawbacks and risks not covered here, it’s important to consider each case as a whole with thoughtfulness about a child’s unique ability to “live and work” in this world.
Dr. Pawlowski is an adult, adolescent, and child psychiatrist at the University of Vermont Medical Center and an assistant professor of psychiatry at UVM, both in Burlington. She reported no relevant financial disclosures. Email her at [email protected].
- A 9-year-old boy has poor impulse control, throws things in class, and cannot sit still. Teachers ask: Is this ADHD and should we start a medication?
- A 9-year-old girl is an inattentive daydreamer with poor class performance and trouble turning in homework. Her parents and teachers ask: Is this ADHD and should we start a medication?
- A 17-year-old boy who is a high achiever is taking the upcoming SATs and does poorly on timed tests because of poor focus and is now wondering: Do I have ADHD and would a medication help me perform better?
- A 17-year-old boy had poor grades for much of his early school years, but his parents always thought he was just a “lazy kid” although he insists he is trying his best. His parents now ask: Is this ADHD and has it been all along?
The above cases may sound familiar to you. They are an oversimplification of the patients who may come to you with two questions: Do I or someone I care about have ADHD and should they have medication for it? What may matter even more is how they are doing with that inattentiveness and how much it impacts their lives.
Sigmund Freud was known to think about goals for treatment as “liebe und arbeit” translated into “to love and to work.” As in, can someone live, love, and work or are their psychiatric symptoms impairing those functionalities? For a child, to live, work, and play (well with others) is most apt here. It is often more helpful to think in terms of childhood daily life when choosing to begin a medication or not. With inattention, a child can range from having a parent hoping for performance enhancement to having a severe impairment in their day-to-day functioning in a classroom. In the above case examples, each child or adolescent has varying impairments in performance – one is a high academic performer with very few issues outside of testing and another is a young child who can’t even sit still in a classroom to learn. Who should be prescribed a stimulant? Any or all of the above? It’s not as easy an answer as you may suspect, and there may not be one “right” answer either.
We know that stimulants can help a great deal of patients. They have the highest effect size for ADHD in that about 80% of children can benefit from stimulant treatment for ADHD. Specifically, “a high response rate of 70%-85% has been noted with methylphenidate and amphetamine formulations. The response rate is lower for atomoxetine [60%-65%] and guanfacine [30%-40%]” (Venkat B, Hechtman L. Considerations in selecting pharmacological treatments for attention deficit hyperactivity disorder. Clinical Pharmacist. 2016 Feb 11). In thinking about when to prescribe, we want to balance offering nonpharmacologic means to address symptoms of inattention (like mindfulness, exercise, and school supports such as individualized learning plans where applicable). We also do not want to withhold helpful treatments such as stimulants or other nonstimulant medications or trend toward overprescribing potentially habit-forming and imperfect medications.
It is important to make that distinction between impairment and the desire for medications to “enhance” life and optimize performance rather than treating symptoms of a disorder. It is most helpful to gain skills to navigate those challenges simultaneously to ultimately help our patients live, learn, love, and play to the best of their abilities.
Where to begin
When I was in training, I had difficulty teasing out the various ADHD stimulant formations. There were and are so many Ritalin preparations! Mostly there is a variation in shorter-acting to longer-acting effects. If the diagnosis is highly suspected and uncomplicated ADHD, I usually choose to start with Concerta 18 mg daily (a long-acting methylphenidate) for children aged over 6 years. Many times I don’t see the need to titrate that upwards much further toward the maximum clinically used dose of 54 mg daily (despite guidelines saying otherwise up to 72 mg daily, which I have found unnecessary usually and poorly tolerated). Concerta has an immediate effect (20%) and then slowly peaks until 12 p.m. (80%) and then is out of system by about 3 p.m. (for a total of 7 hours duration of action). There also are shorter-acting preparations (Ritalin, Methylin) which are “on/off” in 4 hours and use of these is more consistent with an antiquated way of prescribing, often up to twice daily and three times daily dosing schedules with the risk of the harder to tolerate “drop-off” effects with stimulants. And, if there is not an effect, I often reconsider the diagnosis and any co-occurring anxiety disorder, stressful life events, or depression or other illness with the knowledge that these medications so often are effective.
Anxiety + ADHD
If there is prominent anxiety, anxiety disorder, or tics, I often consider Strattera 10-20 mg daily up to around 40 mg. I tend to dose this lower than as written for tolerability and in a “dose low and go slow” approach with kids, which often results in better experiences with the medication. This medication also is recommended to be dosed by weight; this should be taken into account as well. Atomoxetine is a selective serotonin and norepinephrine reuptake inhibitor which is likely similar to Cymbalta (duloxetine). It may have a lower effect size of around less than 60% but this also is around the reported effect sizes for selective serotonin reuptake inhibitors (SSRIs) for depression. If a patient has both ADHD and an anxiety disorder, I often consider an SSRI alternatively first to manage attention issues associated with anxiety and then would add on a stimulant if attention issues persist once anxiety is better treated.
Second/third line ADHD treatments
As a second-line approach to long-acting Ritalin and if there is not a response to it, I would consider extended-release Adderall preparations such as Vyvanse, which is an amphetamine preparation supposedly less abusable than Adderall (one can’t snort it), but I also caution that it releases dopamine, peaks faster, and does not reduce to zero stimulant in 24 hours because of a variable half-life.
In this way, I always have imagined that these amphetamines may be more theoretically concerning than Ritalin/methylphenidate because they increase dopamine dumping into the synapse (which is a different and extra mechanism than just reuptake). For a third line, I may consider guanfacine depending on weight daily, which is an Food and Drug Administration–approved, nonstimulant alpha-2 agonist, which also acts longer than clonidine and may be better for hyperactivity symptoms. I may begin with doses as low as 0.25-0.5 mg in the evening for concerns with sedation or groggy aftereffects in the morning.
Throughout all treatment with medication, I emphasize the importance of assertively managing ADHD symptoms which may be in the form of “behavioral treatment,” like cognitive behavioral therapy, organizational coaching available at some educational centers, or even finding ways to train one’s focus with athletics or practices such as yoga and mindfulness. In addition to this combined approach to treatment, stimulants are not perfect medications. All stimulants have a “drop-off effect” and were made to work during a school day lasting from 8 a.m. to 3 p.m. Some patients and families complain about the drop-off effect and may want to “dose” around a medication more frequently, in the late afternoon and in the evening, which can lead to poor appetite at dinner and insomnia.
My answers to the cases above would be that all the patients could have ADHD, but they also may have anxiety or stress-related disorders, depression, worries about performance, or poor skills to manage inattention. They may not yet have received school supports, coaching, or found ways to manage these symptoms either. Because stimulants can improve and enhance performance but also have their own drawbacks and risks not covered here, it’s important to consider each case as a whole with thoughtfulness about a child’s unique ability to “live and work” in this world.
Dr. Pawlowski is an adult, adolescent, and child psychiatrist at the University of Vermont Medical Center and an assistant professor of psychiatry at UVM, both in Burlington. She reported no relevant financial disclosures. Email her at [email protected].
- A 9-year-old boy has poor impulse control, throws things in class, and cannot sit still. Teachers ask: Is this ADHD and should we start a medication?
- A 9-year-old girl is an inattentive daydreamer with poor class performance and trouble turning in homework. Her parents and teachers ask: Is this ADHD and should we start a medication?
- A 17-year-old boy who is a high achiever is taking the upcoming SATs and does poorly on timed tests because of poor focus and is now wondering: Do I have ADHD and would a medication help me perform better?
- A 17-year-old boy had poor grades for much of his early school years, but his parents always thought he was just a “lazy kid” although he insists he is trying his best. His parents now ask: Is this ADHD and has it been all along?
The above cases may sound familiar to you. They are an oversimplification of the patients who may come to you with two questions: Do I or someone I care about have ADHD and should they have medication for it? What may matter even more is how they are doing with that inattentiveness and how much it impacts their lives.
Sigmund Freud was known to think about goals for treatment as “liebe und arbeit” translated into “to love and to work.” As in, can someone live, love, and work or are their psychiatric symptoms impairing those functionalities? For a child, to live, work, and play (well with others) is most apt here. It is often more helpful to think in terms of childhood daily life when choosing to begin a medication or not. With inattention, a child can range from having a parent hoping for performance enhancement to having a severe impairment in their day-to-day functioning in a classroom. In the above case examples, each child or adolescent has varying impairments in performance – one is a high academic performer with very few issues outside of testing and another is a young child who can’t even sit still in a classroom to learn. Who should be prescribed a stimulant? Any or all of the above? It’s not as easy an answer as you may suspect, and there may not be one “right” answer either.
We know that stimulants can help a great deal of patients. They have the highest effect size for ADHD in that about 80% of children can benefit from stimulant treatment for ADHD. Specifically, “a high response rate of 70%-85% has been noted with methylphenidate and amphetamine formulations. The response rate is lower for atomoxetine [60%-65%] and guanfacine [30%-40%]” (Venkat B, Hechtman L. Considerations in selecting pharmacological treatments for attention deficit hyperactivity disorder. Clinical Pharmacist. 2016 Feb 11). In thinking about when to prescribe, we want to balance offering nonpharmacologic means to address symptoms of inattention (like mindfulness, exercise, and school supports such as individualized learning plans where applicable). We also do not want to withhold helpful treatments such as stimulants or other nonstimulant medications or trend toward overprescribing potentially habit-forming and imperfect medications.
It is important to make that distinction between impairment and the desire for medications to “enhance” life and optimize performance rather than treating symptoms of a disorder. It is most helpful to gain skills to navigate those challenges simultaneously to ultimately help our patients live, learn, love, and play to the best of their abilities.
Where to begin
When I was in training, I had difficulty teasing out the various ADHD stimulant formations. There were and are so many Ritalin preparations! Mostly there is a variation in shorter-acting to longer-acting effects. If the diagnosis is highly suspected and uncomplicated ADHD, I usually choose to start with Concerta 18 mg daily (a long-acting methylphenidate) for children aged over 6 years. Many times I don’t see the need to titrate that upwards much further toward the maximum clinically used dose of 54 mg daily (despite guidelines saying otherwise up to 72 mg daily, which I have found unnecessary usually and poorly tolerated). Concerta has an immediate effect (20%) and then slowly peaks until 12 p.m. (80%) and then is out of system by about 3 p.m. (for a total of 7 hours duration of action). There also are shorter-acting preparations (Ritalin, Methylin) which are “on/off” in 4 hours and use of these is more consistent with an antiquated way of prescribing, often up to twice daily and three times daily dosing schedules with the risk of the harder to tolerate “drop-off” effects with stimulants. And, if there is not an effect, I often reconsider the diagnosis and any co-occurring anxiety disorder, stressful life events, or depression or other illness with the knowledge that these medications so often are effective.
Anxiety + ADHD
If there is prominent anxiety, anxiety disorder, or tics, I often consider Strattera 10-20 mg daily up to around 40 mg. I tend to dose this lower than as written for tolerability and in a “dose low and go slow” approach with kids, which often results in better experiences with the medication. This medication also is recommended to be dosed by weight; this should be taken into account as well. Atomoxetine is a selective serotonin and norepinephrine reuptake inhibitor which is likely similar to Cymbalta (duloxetine). It may have a lower effect size of around less than 60% but this also is around the reported effect sizes for selective serotonin reuptake inhibitors (SSRIs) for depression. If a patient has both ADHD and an anxiety disorder, I often consider an SSRI alternatively first to manage attention issues associated with anxiety and then would add on a stimulant if attention issues persist once anxiety is better treated.
Second/third line ADHD treatments
As a second-line approach to long-acting Ritalin and if there is not a response to it, I would consider extended-release Adderall preparations such as Vyvanse, which is an amphetamine preparation supposedly less abusable than Adderall (one can’t snort it), but I also caution that it releases dopamine, peaks faster, and does not reduce to zero stimulant in 24 hours because of a variable half-life.
In this way, I always have imagined that these amphetamines may be more theoretically concerning than Ritalin/methylphenidate because they increase dopamine dumping into the synapse (which is a different and extra mechanism than just reuptake). For a third line, I may consider guanfacine depending on weight daily, which is an Food and Drug Administration–approved, nonstimulant alpha-2 agonist, which also acts longer than clonidine and may be better for hyperactivity symptoms. I may begin with doses as low as 0.25-0.5 mg in the evening for concerns with sedation or groggy aftereffects in the morning.
Throughout all treatment with medication, I emphasize the importance of assertively managing ADHD symptoms which may be in the form of “behavioral treatment,” like cognitive behavioral therapy, organizational coaching available at some educational centers, or even finding ways to train one’s focus with athletics or practices such as yoga and mindfulness. In addition to this combined approach to treatment, stimulants are not perfect medications. All stimulants have a “drop-off effect” and were made to work during a school day lasting from 8 a.m. to 3 p.m. Some patients and families complain about the drop-off effect and may want to “dose” around a medication more frequently, in the late afternoon and in the evening, which can lead to poor appetite at dinner and insomnia.
My answers to the cases above would be that all the patients could have ADHD, but they also may have anxiety or stress-related disorders, depression, worries about performance, or poor skills to manage inattention. They may not yet have received school supports, coaching, or found ways to manage these symptoms either. Because stimulants can improve and enhance performance but also have their own drawbacks and risks not covered here, it’s important to consider each case as a whole with thoughtfulness about a child’s unique ability to “live and work” in this world.
Dr. Pawlowski is an adult, adolescent, and child psychiatrist at the University of Vermont Medical Center and an assistant professor of psychiatry at UVM, both in Burlington. She reported no relevant financial disclosures. Email her at [email protected].