Opinion

 

Editor’s note: The Hospitalist is pleased to introduce a new recurring column: “The Legacies of Hospital Medicine.” This will be a recurring feature submitted by some of the best and brightest hospitalists in the field who have helped shape our specialty into what it is today. It will be a series of articles that will reflect on hospital medicine and it’s evolution over time from a variety of unique and innovative perspectives. We hope you enjoy this series, and we welcome any feedback as it evolves!

Hearkening back to my early time as a hospital-based physician, I recall the pleasure of waking every day and feeling like I belonged to an exclusive club. I felt passion for my work, along with a tiny cohort of similarly situated docs. We lacked a kinship with other medical organizations, however. We had no union of our own and were invisible upstarts.

While some folks might have perceived our splintering from the mainstream as a liability, back then, we wore it like a badge of honor. No home office. No funds. No central hub to tap into when a notice needed dispatching. We were setting the world ablaze. Or so it was our delusion.

And the question always came: “Tell me again ... you are what kind of doctor?”

The response changed every week. Ditto for my job responsibilities and charges. The memories are wonderful, though, and I have great affection for the early years.

Initially, I recall networking and attending national meetings – SGIM and ACP in particular – spreading the faith and talking up our bona fides. In addition to the registration fees, there came an earful of guff from irate physicians about the new breed of doctors, yet unnamed, who were destroying medicine. Likewise, I recall opinion columns from newspapers and peer-reviewed journals from a spate of “simple country docs.” The writing had a pretense of politeness but with a hint of disdain, predicting nothing less than the destruction of health care as we knew it. And to be standing next to them in conversation: “How dare you hospital docs exhale CO₂!” We might as well have had “KICK ME” signs on our backs.

Inpatient medicine was upending the status quo – or so we believed – while also overturning a generations’ worth of dogma on how hospitals should do their business. Fate also played a role, and we could not have anticipated the arrival of health care consolidation, “To Err Is Human,” managed care, and payment reform – all of which upset practice conditions that had been in existence for decades. We walked a line between old and new, down a path whose purpose we felt but toward a destination we could not entirely envision.

 

That transformed with time.

Like most hospitalists, my ticket in began after some sleuthing and calls to Win Whitcomb, MD, and John Nelson, MD – still trusted friends today. They will make their marks in future columns, but as I am the inaugural contributor, let me be the first to state they both had a sixth sense steering our group of disciples. They became the obvious chiefs, along with Bob Wachter, MD, and took the lead in articulating what we aspired to be. Sounds saccharine now, but it did not then.

Without support, we arranged summits, assembled work groups, passed the hat for loose change, fashioned a newsletter (see accompanying photo), and formed a countrywide network. Our efforts predated the Internet by several years, so it was mail, faxes, pagers, and answering machines only. The hours we would have spared ourselves if we had Doodle, Web Connect, and Skype.

But lucky for us, hospital medicine took off. Our wise choices laid the groundwork for what is now a discipline in repose. “Hospitalist” no longer sounds like a neologism, and the term entered Merriam-Webster to seal our fate.

 

Twenty years out, hospital medicine still feels like a figurative case of Moore’s law. I cannot keep up with the strange faces at annual meetings and membership size, the throng of published articles (I used to pride myself on knowing all the hospitalist studies – no longer), and the lengthy list of initiatives and Society of Hospital Medicine resources on hand.

Without question, SHM has been the most rewarding part of my professional life. Hospital medicine mates sustain and keep me in good stead and have done so since training. Their insights teach me more than journals or any day on the job could impart and have given me a learning windfall for the cost of a song.

I initiated my hospitalist path as a 20-something tenderfoot, but from my interactions with colleagues both liberal and conservative, urban and rural, corporate and academic, and specialist and generalist, I developed into a seasoned craftsman.

Countless times I strode into an SHM activity thinking one way, and through the intellect and conviction of my peers, I got smart. Working in the same setting for most of my career, unchallenged, I could have assimilated a sclerotic worldview, but my hospital medicine colleagues would have none of that – kudos and thanks to them for it.

 

I could cite endless anecdotes – and they are swirling as I write. Crucial positions discussed and adopted, roads taken and those not, specialties angered and appeased, wonderful meals had, and on and on. They are and were the building blocks of a journey – and a joyful one.

As truly notable memories go, however, for me, there is only one.

By far, watching and absorbing the lessons of how an organization develops – goes from zero to sixty – has been a master class in enterprise and execution.

A PGY4 sees a president, CEO, board, ad hoc committees, staff, big budgets, and capital outlays make things happen and assumes it just is. But an operational charter with an instruction manual in-tow didn’t just drop from on high; that’s not how things go down. The right personnel selections, value choices (“SHM is a big tent” was not an accident), affiliate alliances, assessment of risks, and strategies pursued occurred for a reason; keen minds had the vision to set the board right.

 

The privilege of participating in the SHM project has been an education no grant or scholarship could equal. To say I had a tiny role in all of that is just reward.

Through SHM I have made lifelong friends, advanced my perspective and development as a healer, acquired a nifty board certification (one of 1,400 with a Focused Practice in Hospital Medicine), gained a mastership, and yes, met President Obama.

As odysseys go, how many docs can make such lofty claims?

Dr. Flansbaum works for Geisinger Health System in Danville, Pa., in both the divisions of hospital medicine and population health. He began working as a hospitalist in 1996 and is a founding member of the Society of Hospital Medicine.

 

Editor’s note: The Hospitalist is pleased to introduce a new recurring column: “The Legacies of Hospital Medicine.” This will be a recurring feature submitted by some of the best and brightest hospitalists in the field who have helped shape our specialty into what it is today. It will be a series of articles that will reflect on hospital medicine and it’s evolution over time from a variety of unique and innovative perspectives. We hope you enjoy this series, and we welcome any feedback as it evolves!

Hearkening back to my early time as a hospital-based physician, I recall the pleasure of waking every day and feeling like I belonged to an exclusive club. I felt passion for my work, along with a tiny cohort of similarly situated docs. We lacked a kinship with other medical organizations, however. We had no union of our own and were invisible upstarts.

While some folks might have perceived our splintering from the mainstream as a liability, back then, we wore it like a badge of honor. No home office. No funds. No central hub to tap into when a notice needed dispatching. We were setting the world ablaze. Or so it was our delusion.

And the question always came: “Tell me again ... you are what kind of doctor?”

The response changed every week. Ditto for my job responsibilities and charges. The memories are wonderful, though, and I have great affection for the early years.

Initially, I recall networking and attending national meetings – SGIM and ACP in particular – spreading the faith and talking up our bona fides. In addition to the registration fees, there came an earful of guff from irate physicians about the new breed of doctors, yet unnamed, who were destroying medicine. Likewise, I recall opinion columns from newspapers and peer-reviewed journals from a spate of “simple country docs.” The writing had a pretense of politeness but with a hint of disdain, predicting nothing less than the destruction of health care as we knew it. And to be standing next to them in conversation: “How dare you hospital docs exhale CO₂!” We might as well have had “KICK ME” signs on our backs.

Inpatient medicine was upending the status quo – or so we believed – while also overturning a generations’ worth of dogma on how hospitals should do their business. Fate also played a role, and we could not have anticipated the arrival of health care consolidation, “To Err Is Human,” managed care, and payment reform – all of which upset practice conditions that had been in existence for decades. We walked a line between old and new, down a path whose purpose we felt but toward a destination we could not entirely envision.

 

That transformed with time.

Like most hospitalists, my ticket in began after some sleuthing and calls to Win Whitcomb, MD, and John Nelson, MD – still trusted friends today. They will make their marks in future columns, but as I am the inaugural contributor, let me be the first to state they both had a sixth sense steering our group of disciples. They became the obvious chiefs, along with Bob Wachter, MD, and took the lead in articulating what we aspired to be. Sounds saccharine now, but it did not then.

Without support, we arranged summits, assembled work groups, passed the hat for loose change, fashioned a newsletter (see accompanying photo), and formed a countrywide network. Our efforts predated the Internet by several years, so it was mail, faxes, pagers, and answering machines only. The hours we would have spared ourselves if we had Doodle, Web Connect, and Skype.

But lucky for us, hospital medicine took off. Our wise choices laid the groundwork for what is now a discipline in repose. “Hospitalist” no longer sounds like a neologism, and the term entered Merriam-Webster to seal our fate.

 

Twenty years out, hospital medicine still feels like a figurative case of Moore’s law. I cannot keep up with the strange faces at annual meetings and membership size, the throng of published articles (I used to pride myself on knowing all the hospitalist studies – no longer), and the lengthy list of initiatives and Society of Hospital Medicine resources on hand.

Without question, SHM has been the most rewarding part of my professional life. Hospital medicine mates sustain and keep me in good stead and have done so since training. Their insights teach me more than journals or any day on the job could impart and have given me a learning windfall for the cost of a song.

I initiated my hospitalist path as a 20-something tenderfoot, but from my interactions with colleagues both liberal and conservative, urban and rural, corporate and academic, and specialist and generalist, I developed into a seasoned craftsman.

Countless times I strode into an SHM activity thinking one way, and through the intellect and conviction of my peers, I got smart. Working in the same setting for most of my career, unchallenged, I could have assimilated a sclerotic worldview, but my hospital medicine colleagues would have none of that – kudos and thanks to them for it.

 

I could cite endless anecdotes – and they are swirling as I write. Crucial positions discussed and adopted, roads taken and those not, specialties angered and appeased, wonderful meals had, and on and on. They are and were the building blocks of a journey – and a joyful one.

As truly notable memories go, however, for me, there is only one.

By far, watching and absorbing the lessons of how an organization develops – goes from zero to sixty – has been a master class in enterprise and execution.

A PGY4 sees a president, CEO, board, ad hoc committees, staff, big budgets, and capital outlays make things happen and assumes it just is. But an operational charter with an instruction manual in-tow didn’t just drop from on high; that’s not how things go down. The right personnel selections, value choices (“SHM is a big tent” was not an accident), affiliate alliances, assessment of risks, and strategies pursued occurred for a reason; keen minds had the vision to set the board right.

 

The privilege of participating in the SHM project has been an education no grant or scholarship could equal. To say I had a tiny role in all of that is just reward.

Through SHM I have made lifelong friends, advanced my perspective and development as a healer, acquired a nifty board certification (one of 1,400 with a Focused Practice in Hospital Medicine), gained a mastership, and yes, met President Obama.

As odysseys go, how many docs can make such lofty claims?

Dr. Flansbaum works for Geisinger Health System in Danville, Pa., in both the divisions of hospital medicine and population health. He began working as a hospitalist in 1996 and is a founding member of the Society of Hospital Medicine.

 

Editor’s note: The Hospitalist is pleased to introduce a new recurring column: “The Legacies of Hospital Medicine.” This will be a recurring feature submitted by some of the best and brightest hospitalists in the field who have helped shape our specialty into what it is today. It will be a series of articles that will reflect on hospital medicine and it’s evolution over time from a variety of unique and innovative perspectives. We hope you enjoy this series, and we welcome any feedback as it evolves!

Hearkening back to my early time as a hospital-based physician, I recall the pleasure of waking every day and feeling like I belonged to an exclusive club. I felt passion for my work, along with a tiny cohort of similarly situated docs. We lacked a kinship with other medical organizations, however. We had no union of our own and were invisible upstarts.

While some folks might have perceived our splintering from the mainstream as a liability, back then, we wore it like a badge of honor. No home office. No funds. No central hub to tap into when a notice needed dispatching. We were setting the world ablaze. Or so it was our delusion.

And the question always came: “Tell me again ... you are what kind of doctor?”

The response changed every week. Ditto for my job responsibilities and charges. The memories are wonderful, though, and I have great affection for the early years.

Initially, I recall networking and attending national meetings – SGIM and ACP in particular – spreading the faith and talking up our bona fides. In addition to the registration fees, there came an earful of guff from irate physicians about the new breed of doctors, yet unnamed, who were destroying medicine. Likewise, I recall opinion columns from newspapers and peer-reviewed journals from a spate of “simple country docs.” The writing had a pretense of politeness but with a hint of disdain, predicting nothing less than the destruction of health care as we knew it. And to be standing next to them in conversation: “How dare you hospital docs exhale CO₂!” We might as well have had “KICK ME” signs on our backs.

Inpatient medicine was upending the status quo – or so we believed – while also overturning a generations’ worth of dogma on how hospitals should do their business. Fate also played a role, and we could not have anticipated the arrival of health care consolidation, “To Err Is Human,” managed care, and payment reform – all of which upset practice conditions that had been in existence for decades. We walked a line between old and new, down a path whose purpose we felt but toward a destination we could not entirely envision.

 

That transformed with time.

Like most hospitalists, my ticket in began after some sleuthing and calls to Win Whitcomb, MD, and John Nelson, MD – still trusted friends today. They will make their marks in future columns, but as I am the inaugural contributor, let me be the first to state they both had a sixth sense steering our group of disciples. They became the obvious chiefs, along with Bob Wachter, MD, and took the lead in articulating what we aspired to be. Sounds saccharine now, but it did not then.

Without support, we arranged summits, assembled work groups, passed the hat for loose change, fashioned a newsletter (see accompanying photo), and formed a countrywide network. Our efforts predated the Internet by several years, so it was mail, faxes, pagers, and answering machines only. The hours we would have spared ourselves if we had Doodle, Web Connect, and Skype.

But lucky for us, hospital medicine took off. Our wise choices laid the groundwork for what is now a discipline in repose. “Hospitalist” no longer sounds like a neologism, and the term entered Merriam-Webster to seal our fate.

 

Twenty years out, hospital medicine still feels like a figurative case of Moore’s law. I cannot keep up with the strange faces at annual meetings and membership size, the throng of published articles (I used to pride myself on knowing all the hospitalist studies – no longer), and the lengthy list of initiatives and Society of Hospital Medicine resources on hand.

Without question, SHM has been the most rewarding part of my professional life. Hospital medicine mates sustain and keep me in good stead and have done so since training. Their insights teach me more than journals or any day on the job could impart and have given me a learning windfall for the cost of a song.

I initiated my hospitalist path as a 20-something tenderfoot, but from my interactions with colleagues both liberal and conservative, urban and rural, corporate and academic, and specialist and generalist, I developed into a seasoned craftsman.

Countless times I strode into an SHM activity thinking one way, and through the intellect and conviction of my peers, I got smart. Working in the same setting for most of my career, unchallenged, I could have assimilated a sclerotic worldview, but my hospital medicine colleagues would have none of that – kudos and thanks to them for it.

 

I could cite endless anecdotes – and they are swirling as I write. Crucial positions discussed and adopted, roads taken and those not, specialties angered and appeased, wonderful meals had, and on and on. They are and were the building blocks of a journey – and a joyful one.

As truly notable memories go, however, for me, there is only one.

By far, watching and absorbing the lessons of how an organization develops – goes from zero to sixty – has been a master class in enterprise and execution.

A PGY4 sees a president, CEO, board, ad hoc committees, staff, big budgets, and capital outlays make things happen and assumes it just is. But an operational charter with an instruction manual in-tow didn’t just drop from on high; that’s not how things go down. The right personnel selections, value choices (“SHM is a big tent” was not an accident), affiliate alliances, assessment of risks, and strategies pursued occurred for a reason; keen minds had the vision to set the board right.

 

The privilege of participating in the SHM project has been an education no grant or scholarship could equal. To say I had a tiny role in all of that is just reward.

Through SHM I have made lifelong friends, advanced my perspective and development as a healer, acquired a nifty board certification (one of 1,400 with a Focused Practice in Hospital Medicine), gained a mastership, and yes, met President Obama.

As odysseys go, how many docs can make such lofty claims?

Dr. Flansbaum works for Geisinger Health System in Danville, Pa., in both the divisions of hospital medicine and population health. He began working as a hospitalist in 1996 and is a founding member of the Society of Hospital Medicine.

 

When 14-year-old Ryan saw his pediatrician for his annual physical this past August, he was asked a few quick questions about whether he was having any problems, if he was feeling depressed or anxious, and if there was anything he wanted to discuss. Ryan said no to each question, then the doctor examined him, reminded him to get a flu shot, and signed off on the forms he needed to play team sports in high school. The doctor assured Ryan’s mother that he was healthy, and the visit was over. Next August, Ryan’s exam will likely include a more detailed look at his mental health.

In February 2018, the American Academy of Pediatrics updated its guidelines on screening for depression in adolescents in primary care settings. The guidelines address the problem of undiagnosed and untreated psychiatric illness in children over the age of 10 years, the shortage of available mental health professionals, and techniques primary care physicians might use to address psychiatric needs in adolescents. The AAP guidelines include a new recommendation for universal screening with an assessment tool: “Adolescent patients ages 12 years and older should be screened annually for depression [MDD or depressive disorders] with a formal self-report screening tool either on paper or electronically.”

KatarzynaBialasiewicz/Thinkstock

Howard Liu, MD, is a child and adolescent psychiatrist and the interim chair of psychiatry at the University of Nebraska, Omaha, and director of the Behavioral Health Education Center of Nebraska. “I applaud the AAP for recommending universal depression screening for teenagers, as there has been a rising incidence of teen suicide, especially among female adolescents,” he said. “However, when teens screen positive, we must invest in the child mental health infrastructure to support pediatricians. This includes therapists integrated into primary care practices and prescribers with the capacity to take new patients or practice collaborative care.”

Dr. Liu noted that some of his patients drive 4-5 hours each way to see him in Omaha, then spend the night before making the return trip. “There is a dire shortage of pediatric mental health services in every state. This shifts the responsibility for care to pediatricians, teachers, and parents who often lack the resources to keep kids safe and well. It’s an unconscionable gap in care.”

Timothy F. Doran, MD, is chair of pediatrics at the Greater Baltimore Medical Center in Towson, Md., and a past president of the Maryland Chapter of the AAP. “I absolutely think every teenager should be assessed for depression,” he said. With his own patients, he asks open-ended questions about their mental health, then more specific questions about mood, depression, anxiety, sleep, appetite, and libido. If the teen indicates there are problems, he then uses a PHQ-9 to get a sense of whether the depression is mild, moderate, or severe. Dr. Doran estimates that he diagnoses depression in 5%-10% of the adolescents he screens. Baltimore is a metropolitan area with two psychiatry training programs, and Dr. Doran has developed relationships with mental health professionals who will see his patients. If he prescribes an antidepressant, most of those patients will also see a psychotherapist. He notes that it can be more difficult to find resources for children with Medicaid who do not have the resources of some of the families he treats.

Dr. Doran’s practice has not yet implemented the use of a written screening tool for all adolescents. He anticipates doing this soon because of the new guidelines, but he was not enthusiastic about the prospect. “I think I’m catching the kids with depression, and having every child fill out a questionnaire will be an added burden. We are already loaded down with administrative tasks and screening requirements.” Of note, in Dr. Doran’s 35 years in clinical practice, no child under his care has died of suicide.

Allen Frances, MD, offers a different take on the new guidelines. Dr. Frances was the chairman of the DSM-IV task force and is the author of “Saving Normal: An Insider’s Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life” (New York: HarperCollins, 2014). Dr. Frances has used his Twitter feed to express his objections to the new guidelines for universal depression screening for teenagers. “Universal mental health screening of children sounds virtuous but is a big mistake. Massive overdiagnosis results in 1) Too much ineffective/unsafe #medication; 2) Needless #stigma; 3) Wasting precious resources. Instead, provide easy access to treatment for kids who really need it.” He goes on to tweet about unintended consequences of universal screening, including the concern that screening may identify teens with normal transient sadness or substance-induced mood changes as being clinically depressed. In Twitter lingo, Dr. Frances continues: “‘Early-warning signs of mental illness in kids are often false alarms leading to unneeded #medication/#stigma. Also, we don’t provide adequate psych care for kids who desperately need it. It makes no sense to create new fake patients when we are neglecting the real ones we already have.”

 

It will be interesting to see what happens when Ryan goes for a physical next year. Will the pediatrician devote time to a screening form to document psychiatric symptoms? Will that divert time and attention away from concerns that might be more important to Ryan or his parents? Will he be handed an iPad in the waiting room or emailed a link to a portal before the session so that he can fill out the form on his own? If so, will the doctor remember to check the assessment tool and address mental health concerns that Ryan identifies? It may well prove to be a mixed bag, but let’s hope that universal screening tools open the door for more young people to have their mental health concerns addressed in comprehensive and appropriate ways.

Dr. Miller is the coauthor of “Committed: The Battle Over Involuntary Psychiatric Care,” (Baltimore: Johns Hopkins University Press, 2016).

 

When 14-year-old Ryan saw his pediatrician for his annual physical this past August, he was asked a few quick questions about whether he was having any problems, if he was feeling depressed or anxious, and if there was anything he wanted to discuss. Ryan said no to each question, then the doctor examined him, reminded him to get a flu shot, and signed off on the forms he needed to play team sports in high school. The doctor assured Ryan’s mother that he was healthy, and the visit was over. Next August, Ryan’s exam will likely include a more detailed look at his mental health.

In February 2018, the American Academy of Pediatrics updated its guidelines on screening for depression in adolescents in primary care settings. The guidelines address the problem of undiagnosed and untreated psychiatric illness in children over the age of 10 years, the shortage of available mental health professionals, and techniques primary care physicians might use to address psychiatric needs in adolescents. The AAP guidelines include a new recommendation for universal screening with an assessment tool: “Adolescent patients ages 12 years and older should be screened annually for depression [MDD or depressive disorders] with a formal self-report screening tool either on paper or electronically.”

KatarzynaBialasiewicz/Thinkstock

Howard Liu, MD, is a child and adolescent psychiatrist and the interim chair of psychiatry at the University of Nebraska, Omaha, and director of the Behavioral Health Education Center of Nebraska. “I applaud the AAP for recommending universal depression screening for teenagers, as there has been a rising incidence of teen suicide, especially among female adolescents,” he said. “However, when teens screen positive, we must invest in the child mental health infrastructure to support pediatricians. This includes therapists integrated into primary care practices and prescribers with the capacity to take new patients or practice collaborative care.”

Dr. Liu noted that some of his patients drive 4-5 hours each way to see him in Omaha, then spend the night before making the return trip. “There is a dire shortage of pediatric mental health services in every state. This shifts the responsibility for care to pediatricians, teachers, and parents who often lack the resources to keep kids safe and well. It’s an unconscionable gap in care.”

Timothy F. Doran, MD, is chair of pediatrics at the Greater Baltimore Medical Center in Towson, Md., and a past president of the Maryland Chapter of the AAP. “I absolutely think every teenager should be assessed for depression,” he said. With his own patients, he asks open-ended questions about their mental health, then more specific questions about mood, depression, anxiety, sleep, appetite, and libido. If the teen indicates there are problems, he then uses a PHQ-9 to get a sense of whether the depression is mild, moderate, or severe. Dr. Doran estimates that he diagnoses depression in 5%-10% of the adolescents he screens. Baltimore is a metropolitan area with two psychiatry training programs, and Dr. Doran has developed relationships with mental health professionals who will see his patients. If he prescribes an antidepressant, most of those patients will also see a psychotherapist. He notes that it can be more difficult to find resources for children with Medicaid who do not have the resources of some of the families he treats.

Dr. Doran’s practice has not yet implemented the use of a written screening tool for all adolescents. He anticipates doing this soon because of the new guidelines, but he was not enthusiastic about the prospect. “I think I’m catching the kids with depression, and having every child fill out a questionnaire will be an added burden. We are already loaded down with administrative tasks and screening requirements.” Of note, in Dr. Doran’s 35 years in clinical practice, no child under his care has died of suicide.

Allen Frances, MD, offers a different take on the new guidelines. Dr. Frances was the chairman of the DSM-IV task force and is the author of “Saving Normal: An Insider’s Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life” (New York: HarperCollins, 2014). Dr. Frances has used his Twitter feed to express his objections to the new guidelines for universal depression screening for teenagers. “Universal mental health screening of children sounds virtuous but is a big mistake. Massive overdiagnosis results in 1) Too much ineffective/unsafe #medication; 2) Needless #stigma; 3) Wasting precious resources. Instead, provide easy access to treatment for kids who really need it.” He goes on to tweet about unintended consequences of universal screening, including the concern that screening may identify teens with normal transient sadness or substance-induced mood changes as being clinically depressed. In Twitter lingo, Dr. Frances continues: “‘Early-warning signs of mental illness in kids are often false alarms leading to unneeded #medication/#stigma. Also, we don’t provide adequate psych care for kids who desperately need it. It makes no sense to create new fake patients when we are neglecting the real ones we already have.”

 

It will be interesting to see what happens when Ryan goes for a physical next year. Will the pediatrician devote time to a screening form to document psychiatric symptoms? Will that divert time and attention away from concerns that might be more important to Ryan or his parents? Will he be handed an iPad in the waiting room or emailed a link to a portal before the session so that he can fill out the form on his own? If so, will the doctor remember to check the assessment tool and address mental health concerns that Ryan identifies? It may well prove to be a mixed bag, but let’s hope that universal screening tools open the door for more young people to have their mental health concerns addressed in comprehensive and appropriate ways.

Dr. Miller is the coauthor of “Committed: The Battle Over Involuntary Psychiatric Care,” (Baltimore: Johns Hopkins University Press, 2016).

 

When 14-year-old Ryan saw his pediatrician for his annual physical this past August, he was asked a few quick questions about whether he was having any problems, if he was feeling depressed or anxious, and if there was anything he wanted to discuss. Ryan said no to each question, then the doctor examined him, reminded him to get a flu shot, and signed off on the forms he needed to play team sports in high school. The doctor assured Ryan’s mother that he was healthy, and the visit was over. Next August, Ryan’s exam will likely include a more detailed look at his mental health.

In February 2018, the American Academy of Pediatrics updated its guidelines on screening for depression in adolescents in primary care settings. The guidelines address the problem of undiagnosed and untreated psychiatric illness in children over the age of 10 years, the shortage of available mental health professionals, and techniques primary care physicians might use to address psychiatric needs in adolescents. The AAP guidelines include a new recommendation for universal screening with an assessment tool: “Adolescent patients ages 12 years and older should be screened annually for depression [MDD or depressive disorders] with a formal self-report screening tool either on paper or electronically.”

KatarzynaBialasiewicz/Thinkstock

Howard Liu, MD, is a child and adolescent psychiatrist and the interim chair of psychiatry at the University of Nebraska, Omaha, and director of the Behavioral Health Education Center of Nebraska. “I applaud the AAP for recommending universal depression screening for teenagers, as there has been a rising incidence of teen suicide, especially among female adolescents,” he said. “However, when teens screen positive, we must invest in the child mental health infrastructure to support pediatricians. This includes therapists integrated into primary care practices and prescribers with the capacity to take new patients or practice collaborative care.”

Dr. Liu noted that some of his patients drive 4-5 hours each way to see him in Omaha, then spend the night before making the return trip. “There is a dire shortage of pediatric mental health services in every state. This shifts the responsibility for care to pediatricians, teachers, and parents who often lack the resources to keep kids safe and well. It’s an unconscionable gap in care.”

Timothy F. Doran, MD, is chair of pediatrics at the Greater Baltimore Medical Center in Towson, Md., and a past president of the Maryland Chapter of the AAP. “I absolutely think every teenager should be assessed for depression,” he said. With his own patients, he asks open-ended questions about their mental health, then more specific questions about mood, depression, anxiety, sleep, appetite, and libido. If the teen indicates there are problems, he then uses a PHQ-9 to get a sense of whether the depression is mild, moderate, or severe. Dr. Doran estimates that he diagnoses depression in 5%-10% of the adolescents he screens. Baltimore is a metropolitan area with two psychiatry training programs, and Dr. Doran has developed relationships with mental health professionals who will see his patients. If he prescribes an antidepressant, most of those patients will also see a psychotherapist. He notes that it can be more difficult to find resources for children with Medicaid who do not have the resources of some of the families he treats.

Dr. Doran’s practice has not yet implemented the use of a written screening tool for all adolescents. He anticipates doing this soon because of the new guidelines, but he was not enthusiastic about the prospect. “I think I’m catching the kids with depression, and having every child fill out a questionnaire will be an added burden. We are already loaded down with administrative tasks and screening requirements.” Of note, in Dr. Doran’s 35 years in clinical practice, no child under his care has died of suicide.

Allen Frances, MD, offers a different take on the new guidelines. Dr. Frances was the chairman of the DSM-IV task force and is the author of “Saving Normal: An Insider’s Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life” (New York: HarperCollins, 2014). Dr. Frances has used his Twitter feed to express his objections to the new guidelines for universal depression screening for teenagers. “Universal mental health screening of children sounds virtuous but is a big mistake. Massive overdiagnosis results in 1) Too much ineffective/unsafe #medication; 2) Needless #stigma; 3) Wasting precious resources. Instead, provide easy access to treatment for kids who really need it.” He goes on to tweet about unintended consequences of universal screening, including the concern that screening may identify teens with normal transient sadness or substance-induced mood changes as being clinically depressed. In Twitter lingo, Dr. Frances continues: “‘Early-warning signs of mental illness in kids are often false alarms leading to unneeded #medication/#stigma. Also, we don’t provide adequate psych care for kids who desperately need it. It makes no sense to create new fake patients when we are neglecting the real ones we already have.”

 

It will be interesting to see what happens when Ryan goes for a physical next year. Will the pediatrician devote time to a screening form to document psychiatric symptoms? Will that divert time and attention away from concerns that might be more important to Ryan or his parents? Will he be handed an iPad in the waiting room or emailed a link to a portal before the session so that he can fill out the form on his own? If so, will the doctor remember to check the assessment tool and address mental health concerns that Ryan identifies? It may well prove to be a mixed bag, but let’s hope that universal screening tools open the door for more young people to have their mental health concerns addressed in comprehensive and appropriate ways.

Dr. Miller is the coauthor of “Committed: The Battle Over Involuntary Psychiatric Care,” (Baltimore: Johns Hopkins University Press, 2016).

 

I live and work in Maryland, where medical marijuana dispensaries are just beginning to open. So far, my patients have been content to smoke illegal marijuana, even after my admonishments. Last week, however, a patient who suffers from chronic pain told me that one of her doctors suggested she try medical marijuana. What did I think? The patient is in her 70s, and she has not tolerated opiates. She lives an active life, and she drives. I didn’t know what to think and was left to tell her that I had no experience and would not object if she wanted to try it. The timing was right for “Issues and Controversies Around Marijuana Use: What’s the Buzz?” at the American Psychiatric Association’s annual meeting in New York this week.

The symposium was chaired by Godfrey Pearlson, MD, director of the Olin Neuropsychiatry Research Center, New Haven, Conn., and five speakers gave a comprehensive overview of the research on different aspects of cannabis use. Let me share the take-home message that each speaker made.

William Iacono, PhD, a professor of psychiatry at the University of Minnesota, Minneapolis, started with a session called “Does Adolescent Marijuana Use Cause Cognitive Decline?” Dr. Iacono and all the speakers who followed him pointed out how difficult it is to research these issues. The research is largely retrospective, and the questions are complex. The degree of use is determined by self-report, and there are questions about acute versus chronic use, whether cognitive decline is temporary or permanent, whether the age of initiating drug use is important, and finally, which tests are used to measure cognitive abilities. Dr. Iacono noted that results are inconsistent and mentioned a large population study done in Dunedin, New Zealand, which measured a decrease in verbal IQ and vocabulary measures at age 38 years if the user began smoking cannabis as an adolescent. Dr. Iacono’s twin studies showed that marijuana users scored lower on these measures in childhood, well before they began smoking, and poor academic performance predisposes to marijuana use.

“Adolescents who use cannabis are not the same as those who don’t,” Dr. Iacono said, “and heavy or daily use does not cause cognitive decline in those who begin smoking as adults.”

Dr. Pearlson introduced the second speaker by saying, “It’s easier to get funding to show the ill effects of cannabis than to show medicinal effects.” Sue Sisley, MD, director of Midtown Roots, a medical marijuana dispensary in Phoenix, conducts cannabis trials for the treatment of PTSD in veterans and noted that she has had a long and difficult road with marijuana research, and hers is the only controlled trial on cannabis for PTSD. When her Schedule I license was approved by the Food and Drug Administration, she was able to receive marijuana from the National Institute on Drug Abuse that was grown by the University of Mississippi in Oxford – the only federal growing facility. The marijuana was delivered by FedEx, and the drug was the consistency of talcum powder. It was a challenge to find a lab that could verify the components of the test drug, and when she did, she found the tetrahydrocannabinol content was considerably lower than marijuana sold on the black market. Also, the product contained both mold and lead. “As a physician, how do you hand out mold weed to our veterans?”

Her trials are still in progress, and more veterans are needed. Anecdotally, she says, a decrease has been seen in the use of both opiates and Viagra by the research subjects.

Michael Stevens, PhD, adjunct professor of psychiatry at Yale University, New Haven, Conn., discussed the risk of motor vehicle accidents in marijuana smokers and the logistical issues enforcement poses for law enforcement officials. “There is evidence that marijuana increases the risk for accidents.” Dr. Stevens went on to say that the elevated risk is notably less than that associated with the use of alcohol or stimulants. Studying the effects of marijuana on driving is difficult, as driving simulators do not necessarily reflect on-road experiences, and cognitive testing does not always translate into impairment. “We can’t give marijuana to teens and test them, and you can’t tell people who smoke every day that you’ll check in with them in a few years and check their driving records.”

 

In terms of law enforcement issues, roadside sobriety tests have not been validated for marijuana use, and plasma levels of the drug drop within minutes of use. “The alcohol model works well with alcohol, but cannabis is not alcohol.”

Deborah Hasin, PhD, professor of epidemiology (psychiatry) at Columbia University, New York, talked about trends of cannabis use in the United States. “Looking at states before and after legalization, we see that there is an increase in both cannabis use and cannabis disorders in adults.” Adolescents, however, are not smoking more, and rates have not increased in states where marijuana has been legalized for medical or recreational use. “Kids are just not socializing; they are in their bedrooms with their smartphones. Depression is increasing in teens, but substance abuse is not.”

The last speaker was Deepak Cyril D’Souza, MD, a professor of psychiatry at Yale University, who talked about cannabis and psychosis. He defined three distinct relationships: acute transient psychosis that resolves fairly quickly, acute persistent psychosis that takes days or weeks to resolve, and psychotic reactions that are associated with recurrent psychotic symptoms. Studies suggest that those who have a psychotic reaction to marijuana are at elevated risk of being diagnosed with schizophrenia later, and that timing of exposure to marijuana may be important.

In patients with psychotic disorders who are actively being treated with antipsychotics, Dr. D’Souza found that giving tetrahydrocannabinol intravenously increases the symptoms of schizophrenia, even if the patient has the perception that marijuana is helpful. “There was a mismatch between what the patient reported and what we observed.”

 

With regard to the important question of whether marijuana causes schizophrenia, Dr. D’Souza noted that “it’s neither a necessary nor sufficient component, but it does appear it hastens psychosis in schizophrenia and earlier symptoms are associated with a worse prognosis.”

I’ll see what happens with my patient. A Canadian physician in the audience noted that he has treated thousands of patients, and most find medical marijuana to be helpful. In our country, marijuana continues to be a controversial topic with strong opinions about its usefulness and a conversation that is limited by our lack of research.

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care,” (Baltimore: Johns Hopkins University Press, 2016). She practices in Baltimore.

 

I live and work in Maryland, where medical marijuana dispensaries are just beginning to open. So far, my patients have been content to smoke illegal marijuana, even after my admonishments. Last week, however, a patient who suffers from chronic pain told me that one of her doctors suggested she try medical marijuana. What did I think? The patient is in her 70s, and she has not tolerated opiates. She lives an active life, and she drives. I didn’t know what to think and was left to tell her that I had no experience and would not object if she wanted to try it. The timing was right for “Issues and Controversies Around Marijuana Use: What’s the Buzz?” at the American Psychiatric Association’s annual meeting in New York this week.

The symposium was chaired by Godfrey Pearlson, MD, director of the Olin Neuropsychiatry Research Center, New Haven, Conn., and five speakers gave a comprehensive overview of the research on different aspects of cannabis use. Let me share the take-home message that each speaker made.

William Iacono, PhD, a professor of psychiatry at the University of Minnesota, Minneapolis, started with a session called “Does Adolescent Marijuana Use Cause Cognitive Decline?” Dr. Iacono and all the speakers who followed him pointed out how difficult it is to research these issues. The research is largely retrospective, and the questions are complex. The degree of use is determined by self-report, and there are questions about acute versus chronic use, whether cognitive decline is temporary or permanent, whether the age of initiating drug use is important, and finally, which tests are used to measure cognitive abilities. Dr. Iacono noted that results are inconsistent and mentioned a large population study done in Dunedin, New Zealand, which measured a decrease in verbal IQ and vocabulary measures at age 38 years if the user began smoking cannabis as an adolescent. Dr. Iacono’s twin studies showed that marijuana users scored lower on these measures in childhood, well before they began smoking, and poor academic performance predisposes to marijuana use.

“Adolescents who use cannabis are not the same as those who don’t,” Dr. Iacono said, “and heavy or daily use does not cause cognitive decline in those who begin smoking as adults.”

Dr. Pearlson introduced the second speaker by saying, “It’s easier to get funding to show the ill effects of cannabis than to show medicinal effects.” Sue Sisley, MD, director of Midtown Roots, a medical marijuana dispensary in Phoenix, conducts cannabis trials for the treatment of PTSD in veterans and noted that she has had a long and difficult road with marijuana research, and hers is the only controlled trial on cannabis for PTSD. When her Schedule I license was approved by the Food and Drug Administration, she was able to receive marijuana from the National Institute on Drug Abuse that was grown by the University of Mississippi in Oxford – the only federal growing facility. The marijuana was delivered by FedEx, and the drug was the consistency of talcum powder. It was a challenge to find a lab that could verify the components of the test drug, and when she did, she found the tetrahydrocannabinol content was considerably lower than marijuana sold on the black market. Also, the product contained both mold and lead. “As a physician, how do you hand out mold weed to our veterans?”

Her trials are still in progress, and more veterans are needed. Anecdotally, she says, a decrease has been seen in the use of both opiates and Viagra by the research subjects.

Michael Stevens, PhD, adjunct professor of psychiatry at Yale University, New Haven, Conn., discussed the risk of motor vehicle accidents in marijuana smokers and the logistical issues enforcement poses for law enforcement officials. “There is evidence that marijuana increases the risk for accidents.” Dr. Stevens went on to say that the elevated risk is notably less than that associated with the use of alcohol or stimulants. Studying the effects of marijuana on driving is difficult, as driving simulators do not necessarily reflect on-road experiences, and cognitive testing does not always translate into impairment. “We can’t give marijuana to teens and test them, and you can’t tell people who smoke every day that you’ll check in with them in a few years and check their driving records.”

 

In terms of law enforcement issues, roadside sobriety tests have not been validated for marijuana use, and plasma levels of the drug drop within minutes of use. “The alcohol model works well with alcohol, but cannabis is not alcohol.”

Deborah Hasin, PhD, professor of epidemiology (psychiatry) at Columbia University, New York, talked about trends of cannabis use in the United States. “Looking at states before and after legalization, we see that there is an increase in both cannabis use and cannabis disorders in adults.” Adolescents, however, are not smoking more, and rates have not increased in states where marijuana has been legalized for medical or recreational use. “Kids are just not socializing; they are in their bedrooms with their smartphones. Depression is increasing in teens, but substance abuse is not.”

The last speaker was Deepak Cyril D’Souza, MD, a professor of psychiatry at Yale University, who talked about cannabis and psychosis. He defined three distinct relationships: acute transient psychosis that resolves fairly quickly, acute persistent psychosis that takes days or weeks to resolve, and psychotic reactions that are associated with recurrent psychotic symptoms. Studies suggest that those who have a psychotic reaction to marijuana are at elevated risk of being diagnosed with schizophrenia later, and that timing of exposure to marijuana may be important.

In patients with psychotic disorders who are actively being treated with antipsychotics, Dr. D’Souza found that giving tetrahydrocannabinol intravenously increases the symptoms of schizophrenia, even if the patient has the perception that marijuana is helpful. “There was a mismatch between what the patient reported and what we observed.”

 

With regard to the important question of whether marijuana causes schizophrenia, Dr. D’Souza noted that “it’s neither a necessary nor sufficient component, but it does appear it hastens psychosis in schizophrenia and earlier symptoms are associated with a worse prognosis.”

I’ll see what happens with my patient. A Canadian physician in the audience noted that he has treated thousands of patients, and most find medical marijuana to be helpful. In our country, marijuana continues to be a controversial topic with strong opinions about its usefulness and a conversation that is limited by our lack of research.

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care,” (Baltimore: Johns Hopkins University Press, 2016). She practices in Baltimore.

 

I live and work in Maryland, where medical marijuana dispensaries are just beginning to open. So far, my patients have been content to smoke illegal marijuana, even after my admonishments. Last week, however, a patient who suffers from chronic pain told me that one of her doctors suggested she try medical marijuana. What did I think? The patient is in her 70s, and she has not tolerated opiates. She lives an active life, and she drives. I didn’t know what to think and was left to tell her that I had no experience and would not object if she wanted to try it. The timing was right for “Issues and Controversies Around Marijuana Use: What’s the Buzz?” at the American Psychiatric Association’s annual meeting in New York this week.

The symposium was chaired by Godfrey Pearlson, MD, director of the Olin Neuropsychiatry Research Center, New Haven, Conn., and five speakers gave a comprehensive overview of the research on different aspects of cannabis use. Let me share the take-home message that each speaker made.

William Iacono, PhD, a professor of psychiatry at the University of Minnesota, Minneapolis, started with a session called “Does Adolescent Marijuana Use Cause Cognitive Decline?” Dr. Iacono and all the speakers who followed him pointed out how difficult it is to research these issues. The research is largely retrospective, and the questions are complex. The degree of use is determined by self-report, and there are questions about acute versus chronic use, whether cognitive decline is temporary or permanent, whether the age of initiating drug use is important, and finally, which tests are used to measure cognitive abilities. Dr. Iacono noted that results are inconsistent and mentioned a large population study done in Dunedin, New Zealand, which measured a decrease in verbal IQ and vocabulary measures at age 38 years if the user began smoking cannabis as an adolescent. Dr. Iacono’s twin studies showed that marijuana users scored lower on these measures in childhood, well before they began smoking, and poor academic performance predisposes to marijuana use.

“Adolescents who use cannabis are not the same as those who don’t,” Dr. Iacono said, “and heavy or daily use does not cause cognitive decline in those who begin smoking as adults.”

Dr. Pearlson introduced the second speaker by saying, “It’s easier to get funding to show the ill effects of cannabis than to show medicinal effects.” Sue Sisley, MD, director of Midtown Roots, a medical marijuana dispensary in Phoenix, conducts cannabis trials for the treatment of PTSD in veterans and noted that she has had a long and difficult road with marijuana research, and hers is the only controlled trial on cannabis for PTSD. When her Schedule I license was approved by the Food and Drug Administration, she was able to receive marijuana from the National Institute on Drug Abuse that was grown by the University of Mississippi in Oxford – the only federal growing facility. The marijuana was delivered by FedEx, and the drug was the consistency of talcum powder. It was a challenge to find a lab that could verify the components of the test drug, and when she did, she found the tetrahydrocannabinol content was considerably lower than marijuana sold on the black market. Also, the product contained both mold and lead. “As a physician, how do you hand out mold weed to our veterans?”

Her trials are still in progress, and more veterans are needed. Anecdotally, she says, a decrease has been seen in the use of both opiates and Viagra by the research subjects.

Michael Stevens, PhD, adjunct professor of psychiatry at Yale University, New Haven, Conn., discussed the risk of motor vehicle accidents in marijuana smokers and the logistical issues enforcement poses for law enforcement officials. “There is evidence that marijuana increases the risk for accidents.” Dr. Stevens went on to say that the elevated risk is notably less than that associated with the use of alcohol or stimulants. Studying the effects of marijuana on driving is difficult, as driving simulators do not necessarily reflect on-road experiences, and cognitive testing does not always translate into impairment. “We can’t give marijuana to teens and test them, and you can’t tell people who smoke every day that you’ll check in with them in a few years and check their driving records.”

 

In terms of law enforcement issues, roadside sobriety tests have not been validated for marijuana use, and plasma levels of the drug drop within minutes of use. “The alcohol model works well with alcohol, but cannabis is not alcohol.”

Deborah Hasin, PhD, professor of epidemiology (psychiatry) at Columbia University, New York, talked about trends of cannabis use in the United States. “Looking at states before and after legalization, we see that there is an increase in both cannabis use and cannabis disorders in adults.” Adolescents, however, are not smoking more, and rates have not increased in states where marijuana has been legalized for medical or recreational use. “Kids are just not socializing; they are in their bedrooms with their smartphones. Depression is increasing in teens, but substance abuse is not.”

The last speaker was Deepak Cyril D’Souza, MD, a professor of psychiatry at Yale University, who talked about cannabis and psychosis. He defined three distinct relationships: acute transient psychosis that resolves fairly quickly, acute persistent psychosis that takes days or weeks to resolve, and psychotic reactions that are associated with recurrent psychotic symptoms. Studies suggest that those who have a psychotic reaction to marijuana are at elevated risk of being diagnosed with schizophrenia later, and that timing of exposure to marijuana may be important.

In patients with psychotic disorders who are actively being treated with antipsychotics, Dr. D’Souza found that giving tetrahydrocannabinol intravenously increases the symptoms of schizophrenia, even if the patient has the perception that marijuana is helpful. “There was a mismatch between what the patient reported and what we observed.”

 

With regard to the important question of whether marijuana causes schizophrenia, Dr. D’Souza noted that “it’s neither a necessary nor sufficient component, but it does appear it hastens psychosis in schizophrenia and earlier symptoms are associated with a worse prognosis.”

I’ll see what happens with my patient. A Canadian physician in the audience noted that he has treated thousands of patients, and most find medical marijuana to be helpful. In our country, marijuana continues to be a controversial topic with strong opinions about its usefulness and a conversation that is limited by our lack of research.

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care,” (Baltimore: Johns Hopkins University Press, 2016). She practices in Baltimore.

 

In 1946, Psychiatrist Viktor Frankl postulated in “Man’s Search for Meaning” that the expected reaction to being placed in a concentration camp was dehumanization, apathy, and despair. The placement of a person in such a desolate environment, anticipating death, and seeing the affliction of horror, was believed to lead to hopelessness and mental illness. Facing such circumstances, Dr. Frankl advised finding a purpose as a means to stay mentally and physically alive.

As contemporary psychiatrists, we see ourselves confronted with a different kind of challenge. Modern society has left more than a half-million of our fellow Americans on the streets, homeless, and with little connection to the rest of society. Despite their isolation, their paths merge with ours in an array of settings, namely mental health services in emergency departments, community clinics, and local correctional institutions. Nearly all psychiatrists have worked with a homeless patient at some point in their careers. The connection between mental illness and homelessness may be apparent to some, but we remain perplexed and propose more questions than answers.
 

What is the expected reaction to homelessness?

Homelessness presents significant challenges when contextualized in terms of symptoms of mental illness. For instance, in response to a question about sleep, common answers from homeless patients include, “I can’t fall asleep till 2 a.m., when the bars close, and it’s a little more quiet. I get woken up several times a night by a police officer asking me to leave because I’m trespassing. Sometimes when my body finally allows me to sleep, I awake all of a sudden to someone trying to steal my stuff. That makes me not want to sleep at all.” Can we claim that this sleeplessness is a sign of depression or even mania? Or is insomnia a necessary adaptation for survival on the streets?

How might a homeless person describe his fears? “I don’t want to go to the emergency room, doc; these are all the belongings I have, and I have nowhere safe to store them. I have to carry a knife for protection despite the fact that it is illegal. I used to have a circle of support, but my ‘friends’ stole from me, and now I don’t trust anyone. I don’t like to be around a lot of people; I’ve seen some people do really horrible things on the streets that I can’t unsee. Sometimes, I think the cops enjoy arresting me; I wonder if it helps their quotas.” Are those concerns a sign of an anxiety disorder or even paranoia? Or is it how most people would respond if they were placed in similar situations?

How might a homeless person describe her mood? “I have no home. I have not seen my family in a decade. I am so disconnected from society that I do not know who the president is, or what is the date. Nobody has shaken my hand in years.” Yet, we expect that person to possibly narrow and codify her suffering with an adjective on a Likert scale, or even a visual analog scale of mood with a happy or a frowny face. We assume that their mood can even be narrowed to an emoji or a label, despite their complex circumstances.

When asked about social history, we often hear responses such as, “I have no income. I tried to get a job, but it was too hard to maintain my hygiene and transportation, so I quit. I applied for disability once, and I was denied. I want to work, but when you’ve been on the streets this long it’s hard. I mean … look at me. I applied for affordable housing twice, but I didn’t get it because I’ve been evicted in the last 5 years. The only time I had stable housing for an extended period of time in the last 10 years was when I went to jail for trespassing. I want to live, but I can’t go on like this. I think people would be better off without me if I was gone. Heck, maybe they wouldn’t even notice.” Would we permit a patient like this to be heard in a safe and nonconfrontational environment? Do they meet criteria for grave disability and/or danger to self? Or are they doing the best they can to get their needs met in a broken system?

Our clinical experience has taught us that the homeless population suffers from many of the same symptoms as those of patients with mental illness, independent of a diagnosis. Careful examination of their lives can often explain these expected reactions better than contextualizing them through pathological or diagnostic lenses.
 

 

Should homelessness alone be a criterion for mental health treatment?

Despite the enormous challenges facing the homeless population, many are seen in our clinics hopeful and endorsing a fair mood. Many are polite and answer questions in an attempt to diminish the burden they feel they impose on others, including the medical system. Many display strong resiliency and find ways to cope, relate, and find meaning despite their challenging circumstances. Yet, many also come to us suffering and seeking assistance.

We empathize with the frustration psychiatrists feel when using terms such as “homelessidal” to refer to patients who are homeless and suicidal. The term is meant to evoke the perceived helplessness in trying to care for a homeless patient in the emergency department. Although 2 days of housing in an inpatient psychiatric unit and prescribing an antidepressant can give homeless patients a brief respite, it does little to address the root cause of that person’s suffering. We also find that the use of diagnostic labels can be insufficient, and often inappropriate, in the context of the expected reactions to the significant stressors of being homeless.

We routinely see the distress and hopelessness in our patients suffering from homelessness. We think that psychiatry is capable of softening those daily traumas using supportive therapy. We think that psychiatry is capable of positively challenging the despondency by activating meaning and purpose, as suggested by Dr. Frankl. While those are not typical interventions in modern psychiatry, they are established and validated. By considering homelessness in and of itself a criterion for mental health treatment, we can begin to address those challenges, and engage in alternative, longer lasting treatment considerations.
 

How to proceed?

Though the answer for caring for the homeless may not be in psychopharmacology, we think that psychiatry could enhance the care of the homeless by pursuit of two main goals.

 

The first is to advocate for access to mental health services for all homeless persons who desire it, even those who do not meet criteria for a DSM disorder. This charade we are forced to play with insurance companies and community organizations requiring the presence of a “disorder” to justify supportive therapy and/or occasional use of a crisis house bed does not appear warranted. While we understand that resources are limited, we do not think that homeless persons who are in need of care, but do not meet criteria for a DSM disorder, are any less worthy.

The second goal is to advocate for housing first initiatives that incorporate comprehensive supportive services into their facilities. While we acknowledge the problems that can arise by forcing programs to accept clients, we do not see how mental health treatment can be done adequately without an opportunity for housing. Psychiatry must acknowledge that this social determinant of health takes priority over medication adherence, drug use, the ability to fill out forms, and even symptomatology. Sometimes, medications aren’t even necessary – we’ve worked with homeless patients who present initially with insomnia, depression, and anxiety, and as soon as they get stable housing, these symptoms resolve. In these situations, social interventions are more sensical than medication management. The social nature of homelessness should not propel psychiatry to focus its efforts on the biological side of its specialty; it should be seen as an opportunity for us to develop skills in advocacy and lead, or at least support, interventions that target the social determinants of health.

Under our current medical model, as psychiatrists, we understand that our role is to diagnose, and then treat the diagnosed disorder. Homelessness brings a unique challenge; it is a factor, not based on biology, that can cause severe psychiatric symptomatology with or without the presence of a DSM disorder. We worry that current constructs of mental health narrow our reach and inhibit our potential benefit to society. We hope to encourage psychiatry in embracing public health interventions such as housing first and remembering the value of psychological interventions when working with this vulnerable population.
 

Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre mentors residents on projects, including the reduction in the use of solitary confinement of patients with mental illness and examination of the mentally ill offender. Dr. Badre can be reached at Badremd.com. Dr. Janowsky is a combined resident in family medicine and psychiatry at the University of California, San Diego. She spends most of her clinical time at St. Vincent de Paul Family Health Center, a clinic that primarily serves the homeless. Her interests include disease prevention, wellness promotion, and behavioral interventions for chronic disease management. Outside of work, you can find her recharging her batteries via yoga, musical meditation, hiking, beach journaling, and spending time with loved ones.

 

In 1946, Psychiatrist Viktor Frankl postulated in “Man’s Search for Meaning” that the expected reaction to being placed in a concentration camp was dehumanization, apathy, and despair. The placement of a person in such a desolate environment, anticipating death, and seeing the affliction of horror, was believed to lead to hopelessness and mental illness. Facing such circumstances, Dr. Frankl advised finding a purpose as a means to stay mentally and physically alive.

As contemporary psychiatrists, we see ourselves confronted with a different kind of challenge. Modern society has left more than a half-million of our fellow Americans on the streets, homeless, and with little connection to the rest of society. Despite their isolation, their paths merge with ours in an array of settings, namely mental health services in emergency departments, community clinics, and local correctional institutions. Nearly all psychiatrists have worked with a homeless patient at some point in their careers. The connection between mental illness and homelessness may be apparent to some, but we remain perplexed and propose more questions than answers.
 

What is the expected reaction to homelessness?

Homelessness presents significant challenges when contextualized in terms of symptoms of mental illness. For instance, in response to a question about sleep, common answers from homeless patients include, “I can’t fall asleep till 2 a.m., when the bars close, and it’s a little more quiet. I get woken up several times a night by a police officer asking me to leave because I’m trespassing. Sometimes when my body finally allows me to sleep, I awake all of a sudden to someone trying to steal my stuff. That makes me not want to sleep at all.” Can we claim that this sleeplessness is a sign of depression or even mania? Or is insomnia a necessary adaptation for survival on the streets?

How might a homeless person describe his fears? “I don’t want to go to the emergency room, doc; these are all the belongings I have, and I have nowhere safe to store them. I have to carry a knife for protection despite the fact that it is illegal. I used to have a circle of support, but my ‘friends’ stole from me, and now I don’t trust anyone. I don’t like to be around a lot of people; I’ve seen some people do really horrible things on the streets that I can’t unsee. Sometimes, I think the cops enjoy arresting me; I wonder if it helps their quotas.” Are those concerns a sign of an anxiety disorder or even paranoia? Or is it how most people would respond if they were placed in similar situations?

How might a homeless person describe her mood? “I have no home. I have not seen my family in a decade. I am so disconnected from society that I do not know who the president is, or what is the date. Nobody has shaken my hand in years.” Yet, we expect that person to possibly narrow and codify her suffering with an adjective on a Likert scale, or even a visual analog scale of mood with a happy or a frowny face. We assume that their mood can even be narrowed to an emoji or a label, despite their complex circumstances.

When asked about social history, we often hear responses such as, “I have no income. I tried to get a job, but it was too hard to maintain my hygiene and transportation, so I quit. I applied for disability once, and I was denied. I want to work, but when you’ve been on the streets this long it’s hard. I mean … look at me. I applied for affordable housing twice, but I didn’t get it because I’ve been evicted in the last 5 years. The only time I had stable housing for an extended period of time in the last 10 years was when I went to jail for trespassing. I want to live, but I can’t go on like this. I think people would be better off without me if I was gone. Heck, maybe they wouldn’t even notice.” Would we permit a patient like this to be heard in a safe and nonconfrontational environment? Do they meet criteria for grave disability and/or danger to self? Or are they doing the best they can to get their needs met in a broken system?

Our clinical experience has taught us that the homeless population suffers from many of the same symptoms as those of patients with mental illness, independent of a diagnosis. Careful examination of their lives can often explain these expected reactions better than contextualizing them through pathological or diagnostic lenses.
 

 

Should homelessness alone be a criterion for mental health treatment?

Despite the enormous challenges facing the homeless population, many are seen in our clinics hopeful and endorsing a fair mood. Many are polite and answer questions in an attempt to diminish the burden they feel they impose on others, including the medical system. Many display strong resiliency and find ways to cope, relate, and find meaning despite their challenging circumstances. Yet, many also come to us suffering and seeking assistance.

We empathize with the frustration psychiatrists feel when using terms such as “homelessidal” to refer to patients who are homeless and suicidal. The term is meant to evoke the perceived helplessness in trying to care for a homeless patient in the emergency department. Although 2 days of housing in an inpatient psychiatric unit and prescribing an antidepressant can give homeless patients a brief respite, it does little to address the root cause of that person’s suffering. We also find that the use of diagnostic labels can be insufficient, and often inappropriate, in the context of the expected reactions to the significant stressors of being homeless.

We routinely see the distress and hopelessness in our patients suffering from homelessness. We think that psychiatry is capable of softening those daily traumas using supportive therapy. We think that psychiatry is capable of positively challenging the despondency by activating meaning and purpose, as suggested by Dr. Frankl. While those are not typical interventions in modern psychiatry, they are established and validated. By considering homelessness in and of itself a criterion for mental health treatment, we can begin to address those challenges, and engage in alternative, longer lasting treatment considerations.
 

How to proceed?

Though the answer for caring for the homeless may not be in psychopharmacology, we think that psychiatry could enhance the care of the homeless by pursuit of two main goals.

 

The first is to advocate for access to mental health services for all homeless persons who desire it, even those who do not meet criteria for a DSM disorder. This charade we are forced to play with insurance companies and community organizations requiring the presence of a “disorder” to justify supportive therapy and/or occasional use of a crisis house bed does not appear warranted. While we understand that resources are limited, we do not think that homeless persons who are in need of care, but do not meet criteria for a DSM disorder, are any less worthy.

The second goal is to advocate for housing first initiatives that incorporate comprehensive supportive services into their facilities. While we acknowledge the problems that can arise by forcing programs to accept clients, we do not see how mental health treatment can be done adequately without an opportunity for housing. Psychiatry must acknowledge that this social determinant of health takes priority over medication adherence, drug use, the ability to fill out forms, and even symptomatology. Sometimes, medications aren’t even necessary – we’ve worked with homeless patients who present initially with insomnia, depression, and anxiety, and as soon as they get stable housing, these symptoms resolve. In these situations, social interventions are more sensical than medication management. The social nature of homelessness should not propel psychiatry to focus its efforts on the biological side of its specialty; it should be seen as an opportunity for us to develop skills in advocacy and lead, or at least support, interventions that target the social determinants of health.

Under our current medical model, as psychiatrists, we understand that our role is to diagnose, and then treat the diagnosed disorder. Homelessness brings a unique challenge; it is a factor, not based on biology, that can cause severe psychiatric symptomatology with or without the presence of a DSM disorder. We worry that current constructs of mental health narrow our reach and inhibit our potential benefit to society. We hope to encourage psychiatry in embracing public health interventions such as housing first and remembering the value of psychological interventions when working with this vulnerable population.
 

Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre mentors residents on projects, including the reduction in the use of solitary confinement of patients with mental illness and examination of the mentally ill offender. Dr. Badre can be reached at Badremd.com. Dr. Janowsky is a combined resident in family medicine and psychiatry at the University of California, San Diego. She spends most of her clinical time at St. Vincent de Paul Family Health Center, a clinic that primarily serves the homeless. Her interests include disease prevention, wellness promotion, and behavioral interventions for chronic disease management. Outside of work, you can find her recharging her batteries via yoga, musical meditation, hiking, beach journaling, and spending time with loved ones.

 

In 1946, Psychiatrist Viktor Frankl postulated in “Man’s Search for Meaning” that the expected reaction to being placed in a concentration camp was dehumanization, apathy, and despair. The placement of a person in such a desolate environment, anticipating death, and seeing the affliction of horror, was believed to lead to hopelessness and mental illness. Facing such circumstances, Dr. Frankl advised finding a purpose as a means to stay mentally and physically alive.

As contemporary psychiatrists, we see ourselves confronted with a different kind of challenge. Modern society has left more than a half-million of our fellow Americans on the streets, homeless, and with little connection to the rest of society. Despite their isolation, their paths merge with ours in an array of settings, namely mental health services in emergency departments, community clinics, and local correctional institutions. Nearly all psychiatrists have worked with a homeless patient at some point in their careers. The connection between mental illness and homelessness may be apparent to some, but we remain perplexed and propose more questions than answers.
 

What is the expected reaction to homelessness?

Homelessness presents significant challenges when contextualized in terms of symptoms of mental illness. For instance, in response to a question about sleep, common answers from homeless patients include, “I can’t fall asleep till 2 a.m., when the bars close, and it’s a little more quiet. I get woken up several times a night by a police officer asking me to leave because I’m trespassing. Sometimes when my body finally allows me to sleep, I awake all of a sudden to someone trying to steal my stuff. That makes me not want to sleep at all.” Can we claim that this sleeplessness is a sign of depression or even mania? Or is insomnia a necessary adaptation for survival on the streets?

How might a homeless person describe his fears? “I don’t want to go to the emergency room, doc; these are all the belongings I have, and I have nowhere safe to store them. I have to carry a knife for protection despite the fact that it is illegal. I used to have a circle of support, but my ‘friends’ stole from me, and now I don’t trust anyone. I don’t like to be around a lot of people; I’ve seen some people do really horrible things on the streets that I can’t unsee. Sometimes, I think the cops enjoy arresting me; I wonder if it helps their quotas.” Are those concerns a sign of an anxiety disorder or even paranoia? Or is it how most people would respond if they were placed in similar situations?

How might a homeless person describe her mood? “I have no home. I have not seen my family in a decade. I am so disconnected from society that I do not know who the president is, or what is the date. Nobody has shaken my hand in years.” Yet, we expect that person to possibly narrow and codify her suffering with an adjective on a Likert scale, or even a visual analog scale of mood with a happy or a frowny face. We assume that their mood can even be narrowed to an emoji or a label, despite their complex circumstances.

When asked about social history, we often hear responses such as, “I have no income. I tried to get a job, but it was too hard to maintain my hygiene and transportation, so I quit. I applied for disability once, and I was denied. I want to work, but when you’ve been on the streets this long it’s hard. I mean … look at me. I applied for affordable housing twice, but I didn’t get it because I’ve been evicted in the last 5 years. The only time I had stable housing for an extended period of time in the last 10 years was when I went to jail for trespassing. I want to live, but I can’t go on like this. I think people would be better off without me if I was gone. Heck, maybe they wouldn’t even notice.” Would we permit a patient like this to be heard in a safe and nonconfrontational environment? Do they meet criteria for grave disability and/or danger to self? Or are they doing the best they can to get their needs met in a broken system?

Our clinical experience has taught us that the homeless population suffers from many of the same symptoms as those of patients with mental illness, independent of a diagnosis. Careful examination of their lives can often explain these expected reactions better than contextualizing them through pathological or diagnostic lenses.
 

 

Should homelessness alone be a criterion for mental health treatment?

Despite the enormous challenges facing the homeless population, many are seen in our clinics hopeful and endorsing a fair mood. Many are polite and answer questions in an attempt to diminish the burden they feel they impose on others, including the medical system. Many display strong resiliency and find ways to cope, relate, and find meaning despite their challenging circumstances. Yet, many also come to us suffering and seeking assistance.

We empathize with the frustration psychiatrists feel when using terms such as “homelessidal” to refer to patients who are homeless and suicidal. The term is meant to evoke the perceived helplessness in trying to care for a homeless patient in the emergency department. Although 2 days of housing in an inpatient psychiatric unit and prescribing an antidepressant can give homeless patients a brief respite, it does little to address the root cause of that person’s suffering. We also find that the use of diagnostic labels can be insufficient, and often inappropriate, in the context of the expected reactions to the significant stressors of being homeless.

We routinely see the distress and hopelessness in our patients suffering from homelessness. We think that psychiatry is capable of softening those daily traumas using supportive therapy. We think that psychiatry is capable of positively challenging the despondency by activating meaning and purpose, as suggested by Dr. Frankl. While those are not typical interventions in modern psychiatry, they are established and validated. By considering homelessness in and of itself a criterion for mental health treatment, we can begin to address those challenges, and engage in alternative, longer lasting treatment considerations.
 

How to proceed?

Though the answer for caring for the homeless may not be in psychopharmacology, we think that psychiatry could enhance the care of the homeless by pursuit of two main goals.

 

The first is to advocate for access to mental health services for all homeless persons who desire it, even those who do not meet criteria for a DSM disorder. This charade we are forced to play with insurance companies and community organizations requiring the presence of a “disorder” to justify supportive therapy and/or occasional use of a crisis house bed does not appear warranted. While we understand that resources are limited, we do not think that homeless persons who are in need of care, but do not meet criteria for a DSM disorder, are any less worthy.

The second goal is to advocate for housing first initiatives that incorporate comprehensive supportive services into their facilities. While we acknowledge the problems that can arise by forcing programs to accept clients, we do not see how mental health treatment can be done adequately without an opportunity for housing. Psychiatry must acknowledge that this social determinant of health takes priority over medication adherence, drug use, the ability to fill out forms, and even symptomatology. Sometimes, medications aren’t even necessary – we’ve worked with homeless patients who present initially with insomnia, depression, and anxiety, and as soon as they get stable housing, these symptoms resolve. In these situations, social interventions are more sensical than medication management. The social nature of homelessness should not propel psychiatry to focus its efforts on the biological side of its specialty; it should be seen as an opportunity for us to develop skills in advocacy and lead, or at least support, interventions that target the social determinants of health.

Under our current medical model, as psychiatrists, we understand that our role is to diagnose, and then treat the diagnosed disorder. Homelessness brings a unique challenge; it is a factor, not based on biology, that can cause severe psychiatric symptomatology with or without the presence of a DSM disorder. We worry that current constructs of mental health narrow our reach and inhibit our potential benefit to society. We hope to encourage psychiatry in embracing public health interventions such as housing first and remembering the value of psychological interventions when working with this vulnerable population.
 

Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr. Badre mentors residents on projects, including the reduction in the use of solitary confinement of patients with mental illness and examination of the mentally ill offender. Dr. Badre can be reached at Badremd.com. Dr. Janowsky is a combined resident in family medicine and psychiatry at the University of California, San Diego. She spends most of her clinical time at St. Vincent de Paul Family Health Center, a clinic that primarily serves the homeless. Her interests include disease prevention, wellness promotion, and behavioral interventions for chronic disease management. Outside of work, you can find her recharging her batteries via yoga, musical meditation, hiking, beach journaling, and spending time with loved ones.

 

You are on the front lines of the prevention, screening, and treatment decisions for adolescent substance use disorders. You often must choose whether to disclose information about substance use to parents and other concerned adults.

The risk of developing a substance use disorder increases dramatically the earlier an individual begins using a given substance.¹ The neurobiology behind this risk is becoming increasingly clear. Young brains are undergoing crucial developmental processes, including synaptic pruning and myelination. The brain increasingly becomes more efficient in a staggered pattern, with limbic regions preceding frontal and executive regions, so we see adolescents with “more gas than brakes.” This has wisely been identified as developmentally appropriate, and even beneficial, rather than evidence that adolescents are somehow broken.²

SolStock/Getty Images

The adults making rules, regulations, and laws face dual ethical responsibilities: to allow autonomy and striving for independence, while providing guidance, supervision, and protection against harm.

Age-appropriate screening for substance use should occur as early as the preteen years and continue throughout adolescence. The most widely studied screening tools include the CRAFFT screening instrument and the Screening, Brief Intervention, and Referral to Treatment (SBIRT) approach.^3,4 During formal and informal screening, you should lead with genuine concern for the well-being of the adolescent. Beginning a discussion with open-ended questions about substance use in the school and home is a way to build understanding of an adolescent’s environment prior to asking about personal use. While screening, consider well known risk factors including family history of substance use disorders, poor parental supervision, childhood maltreatment or abuse, low academic achievement, and untreated psychiatric disorders such as ADHD, depression, or anxiety, which may contribute to a higher likelihood or more rapid progression of a substance use disorder. Adolescents are more likely to disclose substance use when screening is done in private, rather than in the presence of a parent.⁵

Discussing the limits of confidentiality (generally when there is substantial risk of harm to self or others) with an adolescent shows respect and can be an expression of genuine care and concern. Once substance use or other risk-associated behaviors and choices are disclosed, you often may be asked not to share the information with parents. In some instances, privacy cannot be broken without consent. Be aware of your state laws governing parental and adolescent rights related to confidentiality.

Steve Debenport/Getty Images

When facing decisions about whether to disclose information and include parents in decision-making, consider whether you have implicit bias based on social or political views that may impact your decision. This may include whether you feel a strong tendency to side with adolescents or with parents in family conflict and, if so, why. Both substance use and parental involvement in adolescent health can be polarizing topics, and good decisions more often are evidence based than ideology based. If time permits, consulting with a colleague can provide an opportunity to decrease the impact of implicit bias.

You should strongly consider discussing substance use with the concerned adults when there are these red flags: daily use of any substance, any intravenous substance use, a score of 2 or higher on the CRAFFT, prescription medication misuse, or any change in medical status resulting from substance use, such as alcohol-related blackouts.

 

In most cases, adolescents should be informed of a decision to disclose substance use to their parents. Inviting adolescents to discuss how this will be done, including if the adolescent will be present, and whether you or the adolescent will disclose the use can be an opportunity to discuss their concerns. You should seek to understand if an adolescent has specific fears related to such a disclosure including careful consideration of any history of domestic violence or abuse.

Although adolescents increasingly identify with the opinions and values of their peers, it is a mistake to assume that they therefore do not value the opinions of their parents and the concerned adults in their lives. Parents play an integral role in preventing and treating adolescent substance use disorders. Except in rare instances of severe parent-child relationship problems or abuse, parents can and should be engaged as invaluable participants

Parents should be reminded that their actions speak louder than words and should not assume their teen knows their opinions about substance use until they have been clearly verbalized.⁶ Screening is more accurate when collateral information from a parent is included. Of the therapeutic interventions most effective for treatment of adolescent substance use, five out of six are family-based treatments.⁷ Promising parent-focused interventions such as the Community Reinforcement and Family Training (CRAFT) approach can decrease the duration and severity of that adolescent’s substance use disorder even if the adolescent refuses to participate.⁸ Parents also should be encouraged that positive parenting can lessen the influence of substance use not only in the life of their own child but also in the lives of their children’s peers.⁹

Being aware of the legal and ethical obligations in treatment of adolescents presenting with any level of substance use, you can improve outcomes by thoughtfully inviting the participation of parents and other concerned adults into the prevention, screening, and treatment of adolescent substance use disorders.
 

 

Dr. Jackson is a child and adolescent psychiatrist at the University of Vermont, Burlington.

References

1. “Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings.” NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. (Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013).

2. “The Amazing Teen Brain,” Jay N. Geidd, Scientific American, May 2016.

3. Pediatrics 2011 Oct. doi: 10.1542/peds.2011-1754.

4. Alcohol Screening and Brief Intervention for Youth: A Practitioner’s Guide.

5. Pediatrics. 2016 Jul 1. doi: 10.1542/peds.2016-1211.

6. J Fam Commun. 2014 Jan 1:14(4):328-51.

7. J Clin Child Adolesc. Psychol. 2008;37(1):236-59.

8. J Child Adolesc Subst Abuse. 2015 May 4;24(3):155-65.

9. Arch Pediatr Adolesc Med. 2012;166(12):1132-9.

 

You are on the front lines of the prevention, screening, and treatment decisions for adolescent substance use disorders. You often must choose whether to disclose information about substance use to parents and other concerned adults.

The risk of developing a substance use disorder increases dramatically the earlier an individual begins using a given substance.¹ The neurobiology behind this risk is becoming increasingly clear. Young brains are undergoing crucial developmental processes, including synaptic pruning and myelination. The brain increasingly becomes more efficient in a staggered pattern, with limbic regions preceding frontal and executive regions, so we see adolescents with “more gas than brakes.” This has wisely been identified as developmentally appropriate, and even beneficial, rather than evidence that adolescents are somehow broken.²

SolStock/Getty Images

The adults making rules, regulations, and laws face dual ethical responsibilities: to allow autonomy and striving for independence, while providing guidance, supervision, and protection against harm.

Age-appropriate screening for substance use should occur as early as the preteen years and continue throughout adolescence. The most widely studied screening tools include the CRAFFT screening instrument and the Screening, Brief Intervention, and Referral to Treatment (SBIRT) approach.^3,4 During formal and informal screening, you should lead with genuine concern for the well-being of the adolescent. Beginning a discussion with open-ended questions about substance use in the school and home is a way to build understanding of an adolescent’s environment prior to asking about personal use. While screening, consider well known risk factors including family history of substance use disorders, poor parental supervision, childhood maltreatment or abuse, low academic achievement, and untreated psychiatric disorders such as ADHD, depression, or anxiety, which may contribute to a higher likelihood or more rapid progression of a substance use disorder. Adolescents are more likely to disclose substance use when screening is done in private, rather than in the presence of a parent.⁵

Discussing the limits of confidentiality (generally when there is substantial risk of harm to self or others) with an adolescent shows respect and can be an expression of genuine care and concern. Once substance use or other risk-associated behaviors and choices are disclosed, you often may be asked not to share the information with parents. In some instances, privacy cannot be broken without consent. Be aware of your state laws governing parental and adolescent rights related to confidentiality.

Steve Debenport/Getty Images

When facing decisions about whether to disclose information and include parents in decision-making, consider whether you have implicit bias based on social or political views that may impact your decision. This may include whether you feel a strong tendency to side with adolescents or with parents in family conflict and, if so, why. Both substance use and parental involvement in adolescent health can be polarizing topics, and good decisions more often are evidence based than ideology based. If time permits, consulting with a colleague can provide an opportunity to decrease the impact of implicit bias.

You should strongly consider discussing substance use with the concerned adults when there are these red flags: daily use of any substance, any intravenous substance use, a score of 2 or higher on the CRAFFT, prescription medication misuse, or any change in medical status resulting from substance use, such as alcohol-related blackouts.

 

In most cases, adolescents should be informed of a decision to disclose substance use to their parents. Inviting adolescents to discuss how this will be done, including if the adolescent will be present, and whether you or the adolescent will disclose the use can be an opportunity to discuss their concerns. You should seek to understand if an adolescent has specific fears related to such a disclosure including careful consideration of any history of domestic violence or abuse.

Although adolescents increasingly identify with the opinions and values of their peers, it is a mistake to assume that they therefore do not value the opinions of their parents and the concerned adults in their lives. Parents play an integral role in preventing and treating adolescent substance use disorders. Except in rare instances of severe parent-child relationship problems or abuse, parents can and should be engaged as invaluable participants

Parents should be reminded that their actions speak louder than words and should not assume their teen knows their opinions about substance use until they have been clearly verbalized.⁶ Screening is more accurate when collateral information from a parent is included. Of the therapeutic interventions most effective for treatment of adolescent substance use, five out of six are family-based treatments.⁷ Promising parent-focused interventions such as the Community Reinforcement and Family Training (CRAFT) approach can decrease the duration and severity of that adolescent’s substance use disorder even if the adolescent refuses to participate.⁸ Parents also should be encouraged that positive parenting can lessen the influence of substance use not only in the life of their own child but also in the lives of their children’s peers.⁹

Being aware of the legal and ethical obligations in treatment of adolescents presenting with any level of substance use, you can improve outcomes by thoughtfully inviting the participation of parents and other concerned adults into the prevention, screening, and treatment of adolescent substance use disorders.
 

 

Dr. Jackson is a child and adolescent psychiatrist at the University of Vermont, Burlington.

References

1. “Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings.” NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. (Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013).

2. “The Amazing Teen Brain,” Jay N. Geidd, Scientific American, May 2016.

3. Pediatrics 2011 Oct. doi: 10.1542/peds.2011-1754.

4. Alcohol Screening and Brief Intervention for Youth: A Practitioner’s Guide.

5. Pediatrics. 2016 Jul 1. doi: 10.1542/peds.2016-1211.

6. J Fam Commun. 2014 Jan 1:14(4):328-51.

7. J Clin Child Adolesc. Psychol. 2008;37(1):236-59.

8. J Child Adolesc Subst Abuse. 2015 May 4;24(3):155-65.

9. Arch Pediatr Adolesc Med. 2012;166(12):1132-9.

 

You are on the front lines of the prevention, screening, and treatment decisions for adolescent substance use disorders. You often must choose whether to disclose information about substance use to parents and other concerned adults.

The risk of developing a substance use disorder increases dramatically the earlier an individual begins using a given substance.¹ The neurobiology behind this risk is becoming increasingly clear. Young brains are undergoing crucial developmental processes, including synaptic pruning and myelination. The brain increasingly becomes more efficient in a staggered pattern, with limbic regions preceding frontal and executive regions, so we see adolescents with “more gas than brakes.” This has wisely been identified as developmentally appropriate, and even beneficial, rather than evidence that adolescents are somehow broken.²

SolStock/Getty Images

The adults making rules, regulations, and laws face dual ethical responsibilities: to allow autonomy and striving for independence, while providing guidance, supervision, and protection against harm.

Age-appropriate screening for substance use should occur as early as the preteen years and continue throughout adolescence. The most widely studied screening tools include the CRAFFT screening instrument and the Screening, Brief Intervention, and Referral to Treatment (SBIRT) approach.^3,4 During formal and informal screening, you should lead with genuine concern for the well-being of the adolescent. Beginning a discussion with open-ended questions about substance use in the school and home is a way to build understanding of an adolescent’s environment prior to asking about personal use. While screening, consider well known risk factors including family history of substance use disorders, poor parental supervision, childhood maltreatment or abuse, low academic achievement, and untreated psychiatric disorders such as ADHD, depression, or anxiety, which may contribute to a higher likelihood or more rapid progression of a substance use disorder. Adolescents are more likely to disclose substance use when screening is done in private, rather than in the presence of a parent.⁵

Discussing the limits of confidentiality (generally when there is substantial risk of harm to self or others) with an adolescent shows respect and can be an expression of genuine care and concern. Once substance use or other risk-associated behaviors and choices are disclosed, you often may be asked not to share the information with parents. In some instances, privacy cannot be broken without consent. Be aware of your state laws governing parental and adolescent rights related to confidentiality.

Steve Debenport/Getty Images

When facing decisions about whether to disclose information and include parents in decision-making, consider whether you have implicit bias based on social or political views that may impact your decision. This may include whether you feel a strong tendency to side with adolescents or with parents in family conflict and, if so, why. Both substance use and parental involvement in adolescent health can be polarizing topics, and good decisions more often are evidence based than ideology based. If time permits, consulting with a colleague can provide an opportunity to decrease the impact of implicit bias.

You should strongly consider discussing substance use with the concerned adults when there are these red flags: daily use of any substance, any intravenous substance use, a score of 2 or higher on the CRAFFT, prescription medication misuse, or any change in medical status resulting from substance use, such as alcohol-related blackouts.

 

In most cases, adolescents should be informed of a decision to disclose substance use to their parents. Inviting adolescents to discuss how this will be done, including if the adolescent will be present, and whether you or the adolescent will disclose the use can be an opportunity to discuss their concerns. You should seek to understand if an adolescent has specific fears related to such a disclosure including careful consideration of any history of domestic violence or abuse.

Although adolescents increasingly identify with the opinions and values of their peers, it is a mistake to assume that they therefore do not value the opinions of their parents and the concerned adults in their lives. Parents play an integral role in preventing and treating adolescent substance use disorders. Except in rare instances of severe parent-child relationship problems or abuse, parents can and should be engaged as invaluable participants

Parents should be reminded that their actions speak louder than words and should not assume their teen knows their opinions about substance use until they have been clearly verbalized.⁶ Screening is more accurate when collateral information from a parent is included. Of the therapeutic interventions most effective for treatment of adolescent substance use, five out of six are family-based treatments.⁷ Promising parent-focused interventions such as the Community Reinforcement and Family Training (CRAFT) approach can decrease the duration and severity of that adolescent’s substance use disorder even if the adolescent refuses to participate.⁸ Parents also should be encouraged that positive parenting can lessen the influence of substance use not only in the life of their own child but also in the lives of their children’s peers.⁹

Being aware of the legal and ethical obligations in treatment of adolescents presenting with any level of substance use, you can improve outcomes by thoughtfully inviting the participation of parents and other concerned adults into the prevention, screening, and treatment of adolescent substance use disorders.
 

 

Dr. Jackson is a child and adolescent psychiatrist at the University of Vermont, Burlington.

References

1. “Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings.” NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. (Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013).

2. “The Amazing Teen Brain,” Jay N. Geidd, Scientific American, May 2016.

3. Pediatrics 2011 Oct. doi: 10.1542/peds.2011-1754.

4. Alcohol Screening and Brief Intervention for Youth: A Practitioner’s Guide.

5. Pediatrics. 2016 Jul 1. doi: 10.1542/peds.2016-1211.

6. J Fam Commun. 2014 Jan 1:14(4):328-51.

7. J Clin Child Adolesc. Psychol. 2008;37(1):236-59.

8. J Child Adolesc Subst Abuse. 2015 May 4;24(3):155-65.

9. Arch Pediatr Adolesc Med. 2012;166(12):1132-9.

 

The seventh annual American College of Surgeons Leadership and Advocacy Summit will be held May 19-22 at the Renaissance Washington, DC Downtown Hotel.

The event will kick off with the Leadership portion on Saturday evening, May 19, with a Welcome Reception open to all registrants and continues with a full-day agenda on Sunday, May 20. The program on Sunday includes sessions addressing important topics such as mentoring for a career in surgical leadership, ethics in surgical leadership, leading in times of crisis, change management, managing complex teams, and more.

The Advocacy portion of the Summit begins on Sunday evening with a dinner which will feature a keynote address from a nationally recognized media personality. Monday’s program is packed with a series of sessions on informative and timely topics. Specifically, the panels scheduled for the Advocacy Summit will include:

1) “Understanding Strategic Advocacy” presented by staff of the Washington office

2) “Regulatory Reform: Past, Present, and Patient-Focused” featuring staff from the Centers for Medicare and Medicaid Services.

3) A historical perspective on health care reform entitled, “Health Care Reform, Then and Now,” presented by long-time Health Affairs columnist, Professor Timothy S. Jost.

4) “The Opioid Epidemic: Long-term Solutions for Sustained Success” featuring staff from the Food and Drug Administration and the Drug Enforcement Administration.

 

5) A luncheon, sponsored by the ACSPA-SurgeonsPAC, where attendees will hear remarks on the upcoming mid-term elections from the Executive Directors of both the Democratic Congressional Campaign Committee (DCCC) and the National Republican Congressional Committee (NRCC).

The day will also include issue briefings and specific “asks” on topics in preparation for Hill visits. Specifically, attendees will be briefed on the Pandemic and All-Hazards Preparedness Act (PAHPA), the Standardizing Electronic Prior Authorization for Safe Prescribing Act, the Ensuring Access to General Surgery Act, the Removing Barriers to Colorectal Screening Act, the Childhood Cancer STAR Act, and funding for the CDC to conduct research on firearm injury prevention. Following this training, Fellows will be very well prepared to discuss the issues the following day on Capitol Hill.

Pending last minute conflicts, several Members of Congress are also scheduled to address the group, including a member of leadership from the House of Representatives. Monday’s activities will conclude with an evening reception for 2018 SurgeonsPAC members at the historic Willard InterContinental Hotel. On Tuesday, May 22, attendees will then apply the knowledge and skill gained from Monday’s sessions during meetings with their individual Members of Congress and their staff on Capitol Hill.

As I write, nearly three weeks prior to the event, attendance is already projected to be at record levels. We look forward to welcoming all those already registered to DC for this exciting, informative and important event. Though by press time pre-registration will have closed, on-site registration will be available if you would be able to join us.

 

For questions regarding the Leadership Summit please contact Brian Frankel at [email protected], or 312-202-5361. For questions regarding the Advocacy Summit please contact Michael Carmody at [email protected], or 202-672-1511.

Until next month ….

 

The seventh annual American College of Surgeons Leadership and Advocacy Summit will be held May 19-22 at the Renaissance Washington, DC Downtown Hotel.

The event will kick off with the Leadership portion on Saturday evening, May 19, with a Welcome Reception open to all registrants and continues with a full-day agenda on Sunday, May 20. The program on Sunday includes sessions addressing important topics such as mentoring for a career in surgical leadership, ethics in surgical leadership, leading in times of crisis, change management, managing complex teams, and more.

The Advocacy portion of the Summit begins on Sunday evening with a dinner which will feature a keynote address from a nationally recognized media personality. Monday’s program is packed with a series of sessions on informative and timely topics. Specifically, the panels scheduled for the Advocacy Summit will include:

1) “Understanding Strategic Advocacy” presented by staff of the Washington office

2) “Regulatory Reform: Past, Present, and Patient-Focused” featuring staff from the Centers for Medicare and Medicaid Services.

3) A historical perspective on health care reform entitled, “Health Care Reform, Then and Now,” presented by long-time Health Affairs columnist, Professor Timothy S. Jost.

4) “The Opioid Epidemic: Long-term Solutions for Sustained Success” featuring staff from the Food and Drug Administration and the Drug Enforcement Administration.

 

5) A luncheon, sponsored by the ACSPA-SurgeonsPAC, where attendees will hear remarks on the upcoming mid-term elections from the Executive Directors of both the Democratic Congressional Campaign Committee (DCCC) and the National Republican Congressional Committee (NRCC).

The day will also include issue briefings and specific “asks” on topics in preparation for Hill visits. Specifically, attendees will be briefed on the Pandemic and All-Hazards Preparedness Act (PAHPA), the Standardizing Electronic Prior Authorization for Safe Prescribing Act, the Ensuring Access to General Surgery Act, the Removing Barriers to Colorectal Screening Act, the Childhood Cancer STAR Act, and funding for the CDC to conduct research on firearm injury prevention. Following this training, Fellows will be very well prepared to discuss the issues the following day on Capitol Hill.

Pending last minute conflicts, several Members of Congress are also scheduled to address the group, including a member of leadership from the House of Representatives. Monday’s activities will conclude with an evening reception for 2018 SurgeonsPAC members at the historic Willard InterContinental Hotel. On Tuesday, May 22, attendees will then apply the knowledge and skill gained from Monday’s sessions during meetings with their individual Members of Congress and their staff on Capitol Hill.

As I write, nearly three weeks prior to the event, attendance is already projected to be at record levels. We look forward to welcoming all those already registered to DC for this exciting, informative and important event. Though by press time pre-registration will have closed, on-site registration will be available if you would be able to join us.

 

For questions regarding the Leadership Summit please contact Brian Frankel at [email protected], or 312-202-5361. For questions regarding the Advocacy Summit please contact Michael Carmody at [email protected], or 202-672-1511.

Until next month ….

 

The seventh annual American College of Surgeons Leadership and Advocacy Summit will be held May 19-22 at the Renaissance Washington, DC Downtown Hotel.

The event will kick off with the Leadership portion on Saturday evening, May 19, with a Welcome Reception open to all registrants and continues with a full-day agenda on Sunday, May 20. The program on Sunday includes sessions addressing important topics such as mentoring for a career in surgical leadership, ethics in surgical leadership, leading in times of crisis, change management, managing complex teams, and more.

The Advocacy portion of the Summit begins on Sunday evening with a dinner which will feature a keynote address from a nationally recognized media personality. Monday’s program is packed with a series of sessions on informative and timely topics. Specifically, the panels scheduled for the Advocacy Summit will include:

1) “Understanding Strategic Advocacy” presented by staff of the Washington office

2) “Regulatory Reform: Past, Present, and Patient-Focused” featuring staff from the Centers for Medicare and Medicaid Services.

3) A historical perspective on health care reform entitled, “Health Care Reform, Then and Now,” presented by long-time Health Affairs columnist, Professor Timothy S. Jost.

4) “The Opioid Epidemic: Long-term Solutions for Sustained Success” featuring staff from the Food and Drug Administration and the Drug Enforcement Administration.

 

5) A luncheon, sponsored by the ACSPA-SurgeonsPAC, where attendees will hear remarks on the upcoming mid-term elections from the Executive Directors of both the Democratic Congressional Campaign Committee (DCCC) and the National Republican Congressional Committee (NRCC).

The day will also include issue briefings and specific “asks” on topics in preparation for Hill visits. Specifically, attendees will be briefed on the Pandemic and All-Hazards Preparedness Act (PAHPA), the Standardizing Electronic Prior Authorization for Safe Prescribing Act, the Ensuring Access to General Surgery Act, the Removing Barriers to Colorectal Screening Act, the Childhood Cancer STAR Act, and funding for the CDC to conduct research on firearm injury prevention. Following this training, Fellows will be very well prepared to discuss the issues the following day on Capitol Hill.

Pending last minute conflicts, several Members of Congress are also scheduled to address the group, including a member of leadership from the House of Representatives. Monday’s activities will conclude with an evening reception for 2018 SurgeonsPAC members at the historic Willard InterContinental Hotel. On Tuesday, May 22, attendees will then apply the knowledge and skill gained from Monday’s sessions during meetings with their individual Members of Congress and their staff on Capitol Hill.

As I write, nearly three weeks prior to the event, attendance is already projected to be at record levels. We look forward to welcoming all those already registered to DC for this exciting, informative and important event. Though by press time pre-registration will have closed, on-site registration will be available if you would be able to join us.

 

For questions regarding the Leadership Summit please contact Brian Frankel at [email protected], or 312-202-5361. For questions regarding the Advocacy Summit please contact Michael Carmody at [email protected], or 202-672-1511.

Until next month ….

 

The opioid epidemic continues to devastate the United States across demographic and socioeconomic groups; two-thirds of the 63,632 Americans who died of drug overdoses¹ in 2016 died of prescription or illicit opioids.

In 2015, Theodore J. Cicero, PhD, professor of psychiatry at Washington University, St. Louis, reported on a fundamental change in the nature of the ongoing opioid epidemic: What started as prescription opioid overprescribing, leading to diversion, abuse, and opioid addiction, was transitioning to illicit heroin distribution and consumption. Prescription opioids, namely, extended-release oxycodone (Oxycontin), were perceived initially as pure and safe, as they were specifically dosed and physician prescribed. In addition, filling a prescription for opioids was not associated with the shame or stigma of buying illicit drugs off the street. Because those drugs were seen as therapeutic and pharmacologically “legitimate,” many clinicians and the lay public alike were surprised to see the surge of opioid addiction and overdoses.

Dr. Cicero and others noted² that prescription opioids, whether taken originally for analgesic or recreational purposes, became a “gateway” to heroin, which already was making its way into the United States from Mexico,³ as heroin was cheap and becoming cheaper, easier to find, easy to use, and “pure.” Prescription opioids, on the other hand, were becoming more expensive, and physicians were facing increased regulations in prescribing them. Thus, as prescription opioid use became more and more stigmatized, heroin use was seen, paradoxically, as a more practical alternative. The amount of opioids prescribed in the United States has peaked; physicians are prescribing opioids less often; and the averaged dose has dropped as well, according to the Centers for Disease Control and Prevention.⁴ The first wave of deaths was attributable to prescription opioids, and the second was tied to illicitly obtained potent fentanyl analogs (manufactured in China and smuggled primarily through Mexico), which is added to heroin and sold in the United States.⁵

Many addiction experts and health policy leaders were not surprised by the increases in HIV, TB, and hepatitis B and C that followed the increasing use of intravenous opioids. However, few had experience with previous opioid epidemics in the United States, the most recent being the heroin epidemic occurring in the 1960s-1970s in the aftermath of the Vietnam War. At that time, the notion that heroin was contaminated with other psychoactive drugs, medications, fillers, and other adulterants was a foregone conclusion – though in public health and treatment discussions, this issue is hardly ever raised. We believe this to be a significant lapse in policy and planning. Surveillance by the Drug Enforcement Administration shows that acetyl fentanyl–laced heroin costs a little more on the street than regular heroin. Yet it sells, because users believe its extreme potency produces a better high, thus worth the extra cost. This phenomenon underscores an important point: Opioid addicts often are in search of a better high and will go to any lengths – even risking their lives – to get it.

The “cutting” or “adulteration” of street drugs is common practice in the manufacturing, distribution, and selling of illicit drugs, and the motive is to increase profit. The term “adulterant” generally refers to addition of substances with some psychoactive effects, such as caffeine, ephedra, or even paracetamol. These substances are cheaper than the main substance, have similar or complementary effects when added, and thus help conceal the fact that the desired substance has been cut or diluted. Substances without psychoactive properties such as lactose, other sugars, or talc, are added to a drug primarily to increase the bulk or weight of the illicit substance, or for aesthetic purposes to fool the user. Some adulterants simply are the result of the particular manufacturing process used to make the drug. For example, illicitly manufactured methamphetamine frequently is contaminated by nonstimulant impurities such as lead or mercury (extremely toxic heavy metals), or from carcinogenic solvents used in the synthesis. The local anesthetic lidocaine often is added to cocaine, and the reasons are intuitive: Both drugs are fast-acting local anesthetics.

More intriguing is the story of the antiparasitic medication levamisole. The DEA has estimated that 60%-89% of the seized street cocaine contains levamisole. Levamisole appears to be partly metabolized into an amphetamine-like compound, which could increase dopamine concentration in the reward pathway and thus activate endogenous opioids: It can mimic the effects of cocaine at a fraction of the cost. Levamisole is associated with several types of severe blood disorders, including leukopenia, agranulocytosis, multifocal inflammatory leukoencephalopathy, and neutropenia; a common presentation is vasculitis resulting in loss of limbs. Thus, a real danger in adulterants such as levamisole is their toxicity beyond those of the drug to which they are added, causing numerous medical consequences – including death.

 

The consideration of adulterants is important in another, emerging problem: Cocaine, colloquially thought of as a drug of the 1980s, is making a comeback. A record amount of cocaine is coming across the Mexican border with increased seizures of drug. Also, the number of acres producing cocaine is increasing, the price per unit sold is decreasing, and the prevalence of use has increased. Unfortunately but predictably, cocaine-related deaths are up: National Vital Statistic Systems data indicate that cocaine-related deaths involving opioids climbed from 2000-2006 and 2012-2015. Opioids, primarily heroin and fentanyl, have been driving the recently reported increases in cocaine-related overdose deaths.⁶ At the March 12, 2018, Drug Enforcement Administration panel on the reemergence of cocaine and cocaine-related deaths, experts reported that adulterants, including fentanyl, were responsible for many cocaine-related deaths. Strikingly, the most recent data from the state of Florida suggest that fentanyl is found as a factor in nearly all cocaine-related deaths, and cocaine commonly is found in fentanyl and fentanyl analog-related deaths.

If stigmata of opioid overdose (for example, miotic pupils and respiratory depression) are present in a patient considered to have overdosed on cocaine, naloxone should be administered, as the clinical presentation may be tied to the presence of opioid adulterants. Then, the patient should be engaged in treatment in a long-term care model with evidenced-based therapies, including medication-assisted treatment and contingency management. An important point, however, as described by Thomas Kosten, MD, professor of psychiatry at Baylor University, Houston, is that while we have multiple pharmacologic treatments for opioid overdose and addiction, none exist for cocaine overdose, craving, addiction, or withdrawal.⁷ Dr. Kosten has pioneered novel treatments for cocaine addiction, including anti-cocaine vaccines, but none has been proven safe and effective as of 2018.

Indeed, in the context of the opioid epidemic, the demand for opioid use treatment has increased, though the consequences of addiction, and thus areas requiring treatment in the opioid-addicted patient, are high in number and complexity.⁸ As we discussed previously, unfortunately, most management is aimed solely at reversing the overdose, stabilizing the patient medically, and discharge. We suggest that prior to discharge, the physician should determine whether the overdose was accidental, a suicide⁹ attempt, passive suicidality (for example, asking “Would you be better off dead?”),¹⁰ extreme risk-taking behavior (akin to playing Russian roulette,¹¹ or other causes. We have suggested that naloxone is similar to cardiopulmonary resuscitation: It is a critical life-saving intervention but not an end in itself. Rather, the need for naloxone should serve as a gateway to comprehensive evaluation, diagnosis, treatment, and long-term care.

 

 

Dr. Gold is the 17th Distinguished Alumni Professor at the University of Florida, Gainesville, and professor of psychiatry (adjunct) at Washington University in St. Louis. He also serves as chairman of the scientific advisory boards for RiverMend Health. Dr. Srivastava is a fourth-year resident in the department of psychiatry at Washington University.

References

1 NCHS Data Brief. No. 294. December 2017.

2 N Engl J Med. 2015;373:1789-90.

3 DEA Strategic Intelligence Section. 2017 National Drug Threat Assessment: Drug Enforcement Administration, U.S. Department of Justice, 2017.

4 Centers for Disease Control and Prevention, press release. Mar 29, 2018.

5 MMWR. 2018. Mar 30;67(12):349-58.

6 Am J Public Health. 2017 Mar;107(3):430-2.

7 “Q&A: Thomas Kosten, MD: Anti-drug vaccines.” RiverMend Health.

8 “Q&A: Stacy Seikel, MD. Opioid addiction.” RiverMend Health.

9 N Engl J Med. 2018 Apr 26;378:1567-9. doi: 10.1056/NEJMp1801417.

10 Innov Clin Neurosci. 2014 Sep;11(9-10):182-90.

11 Am J Psychiatry. 187 May;144(5):563-7.

 

The opioid epidemic continues to devastate the United States across demographic and socioeconomic groups; two-thirds of the 63,632 Americans who died of drug overdoses¹ in 2016 died of prescription or illicit opioids.

In 2015, Theodore J. Cicero, PhD, professor of psychiatry at Washington University, St. Louis, reported on a fundamental change in the nature of the ongoing opioid epidemic: What started as prescription opioid overprescribing, leading to diversion, abuse, and opioid addiction, was transitioning to illicit heroin distribution and consumption. Prescription opioids, namely, extended-release oxycodone (Oxycontin), were perceived initially as pure and safe, as they were specifically dosed and physician prescribed. In addition, filling a prescription for opioids was not associated with the shame or stigma of buying illicit drugs off the street. Because those drugs were seen as therapeutic and pharmacologically “legitimate,” many clinicians and the lay public alike were surprised to see the surge of opioid addiction and overdoses.

Dr. Cicero and others noted² that prescription opioids, whether taken originally for analgesic or recreational purposes, became a “gateway” to heroin, which already was making its way into the United States from Mexico,³ as heroin was cheap and becoming cheaper, easier to find, easy to use, and “pure.” Prescription opioids, on the other hand, were becoming more expensive, and physicians were facing increased regulations in prescribing them. Thus, as prescription opioid use became more and more stigmatized, heroin use was seen, paradoxically, as a more practical alternative. The amount of opioids prescribed in the United States has peaked; physicians are prescribing opioids less often; and the averaged dose has dropped as well, according to the Centers for Disease Control and Prevention.⁴ The first wave of deaths was attributable to prescription opioids, and the second was tied to illicitly obtained potent fentanyl analogs (manufactured in China and smuggled primarily through Mexico), which is added to heroin and sold in the United States.⁵

Many addiction experts and health policy leaders were not surprised by the increases in HIV, TB, and hepatitis B and C that followed the increasing use of intravenous opioids. However, few had experience with previous opioid epidemics in the United States, the most recent being the heroin epidemic occurring in the 1960s-1970s in the aftermath of the Vietnam War. At that time, the notion that heroin was contaminated with other psychoactive drugs, medications, fillers, and other adulterants was a foregone conclusion – though in public health and treatment discussions, this issue is hardly ever raised. We believe this to be a significant lapse in policy and planning. Surveillance by the Drug Enforcement Administration shows that acetyl fentanyl–laced heroin costs a little more on the street than regular heroin. Yet it sells, because users believe its extreme potency produces a better high, thus worth the extra cost. This phenomenon underscores an important point: Opioid addicts often are in search of a better high and will go to any lengths – even risking their lives – to get it.

The “cutting” or “adulteration” of street drugs is common practice in the manufacturing, distribution, and selling of illicit drugs, and the motive is to increase profit. The term “adulterant” generally refers to addition of substances with some psychoactive effects, such as caffeine, ephedra, or even paracetamol. These substances are cheaper than the main substance, have similar or complementary effects when added, and thus help conceal the fact that the desired substance has been cut or diluted. Substances without psychoactive properties such as lactose, other sugars, or talc, are added to a drug primarily to increase the bulk or weight of the illicit substance, or for aesthetic purposes to fool the user. Some adulterants simply are the result of the particular manufacturing process used to make the drug. For example, illicitly manufactured methamphetamine frequently is contaminated by nonstimulant impurities such as lead or mercury (extremely toxic heavy metals), or from carcinogenic solvents used in the synthesis. The local anesthetic lidocaine often is added to cocaine, and the reasons are intuitive: Both drugs are fast-acting local anesthetics.

More intriguing is the story of the antiparasitic medication levamisole. The DEA has estimated that 60%-89% of the seized street cocaine contains levamisole. Levamisole appears to be partly metabolized into an amphetamine-like compound, which could increase dopamine concentration in the reward pathway and thus activate endogenous opioids: It can mimic the effects of cocaine at a fraction of the cost. Levamisole is associated with several types of severe blood disorders, including leukopenia, agranulocytosis, multifocal inflammatory leukoencephalopathy, and neutropenia; a common presentation is vasculitis resulting in loss of limbs. Thus, a real danger in adulterants such as levamisole is their toxicity beyond those of the drug to which they are added, causing numerous medical consequences – including death.

 

The consideration of adulterants is important in another, emerging problem: Cocaine, colloquially thought of as a drug of the 1980s, is making a comeback. A record amount of cocaine is coming across the Mexican border with increased seizures of drug. Also, the number of acres producing cocaine is increasing, the price per unit sold is decreasing, and the prevalence of use has increased. Unfortunately but predictably, cocaine-related deaths are up: National Vital Statistic Systems data indicate that cocaine-related deaths involving opioids climbed from 2000-2006 and 2012-2015. Opioids, primarily heroin and fentanyl, have been driving the recently reported increases in cocaine-related overdose deaths.⁶ At the March 12, 2018, Drug Enforcement Administration panel on the reemergence of cocaine and cocaine-related deaths, experts reported that adulterants, including fentanyl, were responsible for many cocaine-related deaths. Strikingly, the most recent data from the state of Florida suggest that fentanyl is found as a factor in nearly all cocaine-related deaths, and cocaine commonly is found in fentanyl and fentanyl analog-related deaths.

If stigmata of opioid overdose (for example, miotic pupils and respiratory depression) are present in a patient considered to have overdosed on cocaine, naloxone should be administered, as the clinical presentation may be tied to the presence of opioid adulterants. Then, the patient should be engaged in treatment in a long-term care model with evidenced-based therapies, including medication-assisted treatment and contingency management. An important point, however, as described by Thomas Kosten, MD, professor of psychiatry at Baylor University, Houston, is that while we have multiple pharmacologic treatments for opioid overdose and addiction, none exist for cocaine overdose, craving, addiction, or withdrawal.⁷ Dr. Kosten has pioneered novel treatments for cocaine addiction, including anti-cocaine vaccines, but none has been proven safe and effective as of 2018.

Indeed, in the context of the opioid epidemic, the demand for opioid use treatment has increased, though the consequences of addiction, and thus areas requiring treatment in the opioid-addicted patient, are high in number and complexity.⁸ As we discussed previously, unfortunately, most management is aimed solely at reversing the overdose, stabilizing the patient medically, and discharge. We suggest that prior to discharge, the physician should determine whether the overdose was accidental, a suicide⁹ attempt, passive suicidality (for example, asking “Would you be better off dead?”),¹⁰ extreme risk-taking behavior (akin to playing Russian roulette,¹¹ or other causes. We have suggested that naloxone is similar to cardiopulmonary resuscitation: It is a critical life-saving intervention but not an end in itself. Rather, the need for naloxone should serve as a gateway to comprehensive evaluation, diagnosis, treatment, and long-term care.

 

 

Dr. Gold is the 17th Distinguished Alumni Professor at the University of Florida, Gainesville, and professor of psychiatry (adjunct) at Washington University in St. Louis. He also serves as chairman of the scientific advisory boards for RiverMend Health. Dr. Srivastava is a fourth-year resident in the department of psychiatry at Washington University.

References

1 NCHS Data Brief. No. 294. December 2017.

2 N Engl J Med. 2015;373:1789-90.

3 DEA Strategic Intelligence Section. 2017 National Drug Threat Assessment: Drug Enforcement Administration, U.S. Department of Justice, 2017.

4 Centers for Disease Control and Prevention, press release. Mar 29, 2018.

5 MMWR. 2018. Mar 30;67(12):349-58.

6 Am J Public Health. 2017 Mar;107(3):430-2.

7 “Q&A: Thomas Kosten, MD: Anti-drug vaccines.” RiverMend Health.

8 “Q&A: Stacy Seikel, MD. Opioid addiction.” RiverMend Health.

9 N Engl J Med. 2018 Apr 26;378:1567-9. doi: 10.1056/NEJMp1801417.

10 Innov Clin Neurosci. 2014 Sep;11(9-10):182-90.

11 Am J Psychiatry. 187 May;144(5):563-7.

 

The opioid epidemic continues to devastate the United States across demographic and socioeconomic groups; two-thirds of the 63,632 Americans who died of drug overdoses¹ in 2016 died of prescription or illicit opioids.

In 2015, Theodore J. Cicero, PhD, professor of psychiatry at Washington University, St. Louis, reported on a fundamental change in the nature of the ongoing opioid epidemic: What started as prescription opioid overprescribing, leading to diversion, abuse, and opioid addiction, was transitioning to illicit heroin distribution and consumption. Prescription opioids, namely, extended-release oxycodone (Oxycontin), were perceived initially as pure and safe, as they were specifically dosed and physician prescribed. In addition, filling a prescription for opioids was not associated with the shame or stigma of buying illicit drugs off the street. Because those drugs were seen as therapeutic and pharmacologically “legitimate,” many clinicians and the lay public alike were surprised to see the surge of opioid addiction and overdoses.

Dr. Cicero and others noted² that prescription opioids, whether taken originally for analgesic or recreational purposes, became a “gateway” to heroin, which already was making its way into the United States from Mexico,³ as heroin was cheap and becoming cheaper, easier to find, easy to use, and “pure.” Prescription opioids, on the other hand, were becoming more expensive, and physicians were facing increased regulations in prescribing them. Thus, as prescription opioid use became more and more stigmatized, heroin use was seen, paradoxically, as a more practical alternative. The amount of opioids prescribed in the United States has peaked; physicians are prescribing opioids less often; and the averaged dose has dropped as well, according to the Centers for Disease Control and Prevention.⁴ The first wave of deaths was attributable to prescription opioids, and the second was tied to illicitly obtained potent fentanyl analogs (manufactured in China and smuggled primarily through Mexico), which is added to heroin and sold in the United States.⁵

Many addiction experts and health policy leaders were not surprised by the increases in HIV, TB, and hepatitis B and C that followed the increasing use of intravenous opioids. However, few had experience with previous opioid epidemics in the United States, the most recent being the heroin epidemic occurring in the 1960s-1970s in the aftermath of the Vietnam War. At that time, the notion that heroin was contaminated with other psychoactive drugs, medications, fillers, and other adulterants was a foregone conclusion – though in public health and treatment discussions, this issue is hardly ever raised. We believe this to be a significant lapse in policy and planning. Surveillance by the Drug Enforcement Administration shows that acetyl fentanyl–laced heroin costs a little more on the street than regular heroin. Yet it sells, because users believe its extreme potency produces a better high, thus worth the extra cost. This phenomenon underscores an important point: Opioid addicts often are in search of a better high and will go to any lengths – even risking their lives – to get it.

The “cutting” or “adulteration” of street drugs is common practice in the manufacturing, distribution, and selling of illicit drugs, and the motive is to increase profit. The term “adulterant” generally refers to addition of substances with some psychoactive effects, such as caffeine, ephedra, or even paracetamol. These substances are cheaper than the main substance, have similar or complementary effects when added, and thus help conceal the fact that the desired substance has been cut or diluted. Substances without psychoactive properties such as lactose, other sugars, or talc, are added to a drug primarily to increase the bulk or weight of the illicit substance, or for aesthetic purposes to fool the user. Some adulterants simply are the result of the particular manufacturing process used to make the drug. For example, illicitly manufactured methamphetamine frequently is contaminated by nonstimulant impurities such as lead or mercury (extremely toxic heavy metals), or from carcinogenic solvents used in the synthesis. The local anesthetic lidocaine often is added to cocaine, and the reasons are intuitive: Both drugs are fast-acting local anesthetics.

More intriguing is the story of the antiparasitic medication levamisole. The DEA has estimated that 60%-89% of the seized street cocaine contains levamisole. Levamisole appears to be partly metabolized into an amphetamine-like compound, which could increase dopamine concentration in the reward pathway and thus activate endogenous opioids: It can mimic the effects of cocaine at a fraction of the cost. Levamisole is associated with several types of severe blood disorders, including leukopenia, agranulocytosis, multifocal inflammatory leukoencephalopathy, and neutropenia; a common presentation is vasculitis resulting in loss of limbs. Thus, a real danger in adulterants such as levamisole is their toxicity beyond those of the drug to which they are added, causing numerous medical consequences – including death.

 

The consideration of adulterants is important in another, emerging problem: Cocaine, colloquially thought of as a drug of the 1980s, is making a comeback. A record amount of cocaine is coming across the Mexican border with increased seizures of drug. Also, the number of acres producing cocaine is increasing, the price per unit sold is decreasing, and the prevalence of use has increased. Unfortunately but predictably, cocaine-related deaths are up: National Vital Statistic Systems data indicate that cocaine-related deaths involving opioids climbed from 2000-2006 and 2012-2015. Opioids, primarily heroin and fentanyl, have been driving the recently reported increases in cocaine-related overdose deaths.⁶ At the March 12, 2018, Drug Enforcement Administration panel on the reemergence of cocaine and cocaine-related deaths, experts reported that adulterants, including fentanyl, were responsible for many cocaine-related deaths. Strikingly, the most recent data from the state of Florida suggest that fentanyl is found as a factor in nearly all cocaine-related deaths, and cocaine commonly is found in fentanyl and fentanyl analog-related deaths.

If stigmata of opioid overdose (for example, miotic pupils and respiratory depression) are present in a patient considered to have overdosed on cocaine, naloxone should be administered, as the clinical presentation may be tied to the presence of opioid adulterants. Then, the patient should be engaged in treatment in a long-term care model with evidenced-based therapies, including medication-assisted treatment and contingency management. An important point, however, as described by Thomas Kosten, MD, professor of psychiatry at Baylor University, Houston, is that while we have multiple pharmacologic treatments for opioid overdose and addiction, none exist for cocaine overdose, craving, addiction, or withdrawal.⁷ Dr. Kosten has pioneered novel treatments for cocaine addiction, including anti-cocaine vaccines, but none has been proven safe and effective as of 2018.

Indeed, in the context of the opioid epidemic, the demand for opioid use treatment has increased, though the consequences of addiction, and thus areas requiring treatment in the opioid-addicted patient, are high in number and complexity.⁸ As we discussed previously, unfortunately, most management is aimed solely at reversing the overdose, stabilizing the patient medically, and discharge. We suggest that prior to discharge, the physician should determine whether the overdose was accidental, a suicide⁹ attempt, passive suicidality (for example, asking “Would you be better off dead?”),¹⁰ extreme risk-taking behavior (akin to playing Russian roulette,¹¹ or other causes. We have suggested that naloxone is similar to cardiopulmonary resuscitation: It is a critical life-saving intervention but not an end in itself. Rather, the need for naloxone should serve as a gateway to comprehensive evaluation, diagnosis, treatment, and long-term care.

 

 

Dr. Gold is the 17th Distinguished Alumni Professor at the University of Florida, Gainesville, and professor of psychiatry (adjunct) at Washington University in St. Louis. He also serves as chairman of the scientific advisory boards for RiverMend Health. Dr. Srivastava is a fourth-year resident in the department of psychiatry at Washington University.

References

1 NCHS Data Brief. No. 294. December 2017.

2 N Engl J Med. 2015;373:1789-90.

3 DEA Strategic Intelligence Section. 2017 National Drug Threat Assessment: Drug Enforcement Administration, U.S. Department of Justice, 2017.

4 Centers for Disease Control and Prevention, press release. Mar 29, 2018.

5 MMWR. 2018. Mar 30;67(12):349-58.

6 Am J Public Health. 2017 Mar;107(3):430-2.

7 “Q&A: Thomas Kosten, MD: Anti-drug vaccines.” RiverMend Health.

8 “Q&A: Stacy Seikel, MD. Opioid addiction.” RiverMend Health.

9 N Engl J Med. 2018 Apr 26;378:1567-9. doi: 10.1056/NEJMp1801417.

10 Innov Clin Neurosci. 2014 Sep;11(9-10):182-90.

11 Am J Psychiatry. 187 May;144(5):563-7.

 

The controversy over psychiatry’s “Goldwater Rule,” specifically as it applies to discussion of President Donald Trump, shows no signs¹ of abating any time soon. In an earlier commentary, we considered the problematic practice of citing a “duty to warn” about the president’s mental state to justify professional assessment from afar. We argued that the Tarasoff principle² presupposes a doctor-patient relationship in which the therapist must break confidentiality to avert imminent harm. Claiming a duty to protect against a politician’s public conduct and utterances is the proverbial square peg in a round hole.

While misapplication of the Tarasoff doctrine persists,³ some outspoken and eminent critics within the psychiatric community have since pursued another line of reasoning: that the Goldwater Rule covers only formal diagnoses and anything short of that is fair game. Here, we consider the argument that applying psychiatric labels to individuals for public consumption, absent examination and authorization, is ethically supportable so long as a definitive diagnosis is avoided. Ultimately, this justification fares no better than the misplaced duty to warn.
 

Explanation or expansion?

The language defining the Goldwater Rule has not changed since its inception in 1973. Section 7.3 of the American Psychiatric Association (APA) code of ethics provides, in relevant part, that when psychiatrists are asked for an opinion about public figures, they may share their “expertise about psychiatric issues in general. However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.”⁴

Nonetheless, several prominent psychiatrists charge⁵ that the APA has impermissibly broadened the Goldwater Rule since President Trump’s inauguration. These critics⁵ are referring not to any modification of Section 7.3 itself, but to an APA Ethics Committee opinion issued in March 2017 that clarified what constitutes a “professional opinion.”⁶ According to this guidance, a professional opinion includes but is not limited to a diagnosis: “... when a psychiatrist renders an opinion about the affect, behavior, speech, or other presentation of an individual that draws on the skills, training, expertise, and/or knowledge inherent in the practice of psychiatry, the opinion is a professional one.” In an accompanying statement,⁷ then-APA President Maria A. Oquendo, MD, PhD, confirmed that the Goldwater Rule “applies to all professional opinions offered by psychiatrists, not just diagnoses.”

Among psychiatrists and other mental health professionals questioning⁸ President Trump’s fitness for office, the reaction to the ethics interpretation was swift and emphatic. Leonard L. Glass, MD, MPH, resigned from the APA in protest after more than four decades of membership. He and Bandy X. Lee, MD, MDiv, editor of a book assessing the president’s purported instability, wrote in Politico: “By fiat of the APA, the Goldwater Rule has effectively turned into a gag rule.”⁹ Dr. Glass and Dr. Lee reiterated their critique in the Boston Globe,¹⁰ and hinted that the APA’s “federal funding” should be jeopardized as a result. Meanwhile, in a New England Journal of Medicine article, Claire L. Pouncey, MD, PhD, called the APA’s interpretation a silencing mechanism whereby “psychiatrists are the only members of the citizenry who may not express concern about the mental health of the president using psychiatric diagnostic terminology.”¹¹

In light of such heated rhetoric, it is worth taking a step back to consider what, if anything, has changed. A brief historical inquiry shows that the answer is not much. Allen R. Dyer, MD, PhD, a psychiatrist and ethicist who helped draft the Goldwater Rule – and whom one of us (LHK) counts as a professional mentor – recalls originally suggesting the term “professional opinion” instead of “psychiatric diagnosis” in order “to reflect the place of ethics in defining a profession.”¹² What Dr. Dyer meant is that standards of conduct, which are the hallmark of any profession, are not intended to be legal rules, but rather normative guidelines for ethical practice.

Thus, the notion that the recent APA opinion expanded the scope of the Goldwater Rule falls flat. The wording was deliberately broad from the outset, because it makes no sense to erect an ethical framework on semantics. As Dr. Dyer explained at a Washington Psychiatric Society forum last year, the APA tried to discourage psychiatrists from using their professional credentials and expertise as a bludgeon to castigate and dominate, rather than a tool to heal and teach. One of the early cases considered by the APA ethics committee involved a psychiatrist who got in an argument at a riding stable and identified his profession in order to gain the upper hand. The problem was not that he had a disagreement, but that he misused (and thereby compromised) his authority. Simply put, being a psychiatrist does not mean that you’re always in the right.

 

A distinction without a difference

Putting aside the historical record, what is the substantive dispute with the APA’s ethics interpretation? In essence, the dissenters contend that even if it remains unethical to offer armchair diagnoses, it should be perfectly acceptable to call someone unstable and dangerous, and to do so as a self-identified psychiatric expert. Dr. Glass and Dr. Lee profess to be “mystified by the lack of recognition” that they aren’t formally diagnosing President Trump.¹³ Instead, they view their actions as performing a public service by illuminating the president’s dangerous psyche.

Yet legalistic parsing cannot delineate ethical boundaries for a profession. Without even addressing the issue of predictive validity when it comes to dangerousness or violence risk, it is clear to many that labeling someone as “dangerous” can be just as, if not more, hurtful than offering an unsolicited diagnosis.¹⁴ Whereas opponents of the Goldwater Rule tend to frame it as organized psychiatry’s response to professional embarrassment,¹⁵ other ethical issues are at play, the foremost being¹⁶ respect for human beings. In other words, psychiatric speculation can cause “real harm to real people.”¹⁷

As Richard A. Friedman, MD, explained long before President Trump emerged as a serious contender on the political scene, the problem with the Goldwater fiasco was not just that psychiatrists offered diagnoses, but that they gave “very specific and damaging psychiatric opinions, using the language and art of their profession, about a man whom they had not examined and who surely would not have consented to such statements.”¹⁸ Indeed, Sen. Barry Goldwater later testified to the toll that psychiatrists’ published comments about his masculinity took on his personal interactions.¹⁹

It is instructive that the survey Fact magazine sent to psychiatrists in 1964 asked20 not for diagnoses, but whether Sen. Goldwater was “psychologically fit” to be president. This question – to which nearly 2,000 psychiatrists replied in the negative – is almost exactly what some members of the profession are asking and answering about President Trump today. There is room for nuanced²¹ debate about what types of pronouncements the Goldwater Rule should cover, but there is nothing nuanced about mounting the pedestal of medical authority to brand someone as unsafe, unfit, and unstable. Doing so is disparaging to the individual and stigmatizing of mental illness in general. Ethical standards cannot condone stopping just short of malfeasance and then claiming to have clean hands.

 

Education vs. stigmatization

The Goldwater Rule is designed as a caveat, not a prohibition. Section 7 of the APA code affirms that psychiatrists, like all physicians,²² have a responsibility to contribute to the common good. A principal way of doing this is through civic education about mental health and illness. 


The Goldwater Rule is embedded in Section 7 as one of several qualifications for psychiatrists to consider when making public forays. For example, psychiatrists should clarify whether they are speaking for themselves or an organization, avoid blanket statements on behalf of the entire profession, and differentiate between their roles as citizen and physician. Viewed in light of these other less-controversial proscriptions, it should become clear that the Goldwater Rule creates minimal barriers to public education.

Specifically, the Goldwater principle is concerned only with psychiatrists’ statements that are professional, public, and individualized. It has nothing to say about opinions that are political, private, or general.¹⁴ As an APA commentary explains, “a general discussion of relevant psychiatric topics – rather than offering opinions about that specific person – is the best means of facilitating public education.”²³ This is not a gag order but a prescription for maintaining professional integrity when exposed to the media limelight.

There are valid reasons to critique the Goldwater Rule, but they require an honest reckoning. Psychiatrists who feel compelled to assess public figures could argue that it is a matter of etiquette, not ethics, and should be left to personal discretion.²⁴

 

So far, the morphing rationales for contravening the Goldwater Rule fall short, because they elide the real issues at stake. Ethical behavior cannot hinge on artificial distinctions. Whereas invoking a duty to warn about presidential fitness was dubious, differentiating between a diagnosis and a professional opinion is specious.

Lt. Col. Kels practices health and disability law in the U.S. Air Force. Dr. Kels teaches and practices psychiatry at the University of the Incarnate Word School of Osteopathic Medicine in San Antonio. Opinions expressed in this article are those of the authors alone and do not necessarily reflect those of the Air Force or Department of Defense.

References

1. Psychiatric Times. Mar 19, 2018.

2. Tarasoff v. Regents of University of California, 551 P2d 334 (Cal 1976).

3.The Boston Globe. Jan 2, 2018.

4. APA Principles of Medical Ethics, 2013 ed. [7.3].

5. Psychiatric Times. Jul 20, 2017.

6. APA Opinions of the Ethics Committee. 2017 ed. [Q.7b].

7. American Psychiatric Association (APA). “APA remains committed to supporting Goldwater Rule,” Mar 17, 2017.

8. The New York Times. Feb 13, 2017.

9. Politico. Jan 10, 2018.

10. The Boston Globe. Feb 26, 2018.

11. N Engl J Med. 2018;378[5]:405-7.

12. Allen R. Dyer, MD, PhD. “Evolution of the so-called ‘Goldwater rule’: An ethical analysis,” revised Sep 23, 2017.

13. The Boston Globe. Jan 10, 2018.

14. Psychiatric Times. Feb 16, 2018.

15. J Am Acad Psychiatry Law. 2016;44[2]:226-35.

16. Psychiatric Times. Jul 20, 2017.

17. J Am Acad Psychiatry Law. 2016;45[2]:228-32.

18. The New York Times. May 24, 2011.

19. Am J Psychiatry. 2015 Aug 1;172[8]:729-30.

20. Fact. Sep-Oct 1964.

21. Psychiatric Times. Oct 7, 2016.

22. AMA Principles of Medical Ethics. 2016 ed. [VII].

23. APA Commentary on Ethics in Practice, 2015 ed. [3.4.7].

24. J Am Acad Psychiatry Law. 2016;44[2]:226-35.

 

The controversy over psychiatry’s “Goldwater Rule,” specifically as it applies to discussion of President Donald Trump, shows no signs¹ of abating any time soon. In an earlier commentary, we considered the problematic practice of citing a “duty to warn” about the president’s mental state to justify professional assessment from afar. We argued that the Tarasoff principle² presupposes a doctor-patient relationship in which the therapist must break confidentiality to avert imminent harm. Claiming a duty to protect against a politician’s public conduct and utterances is the proverbial square peg in a round hole.

While misapplication of the Tarasoff doctrine persists,³ some outspoken and eminent critics within the psychiatric community have since pursued another line of reasoning: that the Goldwater Rule covers only formal diagnoses and anything short of that is fair game. Here, we consider the argument that applying psychiatric labels to individuals for public consumption, absent examination and authorization, is ethically supportable so long as a definitive diagnosis is avoided. Ultimately, this justification fares no better than the misplaced duty to warn.
 

Explanation or expansion?

The language defining the Goldwater Rule has not changed since its inception in 1973. Section 7.3 of the American Psychiatric Association (APA) code of ethics provides, in relevant part, that when psychiatrists are asked for an opinion about public figures, they may share their “expertise about psychiatric issues in general. However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.”⁴

Nonetheless, several prominent psychiatrists charge⁵ that the APA has impermissibly broadened the Goldwater Rule since President Trump’s inauguration. These critics⁵ are referring not to any modification of Section 7.3 itself, but to an APA Ethics Committee opinion issued in March 2017 that clarified what constitutes a “professional opinion.”⁶ According to this guidance, a professional opinion includes but is not limited to a diagnosis: “... when a psychiatrist renders an opinion about the affect, behavior, speech, or other presentation of an individual that draws on the skills, training, expertise, and/or knowledge inherent in the practice of psychiatry, the opinion is a professional one.” In an accompanying statement,⁷ then-APA President Maria A. Oquendo, MD, PhD, confirmed that the Goldwater Rule “applies to all professional opinions offered by psychiatrists, not just diagnoses.”

Among psychiatrists and other mental health professionals questioning⁸ President Trump’s fitness for office, the reaction to the ethics interpretation was swift and emphatic. Leonard L. Glass, MD, MPH, resigned from the APA in protest after more than four decades of membership. He and Bandy X. Lee, MD, MDiv, editor of a book assessing the president’s purported instability, wrote in Politico: “By fiat of the APA, the Goldwater Rule has effectively turned into a gag rule.”⁹ Dr. Glass and Dr. Lee reiterated their critique in the Boston Globe,¹⁰ and hinted that the APA’s “federal funding” should be jeopardized as a result. Meanwhile, in a New England Journal of Medicine article, Claire L. Pouncey, MD, PhD, called the APA’s interpretation a silencing mechanism whereby “psychiatrists are the only members of the citizenry who may not express concern about the mental health of the president using psychiatric diagnostic terminology.”¹¹

In light of such heated rhetoric, it is worth taking a step back to consider what, if anything, has changed. A brief historical inquiry shows that the answer is not much. Allen R. Dyer, MD, PhD, a psychiatrist and ethicist who helped draft the Goldwater Rule – and whom one of us (LHK) counts as a professional mentor – recalls originally suggesting the term “professional opinion” instead of “psychiatric diagnosis” in order “to reflect the place of ethics in defining a profession.”¹² What Dr. Dyer meant is that standards of conduct, which are the hallmark of any profession, are not intended to be legal rules, but rather normative guidelines for ethical practice.

Thus, the notion that the recent APA opinion expanded the scope of the Goldwater Rule falls flat. The wording was deliberately broad from the outset, because it makes no sense to erect an ethical framework on semantics. As Dr. Dyer explained at a Washington Psychiatric Society forum last year, the APA tried to discourage psychiatrists from using their professional credentials and expertise as a bludgeon to castigate and dominate, rather than a tool to heal and teach. One of the early cases considered by the APA ethics committee involved a psychiatrist who got in an argument at a riding stable and identified his profession in order to gain the upper hand. The problem was not that he had a disagreement, but that he misused (and thereby compromised) his authority. Simply put, being a psychiatrist does not mean that you’re always in the right.

 

A distinction without a difference

Putting aside the historical record, what is the substantive dispute with the APA’s ethics interpretation? In essence, the dissenters contend that even if it remains unethical to offer armchair diagnoses, it should be perfectly acceptable to call someone unstable and dangerous, and to do so as a self-identified psychiatric expert. Dr. Glass and Dr. Lee profess to be “mystified by the lack of recognition” that they aren’t formally diagnosing President Trump.¹³ Instead, they view their actions as performing a public service by illuminating the president’s dangerous psyche.

Yet legalistic parsing cannot delineate ethical boundaries for a profession. Without even addressing the issue of predictive validity when it comes to dangerousness or violence risk, it is clear to many that labeling someone as “dangerous” can be just as, if not more, hurtful than offering an unsolicited diagnosis.¹⁴ Whereas opponents of the Goldwater Rule tend to frame it as organized psychiatry’s response to professional embarrassment,¹⁵ other ethical issues are at play, the foremost being¹⁶ respect for human beings. In other words, psychiatric speculation can cause “real harm to real people.”¹⁷

As Richard A. Friedman, MD, explained long before President Trump emerged as a serious contender on the political scene, the problem with the Goldwater fiasco was not just that psychiatrists offered diagnoses, but that they gave “very specific and damaging psychiatric opinions, using the language and art of their profession, about a man whom they had not examined and who surely would not have consented to such statements.”¹⁸ Indeed, Sen. Barry Goldwater later testified to the toll that psychiatrists’ published comments about his masculinity took on his personal interactions.¹⁹

It is instructive that the survey Fact magazine sent to psychiatrists in 1964 asked20 not for diagnoses, but whether Sen. Goldwater was “psychologically fit” to be president. This question – to which nearly 2,000 psychiatrists replied in the negative – is almost exactly what some members of the profession are asking and answering about President Trump today. There is room for nuanced²¹ debate about what types of pronouncements the Goldwater Rule should cover, but there is nothing nuanced about mounting the pedestal of medical authority to brand someone as unsafe, unfit, and unstable. Doing so is disparaging to the individual and stigmatizing of mental illness in general. Ethical standards cannot condone stopping just short of malfeasance and then claiming to have clean hands.

 

Education vs. stigmatization

The Goldwater Rule is designed as a caveat, not a prohibition. Section 7 of the APA code affirms that psychiatrists, like all physicians,²² have a responsibility to contribute to the common good. A principal way of doing this is through civic education about mental health and illness. 


The Goldwater Rule is embedded in Section 7 as one of several qualifications for psychiatrists to consider when making public forays. For example, psychiatrists should clarify whether they are speaking for themselves or an organization, avoid blanket statements on behalf of the entire profession, and differentiate between their roles as citizen and physician. Viewed in light of these other less-controversial proscriptions, it should become clear that the Goldwater Rule creates minimal barriers to public education.

Specifically, the Goldwater principle is concerned only with psychiatrists’ statements that are professional, public, and individualized. It has nothing to say about opinions that are political, private, or general.¹⁴ As an APA commentary explains, “a general discussion of relevant psychiatric topics – rather than offering opinions about that specific person – is the best means of facilitating public education.”²³ This is not a gag order but a prescription for maintaining professional integrity when exposed to the media limelight.

There are valid reasons to critique the Goldwater Rule, but they require an honest reckoning. Psychiatrists who feel compelled to assess public figures could argue that it is a matter of etiquette, not ethics, and should be left to personal discretion.²⁴

 

So far, the morphing rationales for contravening the Goldwater Rule fall short, because they elide the real issues at stake. Ethical behavior cannot hinge on artificial distinctions. Whereas invoking a duty to warn about presidential fitness was dubious, differentiating between a diagnosis and a professional opinion is specious.

Lt. Col. Kels practices health and disability law in the U.S. Air Force. Dr. Kels teaches and practices psychiatry at the University of the Incarnate Word School of Osteopathic Medicine in San Antonio. Opinions expressed in this article are those of the authors alone and do not necessarily reflect those of the Air Force or Department of Defense.

References

1. Psychiatric Times. Mar 19, 2018.

2. Tarasoff v. Regents of University of California, 551 P2d 334 (Cal 1976).

3.The Boston Globe. Jan 2, 2018.

4. APA Principles of Medical Ethics, 2013 ed. [7.3].

5. Psychiatric Times. Jul 20, 2017.

6. APA Opinions of the Ethics Committee. 2017 ed. [Q.7b].

7. American Psychiatric Association (APA). “APA remains committed to supporting Goldwater Rule,” Mar 17, 2017.

8. The New York Times. Feb 13, 2017.

9. Politico. Jan 10, 2018.

10. The Boston Globe. Feb 26, 2018.

11. N Engl J Med. 2018;378[5]:405-7.

12. Allen R. Dyer, MD, PhD. “Evolution of the so-called ‘Goldwater rule’: An ethical analysis,” revised Sep 23, 2017.

13. The Boston Globe. Jan 10, 2018.

14. Psychiatric Times. Feb 16, 2018.

15. J Am Acad Psychiatry Law. 2016;44[2]:226-35.

16. Psychiatric Times. Jul 20, 2017.

17. J Am Acad Psychiatry Law. 2016;45[2]:228-32.

18. The New York Times. May 24, 2011.

19. Am J Psychiatry. 2015 Aug 1;172[8]:729-30.

20. Fact. Sep-Oct 1964.

21. Psychiatric Times. Oct 7, 2016.

22. AMA Principles of Medical Ethics. 2016 ed. [VII].

23. APA Commentary on Ethics in Practice, 2015 ed. [3.4.7].

24. J Am Acad Psychiatry Law. 2016;44[2]:226-35.

 

The controversy over psychiatry’s “Goldwater Rule,” specifically as it applies to discussion of President Donald Trump, shows no signs¹ of abating any time soon. In an earlier commentary, we considered the problematic practice of citing a “duty to warn” about the president’s mental state to justify professional assessment from afar. We argued that the Tarasoff principle² presupposes a doctor-patient relationship in which the therapist must break confidentiality to avert imminent harm. Claiming a duty to protect against a politician’s public conduct and utterances is the proverbial square peg in a round hole.

While misapplication of the Tarasoff doctrine persists,³ some outspoken and eminent critics within the psychiatric community have since pursued another line of reasoning: that the Goldwater Rule covers only formal diagnoses and anything short of that is fair game. Here, we consider the argument that applying psychiatric labels to individuals for public consumption, absent examination and authorization, is ethically supportable so long as a definitive diagnosis is avoided. Ultimately, this justification fares no better than the misplaced duty to warn.
 

Explanation or expansion?

The language defining the Goldwater Rule has not changed since its inception in 1973. Section 7.3 of the American Psychiatric Association (APA) code of ethics provides, in relevant part, that when psychiatrists are asked for an opinion about public figures, they may share their “expertise about psychiatric issues in general. However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.”⁴

Nonetheless, several prominent psychiatrists charge⁵ that the APA has impermissibly broadened the Goldwater Rule since President Trump’s inauguration. These critics⁵ are referring not to any modification of Section 7.3 itself, but to an APA Ethics Committee opinion issued in March 2017 that clarified what constitutes a “professional opinion.”⁶ According to this guidance, a professional opinion includes but is not limited to a diagnosis: “... when a psychiatrist renders an opinion about the affect, behavior, speech, or other presentation of an individual that draws on the skills, training, expertise, and/or knowledge inherent in the practice of psychiatry, the opinion is a professional one.” In an accompanying statement,⁷ then-APA President Maria A. Oquendo, MD, PhD, confirmed that the Goldwater Rule “applies to all professional opinions offered by psychiatrists, not just diagnoses.”

Among psychiatrists and other mental health professionals questioning⁸ President Trump’s fitness for office, the reaction to the ethics interpretation was swift and emphatic. Leonard L. Glass, MD, MPH, resigned from the APA in protest after more than four decades of membership. He and Bandy X. Lee, MD, MDiv, editor of a book assessing the president’s purported instability, wrote in Politico: “By fiat of the APA, the Goldwater Rule has effectively turned into a gag rule.”⁹ Dr. Glass and Dr. Lee reiterated their critique in the Boston Globe,¹⁰ and hinted that the APA’s “federal funding” should be jeopardized as a result. Meanwhile, in a New England Journal of Medicine article, Claire L. Pouncey, MD, PhD, called the APA’s interpretation a silencing mechanism whereby “psychiatrists are the only members of the citizenry who may not express concern about the mental health of the president using psychiatric diagnostic terminology.”¹¹

In light of such heated rhetoric, it is worth taking a step back to consider what, if anything, has changed. A brief historical inquiry shows that the answer is not much. Allen R. Dyer, MD, PhD, a psychiatrist and ethicist who helped draft the Goldwater Rule – and whom one of us (LHK) counts as a professional mentor – recalls originally suggesting the term “professional opinion” instead of “psychiatric diagnosis” in order “to reflect the place of ethics in defining a profession.”¹² What Dr. Dyer meant is that standards of conduct, which are the hallmark of any profession, are not intended to be legal rules, but rather normative guidelines for ethical practice.

Thus, the notion that the recent APA opinion expanded the scope of the Goldwater Rule falls flat. The wording was deliberately broad from the outset, because it makes no sense to erect an ethical framework on semantics. As Dr. Dyer explained at a Washington Psychiatric Society forum last year, the APA tried to discourage psychiatrists from using their professional credentials and expertise as a bludgeon to castigate and dominate, rather than a tool to heal and teach. One of the early cases considered by the APA ethics committee involved a psychiatrist who got in an argument at a riding stable and identified his profession in order to gain the upper hand. The problem was not that he had a disagreement, but that he misused (and thereby compromised) his authority. Simply put, being a psychiatrist does not mean that you’re always in the right.

 

A distinction without a difference

Putting aside the historical record, what is the substantive dispute with the APA’s ethics interpretation? In essence, the dissenters contend that even if it remains unethical to offer armchair diagnoses, it should be perfectly acceptable to call someone unstable and dangerous, and to do so as a self-identified psychiatric expert. Dr. Glass and Dr. Lee profess to be “mystified by the lack of recognition” that they aren’t formally diagnosing President Trump.¹³ Instead, they view their actions as performing a public service by illuminating the president’s dangerous psyche.

Yet legalistic parsing cannot delineate ethical boundaries for a profession. Without even addressing the issue of predictive validity when it comes to dangerousness or violence risk, it is clear to many that labeling someone as “dangerous” can be just as, if not more, hurtful than offering an unsolicited diagnosis.¹⁴ Whereas opponents of the Goldwater Rule tend to frame it as organized psychiatry’s response to professional embarrassment,¹⁵ other ethical issues are at play, the foremost being¹⁶ respect for human beings. In other words, psychiatric speculation can cause “real harm to real people.”¹⁷

As Richard A. Friedman, MD, explained long before President Trump emerged as a serious contender on the political scene, the problem with the Goldwater fiasco was not just that psychiatrists offered diagnoses, but that they gave “very specific and damaging psychiatric opinions, using the language and art of their profession, about a man whom they had not examined and who surely would not have consented to such statements.”¹⁸ Indeed, Sen. Barry Goldwater later testified to the toll that psychiatrists’ published comments about his masculinity took on his personal interactions.¹⁹

It is instructive that the survey Fact magazine sent to psychiatrists in 1964 asked20 not for diagnoses, but whether Sen. Goldwater was “psychologically fit” to be president. This question – to which nearly 2,000 psychiatrists replied in the negative – is almost exactly what some members of the profession are asking and answering about President Trump today. There is room for nuanced²¹ debate about what types of pronouncements the Goldwater Rule should cover, but there is nothing nuanced about mounting the pedestal of medical authority to brand someone as unsafe, unfit, and unstable. Doing so is disparaging to the individual and stigmatizing of mental illness in general. Ethical standards cannot condone stopping just short of malfeasance and then claiming to have clean hands.

 

Education vs. stigmatization

The Goldwater Rule is designed as a caveat, not a prohibition. Section 7 of the APA code affirms that psychiatrists, like all physicians,²² have a responsibility to contribute to the common good. A principal way of doing this is through civic education about mental health and illness. 


The Goldwater Rule is embedded in Section 7 as one of several qualifications for psychiatrists to consider when making public forays. For example, psychiatrists should clarify whether they are speaking for themselves or an organization, avoid blanket statements on behalf of the entire profession, and differentiate between their roles as citizen and physician. Viewed in light of these other less-controversial proscriptions, it should become clear that the Goldwater Rule creates minimal barriers to public education.

Specifically, the Goldwater principle is concerned only with psychiatrists’ statements that are professional, public, and individualized. It has nothing to say about opinions that are political, private, or general.¹⁴ As an APA commentary explains, “a general discussion of relevant psychiatric topics – rather than offering opinions about that specific person – is the best means of facilitating public education.”²³ This is not a gag order but a prescription for maintaining professional integrity when exposed to the media limelight.

There are valid reasons to critique the Goldwater Rule, but they require an honest reckoning. Psychiatrists who feel compelled to assess public figures could argue that it is a matter of etiquette, not ethics, and should be left to personal discretion.²⁴

 

So far, the morphing rationales for contravening the Goldwater Rule fall short, because they elide the real issues at stake. Ethical behavior cannot hinge on artificial distinctions. Whereas invoking a duty to warn about presidential fitness was dubious, differentiating between a diagnosis and a professional opinion is specious.

Lt. Col. Kels practices health and disability law in the U.S. Air Force. Dr. Kels teaches and practices psychiatry at the University of the Incarnate Word School of Osteopathic Medicine in San Antonio. Opinions expressed in this article are those of the authors alone and do not necessarily reflect those of the Air Force or Department of Defense.

References

1. Psychiatric Times. Mar 19, 2018.

2. Tarasoff v. Regents of University of California, 551 P2d 334 (Cal 1976).

3.The Boston Globe. Jan 2, 2018.

4. APA Principles of Medical Ethics, 2013 ed. [7.3].

5. Psychiatric Times. Jul 20, 2017.

6. APA Opinions of the Ethics Committee. 2017 ed. [Q.7b].

7. American Psychiatric Association (APA). “APA remains committed to supporting Goldwater Rule,” Mar 17, 2017.

8. The New York Times. Feb 13, 2017.

9. Politico. Jan 10, 2018.

10. The Boston Globe. Feb 26, 2018.

11. N Engl J Med. 2018;378[5]:405-7.

12. Allen R. Dyer, MD, PhD. “Evolution of the so-called ‘Goldwater rule’: An ethical analysis,” revised Sep 23, 2017.

13. The Boston Globe. Jan 10, 2018.

14. Psychiatric Times. Feb 16, 2018.

15. J Am Acad Psychiatry Law. 2016;44[2]:226-35.

16. Psychiatric Times. Jul 20, 2017.

17. J Am Acad Psychiatry Law. 2016;45[2]:228-32.

18. The New York Times. May 24, 2011.

19. Am J Psychiatry. 2015 Aug 1;172[8]:729-30.

20. Fact. Sep-Oct 1964.

21. Psychiatric Times. Oct 7, 2016.

22. AMA Principles of Medical Ethics. 2016 ed. [VII].

23. APA Commentary on Ethics in Practice, 2015 ed. [3.4.7].

24. J Am Acad Psychiatry Law. 2016;44[2]:226-35.

 

Significant depressive symptoms affect approximately one in four adults with type 1 and type 2 diabetes while a formal diagnosis of depressive disorders is made in approximately 10%-15% of individuals with diabetes.¹ The combination of diabetes and depression presents a major clinical challenge because the outcomes of each condition is worsened by the presence of the other, which results in worsened quality of life, impaired diabetes self-management, and poor clinical outcomes.¹ While the costs of treatment are high for both individual patients and health economies, these costs do not necessarily result in significant improvements in disease or quality of life outcomes.¹ This raises the question, “What is the best approach to managing patients with comorbid depression and diabetes?”

Effective strategies for improving outcomes in patients with diabetes target several areas – health systems (case management, team changes, electronic patient registry, facilitated relay of information to clinicians, continuous quality improvement), health care providers (audit and feedback, clinician education, clinician reminders, financial incentives), and patients (patient education, promotion of self-management, reminder systems).²

Strategies associated with at least a 0.5% reduction in hemoglobin A_1c include team changes (–0.67%) and case management (–0.52%).² The most effective team changes were those that included multidisciplinary, interactive teams with shared care between specialists and primary care providers.² Such a collaborative care model that integrates specialty psychiatric care into primary care has been successfully demonstrated for patients with depression and poorly controlled type 2 diabetes or coronary heart disease.³

In this study, patients at 14 primary care clinics in an integrated health care system in Washington State received either a multidisciplinary, team-based intervention or usual care.³ Components of the intervention in these clinics included the following:

• Three part-time registered nurses who had diabetes education training (certified diabetes educators), as well as training on depression management, behavioral strategies, and glycemic, hypertension, and lipid control.
• Combined support for self-care with pharmacotherapy to control depression, hyperglycemia, hypertension, and hyperlipidemia with algorithm guidance.
• Motivational and encouraging coaching for problem-solving and adherence to self-care.
• Weekly nurse supervision with a psychiatrist, primary care physician, and psychologist, with a nurse communicating recommendations back to the primary care team.

 

An endocrinologist/diabetologist was also incorporated for consultation when needed. After 12 months, patients in the intervention group had greater reduction in hemoglobin A_1c (0.58%), LDL cholesterol (6.9 mg/dL), systolic blood pressure (5.1 mm Hg), and depression scores than did those in the usual care group. Patients in the intervention group were also more likely to have adjustments made to insulin, antihypertensive medications, and antidepressants.

The success of this intervention, known as TEAMCare, highlights the critical need to incorporate mental health care into primary care and endocrinology practice. Currently, psychiatric and psychological care are largely administered separately from medical care for diabetes, despite evidence showing the success of an integrated care delivery model. In order to address the important interaction between mental health disorders, such as depression, and diabetes, it is critical that evaluation and treatment of mental health be integrated into medical practice.

What can we – endocrinologists and psychiatrists – do to facilitate adoption of such models? First, we can lobby our health systems to support reorganization of our health care delivery approach for patients with comorbid depression and diabetes so that endocrinologists, psychiatrists, and behavioral specialists are incorporated into primary care practices. This will facilitate better alignment of specialists and primary care providers and also enable patients to receive care in a clinical environment where they are most comfortable and have established relationships. Instead of the primary care physician referring the patient separately to psychiatry and endocrinology and awaiting feedback, which can sometimes take several weeks, the psychiatrist and endocrinologist would meet weekly with the primary care physician and nurse case manager team to review the entire patient panel, make timely adjustments in diabetes and antidepressant medications, and recommend behavioral therapy. This population health strategy would enable our two specialties to make a greater impact on a larger number of patients than we can in a half-day clinic session.

Second, our other critical role is to collaborate with payers to develop a sustainable financial reimbursement model to support the psychiatrist and endocrinologist in this novel health care delivery approach, which departs from the traditional fee-for-service model.

 

Finally, diabetes remains highly prevalent in the United States and worldwide, and depression is now a widely recognized comorbidity of diabetes. Many behavioral specialists are not trained to address the complexities of diabetes management experienced by patients who also have mental health comorbidities. To this end, the American Diabetes Association and the American Psychological Association established a partnership to build the ADA-APA Mental Health Provider Diabetes Education Program to prepare mental health providers with the knowledge and tools and treat diabetes-related psychosocial factors. Let us join them in supporting this important step toward developing diabetes-mental health collaborative health care delivery models.
 

Dr. Golden is the Hugh P. McCormick Family Professor of Endocrinology and Metabolism and executive vice-chair of the department of medicine at Johns Hopkins University, Baltimore.

References

1. Holt RIG et al. Current Diabetes Reports. 2014;14(6):491.

2. Shojania KG et al. JAMA. 2006;296(4):427-40.

3. Katon WJ et al. N Eng J Med. 2010;363(27):2611-20.

 

Significant depressive symptoms affect approximately one in four adults with type 1 and type 2 diabetes while a formal diagnosis of depressive disorders is made in approximately 10%-15% of individuals with diabetes.¹ The combination of diabetes and depression presents a major clinical challenge because the outcomes of each condition is worsened by the presence of the other, which results in worsened quality of life, impaired diabetes self-management, and poor clinical outcomes.¹ While the costs of treatment are high for both individual patients and health economies, these costs do not necessarily result in significant improvements in disease or quality of life outcomes.¹ This raises the question, “What is the best approach to managing patients with comorbid depression and diabetes?”

Effective strategies for improving outcomes in patients with diabetes target several areas – health systems (case management, team changes, electronic patient registry, facilitated relay of information to clinicians, continuous quality improvement), health care providers (audit and feedback, clinician education, clinician reminders, financial incentives), and patients (patient education, promotion of self-management, reminder systems).²

Strategies associated with at least a 0.5% reduction in hemoglobin A_1c include team changes (–0.67%) and case management (–0.52%).² The most effective team changes were those that included multidisciplinary, interactive teams with shared care between specialists and primary care providers.² Such a collaborative care model that integrates specialty psychiatric care into primary care has been successfully demonstrated for patients with depression and poorly controlled type 2 diabetes or coronary heart disease.³

In this study, patients at 14 primary care clinics in an integrated health care system in Washington State received either a multidisciplinary, team-based intervention or usual care.³ Components of the intervention in these clinics included the following:

• Three part-time registered nurses who had diabetes education training (certified diabetes educators), as well as training on depression management, behavioral strategies, and glycemic, hypertension, and lipid control.
• Combined support for self-care with pharmacotherapy to control depression, hyperglycemia, hypertension, and hyperlipidemia with algorithm guidance.
• Motivational and encouraging coaching for problem-solving and adherence to self-care.
• Weekly nurse supervision with a psychiatrist, primary care physician, and psychologist, with a nurse communicating recommendations back to the primary care team.

 

An endocrinologist/diabetologist was also incorporated for consultation when needed. After 12 months, patients in the intervention group had greater reduction in hemoglobin A_1c (0.58%), LDL cholesterol (6.9 mg/dL), systolic blood pressure (5.1 mm Hg), and depression scores than did those in the usual care group. Patients in the intervention group were also more likely to have adjustments made to insulin, antihypertensive medications, and antidepressants.

The success of this intervention, known as TEAMCare, highlights the critical need to incorporate mental health care into primary care and endocrinology practice. Currently, psychiatric and psychological care are largely administered separately from medical care for diabetes, despite evidence showing the success of an integrated care delivery model. In order to address the important interaction between mental health disorders, such as depression, and diabetes, it is critical that evaluation and treatment of mental health be integrated into medical practice.

What can we – endocrinologists and psychiatrists – do to facilitate adoption of such models? First, we can lobby our health systems to support reorganization of our health care delivery approach for patients with comorbid depression and diabetes so that endocrinologists, psychiatrists, and behavioral specialists are incorporated into primary care practices. This will facilitate better alignment of specialists and primary care providers and also enable patients to receive care in a clinical environment where they are most comfortable and have established relationships. Instead of the primary care physician referring the patient separately to psychiatry and endocrinology and awaiting feedback, which can sometimes take several weeks, the psychiatrist and endocrinologist would meet weekly with the primary care physician and nurse case manager team to review the entire patient panel, make timely adjustments in diabetes and antidepressant medications, and recommend behavioral therapy. This population health strategy would enable our two specialties to make a greater impact on a larger number of patients than we can in a half-day clinic session.

Second, our other critical role is to collaborate with payers to develop a sustainable financial reimbursement model to support the psychiatrist and endocrinologist in this novel health care delivery approach, which departs from the traditional fee-for-service model.

 

Finally, diabetes remains highly prevalent in the United States and worldwide, and depression is now a widely recognized comorbidity of diabetes. Many behavioral specialists are not trained to address the complexities of diabetes management experienced by patients who also have mental health comorbidities. To this end, the American Diabetes Association and the American Psychological Association established a partnership to build the ADA-APA Mental Health Provider Diabetes Education Program to prepare mental health providers with the knowledge and tools and treat diabetes-related psychosocial factors. Let us join them in supporting this important step toward developing diabetes-mental health collaborative health care delivery models.
 

Dr. Golden is the Hugh P. McCormick Family Professor of Endocrinology and Metabolism and executive vice-chair of the department of medicine at Johns Hopkins University, Baltimore.

References

1. Holt RIG et al. Current Diabetes Reports. 2014;14(6):491.

2. Shojania KG et al. JAMA. 2006;296(4):427-40.

3. Katon WJ et al. N Eng J Med. 2010;363(27):2611-20.

 

Significant depressive symptoms affect approximately one in four adults with type 1 and type 2 diabetes while a formal diagnosis of depressive disorders is made in approximately 10%-15% of individuals with diabetes.¹ The combination of diabetes and depression presents a major clinical challenge because the outcomes of each condition is worsened by the presence of the other, which results in worsened quality of life, impaired diabetes self-management, and poor clinical outcomes.¹ While the costs of treatment are high for both individual patients and health economies, these costs do not necessarily result in significant improvements in disease or quality of life outcomes.¹ This raises the question, “What is the best approach to managing patients with comorbid depression and diabetes?”

Effective strategies for improving outcomes in patients with diabetes target several areas – health systems (case management, team changes, electronic patient registry, facilitated relay of information to clinicians, continuous quality improvement), health care providers (audit and feedback, clinician education, clinician reminders, financial incentives), and patients (patient education, promotion of self-management, reminder systems).²

Strategies associated with at least a 0.5% reduction in hemoglobin A_1c include team changes (–0.67%) and case management (–0.52%).² The most effective team changes were those that included multidisciplinary, interactive teams with shared care between specialists and primary care providers.² Such a collaborative care model that integrates specialty psychiatric care into primary care has been successfully demonstrated for patients with depression and poorly controlled type 2 diabetes or coronary heart disease.³

In this study, patients at 14 primary care clinics in an integrated health care system in Washington State received either a multidisciplinary, team-based intervention or usual care.³ Components of the intervention in these clinics included the following:

• Three part-time registered nurses who had diabetes education training (certified diabetes educators), as well as training on depression management, behavioral strategies, and glycemic, hypertension, and lipid control.
• Combined support for self-care with pharmacotherapy to control depression, hyperglycemia, hypertension, and hyperlipidemia with algorithm guidance.
• Motivational and encouraging coaching for problem-solving and adherence to self-care.
• Weekly nurse supervision with a psychiatrist, primary care physician, and psychologist, with a nurse communicating recommendations back to the primary care team.

 

An endocrinologist/diabetologist was also incorporated for consultation when needed. After 12 months, patients in the intervention group had greater reduction in hemoglobin A_1c (0.58%), LDL cholesterol (6.9 mg/dL), systolic blood pressure (5.1 mm Hg), and depression scores than did those in the usual care group. Patients in the intervention group were also more likely to have adjustments made to insulin, antihypertensive medications, and antidepressants.

The success of this intervention, known as TEAMCare, highlights the critical need to incorporate mental health care into primary care and endocrinology practice. Currently, psychiatric and psychological care are largely administered separately from medical care for diabetes, despite evidence showing the success of an integrated care delivery model. In order to address the important interaction between mental health disorders, such as depression, and diabetes, it is critical that evaluation and treatment of mental health be integrated into medical practice.

What can we – endocrinologists and psychiatrists – do to facilitate adoption of such models? First, we can lobby our health systems to support reorganization of our health care delivery approach for patients with comorbid depression and diabetes so that endocrinologists, psychiatrists, and behavioral specialists are incorporated into primary care practices. This will facilitate better alignment of specialists and primary care providers and also enable patients to receive care in a clinical environment where they are most comfortable and have established relationships. Instead of the primary care physician referring the patient separately to psychiatry and endocrinology and awaiting feedback, which can sometimes take several weeks, the psychiatrist and endocrinologist would meet weekly with the primary care physician and nurse case manager team to review the entire patient panel, make timely adjustments in diabetes and antidepressant medications, and recommend behavioral therapy. This population health strategy would enable our two specialties to make a greater impact on a larger number of patients than we can in a half-day clinic session.

Second, our other critical role is to collaborate with payers to develop a sustainable financial reimbursement model to support the psychiatrist and endocrinologist in this novel health care delivery approach, which departs from the traditional fee-for-service model.

 

Finally, diabetes remains highly prevalent in the United States and worldwide, and depression is now a widely recognized comorbidity of diabetes. Many behavioral specialists are not trained to address the complexities of diabetes management experienced by patients who also have mental health comorbidities. To this end, the American Diabetes Association and the American Psychological Association established a partnership to build the ADA-APA Mental Health Provider Diabetes Education Program to prepare mental health providers with the knowledge and tools and treat diabetes-related psychosocial factors. Let us join them in supporting this important step toward developing diabetes-mental health collaborative health care delivery models.
 

Dr. Golden is the Hugh P. McCormick Family Professor of Endocrinology and Metabolism and executive vice-chair of the department of medicine at Johns Hopkins University, Baltimore.

References

1. Holt RIG et al. Current Diabetes Reports. 2014;14(6):491.

2. Shojania KG et al. JAMA. 2006;296(4):427-40.

3. Katon WJ et al. N Eng J Med. 2010;363(27):2611-20.

 

Dermatologists are well suited to understand cosmeceutical science and the benefits of particular cosmeceutical products – especially if they are readers of this column. However, there is another critical thought process that must be undertaken when designing an efficacious skin care regimen for patients: Topical products should be applied in a particular order to maximize efficacy. This is because cosmeceutical ingredients interact with, change each other, and are affected by temperature, pH, humidity, and the microbiome in which they are in contact. This column focuses on the factors that should be considered when recommending skin care regimens to patients and in which order to apply topical products.

The chemistry of ingredients and how they interact is well understood by personal care product formulators. I think of formulators as chefs who are using ingredients and placing them in the formulation in a well-defined order under controlled circumstances that affect the final product. For example, ceramides are used in barrier repair moisturizers. The right form of ceramide must be chosen and used with the 1:1:1 ratio of ceramides, fatty acids, and cholesterol for the product to be effective at repairing the barrier.¹ However, the order of when the ceramides are added to the product formula also impacts efficacy. Waxy ceramides and cholesterol require heat to liquefy and form the proper mixture with the other ingredients. Too much heat can damage fatty acids. Also, heat can inactivate finicky active ingredients such as vitamins C and E. For this reason, the ceramides and cholesterol are often incorporated first, allowing the formula to cool before the active heat labile ingredients are added. The speed at which something is mixed can generate heat and affect the final preparations, so temperature is an important consideration at all steps in the formulation procedure.

PainterSaba/iStock/Getty Images

Just as the order of creating formulations affects the final product, the order of product placement on the skin influences skin care product efficacy. If a low pH skin care product (such as a glycolic acid cleanser) is used on the skin, this is going to affect the efficacy and safety of the product that is applied next to the skin. Such a chemical phenomenon should be considered when designing the order of product applications when designing a skin care regimen, particularly when incorporating ingredients that are known to interact with other ingredients, such as benzoyl peroxide, retinoids, hydroxy acids, hydroquinone, vitamin C, and peptides.

 

 

Efficacy and compliance in product layering

Improper choice and layering of skin care formulations reduces efficacy and increases the risk of side effects resulting in reduced patient compliance. Acne treatments are a good example. Patients are often prescribed a retinoid, benzoyl peroxide, topical antibiotic, and/or salicylic acid treatment product for acne. If the proper cleansers and moisturizers are not chosen, the patient will be more likely to develop redness and scaling and become noncompliant.

Compliance is a concerning issue to dermatologists because studies have shown that 95% of people underdose and one out of every three prescriptions is not even filled.² If patients develop side effects, they are more likely to underdose or stop the treatment. Prescribing the proper cleanser and moisturizer to accompany treatment products will ease side effects and increase compliance. Several studies have demonstrated that the best way to increase compliance is to provide patients with written instructions, so they understand the proper order in which to apply products.
 

The role of cleansers

Cleansers can alter the pH of the skin, loosen attachments between cells, remove lipids – and disrupt the bilayer protective membrane, desquamate layers from the stratum corneum, and influence the penetrability of the skin for the next topical product that is applied. Therefore, cleansers should be selected based on the products that will follow them in the regimen. In addition, cleansers should be chosen according to the patient’s Baumann Skin Type.³ For example, cleansers for use on oily skin should have the ability to remove excess sebum on the skin while cleansers designed for dry skin would not remove as many lipids from the skin. Washing skin with a foaming cleanser can disrupt the skin barrier, allowing increased penetration of the treatment product that follows it. Oleic acid, hyaluronic acid, stearic acid, and other lipids are among the ingredients that influence skin penetration. Cleansers should precede treatment products and should be designed to increase efficacy of the treatment product. For this reason, every ingredient and characteristic of the chosen cleanser is important.

 

The role of eye products

Eye products treat issues such as dryness, puffiness, fine lines, and dark circles. However, they also play an overlooked role of protecting the thin delicate eye area from the treatment product. Using an eye product, especially one with protective ingredients such as barrier repair lipids, will help the patient tolerate the potentially irritating treatment product that follows the eye product. At night, the treatment product ingredients can get on the pillowcase and transfer to the upper and lower eyelids. Use of a protective eye product before bedtime can prevent the accompanying irritation. For example, acne patients often develop redness at the corners of the eyes when using benzoyl peroxide or a retinoid at night. Applying these medications after an eye cream can reduce this side effect.

Improving efficacy of treatment products

Treatments products are defined as corrective products targeted to skin issues such as acne, rosacea, melasma, dryness, skin cancer, eczema, psoriasis, and photoaging. The entire skin care regimen should be designed to enhance efficacy and decrease side effects of the treatment products. Treatment products may be cosmeceuticals, OTC medications, or prescription medications. These products must be able to reach their target in the proper chemical structure to be effective. Each ingredient has various constraints and quirks that should be considered. One well known example is ascorbic acid (vitamin C). Ascorbic acid is a treatment product for skin pigmentation and skin aging that is well known to have specific needs to work properly. Sheldon Pinnell, MD, led multiple investigations demonstrating that the maximum absorption of ascorbic acid occurs at a pH of 2-2.5. He showed that ascorbic acid products should be formulated at a pH of 2-2.5.⁴ However, applying these on skin that has just been cleansed with a soap cleanser with a pH of 9 will raise the skin’s pH and decrease the absorption of ascorbic acid. Having the patient cleanse with a low pH cleanser such as salicylic or glycolic acid cleanser (usually a pH of 2.5-3.5) will lower the pH of the skin and promote absorption of vitamin C.

The role of moisturizers

Moisturizers have many duties, including hydrating the skin, protecting the skin, and delivering important ingredients to the skin. However, moisturizers have a less discussed role of improving the efficacy of the treatment product that is applied beforehand. Moisturizers often contain oleic acid, hyaluronic acid, or other fatty acids that can increase penetration of other skin care ingredients. In addition, many moisturizers provide an occlusive effect that helps increase penetration. They also help protect the underlying treatment product from getting wiped off on a pillowcase or into the environment. In other words, moisturizers “seal in” the treatment product. Some moisturizing ingredients such as heparan sulfate may affect how well the skin cells “hear” and respond to signals elicited by the treatment products. For this reason, moisturizers should also be chosen to improve the efficacy of the treatment product.

Retinoids

When using retinoids for the first time in a patient, applying them last on top of the moisturizer can reduce the incidence of side effects and increase compliance. Retinoids, unlike other ingredients, penetrate easily into the deeper layer of the epidermis. Layering them on top of a moisturizer can help titrate retinoid absorption. The moisturizer can be chosen to slow or increase penetration of retinoids. Retinoids should always be used at nighttime because many of them, especially retinol and tretinoin, are easily broken down by ultraviolet light exposure.

 

Selecting across brands and applying products in the right order

Manufacturers rarely perform research on a complete regimen, but rather on individual products. Dermatologists then are left to figure this out on their own. I recommend choosing the best technologies from each brand based on the patient’s Baumann Skin Type and combining them using the recommended layering technique. I choose the best “hero” products from the various brands and layer them in a sequence that increases efficacy of all of the products. I then test the entire regimen on patients to figure out what combinations have the best efficacy and fewest side effects. Once I solve this “regimen puzzle,” I program software to automatically generate the step-by-step regimen instructions by Baumann Skin Type so that I do not have to rethink this complicated subject matter with every patient. I have developed over 3,300 distinct regimens so I am certain that my patients will get the proper skin care regimen advice from me or any of my staff.

Conclusion

Dermatologists can make a significant difference in their patients’ long-term skin care health by assisting them in identifying the proper skin care formulations for their individual skin type and guiding them as to how much, and in which order, to apply the products in their personalized skin care regimen. Patients will not remember what you told them and will confuse the order in which products should be used. For this reason, providing a written step-by-step skin care regimen is paramount to ensuring patient compliance.

 

Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002) and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014); she also authored a New York Times Best Seller for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance Therapeutics. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC. Write to her at [email protected].

References

1. Man MQ M et al. Optimization of physiological lipid mixtures for barrier repair. J Invest Dermatol. 1996 May;106(5):1096-101.

2. Storm A et al. One in 3 prescriptions are never redeemed: Primary nonadherence in an outpatient clinic. J Am Acad Dermatol. 2008 Jul;59(1):27-33.

3. Baumann LS. The Baumann Skin Typing System, in Farage MA et al. “Textbook of Aging Skin.” Springer-Verlag Berlin Heidelberg, 2017, pp. 1579-94.

4. Pinnell SR et al. Topical L-ascorbic acid: Percutaneous absorption studies. Dermatol Surg. 2001 Feb; 27(2):137-42.

 

Dermatologists are well suited to understand cosmeceutical science and the benefits of particular cosmeceutical products – especially if they are readers of this column. However, there is another critical thought process that must be undertaken when designing an efficacious skin care regimen for patients: Topical products should be applied in a particular order to maximize efficacy. This is because cosmeceutical ingredients interact with, change each other, and are affected by temperature, pH, humidity, and the microbiome in which they are in contact. This column focuses on the factors that should be considered when recommending skin care regimens to patients and in which order to apply topical products.

The chemistry of ingredients and how they interact is well understood by personal care product formulators. I think of formulators as chefs who are using ingredients and placing them in the formulation in a well-defined order under controlled circumstances that affect the final product. For example, ceramides are used in barrier repair moisturizers. The right form of ceramide must be chosen and used with the 1:1:1 ratio of ceramides, fatty acids, and cholesterol for the product to be effective at repairing the barrier.¹ However, the order of when the ceramides are added to the product formula also impacts efficacy. Waxy ceramides and cholesterol require heat to liquefy and form the proper mixture with the other ingredients. Too much heat can damage fatty acids. Also, heat can inactivate finicky active ingredients such as vitamins C and E. For this reason, the ceramides and cholesterol are often incorporated first, allowing the formula to cool before the active heat labile ingredients are added. The speed at which something is mixed can generate heat and affect the final preparations, so temperature is an important consideration at all steps in the formulation procedure.

PainterSaba/iStock/Getty Images

Just as the order of creating formulations affects the final product, the order of product placement on the skin influences skin care product efficacy. If a low pH skin care product (such as a glycolic acid cleanser) is used on the skin, this is going to affect the efficacy and safety of the product that is applied next to the skin. Such a chemical phenomenon should be considered when designing the order of product applications when designing a skin care regimen, particularly when incorporating ingredients that are known to interact with other ingredients, such as benzoyl peroxide, retinoids, hydroxy acids, hydroquinone, vitamin C, and peptides.

 

 

Efficacy and compliance in product layering

Improper choice and layering of skin care formulations reduces efficacy and increases the risk of side effects resulting in reduced patient compliance. Acne treatments are a good example. Patients are often prescribed a retinoid, benzoyl peroxide, topical antibiotic, and/or salicylic acid treatment product for acne. If the proper cleansers and moisturizers are not chosen, the patient will be more likely to develop redness and scaling and become noncompliant.

Compliance is a concerning issue to dermatologists because studies have shown that 95% of people underdose and one out of every three prescriptions is not even filled.² If patients develop side effects, they are more likely to underdose or stop the treatment. Prescribing the proper cleanser and moisturizer to accompany treatment products will ease side effects and increase compliance. Several studies have demonstrated that the best way to increase compliance is to provide patients with written instructions, so they understand the proper order in which to apply products.
 

The role of cleansers

Cleansers can alter the pH of the skin, loosen attachments between cells, remove lipids – and disrupt the bilayer protective membrane, desquamate layers from the stratum corneum, and influence the penetrability of the skin for the next topical product that is applied. Therefore, cleansers should be selected based on the products that will follow them in the regimen. In addition, cleansers should be chosen according to the patient’s Baumann Skin Type.³ For example, cleansers for use on oily skin should have the ability to remove excess sebum on the skin while cleansers designed for dry skin would not remove as many lipids from the skin. Washing skin with a foaming cleanser can disrupt the skin barrier, allowing increased penetration of the treatment product that follows it. Oleic acid, hyaluronic acid, stearic acid, and other lipids are among the ingredients that influence skin penetration. Cleansers should precede treatment products and should be designed to increase efficacy of the treatment product. For this reason, every ingredient and characteristic of the chosen cleanser is important.

 

The role of eye products

Eye products treat issues such as dryness, puffiness, fine lines, and dark circles. However, they also play an overlooked role of protecting the thin delicate eye area from the treatment product. Using an eye product, especially one with protective ingredients such as barrier repair lipids, will help the patient tolerate the potentially irritating treatment product that follows the eye product. At night, the treatment product ingredients can get on the pillowcase and transfer to the upper and lower eyelids. Use of a protective eye product before bedtime can prevent the accompanying irritation. For example, acne patients often develop redness at the corners of the eyes when using benzoyl peroxide or a retinoid at night. Applying these medications after an eye cream can reduce this side effect.

Improving efficacy of treatment products

Treatments products are defined as corrective products targeted to skin issues such as acne, rosacea, melasma, dryness, skin cancer, eczema, psoriasis, and photoaging. The entire skin care regimen should be designed to enhance efficacy and decrease side effects of the treatment products. Treatment products may be cosmeceuticals, OTC medications, or prescription medications. These products must be able to reach their target in the proper chemical structure to be effective. Each ingredient has various constraints and quirks that should be considered. One well known example is ascorbic acid (vitamin C). Ascorbic acid is a treatment product for skin pigmentation and skin aging that is well known to have specific needs to work properly. Sheldon Pinnell, MD, led multiple investigations demonstrating that the maximum absorption of ascorbic acid occurs at a pH of 2-2.5. He showed that ascorbic acid products should be formulated at a pH of 2-2.5.⁴ However, applying these on skin that has just been cleansed with a soap cleanser with a pH of 9 will raise the skin’s pH and decrease the absorption of ascorbic acid. Having the patient cleanse with a low pH cleanser such as salicylic or glycolic acid cleanser (usually a pH of 2.5-3.5) will lower the pH of the skin and promote absorption of vitamin C.

The role of moisturizers

Moisturizers have many duties, including hydrating the skin, protecting the skin, and delivering important ingredients to the skin. However, moisturizers have a less discussed role of improving the efficacy of the treatment product that is applied beforehand. Moisturizers often contain oleic acid, hyaluronic acid, or other fatty acids that can increase penetration of other skin care ingredients. In addition, many moisturizers provide an occlusive effect that helps increase penetration. They also help protect the underlying treatment product from getting wiped off on a pillowcase or into the environment. In other words, moisturizers “seal in” the treatment product. Some moisturizing ingredients such as heparan sulfate may affect how well the skin cells “hear” and respond to signals elicited by the treatment products. For this reason, moisturizers should also be chosen to improve the efficacy of the treatment product.

Retinoids

When using retinoids for the first time in a patient, applying them last on top of the moisturizer can reduce the incidence of side effects and increase compliance. Retinoids, unlike other ingredients, penetrate easily into the deeper layer of the epidermis. Layering them on top of a moisturizer can help titrate retinoid absorption. The moisturizer can be chosen to slow or increase penetration of retinoids. Retinoids should always be used at nighttime because many of them, especially retinol and tretinoin, are easily broken down by ultraviolet light exposure.

 

Selecting across brands and applying products in the right order

Manufacturers rarely perform research on a complete regimen, but rather on individual products. Dermatologists then are left to figure this out on their own. I recommend choosing the best technologies from each brand based on the patient’s Baumann Skin Type and combining them using the recommended layering technique. I choose the best “hero” products from the various brands and layer them in a sequence that increases efficacy of all of the products. I then test the entire regimen on patients to figure out what combinations have the best efficacy and fewest side effects. Once I solve this “regimen puzzle,” I program software to automatically generate the step-by-step regimen instructions by Baumann Skin Type so that I do not have to rethink this complicated subject matter with every patient. I have developed over 3,300 distinct regimens so I am certain that my patients will get the proper skin care regimen advice from me or any of my staff.

Conclusion

Dermatologists can make a significant difference in their patients’ long-term skin care health by assisting them in identifying the proper skin care formulations for their individual skin type and guiding them as to how much, and in which order, to apply the products in their personalized skin care regimen. Patients will not remember what you told them and will confuse the order in which products should be used. For this reason, providing a written step-by-step skin care regimen is paramount to ensuring patient compliance.

 

Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002) and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014); she also authored a New York Times Best Seller for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance Therapeutics. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC. Write to her at [email protected].

References

1. Man MQ M et al. Optimization of physiological lipid mixtures for barrier repair. J Invest Dermatol. 1996 May;106(5):1096-101.

2. Storm A et al. One in 3 prescriptions are never redeemed: Primary nonadherence in an outpatient clinic. J Am Acad Dermatol. 2008 Jul;59(1):27-33.

3. Baumann LS. The Baumann Skin Typing System, in Farage MA et al. “Textbook of Aging Skin.” Springer-Verlag Berlin Heidelberg, 2017, pp. 1579-94.

4. Pinnell SR et al. Topical L-ascorbic acid: Percutaneous absorption studies. Dermatol Surg. 2001 Feb; 27(2):137-42.

 

Dermatologists are well suited to understand cosmeceutical science and the benefits of particular cosmeceutical products – especially if they are readers of this column. However, there is another critical thought process that must be undertaken when designing an efficacious skin care regimen for patients: Topical products should be applied in a particular order to maximize efficacy. This is because cosmeceutical ingredients interact with, change each other, and are affected by temperature, pH, humidity, and the microbiome in which they are in contact. This column focuses on the factors that should be considered when recommending skin care regimens to patients and in which order to apply topical products.

The chemistry of ingredients and how they interact is well understood by personal care product formulators. I think of formulators as chefs who are using ingredients and placing them in the formulation in a well-defined order under controlled circumstances that affect the final product. For example, ceramides are used in barrier repair moisturizers. The right form of ceramide must be chosen and used with the 1:1:1 ratio of ceramides, fatty acids, and cholesterol for the product to be effective at repairing the barrier.¹ However, the order of when the ceramides are added to the product formula also impacts efficacy. Waxy ceramides and cholesterol require heat to liquefy and form the proper mixture with the other ingredients. Too much heat can damage fatty acids. Also, heat can inactivate finicky active ingredients such as vitamins C and E. For this reason, the ceramides and cholesterol are often incorporated first, allowing the formula to cool before the active heat labile ingredients are added. The speed at which something is mixed can generate heat and affect the final preparations, so temperature is an important consideration at all steps in the formulation procedure.

PainterSaba/iStock/Getty Images

Just as the order of creating formulations affects the final product, the order of product placement on the skin influences skin care product efficacy. If a low pH skin care product (such as a glycolic acid cleanser) is used on the skin, this is going to affect the efficacy and safety of the product that is applied next to the skin. Such a chemical phenomenon should be considered when designing the order of product applications when designing a skin care regimen, particularly when incorporating ingredients that are known to interact with other ingredients, such as benzoyl peroxide, retinoids, hydroxy acids, hydroquinone, vitamin C, and peptides.

 

 

Efficacy and compliance in product layering

Improper choice and layering of skin care formulations reduces efficacy and increases the risk of side effects resulting in reduced patient compliance. Acne treatments are a good example. Patients are often prescribed a retinoid, benzoyl peroxide, topical antibiotic, and/or salicylic acid treatment product for acne. If the proper cleansers and moisturizers are not chosen, the patient will be more likely to develop redness and scaling and become noncompliant.

Compliance is a concerning issue to dermatologists because studies have shown that 95% of people underdose and one out of every three prescriptions is not even filled.² If patients develop side effects, they are more likely to underdose or stop the treatment. Prescribing the proper cleanser and moisturizer to accompany treatment products will ease side effects and increase compliance. Several studies have demonstrated that the best way to increase compliance is to provide patients with written instructions, so they understand the proper order in which to apply products.
 

The role of cleansers

Cleansers can alter the pH of the skin, loosen attachments between cells, remove lipids – and disrupt the bilayer protective membrane, desquamate layers from the stratum corneum, and influence the penetrability of the skin for the next topical product that is applied. Therefore, cleansers should be selected based on the products that will follow them in the regimen. In addition, cleansers should be chosen according to the patient’s Baumann Skin Type.³ For example, cleansers for use on oily skin should have the ability to remove excess sebum on the skin while cleansers designed for dry skin would not remove as many lipids from the skin. Washing skin with a foaming cleanser can disrupt the skin barrier, allowing increased penetration of the treatment product that follows it. Oleic acid, hyaluronic acid, stearic acid, and other lipids are among the ingredients that influence skin penetration. Cleansers should precede treatment products and should be designed to increase efficacy of the treatment product. For this reason, every ingredient and characteristic of the chosen cleanser is important.

 

The role of eye products

Eye products treat issues such as dryness, puffiness, fine lines, and dark circles. However, they also play an overlooked role of protecting the thin delicate eye area from the treatment product. Using an eye product, especially one with protective ingredients such as barrier repair lipids, will help the patient tolerate the potentially irritating treatment product that follows the eye product. At night, the treatment product ingredients can get on the pillowcase and transfer to the upper and lower eyelids. Use of a protective eye product before bedtime can prevent the accompanying irritation. For example, acne patients often develop redness at the corners of the eyes when using benzoyl peroxide or a retinoid at night. Applying these medications after an eye cream can reduce this side effect.

Improving efficacy of treatment products

Treatments products are defined as corrective products targeted to skin issues such as acne, rosacea, melasma, dryness, skin cancer, eczema, psoriasis, and photoaging. The entire skin care regimen should be designed to enhance efficacy and decrease side effects of the treatment products. Treatment products may be cosmeceuticals, OTC medications, or prescription medications. These products must be able to reach their target in the proper chemical structure to be effective. Each ingredient has various constraints and quirks that should be considered. One well known example is ascorbic acid (vitamin C). Ascorbic acid is a treatment product for skin pigmentation and skin aging that is well known to have specific needs to work properly. Sheldon Pinnell, MD, led multiple investigations demonstrating that the maximum absorption of ascorbic acid occurs at a pH of 2-2.5. He showed that ascorbic acid products should be formulated at a pH of 2-2.5.⁴ However, applying these on skin that has just been cleansed with a soap cleanser with a pH of 9 will raise the skin’s pH and decrease the absorption of ascorbic acid. Having the patient cleanse with a low pH cleanser such as salicylic or glycolic acid cleanser (usually a pH of 2.5-3.5) will lower the pH of the skin and promote absorption of vitamin C.

The role of moisturizers

Moisturizers have many duties, including hydrating the skin, protecting the skin, and delivering important ingredients to the skin. However, moisturizers have a less discussed role of improving the efficacy of the treatment product that is applied beforehand. Moisturizers often contain oleic acid, hyaluronic acid, or other fatty acids that can increase penetration of other skin care ingredients. In addition, many moisturizers provide an occlusive effect that helps increase penetration. They also help protect the underlying treatment product from getting wiped off on a pillowcase or into the environment. In other words, moisturizers “seal in” the treatment product. Some moisturizing ingredients such as heparan sulfate may affect how well the skin cells “hear” and respond to signals elicited by the treatment products. For this reason, moisturizers should also be chosen to improve the efficacy of the treatment product.

Retinoids

When using retinoids for the first time in a patient, applying them last on top of the moisturizer can reduce the incidence of side effects and increase compliance. Retinoids, unlike other ingredients, penetrate easily into the deeper layer of the epidermis. Layering them on top of a moisturizer can help titrate retinoid absorption. The moisturizer can be chosen to slow or increase penetration of retinoids. Retinoids should always be used at nighttime because many of them, especially retinol and tretinoin, are easily broken down by ultraviolet light exposure.

 

Selecting across brands and applying products in the right order

Manufacturers rarely perform research on a complete regimen, but rather on individual products. Dermatologists then are left to figure this out on their own. I recommend choosing the best technologies from each brand based on the patient’s Baumann Skin Type and combining them using the recommended layering technique. I choose the best “hero” products from the various brands and layer them in a sequence that increases efficacy of all of the products. I then test the entire regimen on patients to figure out what combinations have the best efficacy and fewest side effects. Once I solve this “regimen puzzle,” I program software to automatically generate the step-by-step regimen instructions by Baumann Skin Type so that I do not have to rethink this complicated subject matter with every patient. I have developed over 3,300 distinct regimens so I am certain that my patients will get the proper skin care regimen advice from me or any of my staff.

Conclusion

Dermatologists can make a significant difference in their patients’ long-term skin care health by assisting them in identifying the proper skin care formulations for their individual skin type and guiding them as to how much, and in which order, to apply the products in their personalized skin care regimen. Patients will not remember what you told them and will confuse the order in which products should be used. For this reason, providing a written step-by-step skin care regimen is paramount to ensuring patient compliance.

 

Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002) and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014); she also authored a New York Times Best Seller for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance Therapeutics. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC. Write to her at [email protected].

References

1. Man MQ M et al. Optimization of physiological lipid mixtures for barrier repair. J Invest Dermatol. 1996 May;106(5):1096-101.

2. Storm A et al. One in 3 prescriptions are never redeemed: Primary nonadherence in an outpatient clinic. J Am Acad Dermatol. 2008 Jul;59(1):27-33.

3. Baumann LS. The Baumann Skin Typing System, in Farage MA et al. “Textbook of Aging Skin.” Springer-Verlag Berlin Heidelberg, 2017, pp. 1579-94.

4. Pinnell SR et al. Topical L-ascorbic acid: Percutaneous absorption studies. Dermatol Surg. 2001 Feb; 27(2):137-42.