Clinical Psychiatry News

Sleep disorders may be silent precursors of cardiometabolic disease among U.S. Latinos, said authors of a newly published study.

Xiaoyu Li, ScD, and Susan Redline, MD, MPH, of Harvard Medical School and Brigham and Women’s Hospital, Boston, and coauthors conducted a study of people who self-identified as Latino, who had baseline sleeping disorders, and who developed hypertension and diabetes over time. The study was published in the American Journal of Respiratory and Critical Care Medicine.

The findings suggested that sleep disorders preceded the development of hypertension and diabetes. Examining records from a major multiyear federal project, the Hispanic Community Health Study/Study of Latinos, Dr. Li, Dr. Redline, and coauthors found sleep-disordered breathing (SDB) was associated with a 1.54 higher adjusted odds of incident hypertension (95% confidence interval [CI], 1.18-2.00) and 1.33 higher odds of incident diabetes (95% CI, 1.05-1.67), compared with no SDB. Insomnia was associated with incident hypertension (odds ratio, 1.37; 95% CI, 1.11-1.69), but not diabetes. The association between insomnia and incident hypertension was stronger among men than women, they reported.

“We now need large-scale rigorous trials to evaluate the impact of early treatment of sleep disordered breathing and insomnia on preventing the development of hypertension and diabetes,” Dr. Redline said in an interview. “Clinicians should consider screening their patients at risk for hypertension and diabetes for both sleep-disordered breathing and insomnia.”
 

Implications for public health strategies

The study results may have implications for health strategies and policies aimed at addressing health differentials among ethnic and economic groups in the United States.

Suboptimal sleep health may be an important fundamental but understudied contributor to health disparities, Chandra L. Jackson, PhD, MS, of the National Institute of Environmental Health Sciences, Research Triangle, N.C., said in an interview. Dr. Jackson is the lead author for a report published in August on a 2018 National Institutes of Health workshop regarding the importance of studying sleep health disparities (Sleep 2020 Mar 10. doi: 10.1093/sleep/zsaa037). The NIH workshop emphasized how little research has been done on the prevalence, incidence, morbidity, or mortality of sleep deficiencies of racial and ethnic minority populations, even though members of these groups are generally more likely to experience sleep disorders. The report urged “a nuanced integration between health disparity causal pathways and sleep and circadian-related mechanisms” tailored for these groups, with attention paid to sociocultural context.

Dr. Jackson said the study by Dr. Li and colleagues fits nicely with the strategies recommended in this report. She added: “Prospective design is particularly important for establishing temporality or that the SDB and insomnia symptoms occurred before the outcomes of hypertension and diabetes.”

In commenting on the Xi/Redline paper, Krishna M. Sundar, MD, FCCP, medical director of the Sleep-Wake Center at the University of Utah, Salt Lake City, commended the study and noted that one of the challenges in sleep research is the long time period over which the effects of disordered breathing become clear, he said.

“Things don’t happen immediately. It takes months, years for the effects to develop,” Dr. Sundar said. “To try to piece together the relationships, you need very well planned studies.”
 

Study design: Participants and exclusions

Latinos currently make up 17.8%, or 57.5 million, of the U.S. population, and this group is expected to double within the next 4 decades, the investigators wrote. A few prior studies on the roles of sleep disorders in the cardiometabolic health of Latinos, though suggestive, were limited by cross-sectional designs, relatively small samples, and underrepresentation of various Latino heritage groups.

The investigators on this new study worked with data from the federal Hispanic Community Health Study/Study of Latinos (HCHS/SOL) in which more than 16,000 people participated.

This multiyear federal study drew people who self-identified with different heritage groups, including Cuban, Dominican, Mexican, Central American, South American, and Puerto Rican. Participants initially aged 18-74 years underwent a first round of exams and assessments between 2008 and 2011 to determine what risk factors they had at the start of the study. In the second phase, which took place from 2013 to 2018, participants had a second set of exams. The National Heart, Lung, and Blood Institute and the National Institute of Diabetes and Digestive and Kidney Diseases funded the HCHS/SOL.

The investigators initially had a potential data pool of 11,623 participants in the HCHS/SOL. About 1 of 8 in this group, or 1,424 participants (12.3%), did not undergo a sleep study or did not have sufficient sleep data for analyses. Another 93 (0.8%) participants were excluded for missing data on covariates.

For incident hypertension analyses, participants who had prevalent hypertension at the first screening in the HCHS/SOL (n = 3,139) or had missing data on hypertension (n = 2) were excluded. That resulted in an analytic sample of 6,965 for hypertension questions.

For incident diabetes analyses, participants who had prevalent diabetes at the first screening (n = 2,062) or had missing data on diabetes (n = 21) were excluded, yielding an analytic sample of 8,023.

Incident hypertension was defined as participants not having hypertension at baseline and having hypertension, defined as a systolic blood pressure 140 mm Hg or greater, diastolic blood pressure 90 mm Hg or greater, or receiving antihypertensive medication within 4 weeks, at the second round of screening.
 

Cardiometabolic disease definitions

The researchers did not discriminate between type 1 and type 2 diabetes. They used the American Diabetes Association definition as a fasting plasma glucose 126 mg/dL or greater, 2-hour, postload plasma glucose 200 mg/dL or greater, or hemoglobin A1c 6.5% or greater, with an additional criterion on self-reported use of antidiabetic medication within 4 weeks before the visit.

In line with previous research, the investigators controlled for potential confounders measured at baseline including sociodemographic factors, health behaviors, and adiposity, which are considered important risk factors for both sleep disorders and incident metabolic diseases. These factors include education level, age, gender, and body mass index and whether participants had ever been smokers or users of alcohol.
 

Study limitations

Limitations of the study include use of a home sleep apnea test device that did not allow evaluation of arousal or sleep architecture. The researchers said this may have led to an underestimation of disease severity both due to overestimation of sleep time and underrecognition of hypopneas unassociated with desaturation. In addition, prior research has suggested that minority populations might underreport sleep disturbances, possibly “due to social desirability (a tendency not to encode a negative event), stress, stereotype threat, acculturation, attitudes, etc.” The participants were recruited mostly from urban areas, and the results might not be generalized to rural populations. In addition, 41% of study participants were of Mexican heritage, compared with 63% of the Hispanic population being of Mexican heritage in the United States.

Another researcher in the field of health disparities, Julia Roncoroni, PhD, assistant professor of psychology at the University of Denver, also noted this slight underrepresentation of Hispanics of Mexican origin and an overrepresentation of urban individuals in the HCHS/SOL.

“However, using data from HCHS/SOL, which is the largest multicenter epidemiological study of cardiovascular risk factors and sleep traits in U.S. Hispanics/Latinx, allows researchers to answer a high-impact question that would otherwise be prohibitively expensive and time consuming,” wrote Dr. Roncoroni.
 

Conclusions

The study offers “the first prospective evidence on the associations between SDB and insomnia with incident hypertension and diabetes in US Hispanics/Latinos.” The investigators concluded: “Given the fact that sleep disorders are largely undiagnosed and undertreated, they might represent modifiable targets for disease prevention and reduction among US Hispanics/Latinos. Culturally informed interventions focusing on detecting and treating sleep disorders might improve cardiometabolic health among US Hispanics/Latinos.”

Dr. Redline was partially supported by NIH grant R35 HL135818. This study drew from the Hispanic Community Health Study/Study of Latinos, which has been supported by contracts from the National Heart, Lung, and Blood Institute.

SOURCE: Li X et al. Am J Respir Crit Care Med. 2020 Aug 6. doi: 10.1164/rccm.201912-2330OC.

Sleep disorders may be silent precursors of cardiometabolic disease among U.S. Latinos, said authors of a newly published study.

Xiaoyu Li, ScD, and Susan Redline, MD, MPH, of Harvard Medical School and Brigham and Women’s Hospital, Boston, and coauthors conducted a study of people who self-identified as Latino, who had baseline sleeping disorders, and who developed hypertension and diabetes over time. The study was published in the American Journal of Respiratory and Critical Care Medicine.

The findings suggested that sleep disorders preceded the development of hypertension and diabetes. Examining records from a major multiyear federal project, the Hispanic Community Health Study/Study of Latinos, Dr. Li, Dr. Redline, and coauthors found sleep-disordered breathing (SDB) was associated with a 1.54 higher adjusted odds of incident hypertension (95% confidence interval [CI], 1.18-2.00) and 1.33 higher odds of incident diabetes (95% CI, 1.05-1.67), compared with no SDB. Insomnia was associated with incident hypertension (odds ratio, 1.37; 95% CI, 1.11-1.69), but not diabetes. The association between insomnia and incident hypertension was stronger among men than women, they reported.

“We now need large-scale rigorous trials to evaluate the impact of early treatment of sleep disordered breathing and insomnia on preventing the development of hypertension and diabetes,” Dr. Redline said in an interview. “Clinicians should consider screening their patients at risk for hypertension and diabetes for both sleep-disordered breathing and insomnia.”
 

Implications for public health strategies

The study results may have implications for health strategies and policies aimed at addressing health differentials among ethnic and economic groups in the United States.

Suboptimal sleep health may be an important fundamental but understudied contributor to health disparities, Chandra L. Jackson, PhD, MS, of the National Institute of Environmental Health Sciences, Research Triangle, N.C., said in an interview. Dr. Jackson is the lead author for a report published in August on a 2018 National Institutes of Health workshop regarding the importance of studying sleep health disparities (Sleep 2020 Mar 10. doi: 10.1093/sleep/zsaa037). The NIH workshop emphasized how little research has been done on the prevalence, incidence, morbidity, or mortality of sleep deficiencies of racial and ethnic minority populations, even though members of these groups are generally more likely to experience sleep disorders. The report urged “a nuanced integration between health disparity causal pathways and sleep and circadian-related mechanisms” tailored for these groups, with attention paid to sociocultural context.

Dr. Jackson said the study by Dr. Li and colleagues fits nicely with the strategies recommended in this report. She added: “Prospective design is particularly important for establishing temporality or that the SDB and insomnia symptoms occurred before the outcomes of hypertension and diabetes.”

In commenting on the Xi/Redline paper, Krishna M. Sundar, MD, FCCP, medical director of the Sleep-Wake Center at the University of Utah, Salt Lake City, commended the study and noted that one of the challenges in sleep research is the long time period over which the effects of disordered breathing become clear, he said.

“Things don’t happen immediately. It takes months, years for the effects to develop,” Dr. Sundar said. “To try to piece together the relationships, you need very well planned studies.”
 

Study design: Participants and exclusions

Latinos currently make up 17.8%, or 57.5 million, of the U.S. population, and this group is expected to double within the next 4 decades, the investigators wrote. A few prior studies on the roles of sleep disorders in the cardiometabolic health of Latinos, though suggestive, were limited by cross-sectional designs, relatively small samples, and underrepresentation of various Latino heritage groups.

The investigators on this new study worked with data from the federal Hispanic Community Health Study/Study of Latinos (HCHS/SOL) in which more than 16,000 people participated.

This multiyear federal study drew people who self-identified with different heritage groups, including Cuban, Dominican, Mexican, Central American, South American, and Puerto Rican. Participants initially aged 18-74 years underwent a first round of exams and assessments between 2008 and 2011 to determine what risk factors they had at the start of the study. In the second phase, which took place from 2013 to 2018, participants had a second set of exams. The National Heart, Lung, and Blood Institute and the National Institute of Diabetes and Digestive and Kidney Diseases funded the HCHS/SOL.

The investigators initially had a potential data pool of 11,623 participants in the HCHS/SOL. About 1 of 8 in this group, or 1,424 participants (12.3%), did not undergo a sleep study or did not have sufficient sleep data for analyses. Another 93 (0.8%) participants were excluded for missing data on covariates.

For incident hypertension analyses, participants who had prevalent hypertension at the first screening in the HCHS/SOL (n = 3,139) or had missing data on hypertension (n = 2) were excluded. That resulted in an analytic sample of 6,965 for hypertension questions.

For incident diabetes analyses, participants who had prevalent diabetes at the first screening (n = 2,062) or had missing data on diabetes (n = 21) were excluded, yielding an analytic sample of 8,023.

Incident hypertension was defined as participants not having hypertension at baseline and having hypertension, defined as a systolic blood pressure 140 mm Hg or greater, diastolic blood pressure 90 mm Hg or greater, or receiving antihypertensive medication within 4 weeks, at the second round of screening.
 

Cardiometabolic disease definitions

The researchers did not discriminate between type 1 and type 2 diabetes. They used the American Diabetes Association definition as a fasting plasma glucose 126 mg/dL or greater, 2-hour, postload plasma glucose 200 mg/dL or greater, or hemoglobin A1c 6.5% or greater, with an additional criterion on self-reported use of antidiabetic medication within 4 weeks before the visit.

In line with previous research, the investigators controlled for potential confounders measured at baseline including sociodemographic factors, health behaviors, and adiposity, which are considered important risk factors for both sleep disorders and incident metabolic diseases. These factors include education level, age, gender, and body mass index and whether participants had ever been smokers or users of alcohol.
 

Study limitations

Limitations of the study include use of a home sleep apnea test device that did not allow evaluation of arousal or sleep architecture. The researchers said this may have led to an underestimation of disease severity both due to overestimation of sleep time and underrecognition of hypopneas unassociated with desaturation. In addition, prior research has suggested that minority populations might underreport sleep disturbances, possibly “due to social desirability (a tendency not to encode a negative event), stress, stereotype threat, acculturation, attitudes, etc.” The participants were recruited mostly from urban areas, and the results might not be generalized to rural populations. In addition, 41% of study participants were of Mexican heritage, compared with 63% of the Hispanic population being of Mexican heritage in the United States.

Another researcher in the field of health disparities, Julia Roncoroni, PhD, assistant professor of psychology at the University of Denver, also noted this slight underrepresentation of Hispanics of Mexican origin and an overrepresentation of urban individuals in the HCHS/SOL.

“However, using data from HCHS/SOL, which is the largest multicenter epidemiological study of cardiovascular risk factors and sleep traits in U.S. Hispanics/Latinx, allows researchers to answer a high-impact question that would otherwise be prohibitively expensive and time consuming,” wrote Dr. Roncoroni.
 

Conclusions

The study offers “the first prospective evidence on the associations between SDB and insomnia with incident hypertension and diabetes in US Hispanics/Latinos.” The investigators concluded: “Given the fact that sleep disorders are largely undiagnosed and undertreated, they might represent modifiable targets for disease prevention and reduction among US Hispanics/Latinos. Culturally informed interventions focusing on detecting and treating sleep disorders might improve cardiometabolic health among US Hispanics/Latinos.”

Dr. Redline was partially supported by NIH grant R35 HL135818. This study drew from the Hispanic Community Health Study/Study of Latinos, which has been supported by contracts from the National Heart, Lung, and Blood Institute.

SOURCE: Li X et al. Am J Respir Crit Care Med. 2020 Aug 6. doi: 10.1164/rccm.201912-2330OC.

Sleep disorders may be silent precursors of cardiometabolic disease among U.S. Latinos, said authors of a newly published study.

Xiaoyu Li, ScD, and Susan Redline, MD, MPH, of Harvard Medical School and Brigham and Women’s Hospital, Boston, and coauthors conducted a study of people who self-identified as Latino, who had baseline sleeping disorders, and who developed hypertension and diabetes over time. The study was published in the American Journal of Respiratory and Critical Care Medicine.

The findings suggested that sleep disorders preceded the development of hypertension and diabetes. Examining records from a major multiyear federal project, the Hispanic Community Health Study/Study of Latinos, Dr. Li, Dr. Redline, and coauthors found sleep-disordered breathing (SDB) was associated with a 1.54 higher adjusted odds of incident hypertension (95% confidence interval [CI], 1.18-2.00) and 1.33 higher odds of incident diabetes (95% CI, 1.05-1.67), compared with no SDB. Insomnia was associated with incident hypertension (odds ratio, 1.37; 95% CI, 1.11-1.69), but not diabetes. The association between insomnia and incident hypertension was stronger among men than women, they reported.

“We now need large-scale rigorous trials to evaluate the impact of early treatment of sleep disordered breathing and insomnia on preventing the development of hypertension and diabetes,” Dr. Redline said in an interview. “Clinicians should consider screening their patients at risk for hypertension and diabetes for both sleep-disordered breathing and insomnia.”
 

Implications for public health strategies

The study results may have implications for health strategies and policies aimed at addressing health differentials among ethnic and economic groups in the United States.

Suboptimal sleep health may be an important fundamental but understudied contributor to health disparities, Chandra L. Jackson, PhD, MS, of the National Institute of Environmental Health Sciences, Research Triangle, N.C., said in an interview. Dr. Jackson is the lead author for a report published in August on a 2018 National Institutes of Health workshop regarding the importance of studying sleep health disparities (Sleep 2020 Mar 10. doi: 10.1093/sleep/zsaa037). The NIH workshop emphasized how little research has been done on the prevalence, incidence, morbidity, or mortality of sleep deficiencies of racial and ethnic minority populations, even though members of these groups are generally more likely to experience sleep disorders. The report urged “a nuanced integration between health disparity causal pathways and sleep and circadian-related mechanisms” tailored for these groups, with attention paid to sociocultural context.

Dr. Jackson said the study by Dr. Li and colleagues fits nicely with the strategies recommended in this report. She added: “Prospective design is particularly important for establishing temporality or that the SDB and insomnia symptoms occurred before the outcomes of hypertension and diabetes.”

In commenting on the Xi/Redline paper, Krishna M. Sundar, MD, FCCP, medical director of the Sleep-Wake Center at the University of Utah, Salt Lake City, commended the study and noted that one of the challenges in sleep research is the long time period over which the effects of disordered breathing become clear, he said.

“Things don’t happen immediately. It takes months, years for the effects to develop,” Dr. Sundar said. “To try to piece together the relationships, you need very well planned studies.”
 

Study design: Participants and exclusions

Latinos currently make up 17.8%, or 57.5 million, of the U.S. population, and this group is expected to double within the next 4 decades, the investigators wrote. A few prior studies on the roles of sleep disorders in the cardiometabolic health of Latinos, though suggestive, were limited by cross-sectional designs, relatively small samples, and underrepresentation of various Latino heritage groups.

The investigators on this new study worked with data from the federal Hispanic Community Health Study/Study of Latinos (HCHS/SOL) in which more than 16,000 people participated.

This multiyear federal study drew people who self-identified with different heritage groups, including Cuban, Dominican, Mexican, Central American, South American, and Puerto Rican. Participants initially aged 18-74 years underwent a first round of exams and assessments between 2008 and 2011 to determine what risk factors they had at the start of the study. In the second phase, which took place from 2013 to 2018, participants had a second set of exams. The National Heart, Lung, and Blood Institute and the National Institute of Diabetes and Digestive and Kidney Diseases funded the HCHS/SOL.

The investigators initially had a potential data pool of 11,623 participants in the HCHS/SOL. About 1 of 8 in this group, or 1,424 participants (12.3%), did not undergo a sleep study or did not have sufficient sleep data for analyses. Another 93 (0.8%) participants were excluded for missing data on covariates.

For incident hypertension analyses, participants who had prevalent hypertension at the first screening in the HCHS/SOL (n = 3,139) or had missing data on hypertension (n = 2) were excluded. That resulted in an analytic sample of 6,965 for hypertension questions.

For incident diabetes analyses, participants who had prevalent diabetes at the first screening (n = 2,062) or had missing data on diabetes (n = 21) were excluded, yielding an analytic sample of 8,023.

Incident hypertension was defined as participants not having hypertension at baseline and having hypertension, defined as a systolic blood pressure 140 mm Hg or greater, diastolic blood pressure 90 mm Hg or greater, or receiving antihypertensive medication within 4 weeks, at the second round of screening.
 

Cardiometabolic disease definitions

The researchers did not discriminate between type 1 and type 2 diabetes. They used the American Diabetes Association definition as a fasting plasma glucose 126 mg/dL or greater, 2-hour, postload plasma glucose 200 mg/dL or greater, or hemoglobin A1c 6.5% or greater, with an additional criterion on self-reported use of antidiabetic medication within 4 weeks before the visit.

In line with previous research, the investigators controlled for potential confounders measured at baseline including sociodemographic factors, health behaviors, and adiposity, which are considered important risk factors for both sleep disorders and incident metabolic diseases. These factors include education level, age, gender, and body mass index and whether participants had ever been smokers or users of alcohol.
 

Study limitations

Limitations of the study include use of a home sleep apnea test device that did not allow evaluation of arousal or sleep architecture. The researchers said this may have led to an underestimation of disease severity both due to overestimation of sleep time and underrecognition of hypopneas unassociated with desaturation. In addition, prior research has suggested that minority populations might underreport sleep disturbances, possibly “due to social desirability (a tendency not to encode a negative event), stress, stereotype threat, acculturation, attitudes, etc.” The participants were recruited mostly from urban areas, and the results might not be generalized to rural populations. In addition, 41% of study participants were of Mexican heritage, compared with 63% of the Hispanic population being of Mexican heritage in the United States.

Another researcher in the field of health disparities, Julia Roncoroni, PhD, assistant professor of psychology at the University of Denver, also noted this slight underrepresentation of Hispanics of Mexican origin and an overrepresentation of urban individuals in the HCHS/SOL.

“However, using data from HCHS/SOL, which is the largest multicenter epidemiological study of cardiovascular risk factors and sleep traits in U.S. Hispanics/Latinx, allows researchers to answer a high-impact question that would otherwise be prohibitively expensive and time consuming,” wrote Dr. Roncoroni.
 

Conclusions

The study offers “the first prospective evidence on the associations between SDB and insomnia with incident hypertension and diabetes in US Hispanics/Latinos.” The investigators concluded: “Given the fact that sleep disorders are largely undiagnosed and undertreated, they might represent modifiable targets for disease prevention and reduction among US Hispanics/Latinos. Culturally informed interventions focusing on detecting and treating sleep disorders might improve cardiometabolic health among US Hispanics/Latinos.”

Dr. Redline was partially supported by NIH grant R35 HL135818. This study drew from the Hispanic Community Health Study/Study of Latinos, which has been supported by contracts from the National Heart, Lung, and Blood Institute.

SOURCE: Li X et al. Am J Respir Crit Care Med. 2020 Aug 6. doi: 10.1164/rccm.201912-2330OC.

Shorter sleep duration, more wakefulness, and changes in the sleep cycle brought on by microgravity make it tough for astronauts to get a good night’s sleep while they’re in outer space, a new study shows. In research that has implications for earthlings as well as astronauts, scientists found that the “significant sleep changes induced by the extreme environmental conditions of spaceflight can magnify and help reveal similar, though potentially less noticeable, changes that are induced by the more moderate conditions of Earth.

“Our results support other studies indicating that sleep architecture can adapt to different environments. Also, the sleep deficits that our subjects were facing while working around the clock in a high-pressure environment provide further evidence for the danger of stress and shift-work schedules for humans anywhere,” study investigator Oliver Piltch, of Harvard University, Cambridge, Mass., said in a release.

The findings were presented at the virtual annual meeting of the Associated Professional Sleep Societies.
 

Sleep architecture affected

The researchers studied sleep architecture in four cosmonauts and one astronaut before, during, and after missions to the Mir space station. Using the NightCap sleep monitor, they recorded a total of 324 nights of sleep – 112 preflight nights, 83 in-flight nights, and 61 postflight nights.

Despite having the same “sleep opportunity” in space as on earth, the astronauts were on average sleeping an hour less each night during the space mission compared with when on earth before or after their mission (5.7 vs. 6.7 hours; P < .0001). In space, the astronauts also spent significantly more time awake in bed, leading to a 17.7% reduction in sleep efficiency.

Sleep architecture was also affected by spaceflight. In space, the time in non–rapid eye movement (non–REM) and REM sleep decreased by 14.1% and 25.8%, respectively. On average, it took about 90 minutes after falling asleep for astronauts to reach their first episode of REM sleep in space – nearly 1.5 times longer than on earth. “There were marked shifts in sleep architecture compared to baseline, and some of these evolved over the course of the mission,” said Mr. Piltch.

“Our findings were consistent with previous studies that focus on the issue of sleep continuity. We found significant decreases in sleep efficiency during spaceflight despite similar times in bed,” he noted.

Mr. Piltch said it’s important to understand how sleep is affected by spaceflight in order to better equip astronauts for success on long-duration flights, such as a trip to Mars or the Moon. He also pointed to a recent study in the Lancet Neurology that showed that 78% of the international space station crew take hypnotics on 52% of nights in space. “So it doesn’t look like they sleep very well in space,” he said.
 

High-stakes environment

Reached for comment, Camilo A. Ruiz, DO, medical director, Choice Physicians Sleep Center, Fort Lauderdale, Fla., said the findings add to the “limited” data currently available on sleep in space and microgravity. “To a certain point, the results of this study could have been expected since sleep continuity and sleep architecture disruption is present during stressful periods of human life or in changes to the sleep rituals we hold dear, such as our beds and quiet bedrooms,” said Dr. Ruiz, who was not involved in the study.

“The potential harm to astronauts from their sleep continuity and deranged sleep architecture is that the decreased alertness, performance, vigilance, and psychomotor skills they exhibit in that high-stakes environment such as space flight can lead to serious accidents that can jeopardize the safety of the crew and vessel,” Dr. Ruiz noted.

“These research areas are on the forefront of space medicine that will allow mankind to lead successful interplanetary missions and colonization of these planets with long-term resident astronauts,” he added.

The study was supported by funding from the Mary Gordon Roberts Fellowship, the National Academy of Sciences, the National Institute of Mental Health, the MacArthur Foundation Mind-Body Network, and Healthdyne Technologies. Mr. Piltch and Dr. Ruiz have no disclosed no relevant financial relationships.
 

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

Shorter sleep duration, more wakefulness, and changes in the sleep cycle brought on by microgravity make it tough for astronauts to get a good night’s sleep while they’re in outer space, a new study shows. In research that has implications for earthlings as well as astronauts, scientists found that the “significant sleep changes induced by the extreme environmental conditions of spaceflight can magnify and help reveal similar, though potentially less noticeable, changes that are induced by the more moderate conditions of Earth.

“Our results support other studies indicating that sleep architecture can adapt to different environments. Also, the sleep deficits that our subjects were facing while working around the clock in a high-pressure environment provide further evidence for the danger of stress and shift-work schedules for humans anywhere,” study investigator Oliver Piltch, of Harvard University, Cambridge, Mass., said in a release.

The findings were presented at the virtual annual meeting of the Associated Professional Sleep Societies.
 

Sleep architecture affected

The researchers studied sleep architecture in four cosmonauts and one astronaut before, during, and after missions to the Mir space station. Using the NightCap sleep monitor, they recorded a total of 324 nights of sleep – 112 preflight nights, 83 in-flight nights, and 61 postflight nights.

Despite having the same “sleep opportunity” in space as on earth, the astronauts were on average sleeping an hour less each night during the space mission compared with when on earth before or after their mission (5.7 vs. 6.7 hours; P < .0001). In space, the astronauts also spent significantly more time awake in bed, leading to a 17.7% reduction in sleep efficiency.

Sleep architecture was also affected by spaceflight. In space, the time in non–rapid eye movement (non–REM) and REM sleep decreased by 14.1% and 25.8%, respectively. On average, it took about 90 minutes after falling asleep for astronauts to reach their first episode of REM sleep in space – nearly 1.5 times longer than on earth. “There were marked shifts in sleep architecture compared to baseline, and some of these evolved over the course of the mission,” said Mr. Piltch.

“Our findings were consistent with previous studies that focus on the issue of sleep continuity. We found significant decreases in sleep efficiency during spaceflight despite similar times in bed,” he noted.

Mr. Piltch said it’s important to understand how sleep is affected by spaceflight in order to better equip astronauts for success on long-duration flights, such as a trip to Mars or the Moon. He also pointed to a recent study in the Lancet Neurology that showed that 78% of the international space station crew take hypnotics on 52% of nights in space. “So it doesn’t look like they sleep very well in space,” he said.
 

High-stakes environment

Reached for comment, Camilo A. Ruiz, DO, medical director, Choice Physicians Sleep Center, Fort Lauderdale, Fla., said the findings add to the “limited” data currently available on sleep in space and microgravity. “To a certain point, the results of this study could have been expected since sleep continuity and sleep architecture disruption is present during stressful periods of human life or in changes to the sleep rituals we hold dear, such as our beds and quiet bedrooms,” said Dr. Ruiz, who was not involved in the study.

“The potential harm to astronauts from their sleep continuity and deranged sleep architecture is that the decreased alertness, performance, vigilance, and psychomotor skills they exhibit in that high-stakes environment such as space flight can lead to serious accidents that can jeopardize the safety of the crew and vessel,” Dr. Ruiz noted.

“These research areas are on the forefront of space medicine that will allow mankind to lead successful interplanetary missions and colonization of these planets with long-term resident astronauts,” he added.

The study was supported by funding from the Mary Gordon Roberts Fellowship, the National Academy of Sciences, the National Institute of Mental Health, the MacArthur Foundation Mind-Body Network, and Healthdyne Technologies. Mr. Piltch and Dr. Ruiz have no disclosed no relevant financial relationships.
 

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

Shorter sleep duration, more wakefulness, and changes in the sleep cycle brought on by microgravity make it tough for astronauts to get a good night’s sleep while they’re in outer space, a new study shows. In research that has implications for earthlings as well as astronauts, scientists found that the “significant sleep changes induced by the extreme environmental conditions of spaceflight can magnify and help reveal similar, though potentially less noticeable, changes that are induced by the more moderate conditions of Earth.

“Our results support other studies indicating that sleep architecture can adapt to different environments. Also, the sleep deficits that our subjects were facing while working around the clock in a high-pressure environment provide further evidence for the danger of stress and shift-work schedules for humans anywhere,” study investigator Oliver Piltch, of Harvard University, Cambridge, Mass., said in a release.

The findings were presented at the virtual annual meeting of the Associated Professional Sleep Societies.
 

Sleep architecture affected

The researchers studied sleep architecture in four cosmonauts and one astronaut before, during, and after missions to the Mir space station. Using the NightCap sleep monitor, they recorded a total of 324 nights of sleep – 112 preflight nights, 83 in-flight nights, and 61 postflight nights.

Despite having the same “sleep opportunity” in space as on earth, the astronauts were on average sleeping an hour less each night during the space mission compared with when on earth before or after their mission (5.7 vs. 6.7 hours; P < .0001). In space, the astronauts also spent significantly more time awake in bed, leading to a 17.7% reduction in sleep efficiency.

Sleep architecture was also affected by spaceflight. In space, the time in non–rapid eye movement (non–REM) and REM sleep decreased by 14.1% and 25.8%, respectively. On average, it took about 90 minutes after falling asleep for astronauts to reach their first episode of REM sleep in space – nearly 1.5 times longer than on earth. “There were marked shifts in sleep architecture compared to baseline, and some of these evolved over the course of the mission,” said Mr. Piltch.

“Our findings were consistent with previous studies that focus on the issue of sleep continuity. We found significant decreases in sleep efficiency during spaceflight despite similar times in bed,” he noted.

Mr. Piltch said it’s important to understand how sleep is affected by spaceflight in order to better equip astronauts for success on long-duration flights, such as a trip to Mars or the Moon. He also pointed to a recent study in the Lancet Neurology that showed that 78% of the international space station crew take hypnotics on 52% of nights in space. “So it doesn’t look like they sleep very well in space,” he said.
 

High-stakes environment

Reached for comment, Camilo A. Ruiz, DO, medical director, Choice Physicians Sleep Center, Fort Lauderdale, Fla., said the findings add to the “limited” data currently available on sleep in space and microgravity. “To a certain point, the results of this study could have been expected since sleep continuity and sleep architecture disruption is present during stressful periods of human life or in changes to the sleep rituals we hold dear, such as our beds and quiet bedrooms,” said Dr. Ruiz, who was not involved in the study.

“The potential harm to astronauts from their sleep continuity and deranged sleep architecture is that the decreased alertness, performance, vigilance, and psychomotor skills they exhibit in that high-stakes environment such as space flight can lead to serious accidents that can jeopardize the safety of the crew and vessel,” Dr. Ruiz noted.

“These research areas are on the forefront of space medicine that will allow mankind to lead successful interplanetary missions and colonization of these planets with long-term resident astronauts,” he added.

The study was supported by funding from the Mary Gordon Roberts Fellowship, the National Academy of Sciences, the National Institute of Mental Health, the MacArthur Foundation Mind-Body Network, and Healthdyne Technologies. Mr. Piltch and Dr. Ruiz have no disclosed no relevant financial relationships.
 

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

Magnetic seizure therapy (MST) appears to be a viable alternative to electroconvulsive therapy (ECT) in reducing suicide risk in patients with treatment-resistant depression (TRD), early research suggests.

In a single-center, open-label study, MST produced complete remission from suicidality in almost half of the patients who received the treatment.

“The results are promising,” lead author Cory R. Weissman, MD, Centre for Addiction and Mental Health, University of Toronto, told Medscape Medical News.

“The field needs new ways of approaching suicidality because it’s becoming a bigger issue and a major concern, especially now with COVID. These are early but promising results that need to be followed up,” Weissman said.

The study was published online August 18 in JAMA Network Open.
 

Fewer side effects, less stigma

MST is similar to ECT, which is an effective treatment for suicidality in mood disorders. However, ECT is underutilized – fewer than 1% of patients with TRD receive the treatment – because of stigma and/or a perceived risk of cognitive adverse effects, he said.

“MST is a focal magnetic pulse that leads to discharge or depolarization within the frontal lobe of the brain with the goal of inducing a seizure. It works quite similarly to ECT, which we know is quite a good anti-suicidal treatment, especially in depression,” Weissman explained

However, MST has fewer side effects, particularly on cognition, and less stigma compared to ECT. It also has a different mechanism of action, with a “more focal treatment target in the brain than ECT to induce seizures,” Weissman said.

The Toronto group has been studying MST in various mood disorders for several years. As previously reported by Medscape Medical News, MST is effective in reducing suicidal thoughts in treatment-resistant bipolar disorder. 

The current study is a post hoc secondary analysis of data from the group’s original trial of MST as a treatment for treatment resistant depression in patients initially referred for ECT. The trial ran from February 2012 through June 2019 and with a post-treatment 6-month follow-up.

The secondary analysis was performed from January 2019 to November 2019.

The secondary analysis included 67 patients who underwent MST 2 to 3 times per week until they achieved remission from a depressive episode or until they reached a maximum of 24 sessions. All had baseline suicidality, as defined by a score greater than 0 on the Beck Scale for Suicidal Ideation (Beck SSI).

MST was administered using the MagPro MST device with Twin Coil-XS (MagVenture) applied over the frontal cortex at 100% machine output with low (25 Hz), moderate (50 or 60 Hz), or high (100 Hz) frequency.

“It’s very similar to ECT. The actual seizure lasts about a minute or two, and patients recover in about 10 to 15 minutes and they go home afterwards,” Weissman said.

The main outcome was remission from suicidality as measured by an end-point score of 0 on the Beck SSI. Of the 67 patients, 32 (47.8%) achieved remission from suicidality.

Low and moderate frequencies appeared to be more effective for suicidality; 16 of 29 patients (55.2%) receiving low frequency MST achieved remission, as did 12 of 22 patients (54.5%) receiving moderate frequency MST. Four of 16 patients (25%) who received high frequency MST achieved remission from suicidality.
 

A “valuable contribution”

Commenting on the findings for Medscape Medical News, Manish K. Jha, MD, Icahn School of Medicine at Mount Sinai in New York City, said there is an urgent need to develop safe and effective treatment for patients with treatment-resistant depression (TRD).

“The Sequenced Treatment Alternative to Relieve Depression (STAR*D) trial showed that after inadequate improvement with two antidepressants, the likelihood of improvement with a third or fourth antidepressant trial was very low. Therefore, we need effective treatment for TRD,” noted Jha, who was not involved in the research.

The current study represents a “valuable contribution, as it shows improvement in suicidal ideation with magnetic seizure therapy,” he added.

The study’s findings suggest that MST may offer a “viable new treatment” for patients with TRD. He added that the upcoming results of an ongoing clinical trial testing MST against ECT are of “great interest to the field.”

Although the findings are compelling, Jha also noted the study had several limitations, include a relatively “modest” sample size and no sham or active comparator.

In addition, he said, the level of suicidality in this study was limited because of eligibility restrictions, such as exclusion of individuals who had attempted suicide in the prior 6 months.

“While authors use a broad term of ‘suicidality,’ their study is focused on suicidal ideation. Future studies that target suicide behavior are urgently needed. This may mean that we need to study individuals with recent suicide attempts in settings such as emergency rooms and inpatient units,” said Jha.

The study had no specific funding. Weissman has disclosed no relevant financial relationships. Several other study authors reported relationships with industry. The full list can be found with the original article. Jha has received contract research grants from Acadia Pharmaceuticals and Janssen Research & Development, and honoraria for CME presentations from North American Center for Continuing Medical Education and Global Medical Education.

This article first appeared on Medscape.com.

Magnetic seizure therapy (MST) appears to be a viable alternative to electroconvulsive therapy (ECT) in reducing suicide risk in patients with treatment-resistant depression (TRD), early research suggests.

In a single-center, open-label study, MST produced complete remission from suicidality in almost half of the patients who received the treatment.

“The results are promising,” lead author Cory R. Weissman, MD, Centre for Addiction and Mental Health, University of Toronto, told Medscape Medical News.

“The field needs new ways of approaching suicidality because it’s becoming a bigger issue and a major concern, especially now with COVID. These are early but promising results that need to be followed up,” Weissman said.

The study was published online August 18 in JAMA Network Open.
 

Fewer side effects, less stigma

MST is similar to ECT, which is an effective treatment for suicidality in mood disorders. However, ECT is underutilized – fewer than 1% of patients with TRD receive the treatment – because of stigma and/or a perceived risk of cognitive adverse effects, he said.

“MST is a focal magnetic pulse that leads to discharge or depolarization within the frontal lobe of the brain with the goal of inducing a seizure. It works quite similarly to ECT, which we know is quite a good anti-suicidal treatment, especially in depression,” Weissman explained

However, MST has fewer side effects, particularly on cognition, and less stigma compared to ECT. It also has a different mechanism of action, with a “more focal treatment target in the brain than ECT to induce seizures,” Weissman said.

The Toronto group has been studying MST in various mood disorders for several years. As previously reported by Medscape Medical News, MST is effective in reducing suicidal thoughts in treatment-resistant bipolar disorder. 

The current study is a post hoc secondary analysis of data from the group’s original trial of MST as a treatment for treatment resistant depression in patients initially referred for ECT. The trial ran from February 2012 through June 2019 and with a post-treatment 6-month follow-up.

The secondary analysis was performed from January 2019 to November 2019.

The secondary analysis included 67 patients who underwent MST 2 to 3 times per week until they achieved remission from a depressive episode or until they reached a maximum of 24 sessions. All had baseline suicidality, as defined by a score greater than 0 on the Beck Scale for Suicidal Ideation (Beck SSI).

MST was administered using the MagPro MST device with Twin Coil-XS (MagVenture) applied over the frontal cortex at 100% machine output with low (25 Hz), moderate (50 or 60 Hz), or high (100 Hz) frequency.

“It’s very similar to ECT. The actual seizure lasts about a minute or two, and patients recover in about 10 to 15 minutes and they go home afterwards,” Weissman said.

The main outcome was remission from suicidality as measured by an end-point score of 0 on the Beck SSI. Of the 67 patients, 32 (47.8%) achieved remission from suicidality.

Low and moderate frequencies appeared to be more effective for suicidality; 16 of 29 patients (55.2%) receiving low frequency MST achieved remission, as did 12 of 22 patients (54.5%) receiving moderate frequency MST. Four of 16 patients (25%) who received high frequency MST achieved remission from suicidality.
 

A “valuable contribution”

Commenting on the findings for Medscape Medical News, Manish K. Jha, MD, Icahn School of Medicine at Mount Sinai in New York City, said there is an urgent need to develop safe and effective treatment for patients with treatment-resistant depression (TRD).

“The Sequenced Treatment Alternative to Relieve Depression (STAR*D) trial showed that after inadequate improvement with two antidepressants, the likelihood of improvement with a third or fourth antidepressant trial was very low. Therefore, we need effective treatment for TRD,” noted Jha, who was not involved in the research.

The current study represents a “valuable contribution, as it shows improvement in suicidal ideation with magnetic seizure therapy,” he added.

The study’s findings suggest that MST may offer a “viable new treatment” for patients with TRD. He added that the upcoming results of an ongoing clinical trial testing MST against ECT are of “great interest to the field.”

Although the findings are compelling, Jha also noted the study had several limitations, include a relatively “modest” sample size and no sham or active comparator.

In addition, he said, the level of suicidality in this study was limited because of eligibility restrictions, such as exclusion of individuals who had attempted suicide in the prior 6 months.

“While authors use a broad term of ‘suicidality,’ their study is focused on suicidal ideation. Future studies that target suicide behavior are urgently needed. This may mean that we need to study individuals with recent suicide attempts in settings such as emergency rooms and inpatient units,” said Jha.

The study had no specific funding. Weissman has disclosed no relevant financial relationships. Several other study authors reported relationships with industry. The full list can be found with the original article. Jha has received contract research grants from Acadia Pharmaceuticals and Janssen Research & Development, and honoraria for CME presentations from North American Center for Continuing Medical Education and Global Medical Education.

This article first appeared on Medscape.com.

Magnetic seizure therapy (MST) appears to be a viable alternative to electroconvulsive therapy (ECT) in reducing suicide risk in patients with treatment-resistant depression (TRD), early research suggests.

In a single-center, open-label study, MST produced complete remission from suicidality in almost half of the patients who received the treatment.

“The results are promising,” lead author Cory R. Weissman, MD, Centre for Addiction and Mental Health, University of Toronto, told Medscape Medical News.

“The field needs new ways of approaching suicidality because it’s becoming a bigger issue and a major concern, especially now with COVID. These are early but promising results that need to be followed up,” Weissman said.

The study was published online August 18 in JAMA Network Open.
 

Fewer side effects, less stigma

MST is similar to ECT, which is an effective treatment for suicidality in mood disorders. However, ECT is underutilized – fewer than 1% of patients with TRD receive the treatment – because of stigma and/or a perceived risk of cognitive adverse effects, he said.

“MST is a focal magnetic pulse that leads to discharge or depolarization within the frontal lobe of the brain with the goal of inducing a seizure. It works quite similarly to ECT, which we know is quite a good anti-suicidal treatment, especially in depression,” Weissman explained

However, MST has fewer side effects, particularly on cognition, and less stigma compared to ECT. It also has a different mechanism of action, with a “more focal treatment target in the brain than ECT to induce seizures,” Weissman said.

The Toronto group has been studying MST in various mood disorders for several years. As previously reported by Medscape Medical News, MST is effective in reducing suicidal thoughts in treatment-resistant bipolar disorder. 

The current study is a post hoc secondary analysis of data from the group’s original trial of MST as a treatment for treatment resistant depression in patients initially referred for ECT. The trial ran from February 2012 through June 2019 and with a post-treatment 6-month follow-up.

The secondary analysis was performed from January 2019 to November 2019.

The secondary analysis included 67 patients who underwent MST 2 to 3 times per week until they achieved remission from a depressive episode or until they reached a maximum of 24 sessions. All had baseline suicidality, as defined by a score greater than 0 on the Beck Scale for Suicidal Ideation (Beck SSI).

MST was administered using the MagPro MST device with Twin Coil-XS (MagVenture) applied over the frontal cortex at 100% machine output with low (25 Hz), moderate (50 or 60 Hz), or high (100 Hz) frequency.

“It’s very similar to ECT. The actual seizure lasts about a minute or two, and patients recover in about 10 to 15 minutes and they go home afterwards,” Weissman said.

The main outcome was remission from suicidality as measured by an end-point score of 0 on the Beck SSI. Of the 67 patients, 32 (47.8%) achieved remission from suicidality.

Low and moderate frequencies appeared to be more effective for suicidality; 16 of 29 patients (55.2%) receiving low frequency MST achieved remission, as did 12 of 22 patients (54.5%) receiving moderate frequency MST. Four of 16 patients (25%) who received high frequency MST achieved remission from suicidality.
 

A “valuable contribution”

Commenting on the findings for Medscape Medical News, Manish K. Jha, MD, Icahn School of Medicine at Mount Sinai in New York City, said there is an urgent need to develop safe and effective treatment for patients with treatment-resistant depression (TRD).

“The Sequenced Treatment Alternative to Relieve Depression (STAR*D) trial showed that after inadequate improvement with two antidepressants, the likelihood of improvement with a third or fourth antidepressant trial was very low. Therefore, we need effective treatment for TRD,” noted Jha, who was not involved in the research.

The current study represents a “valuable contribution, as it shows improvement in suicidal ideation with magnetic seizure therapy,” he added.

The study’s findings suggest that MST may offer a “viable new treatment” for patients with TRD. He added that the upcoming results of an ongoing clinical trial testing MST against ECT are of “great interest to the field.”

Although the findings are compelling, Jha also noted the study had several limitations, include a relatively “modest” sample size and no sham or active comparator.

In addition, he said, the level of suicidality in this study was limited because of eligibility restrictions, such as exclusion of individuals who had attempted suicide in the prior 6 months.

“While authors use a broad term of ‘suicidality,’ their study is focused on suicidal ideation. Future studies that target suicide behavior are urgently needed. This may mean that we need to study individuals with recent suicide attempts in settings such as emergency rooms and inpatient units,” said Jha.

The study had no specific funding. Weissman has disclosed no relevant financial relationships. Several other study authors reported relationships with industry. The full list can be found with the original article. Jha has received contract research grants from Acadia Pharmaceuticals and Janssen Research & Development, and honoraria for CME presentations from North American Center for Continuing Medical Education and Global Medical Education.

This article first appeared on Medscape.com.

SSRIs effectively treat depression following intracerebral hemorrhage (ICH) but also increase risk for recurrent hemorrhagic stroke, particularly in patients at high risk for repeat ICH, new research indicates.

“Clinicians must exercise judgment when weighing the use of SSRIs for ICH survivors in the high risk category – especially those with multiple ICH events,” study investigator Alessandro Biffi, MD, director, Aging and Brain Health Research (ABHR) Group, Departments of Neurology and Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, told Medscape Medical News.

The study was published online August 31 in JAMA Neurology.
 

Risks and benefits

Depression is common following stroke. SSRIs are generally considered first-line treatment for post-stroke depression but are associated with increased risk for first ICH, most likely owing to their antithrombotic effects. Less is known about SSRI use and recurrent ICH risk.

To investigate, Biffi and colleagues followed 1,279 adults (mean age, 71.3 years) for a median of 53.2 months (4.5 years) following primary ICH; 602 were women, 1049 were White, 89 Black, 77 Hispanic, and 64 were other race/ethnicity.

During follow-up, 128 adults suffered recurrent ICH (annual rate, 4.2%) and 766 (60%) were diagnosed with depression.

In multivariable analyses, SSRIs were associated with an increased likelihood of post-ICH depression remission (subhazard ratio, 1.53; 95% CI, 1.12-2.09; P = .009).

However, SSRI use was also an independent risk factor for recurrent ICH (SHR, 1.31; 95% CI, 1.08-1.59; P = .006).

High SSRI dose was associated with higher ICH recurrence risk (SHR, 1.61; 95% CI, 1.15-2.25), with a larger effect size (comparison P = .02) than low SSRI dose (SHR, 1.25; 95% CI, 1.01-1.55), but there was no difference in depression remission comparing low vs. high SSRI dose.

Among individuals at high risk for recurrent ICH, SSRI use was associated with further increased risk for ICH recurrence (SHR, 1.79; 95% CI, 1.22 - 2.64) compared with all other survivors of ICH (SHR, 1.20; 95% CI, 1.01-1.42; P = .008 for comparison of effect sizes).

These higher-risk subgroups included carriers of the APOE e2/e4 alleles, patients with lobar ICH, patients with prior ICH, and minority participants.

“Our analyses identified patients for whom the risks are higher, and therefore additional thought is warranted. This approach may in the future lead to personalized/precision medicine approaches to determining whether these patients should receive SSRIs or not,” said Biffi.
 

Experts weigh in

Commenting on the research for Medscape Medical News, Daniel G. Hackam, MD, division of clinical pharmacology, Western University, London, Ont., said the study is “an important contribution to the literature, as there are to date no data on the risk of ICH in prior ICH survivors in relation to SSRI exposure.”

“The bottom line is that I would be very cautious about initiating SSRIs in patients with a history of ICH,” said Hackam, who was not involved with the study.

“There are other nonserotonergic antidepressants that could be used instead, which do not inhibit platelet function. There was still a risk even in the lower-risk ICH survivors. ICH is a highly recurrent disease. We already avoid antiplatelets, anticoagulants, and high dose statins in these patients. I would add SSRI’s to that list, based on this study,” said Hackam.

Also weighing in, Amytis Towfighi, MD, associate professor of neurology, University of Southern California, Los Angeles, said this study addresses a “common clinical dilemma: how to manage depression among individuals with ICH, given the high risk of recurrent ICH among ICH survivors and potential for SSRIs to increase that risk. This scenario is common, and a source of debate for practicing clinicians.”

“The authors conducted an elegant study,” said Towfighi, by considering sociodemographic, historical, imaging, and genetic factors.

“One must interpret this study with caution as it is a single-center cohort study. However, it provides the most rigorous information to date regarding the associations between SSRI use and recurrent ICH,” she told Medscape Medical News.

The study was supported by the National Institutes of Health. Biffi, Hackam, and Towfighi have disclosed no relevant financial relationships.

This article first appeared on Medscape.com.

SSRIs effectively treat depression following intracerebral hemorrhage (ICH) but also increase risk for recurrent hemorrhagic stroke, particularly in patients at high risk for repeat ICH, new research indicates.

“Clinicians must exercise judgment when weighing the use of SSRIs for ICH survivors in the high risk category – especially those with multiple ICH events,” study investigator Alessandro Biffi, MD, director, Aging and Brain Health Research (ABHR) Group, Departments of Neurology and Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, told Medscape Medical News.

The study was published online August 31 in JAMA Neurology.
 

Risks and benefits

Depression is common following stroke. SSRIs are generally considered first-line treatment for post-stroke depression but are associated with increased risk for first ICH, most likely owing to their antithrombotic effects. Less is known about SSRI use and recurrent ICH risk.

To investigate, Biffi and colleagues followed 1,279 adults (mean age, 71.3 years) for a median of 53.2 months (4.5 years) following primary ICH; 602 were women, 1049 were White, 89 Black, 77 Hispanic, and 64 were other race/ethnicity.

During follow-up, 128 adults suffered recurrent ICH (annual rate, 4.2%) and 766 (60%) were diagnosed with depression.

In multivariable analyses, SSRIs were associated with an increased likelihood of post-ICH depression remission (subhazard ratio, 1.53; 95% CI, 1.12-2.09; P = .009).

However, SSRI use was also an independent risk factor for recurrent ICH (SHR, 1.31; 95% CI, 1.08-1.59; P = .006).

High SSRI dose was associated with higher ICH recurrence risk (SHR, 1.61; 95% CI, 1.15-2.25), with a larger effect size (comparison P = .02) than low SSRI dose (SHR, 1.25; 95% CI, 1.01-1.55), but there was no difference in depression remission comparing low vs. high SSRI dose.

Among individuals at high risk for recurrent ICH, SSRI use was associated with further increased risk for ICH recurrence (SHR, 1.79; 95% CI, 1.22 - 2.64) compared with all other survivors of ICH (SHR, 1.20; 95% CI, 1.01-1.42; P = .008 for comparison of effect sizes).

These higher-risk subgroups included carriers of the APOE e2/e4 alleles, patients with lobar ICH, patients with prior ICH, and minority participants.

“Our analyses identified patients for whom the risks are higher, and therefore additional thought is warranted. This approach may in the future lead to personalized/precision medicine approaches to determining whether these patients should receive SSRIs or not,” said Biffi.
 

Experts weigh in

Commenting on the research for Medscape Medical News, Daniel G. Hackam, MD, division of clinical pharmacology, Western University, London, Ont., said the study is “an important contribution to the literature, as there are to date no data on the risk of ICH in prior ICH survivors in relation to SSRI exposure.”

“The bottom line is that I would be very cautious about initiating SSRIs in patients with a history of ICH,” said Hackam, who was not involved with the study.

“There are other nonserotonergic antidepressants that could be used instead, which do not inhibit platelet function. There was still a risk even in the lower-risk ICH survivors. ICH is a highly recurrent disease. We already avoid antiplatelets, anticoagulants, and high dose statins in these patients. I would add SSRI’s to that list, based on this study,” said Hackam.

Also weighing in, Amytis Towfighi, MD, associate professor of neurology, University of Southern California, Los Angeles, said this study addresses a “common clinical dilemma: how to manage depression among individuals with ICH, given the high risk of recurrent ICH among ICH survivors and potential for SSRIs to increase that risk. This scenario is common, and a source of debate for practicing clinicians.”

“The authors conducted an elegant study,” said Towfighi, by considering sociodemographic, historical, imaging, and genetic factors.

“One must interpret this study with caution as it is a single-center cohort study. However, it provides the most rigorous information to date regarding the associations between SSRI use and recurrent ICH,” she told Medscape Medical News.

The study was supported by the National Institutes of Health. Biffi, Hackam, and Towfighi have disclosed no relevant financial relationships.

This article first appeared on Medscape.com.

SSRIs effectively treat depression following intracerebral hemorrhage (ICH) but also increase risk for recurrent hemorrhagic stroke, particularly in patients at high risk for repeat ICH, new research indicates.

“Clinicians must exercise judgment when weighing the use of SSRIs for ICH survivors in the high risk category – especially those with multiple ICH events,” study investigator Alessandro Biffi, MD, director, Aging and Brain Health Research (ABHR) Group, Departments of Neurology and Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, told Medscape Medical News.

The study was published online August 31 in JAMA Neurology.
 

Risks and benefits

Depression is common following stroke. SSRIs are generally considered first-line treatment for post-stroke depression but are associated with increased risk for first ICH, most likely owing to their antithrombotic effects. Less is known about SSRI use and recurrent ICH risk.

To investigate, Biffi and colleagues followed 1,279 adults (mean age, 71.3 years) for a median of 53.2 months (4.5 years) following primary ICH; 602 were women, 1049 were White, 89 Black, 77 Hispanic, and 64 were other race/ethnicity.

During follow-up, 128 adults suffered recurrent ICH (annual rate, 4.2%) and 766 (60%) were diagnosed with depression.

In multivariable analyses, SSRIs were associated with an increased likelihood of post-ICH depression remission (subhazard ratio, 1.53; 95% CI, 1.12-2.09; P = .009).

However, SSRI use was also an independent risk factor for recurrent ICH (SHR, 1.31; 95% CI, 1.08-1.59; P = .006).

High SSRI dose was associated with higher ICH recurrence risk (SHR, 1.61; 95% CI, 1.15-2.25), with a larger effect size (comparison P = .02) than low SSRI dose (SHR, 1.25; 95% CI, 1.01-1.55), but there was no difference in depression remission comparing low vs. high SSRI dose.

Among individuals at high risk for recurrent ICH, SSRI use was associated with further increased risk for ICH recurrence (SHR, 1.79; 95% CI, 1.22 - 2.64) compared with all other survivors of ICH (SHR, 1.20; 95% CI, 1.01-1.42; P = .008 for comparison of effect sizes).

These higher-risk subgroups included carriers of the APOE e2/e4 alleles, patients with lobar ICH, patients with prior ICH, and minority participants.

“Our analyses identified patients for whom the risks are higher, and therefore additional thought is warranted. This approach may in the future lead to personalized/precision medicine approaches to determining whether these patients should receive SSRIs or not,” said Biffi.
 

Experts weigh in

Commenting on the research for Medscape Medical News, Daniel G. Hackam, MD, division of clinical pharmacology, Western University, London, Ont., said the study is “an important contribution to the literature, as there are to date no data on the risk of ICH in prior ICH survivors in relation to SSRI exposure.”

“The bottom line is that I would be very cautious about initiating SSRIs in patients with a history of ICH,” said Hackam, who was not involved with the study.

“There are other nonserotonergic antidepressants that could be used instead, which do not inhibit platelet function. There was still a risk even in the lower-risk ICH survivors. ICH is a highly recurrent disease. We already avoid antiplatelets, anticoagulants, and high dose statins in these patients. I would add SSRI’s to that list, based on this study,” said Hackam.

Also weighing in, Amytis Towfighi, MD, associate professor of neurology, University of Southern California, Los Angeles, said this study addresses a “common clinical dilemma: how to manage depression among individuals with ICH, given the high risk of recurrent ICH among ICH survivors and potential for SSRIs to increase that risk. This scenario is common, and a source of debate for practicing clinicians.”

“The authors conducted an elegant study,” said Towfighi, by considering sociodemographic, historical, imaging, and genetic factors.

“One must interpret this study with caution as it is a single-center cohort study. However, it provides the most rigorous information to date regarding the associations between SSRI use and recurrent ICH,” she told Medscape Medical News.

The study was supported by the National Institutes of Health. Biffi, Hackam, and Towfighi have disclosed no relevant financial relationships.

This article first appeared on Medscape.com.

Treatment with statins was associated with a reduced risk of a severe or fatal course of COVID-19 by 30%, a meta-analysis of four published studies has shown.

RogerAshford/Thinkstock

In the analysis that included almost 9,000 COVID-19 patients, there was a significantly reduced risk for fatal or severe COVID-19 among patients who were users of statins, compared with nonusers (pooled hazard ratio, 0.70; 95% confidence interval, 0.53-0.94).

Based on the findings, “it may be time we shift our focus to statins as the potential therapeutic options in COVID-19 patients,” authors Syed Shahzad Hasan, PhD, University of Huddersfield (England), and Chia Siang Kow, MPharm, International Medical University, Kuala Lumpur, Malaysia, said in an interview.

The study was published online August 11 in The American Journal of Cardiology.
 

Moderate- to good-quality data

The analysis included four studies published up to July 27 of this year. Eligible studies included those with a cohort or case-control designs, enrolled patients with confirmed COVID-19, and had data available allowing comparison of the risk of severe illness and/or mortality among statin users versus nonusers in adjusted analyses, the authors noted.

The four studies – one of “moderate” quality and three of “good” quality – included a total of 8,990 COVID-19 patients.

In the pooled analysis, there was a significantly reduced risk for fatal or severe COVID-19 with use of statins, compared with non-use of statins (pooled HR, 0.70; 95% CI, 0.53-0.94).

Their findings also “discredited the suggestion of harms with the use of statins in COVID-19 patients,” the authors concluded.

“Since our meta-analysis included a fairly large total number of COVID-19 patients from four studies in which three are large-scale studies that adjusted extensively for multiple potential confounding factors, the findings can be considered reliable,” Dr. Hasan and Mr. Kow wrote in their article.

Based on the results, “moderate- to high-intensity statin therapy is likely to be beneficial” in patients with COVID-19, they said.

However, they cautioned that more data from prospective studies are needed to substantiate the findings and to determine the appropriate regimen for a statin in COVID-19 patients.

Yibin Wang, PhD, of the University of California, Los Angeles, said that “this is a very simple meta-analysis from four published studies which consistently reported a protective or neutral effect of statin usage on mortality or severe complications in COVID-19 patients.”

Although the scope of this meta-analysis was “quite limited, the conclusion was not unexpected, as most of the clinical analysis so far reported supports the benefits or safety of statin usage in COVID-19 patients,” Dr. Wang said in an interview.
 

Nonetheless, questions remain

While there is “almost no dispute” about the safety of continuing statin therapy in COVID-19 patients, it remains to be determined if statin therapy can be implemented as an adjuvant or independent therapy and a part of the standard care for COVID-19 patients regardless of their hyperlipidemia status, said Dr. Wang, who was not associated with Dr. Hasan’s and Mr. Kow’s research.

“While statin usage is associated with several beneficial effects such as anti-inflammation and cytoprotection, these effects are usually observed from long-term usage rather than short-term/acute administration. Therefore, prospective studies and randomized trials should be conducted to test the efficacy of stain usage for COVID-19 patients with mild to severe symptoms,” he noted.

“Considering the excellent record of statins as a safe and cheap drug, it is certainly a worthwhile effort to consider its broad-based usage for COVID-19 in order to lower the overall death and severe complications,” Dr. Wang concluded.

Guillermo Rodriguez-Nava, MD, department of internal medicine, AMITA Health Saint Francis Hospital, Evanston, Ill., is first author on one of the studies included in this meta-analysis.

The retrospective, single-center study found slower progression to death associated with atorvastatin in older patients with COVID-19 admitted to the ICU. 

“Currently, there are hundreds of clinical trials evaluating a wide variety of pharmacological therapies for COVID-19. Unfortunately, these trials take time, and we are getting results in dribs and drabs,” Dr. Rodriguez-Nava said in an interview.

“In the meantime, the best available evidence is observational, and COVID-19 treatment regiments will continue to evolve. Whether atorvastatin is effective against COVID-19 is still under investigation. Nevertheless, clinicians should consider at least continuing them in patients with COVID-19,” he advised.

The study had no specific funding. Dr. Hasan, Mr. Kow, Dr. Wang, and Dr. Rodriguez-Nava disclosed no relationships relevant to this research.

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

Treatment with statins was associated with a reduced risk of a severe or fatal course of COVID-19 by 30%, a meta-analysis of four published studies has shown.

RogerAshford/Thinkstock

In the analysis that included almost 9,000 COVID-19 patients, there was a significantly reduced risk for fatal or severe COVID-19 among patients who were users of statins, compared with nonusers (pooled hazard ratio, 0.70; 95% confidence interval, 0.53-0.94).

Based on the findings, “it may be time we shift our focus to statins as the potential therapeutic options in COVID-19 patients,” authors Syed Shahzad Hasan, PhD, University of Huddersfield (England), and Chia Siang Kow, MPharm, International Medical University, Kuala Lumpur, Malaysia, said in an interview.

The study was published online August 11 in The American Journal of Cardiology.
 

Moderate- to good-quality data

The analysis included four studies published up to July 27 of this year. Eligible studies included those with a cohort or case-control designs, enrolled patients with confirmed COVID-19, and had data available allowing comparison of the risk of severe illness and/or mortality among statin users versus nonusers in adjusted analyses, the authors noted.

The four studies – one of “moderate” quality and three of “good” quality – included a total of 8,990 COVID-19 patients.

In the pooled analysis, there was a significantly reduced risk for fatal or severe COVID-19 with use of statins, compared with non-use of statins (pooled HR, 0.70; 95% CI, 0.53-0.94).

Their findings also “discredited the suggestion of harms with the use of statins in COVID-19 patients,” the authors concluded.

“Since our meta-analysis included a fairly large total number of COVID-19 patients from four studies in which three are large-scale studies that adjusted extensively for multiple potential confounding factors, the findings can be considered reliable,” Dr. Hasan and Mr. Kow wrote in their article.

Based on the results, “moderate- to high-intensity statin therapy is likely to be beneficial” in patients with COVID-19, they said.

However, they cautioned that more data from prospective studies are needed to substantiate the findings and to determine the appropriate regimen for a statin in COVID-19 patients.

Yibin Wang, PhD, of the University of California, Los Angeles, said that “this is a very simple meta-analysis from four published studies which consistently reported a protective or neutral effect of statin usage on mortality or severe complications in COVID-19 patients.”

Although the scope of this meta-analysis was “quite limited, the conclusion was not unexpected, as most of the clinical analysis so far reported supports the benefits or safety of statin usage in COVID-19 patients,” Dr. Wang said in an interview.
 

Nonetheless, questions remain

While there is “almost no dispute” about the safety of continuing statin therapy in COVID-19 patients, it remains to be determined if statin therapy can be implemented as an adjuvant or independent therapy and a part of the standard care for COVID-19 patients regardless of their hyperlipidemia status, said Dr. Wang, who was not associated with Dr. Hasan’s and Mr. Kow’s research.

“While statin usage is associated with several beneficial effects such as anti-inflammation and cytoprotection, these effects are usually observed from long-term usage rather than short-term/acute administration. Therefore, prospective studies and randomized trials should be conducted to test the efficacy of stain usage for COVID-19 patients with mild to severe symptoms,” he noted.

“Considering the excellent record of statins as a safe and cheap drug, it is certainly a worthwhile effort to consider its broad-based usage for COVID-19 in order to lower the overall death and severe complications,” Dr. Wang concluded.

Guillermo Rodriguez-Nava, MD, department of internal medicine, AMITA Health Saint Francis Hospital, Evanston, Ill., is first author on one of the studies included in this meta-analysis.

The retrospective, single-center study found slower progression to death associated with atorvastatin in older patients with COVID-19 admitted to the ICU. 

“Currently, there are hundreds of clinical trials evaluating a wide variety of pharmacological therapies for COVID-19. Unfortunately, these trials take time, and we are getting results in dribs and drabs,” Dr. Rodriguez-Nava said in an interview.

“In the meantime, the best available evidence is observational, and COVID-19 treatment regiments will continue to evolve. Whether atorvastatin is effective against COVID-19 is still under investigation. Nevertheless, clinicians should consider at least continuing them in patients with COVID-19,” he advised.

The study had no specific funding. Dr. Hasan, Mr. Kow, Dr. Wang, and Dr. Rodriguez-Nava disclosed no relationships relevant to this research.

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

Treatment with statins was associated with a reduced risk of a severe or fatal course of COVID-19 by 30%, a meta-analysis of four published studies has shown.

RogerAshford/Thinkstock

In the analysis that included almost 9,000 COVID-19 patients, there was a significantly reduced risk for fatal or severe COVID-19 among patients who were users of statins, compared with nonusers (pooled hazard ratio, 0.70; 95% confidence interval, 0.53-0.94).

Based on the findings, “it may be time we shift our focus to statins as the potential therapeutic options in COVID-19 patients,” authors Syed Shahzad Hasan, PhD, University of Huddersfield (England), and Chia Siang Kow, MPharm, International Medical University, Kuala Lumpur, Malaysia, said in an interview.

The study was published online August 11 in The American Journal of Cardiology.
 

Moderate- to good-quality data

The analysis included four studies published up to July 27 of this year. Eligible studies included those with a cohort or case-control designs, enrolled patients with confirmed COVID-19, and had data available allowing comparison of the risk of severe illness and/or mortality among statin users versus nonusers in adjusted analyses, the authors noted.

The four studies – one of “moderate” quality and three of “good” quality – included a total of 8,990 COVID-19 patients.

In the pooled analysis, there was a significantly reduced risk for fatal or severe COVID-19 with use of statins, compared with non-use of statins (pooled HR, 0.70; 95% CI, 0.53-0.94).

Their findings also “discredited the suggestion of harms with the use of statins in COVID-19 patients,” the authors concluded.

“Since our meta-analysis included a fairly large total number of COVID-19 patients from four studies in which three are large-scale studies that adjusted extensively for multiple potential confounding factors, the findings can be considered reliable,” Dr. Hasan and Mr. Kow wrote in their article.

Based on the results, “moderate- to high-intensity statin therapy is likely to be beneficial” in patients with COVID-19, they said.

However, they cautioned that more data from prospective studies are needed to substantiate the findings and to determine the appropriate regimen for a statin in COVID-19 patients.

Yibin Wang, PhD, of the University of California, Los Angeles, said that “this is a very simple meta-analysis from four published studies which consistently reported a protective or neutral effect of statin usage on mortality or severe complications in COVID-19 patients.”

Although the scope of this meta-analysis was “quite limited, the conclusion was not unexpected, as most of the clinical analysis so far reported supports the benefits or safety of statin usage in COVID-19 patients,” Dr. Wang said in an interview.
 

Nonetheless, questions remain

While there is “almost no dispute” about the safety of continuing statin therapy in COVID-19 patients, it remains to be determined if statin therapy can be implemented as an adjuvant or independent therapy and a part of the standard care for COVID-19 patients regardless of their hyperlipidemia status, said Dr. Wang, who was not associated with Dr. Hasan’s and Mr. Kow’s research.

“While statin usage is associated with several beneficial effects such as anti-inflammation and cytoprotection, these effects are usually observed from long-term usage rather than short-term/acute administration. Therefore, prospective studies and randomized trials should be conducted to test the efficacy of stain usage for COVID-19 patients with mild to severe symptoms,” he noted.

“Considering the excellent record of statins as a safe and cheap drug, it is certainly a worthwhile effort to consider its broad-based usage for COVID-19 in order to lower the overall death and severe complications,” Dr. Wang concluded.

Guillermo Rodriguez-Nava, MD, department of internal medicine, AMITA Health Saint Francis Hospital, Evanston, Ill., is first author on one of the studies included in this meta-analysis.

The retrospective, single-center study found slower progression to death associated with atorvastatin in older patients with COVID-19 admitted to the ICU. 

“Currently, there are hundreds of clinical trials evaluating a wide variety of pharmacological therapies for COVID-19. Unfortunately, these trials take time, and we are getting results in dribs and drabs,” Dr. Rodriguez-Nava said in an interview.

“In the meantime, the best available evidence is observational, and COVID-19 treatment regiments will continue to evolve. Whether atorvastatin is effective against COVID-19 is still under investigation. Nevertheless, clinicians should consider at least continuing them in patients with COVID-19,” he advised.

The study had no specific funding. Dr. Hasan, Mr. Kow, Dr. Wang, and Dr. Rodriguez-Nava disclosed no relationships relevant to this research.

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

Self-employed physicians have the highest salaries, largest homes, and greatest wealth – yet they feel the least fairly compensated, according to an analysis of data from over 17,000 physicians.

A new examination of survey responses from the Medscape Physician Compensation Report 2020, which included information about income, job satisfaction, and more, compared responses from self-employed physicians, independent contractors, and employed physicians.

Income and wealth, benefits, and job satisfaction were compared. From the results of the questionnaire, self-employed physicians stand out among their peers across all categories: They enjoy greater income, wealth, and benefits and appear to be more satisfied by their choice of practice.

“The survey confirms that self-employed is the most satisfying, although the trend in health care is to take employed positions,” said Robert Scroggins, JD, CPA, certified health care business consultant with ScrogginsGreer, Cincinnati. “Doctors who become employees primarily do that to escape the management responsibilities for the practice. It seems to be more a decision to get away from something than to go toward something.”
 

The financial and work picture for self-employed physicians

Self-employed physicians reported the largest salaries for 2019 (average, $360,752), followed by independent contractors ($336,005). Employees reported the lowest average salary ($297,332).

The largest percentage of self-employed physicians (46%) work in an office-based group practice, followed by those in office-based solo practices (30%). Almost two-thirds of self-employed respondents are owners and 37% are partners.

Self-employed physicians are more likely to be older than 45 years; 79% fall into that age bracket, compared with 57% of employees and 70% of independent contractors.

Self-employed physicians reported the highest levels of wealth among their peers. About 44% of self-employed respondents declared a net wealth of over $2 million, compared with 25% of employees. Only 6% of contractors and employed physicians reported a net wealth of over $5 million, compared with 13% of self-employed physicians.

Self-employed physicians also managed their personal expenses slightly differently. They were more likely to pool their income with their spouse in a common account used for bills and expenses, regardless of how much they each earned (63% of self-employed respondents, compared with 58% of employees and 50% of independent contractors).

Perhaps unsurprisingly, self-employed physicians also reported having the largest homes, with an average square footage of 3,629 square feet, compared with 3,023 square feet for employees and 2,984 square feet for independent contractors. Self-employed physicians’ mortgages (average, $240,389) were similar to those of employed physicians’ mortgages but were higher than those of independent contractors’ mortgages (average, $213,740).

Self-employed physicians were also most likely to highly appraise their own performance: Half of all self-employed respondents felt “very satisfied” with their job performance, compared with 40% of employees and 44% of independent contractors.

When asked what they consider to be the most rewarding aspect of their job, self-employed physicians were more likely to choose gratitude and patient relationships than their peers (32%, compared with 26% of employees and 19% of independent contractors).

Despite their higher net wealth and larger salaries, self-employed physicians were least likely to feel fairly compensated; 49% of self-employed physicians said they did not feel fairly compensated for their work, compared with 40% of employees and 40% of independent contractors.

“Self-employed physicians may be better compensated than others of the same specialty who are employees, so some of that may be perception,” said Mr. Scroggins. “Or they feel they should be compensated to a far greater degree than those who are employed.”

Self-employed physicians were also more likely to respond that they would choose the same practice setting again, though across all three categories, fewer than 50% of respondents would do so: 34% of self-employed physicians, compared with 29% of employees and 28% of independent contractors.
 

The financial and work picture for employed physicians

About a third (32%) of employed physician respondents work in hospitals; 28% work in private practices.

Employed physicians were most likely to report a salary increase from 2018 to 2019: 74%, compared with 45% of self-employed and 52% of independent contractors.

As for declines in income, self-employed physicians and independent contractors suffered a comparable loss, with 13% and 12% of them, respectively, reporting salary cuts greater than 10%. Decreases of up to 10% were felt mostly by the self-employed, with 17% experiencing such cuts, compared with 7% of employees and 10% of independent contractors.

In contrast, employees were the least likely of the three categories to have incurred large financial losses over the past year: 77% of employed respondents indicated that they had not experienced any significant financial losses in the past year, compared with 63% of self-employed physicians and 63% of independent contractors. They were also least likely to have made any investments at all over the past year – 21% of employees reported having made none at all in 2019, compared to 11% of self-employed physicians and 16% of independent contractors.
 

The financial and work picture for independent contractors

Just over half (52%) of all independent contractors who responded to our questionnaire work in hospitals, 15% work in group practices, 9% work in outpatient clinics, and just 2% work in solo practices.

Independent contractors were less likely than their peers to have received employment benefits such as health insurance, malpractice coverage, and paid time off. They were also less likely to be saving for retirement. Almost half (45%) of independent contractors said they received no employment benefits at all, compared to 20% of self-employed physicians and just 8% of employees.

What’s more, 27% of independent contractors do not currently put money into a 401(k) retirement account or tax-deferred college savings account on a regular basis, compared with 16% of self-employed physicians and 8% of employees. Similarly, they were less likely to put money into a taxable savings account (39% responded that they do not, compared with 32% of self-employed physicians and 27% of employees).

“Net worth and retirement funding findings do line up with what I’ve observed,” said Mr. Scroggins. “Those who have independent practices as opposed to working for a hospital do tend to more heavily fund retirement plan accounts, which is typically the biggest driver of building net worth.”

Despite the lack of retirement planning, independent contractors were more likely than their peers to derive satisfaction from making money at a job they like (18%, compared with 12% of employees and 11% of self-employed physicians). They’re also far more likely to be in emergency medicine (22% of independent contractors, compared with 3% of self-employed and 5% of employees) or psychiatry (11% of independent contractors, compared with 5% of self-employed and 6% of employees).

Among the three categories of physicians, independent contractors were least likely to say that they would choose the same practice setting again. Across all three categories, fewer than 50% of respondents would do so: 34% of self-employed physicians, compared with 29% of employees and 28% of independent contractors.

Physicians who are considering leaving their own practice for a hospital setting should do so with caution and fully understand what they are getting into, said Mr. Scroggins. “If they’re just looking at compensation, they also should be looking very carefully at retirement plan benefits. If that’s their main method of saving and building net worth, then that’s a dramatic difference.”

And of course, there’s always the intangible value of feeling connected to a practice and its patients: “Physicians got into this line of work to treat patients and help people become healthier, and in hospitals they end up being more disconnected from their patients,” Mr. Scroggins said. “That’s a big factor as well.”

Editor’s note: Only differences that are statistically significant at a 95% confidence level between categories of employment have been included. Of the 13,893 responses included in this analysis, 3,860 physicians identified as self-employed, 9,262 as employees, and 772 as independent contractors.

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

Self-employed physicians have the highest salaries, largest homes, and greatest wealth – yet they feel the least fairly compensated, according to an analysis of data from over 17,000 physicians.

A new examination of survey responses from the Medscape Physician Compensation Report 2020, which included information about income, job satisfaction, and more, compared responses from self-employed physicians, independent contractors, and employed physicians.

Income and wealth, benefits, and job satisfaction were compared. From the results of the questionnaire, self-employed physicians stand out among their peers across all categories: They enjoy greater income, wealth, and benefits and appear to be more satisfied by their choice of practice.

“The survey confirms that self-employed is the most satisfying, although the trend in health care is to take employed positions,” said Robert Scroggins, JD, CPA, certified health care business consultant with ScrogginsGreer, Cincinnati. “Doctors who become employees primarily do that to escape the management responsibilities for the practice. It seems to be more a decision to get away from something than to go toward something.”
 

The financial and work picture for self-employed physicians

Self-employed physicians reported the largest salaries for 2019 (average, $360,752), followed by independent contractors ($336,005). Employees reported the lowest average salary ($297,332).

The largest percentage of self-employed physicians (46%) work in an office-based group practice, followed by those in office-based solo practices (30%). Almost two-thirds of self-employed respondents are owners and 37% are partners.

Self-employed physicians are more likely to be older than 45 years; 79% fall into that age bracket, compared with 57% of employees and 70% of independent contractors.

Self-employed physicians reported the highest levels of wealth among their peers. About 44% of self-employed respondents declared a net wealth of over $2 million, compared with 25% of employees. Only 6% of contractors and employed physicians reported a net wealth of over $5 million, compared with 13% of self-employed physicians.

Self-employed physicians also managed their personal expenses slightly differently. They were more likely to pool their income with their spouse in a common account used for bills and expenses, regardless of how much they each earned (63% of self-employed respondents, compared with 58% of employees and 50% of independent contractors).

Perhaps unsurprisingly, self-employed physicians also reported having the largest homes, with an average square footage of 3,629 square feet, compared with 3,023 square feet for employees and 2,984 square feet for independent contractors. Self-employed physicians’ mortgages (average, $240,389) were similar to those of employed physicians’ mortgages but were higher than those of independent contractors’ mortgages (average, $213,740).

Self-employed physicians were also most likely to highly appraise their own performance: Half of all self-employed respondents felt “very satisfied” with their job performance, compared with 40% of employees and 44% of independent contractors.

When asked what they consider to be the most rewarding aspect of their job, self-employed physicians were more likely to choose gratitude and patient relationships than their peers (32%, compared with 26% of employees and 19% of independent contractors).

Despite their higher net wealth and larger salaries, self-employed physicians were least likely to feel fairly compensated; 49% of self-employed physicians said they did not feel fairly compensated for their work, compared with 40% of employees and 40% of independent contractors.

“Self-employed physicians may be better compensated than others of the same specialty who are employees, so some of that may be perception,” said Mr. Scroggins. “Or they feel they should be compensated to a far greater degree than those who are employed.”

Self-employed physicians were also more likely to respond that they would choose the same practice setting again, though across all three categories, fewer than 50% of respondents would do so: 34% of self-employed physicians, compared with 29% of employees and 28% of independent contractors.
 

The financial and work picture for employed physicians

About a third (32%) of employed physician respondents work in hospitals; 28% work in private practices.

Employed physicians were most likely to report a salary increase from 2018 to 2019: 74%, compared with 45% of self-employed and 52% of independent contractors.

As for declines in income, self-employed physicians and independent contractors suffered a comparable loss, with 13% and 12% of them, respectively, reporting salary cuts greater than 10%. Decreases of up to 10% were felt mostly by the self-employed, with 17% experiencing such cuts, compared with 7% of employees and 10% of independent contractors.

In contrast, employees were the least likely of the three categories to have incurred large financial losses over the past year: 77% of employed respondents indicated that they had not experienced any significant financial losses in the past year, compared with 63% of self-employed physicians and 63% of independent contractors. They were also least likely to have made any investments at all over the past year – 21% of employees reported having made none at all in 2019, compared to 11% of self-employed physicians and 16% of independent contractors.
 

The financial and work picture for independent contractors

Just over half (52%) of all independent contractors who responded to our questionnaire work in hospitals, 15% work in group practices, 9% work in outpatient clinics, and just 2% work in solo practices.

Independent contractors were less likely than their peers to have received employment benefits such as health insurance, malpractice coverage, and paid time off. They were also less likely to be saving for retirement. Almost half (45%) of independent contractors said they received no employment benefits at all, compared to 20% of self-employed physicians and just 8% of employees.

What’s more, 27% of independent contractors do not currently put money into a 401(k) retirement account or tax-deferred college savings account on a regular basis, compared with 16% of self-employed physicians and 8% of employees. Similarly, they were less likely to put money into a taxable savings account (39% responded that they do not, compared with 32% of self-employed physicians and 27% of employees).

“Net worth and retirement funding findings do line up with what I’ve observed,” said Mr. Scroggins. “Those who have independent practices as opposed to working for a hospital do tend to more heavily fund retirement plan accounts, which is typically the biggest driver of building net worth.”

Despite the lack of retirement planning, independent contractors were more likely than their peers to derive satisfaction from making money at a job they like (18%, compared with 12% of employees and 11% of self-employed physicians). They’re also far more likely to be in emergency medicine (22% of independent contractors, compared with 3% of self-employed and 5% of employees) or psychiatry (11% of independent contractors, compared with 5% of self-employed and 6% of employees).

Among the three categories of physicians, independent contractors were least likely to say that they would choose the same practice setting again. Across all three categories, fewer than 50% of respondents would do so: 34% of self-employed physicians, compared with 29% of employees and 28% of independent contractors.

Physicians who are considering leaving their own practice for a hospital setting should do so with caution and fully understand what they are getting into, said Mr. Scroggins. “If they’re just looking at compensation, they also should be looking very carefully at retirement plan benefits. If that’s their main method of saving and building net worth, then that’s a dramatic difference.”

And of course, there’s always the intangible value of feeling connected to a practice and its patients: “Physicians got into this line of work to treat patients and help people become healthier, and in hospitals they end up being more disconnected from their patients,” Mr. Scroggins said. “That’s a big factor as well.”

Editor’s note: Only differences that are statistically significant at a 95% confidence level between categories of employment have been included. Of the 13,893 responses included in this analysis, 3,860 physicians identified as self-employed, 9,262 as employees, and 772 as independent contractors.

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

Self-employed physicians have the highest salaries, largest homes, and greatest wealth – yet they feel the least fairly compensated, according to an analysis of data from over 17,000 physicians.

A new examination of survey responses from the Medscape Physician Compensation Report 2020, which included information about income, job satisfaction, and more, compared responses from self-employed physicians, independent contractors, and employed physicians.

Income and wealth, benefits, and job satisfaction were compared. From the results of the questionnaire, self-employed physicians stand out among their peers across all categories: They enjoy greater income, wealth, and benefits and appear to be more satisfied by their choice of practice.

“The survey confirms that self-employed is the most satisfying, although the trend in health care is to take employed positions,” said Robert Scroggins, JD, CPA, certified health care business consultant with ScrogginsGreer, Cincinnati. “Doctors who become employees primarily do that to escape the management responsibilities for the practice. It seems to be more a decision to get away from something than to go toward something.”
 

The financial and work picture for self-employed physicians

Self-employed physicians reported the largest salaries for 2019 (average, $360,752), followed by independent contractors ($336,005). Employees reported the lowest average salary ($297,332).

The largest percentage of self-employed physicians (46%) work in an office-based group practice, followed by those in office-based solo practices (30%). Almost two-thirds of self-employed respondents are owners and 37% are partners.

Self-employed physicians are more likely to be older than 45 years; 79% fall into that age bracket, compared with 57% of employees and 70% of independent contractors.

Self-employed physicians reported the highest levels of wealth among their peers. About 44% of self-employed respondents declared a net wealth of over $2 million, compared with 25% of employees. Only 6% of contractors and employed physicians reported a net wealth of over $5 million, compared with 13% of self-employed physicians.

Self-employed physicians also managed their personal expenses slightly differently. They were more likely to pool their income with their spouse in a common account used for bills and expenses, regardless of how much they each earned (63% of self-employed respondents, compared with 58% of employees and 50% of independent contractors).

Perhaps unsurprisingly, self-employed physicians also reported having the largest homes, with an average square footage of 3,629 square feet, compared with 3,023 square feet for employees and 2,984 square feet for independent contractors. Self-employed physicians’ mortgages (average, $240,389) were similar to those of employed physicians’ mortgages but were higher than those of independent contractors’ mortgages (average, $213,740).

Self-employed physicians were also most likely to highly appraise their own performance: Half of all self-employed respondents felt “very satisfied” with their job performance, compared with 40% of employees and 44% of independent contractors.

When asked what they consider to be the most rewarding aspect of their job, self-employed physicians were more likely to choose gratitude and patient relationships than their peers (32%, compared with 26% of employees and 19% of independent contractors).

Despite their higher net wealth and larger salaries, self-employed physicians were least likely to feel fairly compensated; 49% of self-employed physicians said they did not feel fairly compensated for their work, compared with 40% of employees and 40% of independent contractors.

“Self-employed physicians may be better compensated than others of the same specialty who are employees, so some of that may be perception,” said Mr. Scroggins. “Or they feel they should be compensated to a far greater degree than those who are employed.”

Self-employed physicians were also more likely to respond that they would choose the same practice setting again, though across all three categories, fewer than 50% of respondents would do so: 34% of self-employed physicians, compared with 29% of employees and 28% of independent contractors.
 

The financial and work picture for employed physicians

About a third (32%) of employed physician respondents work in hospitals; 28% work in private practices.

Employed physicians were most likely to report a salary increase from 2018 to 2019: 74%, compared with 45% of self-employed and 52% of independent contractors.

As for declines in income, self-employed physicians and independent contractors suffered a comparable loss, with 13% and 12% of them, respectively, reporting salary cuts greater than 10%. Decreases of up to 10% were felt mostly by the self-employed, with 17% experiencing such cuts, compared with 7% of employees and 10% of independent contractors.

In contrast, employees were the least likely of the three categories to have incurred large financial losses over the past year: 77% of employed respondents indicated that they had not experienced any significant financial losses in the past year, compared with 63% of self-employed physicians and 63% of independent contractors. They were also least likely to have made any investments at all over the past year – 21% of employees reported having made none at all in 2019, compared to 11% of self-employed physicians and 16% of independent contractors.
 

The financial and work picture for independent contractors

Just over half (52%) of all independent contractors who responded to our questionnaire work in hospitals, 15% work in group practices, 9% work in outpatient clinics, and just 2% work in solo practices.

Independent contractors were less likely than their peers to have received employment benefits such as health insurance, malpractice coverage, and paid time off. They were also less likely to be saving for retirement. Almost half (45%) of independent contractors said they received no employment benefits at all, compared to 20% of self-employed physicians and just 8% of employees.

What’s more, 27% of independent contractors do not currently put money into a 401(k) retirement account or tax-deferred college savings account on a regular basis, compared with 16% of self-employed physicians and 8% of employees. Similarly, they were less likely to put money into a taxable savings account (39% responded that they do not, compared with 32% of self-employed physicians and 27% of employees).

“Net worth and retirement funding findings do line up with what I’ve observed,” said Mr. Scroggins. “Those who have independent practices as opposed to working for a hospital do tend to more heavily fund retirement plan accounts, which is typically the biggest driver of building net worth.”

Despite the lack of retirement planning, independent contractors were more likely than their peers to derive satisfaction from making money at a job they like (18%, compared with 12% of employees and 11% of self-employed physicians). They’re also far more likely to be in emergency medicine (22% of independent contractors, compared with 3% of self-employed and 5% of employees) or psychiatry (11% of independent contractors, compared with 5% of self-employed and 6% of employees).

Among the three categories of physicians, independent contractors were least likely to say that they would choose the same practice setting again. Across all three categories, fewer than 50% of respondents would do so: 34% of self-employed physicians, compared with 29% of employees and 28% of independent contractors.

Physicians who are considering leaving their own practice for a hospital setting should do so with caution and fully understand what they are getting into, said Mr. Scroggins. “If they’re just looking at compensation, they also should be looking very carefully at retirement plan benefits. If that’s their main method of saving and building net worth, then that’s a dramatic difference.”

And of course, there’s always the intangible value of feeling connected to a practice and its patients: “Physicians got into this line of work to treat patients and help people become healthier, and in hospitals they end up being more disconnected from their patients,” Mr. Scroggins said. “That’s a big factor as well.”

Editor’s note: Only differences that are statistically significant at a 95% confidence level between categories of employment have been included. Of the 13,893 responses included in this analysis, 3,860 physicians identified as self-employed, 9,262 as employees, and 772 as independent contractors.

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

In 2019, more than five times as many high school students were using tobacco electronically than smoking actual cigarettes, according to the Centers for Disease Control and Prevention.

From 2015 to 2019, current use of electronic vapor products among students in grades 9-12 rose from 24.1% to 32.7%, while the same level of cigarette use – on 1 or more days in the previous 30 – dropped from 10.8% to 6.0%, based on data from the Youth Risk Behavior Survey.

Among the survey respondents, 50.1% had at least tried an electronic vapor product by 2019, up from 44.9% in 2015. Cigarettes again showed a decline, as ever use fell from 32.3% to 24.1%, or less than half of the e-product prevalence. Everyday use of vaping products was 7.2% in 2019 (up from 2.0% in 2015), compared with 1.1% for cigarettes (down from 2.3%), the YRBS data show.

“The dramatic increase in electronic vapor product use among high school students has led to increases in overall tobacco product use among U.S. youths, erasing gains made in previous years and leading the U.S. Surgeon General to declare youth e-cigarette use an epidemic in the United States,” MeLisa R. Creamer, PhD, and associates at the CDC wrote in the MMWR.

Electronic vapor products, as defined by the survey, “include e-cigarettes, vapes, vape pens, e-cigars, e-hookahs, hookah pens, and mods.”

Current use of cigarettes among high school students, as measured by the YRBS, has been declining since reaching a high of 36.4% in 1997; the prevalence of everyday use peaked at 12.8% in 1999. Current use of cigars declined as well, falling from 17.7% in 1999 to 5.7% in 2019, according to YRBS data.

“In 2019, a total of 36.5% of high school students currently used any tobacco product, with electronic vapor products being the most commonly used product,” Dr. Creamer and associates wrote in their recent analysis of the YRBS data (MMWR Supp. 2020 Aug 21;69[1]:56-63).

For the first time since the use of electronic vapor products was included in the every-other-year survey in 2015, females were more likely than males to be current users of vaping products last year, 33.5% to 32.0%. Males were heavier users of cigarettes by a margin of 6.9% to 4.9%, the CDC reported.

Geographically speaking, use of both electronic vapor products and cigarettes varied considerably among the 43 states with available data. Current use of electronic products ranged from a low of 9.7% in Utah to a high of 35.7% in West Virginia, with the two states in the same positions regarding current cigarette use: Utah (2.2%) lowest and West Virginia (13.5%) highest, based on the 2019 YRBS data.

“Tobacco product usage has evolved, and the increasing prevalence of electronic vapor product use among youths during recent years is concerning,” Dr. Creamer and associates wrote.

[email protected]

In 2019, more than five times as many high school students were using tobacco electronically than smoking actual cigarettes, according to the Centers for Disease Control and Prevention.

From 2015 to 2019, current use of electronic vapor products among students in grades 9-12 rose from 24.1% to 32.7%, while the same level of cigarette use – on 1 or more days in the previous 30 – dropped from 10.8% to 6.0%, based on data from the Youth Risk Behavior Survey.

Among the survey respondents, 50.1% had at least tried an electronic vapor product by 2019, up from 44.9% in 2015. Cigarettes again showed a decline, as ever use fell from 32.3% to 24.1%, or less than half of the e-product prevalence. Everyday use of vaping products was 7.2% in 2019 (up from 2.0% in 2015), compared with 1.1% for cigarettes (down from 2.3%), the YRBS data show.

“The dramatic increase in electronic vapor product use among high school students has led to increases in overall tobacco product use among U.S. youths, erasing gains made in previous years and leading the U.S. Surgeon General to declare youth e-cigarette use an epidemic in the United States,” MeLisa R. Creamer, PhD, and associates at the CDC wrote in the MMWR.

Electronic vapor products, as defined by the survey, “include e-cigarettes, vapes, vape pens, e-cigars, e-hookahs, hookah pens, and mods.”

Current use of cigarettes among high school students, as measured by the YRBS, has been declining since reaching a high of 36.4% in 1997; the prevalence of everyday use peaked at 12.8% in 1999. Current use of cigars declined as well, falling from 17.7% in 1999 to 5.7% in 2019, according to YRBS data.

“In 2019, a total of 36.5% of high school students currently used any tobacco product, with electronic vapor products being the most commonly used product,” Dr. Creamer and associates wrote in their recent analysis of the YRBS data (MMWR Supp. 2020 Aug 21;69[1]:56-63).

For the first time since the use of electronic vapor products was included in the every-other-year survey in 2015, females were more likely than males to be current users of vaping products last year, 33.5% to 32.0%. Males were heavier users of cigarettes by a margin of 6.9% to 4.9%, the CDC reported.

Geographically speaking, use of both electronic vapor products and cigarettes varied considerably among the 43 states with available data. Current use of electronic products ranged from a low of 9.7% in Utah to a high of 35.7% in West Virginia, with the two states in the same positions regarding current cigarette use: Utah (2.2%) lowest and West Virginia (13.5%) highest, based on the 2019 YRBS data.

“Tobacco product usage has evolved, and the increasing prevalence of electronic vapor product use among youths during recent years is concerning,” Dr. Creamer and associates wrote.

[email protected]

In 2019, more than five times as many high school students were using tobacco electronically than smoking actual cigarettes, according to the Centers for Disease Control and Prevention.

From 2015 to 2019, current use of electronic vapor products among students in grades 9-12 rose from 24.1% to 32.7%, while the same level of cigarette use – on 1 or more days in the previous 30 – dropped from 10.8% to 6.0%, based on data from the Youth Risk Behavior Survey.

Among the survey respondents, 50.1% had at least tried an electronic vapor product by 2019, up from 44.9% in 2015. Cigarettes again showed a decline, as ever use fell from 32.3% to 24.1%, or less than half of the e-product prevalence. Everyday use of vaping products was 7.2% in 2019 (up from 2.0% in 2015), compared with 1.1% for cigarettes (down from 2.3%), the YRBS data show.

“The dramatic increase in electronic vapor product use among high school students has led to increases in overall tobacco product use among U.S. youths, erasing gains made in previous years and leading the U.S. Surgeon General to declare youth e-cigarette use an epidemic in the United States,” MeLisa R. Creamer, PhD, and associates at the CDC wrote in the MMWR.

Electronic vapor products, as defined by the survey, “include e-cigarettes, vapes, vape pens, e-cigars, e-hookahs, hookah pens, and mods.”

Current use of cigarettes among high school students, as measured by the YRBS, has been declining since reaching a high of 36.4% in 1997; the prevalence of everyday use peaked at 12.8% in 1999. Current use of cigars declined as well, falling from 17.7% in 1999 to 5.7% in 2019, according to YRBS data.

“In 2019, a total of 36.5% of high school students currently used any tobacco product, with electronic vapor products being the most commonly used product,” Dr. Creamer and associates wrote in their recent analysis of the YRBS data (MMWR Supp. 2020 Aug 21;69[1]:56-63).

For the first time since the use of electronic vapor products was included in the every-other-year survey in 2015, females were more likely than males to be current users of vaping products last year, 33.5% to 32.0%. Males were heavier users of cigarettes by a margin of 6.9% to 4.9%, the CDC reported.

Geographically speaking, use of both electronic vapor products and cigarettes varied considerably among the 43 states with available data. Current use of electronic products ranged from a low of 9.7% in Utah to a high of 35.7% in West Virginia, with the two states in the same positions regarding current cigarette use: Utah (2.2%) lowest and West Virginia (13.5%) highest, based on the 2019 YRBS data.

“Tobacco product usage has evolved, and the increasing prevalence of electronic vapor product use among youths during recent years is concerning,” Dr. Creamer and associates wrote.

[email protected]

Factors including older age and certain comorbidities have been linked to more serious COVID-19 outcomes in previous research, and now a large dataset collected from hundreds of hospitals nationwide provides more detailed data regarding risk for mechanical ventilation and death.

Comorbidities such as cardiovascular disease, chronic kidney disease, and obesity also were associated with more severe COVID-19 outcomes in this observational study of 11,721 adults. History of pulmonary disease or smoking, interestingly, were not.

One expert urges caution when interpreting the results, however. Although the study found a number of risk factors for ventilation and mortality, she says the dataset lacks information on race and disease severity, and the sample may not be nationally representative. 

The investigators hope their level of granularity will further assist researchers searching for effective treatments and clinicians seeking to triage patients during the COVID-19 pandemic.

The study was published online August 28 in Clinical Infectious Diseases.
 

COVID-19 and comorbidities

“What I found most illuminating was this whole concept of comorbid conditions. This provides suggestive data about who we need to worry about most and who we may need to worry about less,” study author Robert S. Brown Jr, MD, MPH, told Medscape Medical News.

Comorbid conditions included hypertension in 47% of patients, diabetes in 28%, and cardiovascular disease in 19%. Another 16% were obese and 12% had chronic kidney disease. People with comorbid obesity, chronic kidney disease, and cardiovascular disease were more likely to receive mechanical ventilation compared to those without a history of these conditions in an adjusted, multivariable logistic analysis.

With the exception of obesity, the same factors were associated with risk for death during hospitalization.

In contrast, hypertension, history of smoking, and history of pulmonary disease were associated with a lower risk of needing mechanical ventilation and/or lower risk for mortality.

Furthermore, people with liver disease, gastrointestinal diseases, and even autoimmune diseases – which are likely associated with immunosuppression – “are not at that much of an increased risk that we noticed it in our data,” Brown said.

“As I tell many of my patients who have mild liver disease, for example, I would rather have mild liver disease and be on immunosuppressant therapy than be an older, obese male,” he added.

Assessing data for people in 38 U.S. states, and not limiting outcomes to patients in a particular COVID-19 hot spot, was a unique aspect of the research, said Brown, clinical chief of the Division of Gastroenterology and Hepatology at Weill Cornell Medicine in New York City.

Brown, lead author Michael W. Fried, MD, from TARGET PharmaSolutions in Durham, North Carolina, and colleagues studied adults from a commercially available Target Real-World Evidence (RWE) dataset of nearly 70,000 patients. They examined hospital chargemaster data and ICD-10 codes for COVID-19 inpatients between February 15 and April 20.

This population tended to be older, with 60% older than 60 years. A little more than half of participants, 53%, were men.
 

Key findings

A total of 21% of patients died after a median hospital length of stay of 8 days.

Older patients were significantly more likely to die, particularly those older than 60 years (P < .0001).

“This confirms some of the things we know about age and its impact on outcome,” Brown said.

The risk for mortality among patients older than 60 years was 7.2 times that of patients between 18 and 40 years in an adjusted multivariate analysis. The risk for death for those between 41 and 60 years of age was lower (odds ratio [OR], 2.6), compared with the youngest cohort.  

Men were more likely to die than women (OR, 1.5).

When asked if he was surprised by the high mortality rates, Brown said, “Having worked here in New York? No, I was not.”
 

Mechanical ventilation and mortality

Male sex, age older than 40 years, obesity, and presence of cardiovascular or chronic kidney disease were risk factors for mechanical ventilation.

Among the nearly 2,000 hospitalized adults requiring mechanical ventilation in the current report, only 27% were discharged alive. “The outcomes of people who are mechanically ventilated are really quite sobering,” Brown said.

People who ever required mechanical ventilation were 32 times more likely to die compared with others whose highest level of oxygenation was low-flow, high-flow, or no-oxygen therapy in an analysis that controlled for demographics and comorbidities.

Furthermore, patients placed on mechanical ventilation earlier – within 24 hours of admission – tended to experience better outcomes.
 

COVID-19 therapies?

Brown and colleagues also evaluated outcomes in patients who were taking either remdesivir or hydroxychloroquine. A total of 48 people were treated with remdesivir.

The four individuals receiving remdesivir who died were among 11 who were taking remdesivir and also on mechanical ventilation.

“The data for remdesivir is very encouraging,” Brown said.

Many more participants were treated with hydroxychloroquine, more than 4,200 or 36% of the total study population.

A higher proportion of people treated with hydroxychloroquine received mechanical ventilation, at 25%, versus 12% not treated with hydroxychloroquine.

The unadjusted mortality rate was also higher among those treated with the agent, at 25%, compared to 20% not receiving hydroxychloroquine.

The data with hydroxychloroquine can lead to two conclusions, Brown said: “One, it doesn’t work. Or two, it doesn’t work in the way that we use it.”

The researchers cautioned that their hydroxychloroquine findings must be interpreted carefully because those treated with the agent were also more likely to have comorbidities and greater COVID-19 disease severity.

“This study greatly contributes to understanding the natural course of COVID-19 infection by describing characteristics and outcomes of patients with COVID-19 hospitalized throughout the US,” the investigators note. “It identified categories of patients at greatest risk for poor outcomes, which should be used to prioritize prevention and treatment strategies in the future.”
 

Some limitations

“The findings that patients with hypertension and who were smokers had lower ventilation rates, and patients with hypertension, pulmonary disease, who were smokers had lower mortality risks was very surprising,” Ninez A. Ponce, PhD, MPP, told Medscape Medical News when asked to comment on the study.

Although the study identified multiple risk factors for ventilation and mortality, “unfortunately the dataset did not have race available or disease severity,” said Ponce, director of the UCLA Center for Health Policy Research and professor in the Department of Health Policy and Management at the UCLA Fielding School of Public Health.

“These omitted variables could have a considerable effect on the significance, magnitude, and direction of point estimates provided, so I would be cautious in interpreting the results as a picture of a nationally representative sample,” she said.

On a positive note, the study and dataset could illuminate the utility of medications used to treat COVID-19, Ponce said. In addition, as the authors note, “the data will expand over time.” 

Brown has reported receiving grants and consulting for Gilead. Ponce has disclosed no relevant financial relationships.
 

This article first appeared on Medscape.com.

Factors including older age and certain comorbidities have been linked to more serious COVID-19 outcomes in previous research, and now a large dataset collected from hundreds of hospitals nationwide provides more detailed data regarding risk for mechanical ventilation and death.

Comorbidities such as cardiovascular disease, chronic kidney disease, and obesity also were associated with more severe COVID-19 outcomes in this observational study of 11,721 adults. History of pulmonary disease or smoking, interestingly, were not.

One expert urges caution when interpreting the results, however. Although the study found a number of risk factors for ventilation and mortality, she says the dataset lacks information on race and disease severity, and the sample may not be nationally representative. 

The investigators hope their level of granularity will further assist researchers searching for effective treatments and clinicians seeking to triage patients during the COVID-19 pandemic.

The study was published online August 28 in Clinical Infectious Diseases.
 

COVID-19 and comorbidities

“What I found most illuminating was this whole concept of comorbid conditions. This provides suggestive data about who we need to worry about most and who we may need to worry about less,” study author Robert S. Brown Jr, MD, MPH, told Medscape Medical News.

Comorbid conditions included hypertension in 47% of patients, diabetes in 28%, and cardiovascular disease in 19%. Another 16% were obese and 12% had chronic kidney disease. People with comorbid obesity, chronic kidney disease, and cardiovascular disease were more likely to receive mechanical ventilation compared to those without a history of these conditions in an adjusted, multivariable logistic analysis.

With the exception of obesity, the same factors were associated with risk for death during hospitalization.

In contrast, hypertension, history of smoking, and history of pulmonary disease were associated with a lower risk of needing mechanical ventilation and/or lower risk for mortality.

Furthermore, people with liver disease, gastrointestinal diseases, and even autoimmune diseases – which are likely associated with immunosuppression – “are not at that much of an increased risk that we noticed it in our data,” Brown said.

“As I tell many of my patients who have mild liver disease, for example, I would rather have mild liver disease and be on immunosuppressant therapy than be an older, obese male,” he added.

Assessing data for people in 38 U.S. states, and not limiting outcomes to patients in a particular COVID-19 hot spot, was a unique aspect of the research, said Brown, clinical chief of the Division of Gastroenterology and Hepatology at Weill Cornell Medicine in New York City.

Brown, lead author Michael W. Fried, MD, from TARGET PharmaSolutions in Durham, North Carolina, and colleagues studied adults from a commercially available Target Real-World Evidence (RWE) dataset of nearly 70,000 patients. They examined hospital chargemaster data and ICD-10 codes for COVID-19 inpatients between February 15 and April 20.

This population tended to be older, with 60% older than 60 years. A little more than half of participants, 53%, were men.
 

Key findings

A total of 21% of patients died after a median hospital length of stay of 8 days.

Older patients were significantly more likely to die, particularly those older than 60 years (P < .0001).

“This confirms some of the things we know about age and its impact on outcome,” Brown said.

The risk for mortality among patients older than 60 years was 7.2 times that of patients between 18 and 40 years in an adjusted multivariate analysis. The risk for death for those between 41 and 60 years of age was lower (odds ratio [OR], 2.6), compared with the youngest cohort.  

Men were more likely to die than women (OR, 1.5).

When asked if he was surprised by the high mortality rates, Brown said, “Having worked here in New York? No, I was not.”
 

Mechanical ventilation and mortality

Male sex, age older than 40 years, obesity, and presence of cardiovascular or chronic kidney disease were risk factors for mechanical ventilation.

Among the nearly 2,000 hospitalized adults requiring mechanical ventilation in the current report, only 27% were discharged alive. “The outcomes of people who are mechanically ventilated are really quite sobering,” Brown said.

People who ever required mechanical ventilation were 32 times more likely to die compared with others whose highest level of oxygenation was low-flow, high-flow, or no-oxygen therapy in an analysis that controlled for demographics and comorbidities.

Furthermore, patients placed on mechanical ventilation earlier – within 24 hours of admission – tended to experience better outcomes.
 

COVID-19 therapies?

Brown and colleagues also evaluated outcomes in patients who were taking either remdesivir or hydroxychloroquine. A total of 48 people were treated with remdesivir.

The four individuals receiving remdesivir who died were among 11 who were taking remdesivir and also on mechanical ventilation.

“The data for remdesivir is very encouraging,” Brown said.

Many more participants were treated with hydroxychloroquine, more than 4,200 or 36% of the total study population.

A higher proportion of people treated with hydroxychloroquine received mechanical ventilation, at 25%, versus 12% not treated with hydroxychloroquine.

The unadjusted mortality rate was also higher among those treated with the agent, at 25%, compared to 20% not receiving hydroxychloroquine.

The data with hydroxychloroquine can lead to two conclusions, Brown said: “One, it doesn’t work. Or two, it doesn’t work in the way that we use it.”

The researchers cautioned that their hydroxychloroquine findings must be interpreted carefully because those treated with the agent were also more likely to have comorbidities and greater COVID-19 disease severity.

“This study greatly contributes to understanding the natural course of COVID-19 infection by describing characteristics and outcomes of patients with COVID-19 hospitalized throughout the US,” the investigators note. “It identified categories of patients at greatest risk for poor outcomes, which should be used to prioritize prevention and treatment strategies in the future.”
 

Some limitations

“The findings that patients with hypertension and who were smokers had lower ventilation rates, and patients with hypertension, pulmonary disease, who were smokers had lower mortality risks was very surprising,” Ninez A. Ponce, PhD, MPP, told Medscape Medical News when asked to comment on the study.

Although the study identified multiple risk factors for ventilation and mortality, “unfortunately the dataset did not have race available or disease severity,” said Ponce, director of the UCLA Center for Health Policy Research and professor in the Department of Health Policy and Management at the UCLA Fielding School of Public Health.

“These omitted variables could have a considerable effect on the significance, magnitude, and direction of point estimates provided, so I would be cautious in interpreting the results as a picture of a nationally representative sample,” she said.

On a positive note, the study and dataset could illuminate the utility of medications used to treat COVID-19, Ponce said. In addition, as the authors note, “the data will expand over time.” 

Brown has reported receiving grants and consulting for Gilead. Ponce has disclosed no relevant financial relationships.
 

This article first appeared on Medscape.com.

Factors including older age and certain comorbidities have been linked to more serious COVID-19 outcomes in previous research, and now a large dataset collected from hundreds of hospitals nationwide provides more detailed data regarding risk for mechanical ventilation and death.

Comorbidities such as cardiovascular disease, chronic kidney disease, and obesity also were associated with more severe COVID-19 outcomes in this observational study of 11,721 adults. History of pulmonary disease or smoking, interestingly, were not.

One expert urges caution when interpreting the results, however. Although the study found a number of risk factors for ventilation and mortality, she says the dataset lacks information on race and disease severity, and the sample may not be nationally representative. 

The investigators hope their level of granularity will further assist researchers searching for effective treatments and clinicians seeking to triage patients during the COVID-19 pandemic.

The study was published online August 28 in Clinical Infectious Diseases.
 

COVID-19 and comorbidities

“What I found most illuminating was this whole concept of comorbid conditions. This provides suggestive data about who we need to worry about most and who we may need to worry about less,” study author Robert S. Brown Jr, MD, MPH, told Medscape Medical News.

Comorbid conditions included hypertension in 47% of patients, diabetes in 28%, and cardiovascular disease in 19%. Another 16% were obese and 12% had chronic kidney disease. People with comorbid obesity, chronic kidney disease, and cardiovascular disease were more likely to receive mechanical ventilation compared to those without a history of these conditions in an adjusted, multivariable logistic analysis.

With the exception of obesity, the same factors were associated with risk for death during hospitalization.

In contrast, hypertension, history of smoking, and history of pulmonary disease were associated with a lower risk of needing mechanical ventilation and/or lower risk for mortality.

Furthermore, people with liver disease, gastrointestinal diseases, and even autoimmune diseases – which are likely associated with immunosuppression – “are not at that much of an increased risk that we noticed it in our data,” Brown said.

“As I tell many of my patients who have mild liver disease, for example, I would rather have mild liver disease and be on immunosuppressant therapy than be an older, obese male,” he added.

Assessing data for people in 38 U.S. states, and not limiting outcomes to patients in a particular COVID-19 hot spot, was a unique aspect of the research, said Brown, clinical chief of the Division of Gastroenterology and Hepatology at Weill Cornell Medicine in New York City.

Brown, lead author Michael W. Fried, MD, from TARGET PharmaSolutions in Durham, North Carolina, and colleagues studied adults from a commercially available Target Real-World Evidence (RWE) dataset of nearly 70,000 patients. They examined hospital chargemaster data and ICD-10 codes for COVID-19 inpatients between February 15 and April 20.

This population tended to be older, with 60% older than 60 years. A little more than half of participants, 53%, were men.
 

Key findings

A total of 21% of patients died after a median hospital length of stay of 8 days.

Older patients were significantly more likely to die, particularly those older than 60 years (P < .0001).

“This confirms some of the things we know about age and its impact on outcome,” Brown said.

The risk for mortality among patients older than 60 years was 7.2 times that of patients between 18 and 40 years in an adjusted multivariate analysis. The risk for death for those between 41 and 60 years of age was lower (odds ratio [OR], 2.6), compared with the youngest cohort.  

Men were more likely to die than women (OR, 1.5).

When asked if he was surprised by the high mortality rates, Brown said, “Having worked here in New York? No, I was not.”
 

Mechanical ventilation and mortality

Male sex, age older than 40 years, obesity, and presence of cardiovascular or chronic kidney disease were risk factors for mechanical ventilation.

Among the nearly 2,000 hospitalized adults requiring mechanical ventilation in the current report, only 27% were discharged alive. “The outcomes of people who are mechanically ventilated are really quite sobering,” Brown said.

People who ever required mechanical ventilation were 32 times more likely to die compared with others whose highest level of oxygenation was low-flow, high-flow, or no-oxygen therapy in an analysis that controlled for demographics and comorbidities.

Furthermore, patients placed on mechanical ventilation earlier – within 24 hours of admission – tended to experience better outcomes.
 

COVID-19 therapies?

Brown and colleagues also evaluated outcomes in patients who were taking either remdesivir or hydroxychloroquine. A total of 48 people were treated with remdesivir.

The four individuals receiving remdesivir who died were among 11 who were taking remdesivir and also on mechanical ventilation.

“The data for remdesivir is very encouraging,” Brown said.

Many more participants were treated with hydroxychloroquine, more than 4,200 or 36% of the total study population.

A higher proportion of people treated with hydroxychloroquine received mechanical ventilation, at 25%, versus 12% not treated with hydroxychloroquine.

The unadjusted mortality rate was also higher among those treated with the agent, at 25%, compared to 20% not receiving hydroxychloroquine.

The data with hydroxychloroquine can lead to two conclusions, Brown said: “One, it doesn’t work. Or two, it doesn’t work in the way that we use it.”

The researchers cautioned that their hydroxychloroquine findings must be interpreted carefully because those treated with the agent were also more likely to have comorbidities and greater COVID-19 disease severity.

“This study greatly contributes to understanding the natural course of COVID-19 infection by describing characteristics and outcomes of patients with COVID-19 hospitalized throughout the US,” the investigators note. “It identified categories of patients at greatest risk for poor outcomes, which should be used to prioritize prevention and treatment strategies in the future.”
 

Some limitations

“The findings that patients with hypertension and who were smokers had lower ventilation rates, and patients with hypertension, pulmonary disease, who were smokers had lower mortality risks was very surprising,” Ninez A. Ponce, PhD, MPP, told Medscape Medical News when asked to comment on the study.

Although the study identified multiple risk factors for ventilation and mortality, “unfortunately the dataset did not have race available or disease severity,” said Ponce, director of the UCLA Center for Health Policy Research and professor in the Department of Health Policy and Management at the UCLA Fielding School of Public Health.

“These omitted variables could have a considerable effect on the significance, magnitude, and direction of point estimates provided, so I would be cautious in interpreting the results as a picture of a nationally representative sample,” she said.

On a positive note, the study and dataset could illuminate the utility of medications used to treat COVID-19, Ponce said. In addition, as the authors note, “the data will expand over time.” 

Brown has reported receiving grants and consulting for Gilead. Ponce has disclosed no relevant financial relationships.
 

This article first appeared on Medscape.com.

Frequent nightmares are independently linked to an increased risk for cardiovascular disease (CVD), new research shows. In what researchers describe as “surprising” findings, results from a large study of relatively young military veterans showed those who had nightmares two or more times per week had significantly increased risks for hypertension, myocardial infarction, or other heart problems.  

“A diagnosis of PTSD incorporates sleep disturbance as a symptom. Thus, we were surprised to find that nightmares continued to be associated with CVD after controlling not only for PTSD and demographic factors, but also smoking and depression diagnosis,” said Christi Ulmer, PhD, of the department of psychiatry and behavioral sciences, Duke University Medical Center, Durham, N.C.

The findings were presented at the virtual annual meeting of the Associated Professional Sleep Societies.
 

Unclear mechanism

The study included 3,468 veterans (77% male) with a mean age of 38 years who had served one or two tours of duty since Sept. 11, 2001. Nearly one-third (31%) met criteria for PTSD, and 33% self-reported having at least one cardiovascular condition, such as heart problems, hypertension, stroke, and MI.

Nightmare frequency and severity was assessed using the Davidson Trauma Scale. Nightmares were considered frequent if they occurred two or more times per week and moderate to severe if they were at least moderately distressing. About 31% of veterans reported having frequent nightmares, and 35% reported moderately distressing nightmares over the past week.

After adjusting for age, race, and sex, frequent nightmares were associated with hypertension (odds ratio, 1.51; 95% confidence interval, 1.28-1.78), heart problems (OR, 1.50; 95% CI, 1.11-2.02), and MI (OR, 2.32; 95% CI, 1.18-4.54).

Associations between frequent nightmares and hypertension (OR, 1.43; 95% CI, 1.17-1.73) and heart problems (OR, 1.43; 95% CI, 1.00-2.05) remained significant after further adjusting for smoking, depression, and PTSD.

“Our cross-sectional findings set the stage for future research examining the possibility that nightmares may confer cardiovascular disease risks beyond those conferred by PTSD diagnosis alone,” Dr. Ulmer said in a news release.

Dr. Ulmer also said that, because the study was based on self-reported data, the findings are “very preliminary.” Before doctors adjust clinical practices, it’s important that our findings be replicated using longitudinal studies, clinically diagnosed medical conditions, and objectively assessed sleep,” she said.

She added that more research is needed to uncover mechanisms explaining these associations and determine if reducing the frequency and severity of nightmares can lead to improved cardiovascular health.
 

Timely research

Reached for comment, Rajkumar (Raj) Dasgupta, MD, of the University of Southern California, Los Angeles, noted “the correlation between nightmares and heart disease is a timely topic right now with COVID-19 as more people may be having nightmares.”

“If a patient mentions nightmares, I do think it’s important not to just glaze over it, but to talk more about it and document it in the patient record, especially in patients with cardiovascular disease, atrial fibrillation, diabetes, and hypertension,” said Dr. Dasgupta, who wasn’t involved in the study.

The research was supported by the Veterans Integrated Service Network 6 Mental Illness Research, Education and Clinical Center and the Department of Veterans Affairs HSR&D ADAPT Center at the Durham VA Health Care System. Dr. Ulmer and Dr. Dasgupta have disclosed no relevant financial relationships.

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

Frequent nightmares are independently linked to an increased risk for cardiovascular disease (CVD), new research shows. In what researchers describe as “surprising” findings, results from a large study of relatively young military veterans showed those who had nightmares two or more times per week had significantly increased risks for hypertension, myocardial infarction, or other heart problems.  

“A diagnosis of PTSD incorporates sleep disturbance as a symptom. Thus, we were surprised to find that nightmares continued to be associated with CVD after controlling not only for PTSD and demographic factors, but also smoking and depression diagnosis,” said Christi Ulmer, PhD, of the department of psychiatry and behavioral sciences, Duke University Medical Center, Durham, N.C.

The findings were presented at the virtual annual meeting of the Associated Professional Sleep Societies.
 

Unclear mechanism

The study included 3,468 veterans (77% male) with a mean age of 38 years who had served one or two tours of duty since Sept. 11, 2001. Nearly one-third (31%) met criteria for PTSD, and 33% self-reported having at least one cardiovascular condition, such as heart problems, hypertension, stroke, and MI.

Nightmare frequency and severity was assessed using the Davidson Trauma Scale. Nightmares were considered frequent if they occurred two or more times per week and moderate to severe if they were at least moderately distressing. About 31% of veterans reported having frequent nightmares, and 35% reported moderately distressing nightmares over the past week.

After adjusting for age, race, and sex, frequent nightmares were associated with hypertension (odds ratio, 1.51; 95% confidence interval, 1.28-1.78), heart problems (OR, 1.50; 95% CI, 1.11-2.02), and MI (OR, 2.32; 95% CI, 1.18-4.54).

Associations between frequent nightmares and hypertension (OR, 1.43; 95% CI, 1.17-1.73) and heart problems (OR, 1.43; 95% CI, 1.00-2.05) remained significant after further adjusting for smoking, depression, and PTSD.

“Our cross-sectional findings set the stage for future research examining the possibility that nightmares may confer cardiovascular disease risks beyond those conferred by PTSD diagnosis alone,” Dr. Ulmer said in a news release.

Dr. Ulmer also said that, because the study was based on self-reported data, the findings are “very preliminary.” Before doctors adjust clinical practices, it’s important that our findings be replicated using longitudinal studies, clinically diagnosed medical conditions, and objectively assessed sleep,” she said.

She added that more research is needed to uncover mechanisms explaining these associations and determine if reducing the frequency and severity of nightmares can lead to improved cardiovascular health.
 

Timely research

Reached for comment, Rajkumar (Raj) Dasgupta, MD, of the University of Southern California, Los Angeles, noted “the correlation between nightmares and heart disease is a timely topic right now with COVID-19 as more people may be having nightmares.”

“If a patient mentions nightmares, I do think it’s important not to just glaze over it, but to talk more about it and document it in the patient record, especially in patients with cardiovascular disease, atrial fibrillation, diabetes, and hypertension,” said Dr. Dasgupta, who wasn’t involved in the study.

The research was supported by the Veterans Integrated Service Network 6 Mental Illness Research, Education and Clinical Center and the Department of Veterans Affairs HSR&D ADAPT Center at the Durham VA Health Care System. Dr. Ulmer and Dr. Dasgupta have disclosed no relevant financial relationships.

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

Frequent nightmares are independently linked to an increased risk for cardiovascular disease (CVD), new research shows. In what researchers describe as “surprising” findings, results from a large study of relatively young military veterans showed those who had nightmares two or more times per week had significantly increased risks for hypertension, myocardial infarction, or other heart problems.  

“A diagnosis of PTSD incorporates sleep disturbance as a symptom. Thus, we were surprised to find that nightmares continued to be associated with CVD after controlling not only for PTSD and demographic factors, but also smoking and depression diagnosis,” said Christi Ulmer, PhD, of the department of psychiatry and behavioral sciences, Duke University Medical Center, Durham, N.C.

The findings were presented at the virtual annual meeting of the Associated Professional Sleep Societies.
 

Unclear mechanism

The study included 3,468 veterans (77% male) with a mean age of 38 years who had served one or two tours of duty since Sept. 11, 2001. Nearly one-third (31%) met criteria for PTSD, and 33% self-reported having at least one cardiovascular condition, such as heart problems, hypertension, stroke, and MI.

Nightmare frequency and severity was assessed using the Davidson Trauma Scale. Nightmares were considered frequent if they occurred two or more times per week and moderate to severe if they were at least moderately distressing. About 31% of veterans reported having frequent nightmares, and 35% reported moderately distressing nightmares over the past week.

After adjusting for age, race, and sex, frequent nightmares were associated with hypertension (odds ratio, 1.51; 95% confidence interval, 1.28-1.78), heart problems (OR, 1.50; 95% CI, 1.11-2.02), and MI (OR, 2.32; 95% CI, 1.18-4.54).

Associations between frequent nightmares and hypertension (OR, 1.43; 95% CI, 1.17-1.73) and heart problems (OR, 1.43; 95% CI, 1.00-2.05) remained significant after further adjusting for smoking, depression, and PTSD.

“Our cross-sectional findings set the stage for future research examining the possibility that nightmares may confer cardiovascular disease risks beyond those conferred by PTSD diagnosis alone,” Dr. Ulmer said in a news release.

Dr. Ulmer also said that, because the study was based on self-reported data, the findings are “very preliminary.” Before doctors adjust clinical practices, it’s important that our findings be replicated using longitudinal studies, clinically diagnosed medical conditions, and objectively assessed sleep,” she said.

She added that more research is needed to uncover mechanisms explaining these associations and determine if reducing the frequency and severity of nightmares can lead to improved cardiovascular health.
 

Timely research

Reached for comment, Rajkumar (Raj) Dasgupta, MD, of the University of Southern California, Los Angeles, noted “the correlation between nightmares and heart disease is a timely topic right now with COVID-19 as more people may be having nightmares.”

“If a patient mentions nightmares, I do think it’s important not to just glaze over it, but to talk more about it and document it in the patient record, especially in patients with cardiovascular disease, atrial fibrillation, diabetes, and hypertension,” said Dr. Dasgupta, who wasn’t involved in the study.

The research was supported by the Veterans Integrated Service Network 6 Mental Illness Research, Education and Clinical Center and the Department of Veterans Affairs HSR&D ADAPT Center at the Durham VA Health Care System. Dr. Ulmer and Dr. Dasgupta have disclosed no relevant financial relationships.

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

The color hue of a person’s skin is the most obvious criteria for society to judge a person and has always been deeply rooted in racism. Discrimination based on skin color is called colorism and is usually meted out by members of the same race and in the same family. The general belief is that someone with a lighter complexion is more beautiful, intelligent, or valuable than someone with a darker complexion. The term colorism can be widely applied in our assessment of conflict within families and society. The following case example gives guidance for psychiatrists faced with a family where colorism fuels family conflict.

Meeting the family

The Jaspers, a Black family, arrive at the psychiatrist’s office. They come in and look around before they choose their seats. Dr. Sally watches who sits next to whom and how they organize themselves in the office. After brief introductions, Mr. Jaspers begins, explaining why they are there.

“We are always fighting. We need this to stop. She, my wife, contradicts me all the time. Our kids are getting frustrated, and Bruce is acting out in school. He got in a fight again last week.”

Everyone looks at Bruce. He is darker skinned than the other siblings and carries all the African features in a family that favors the lighter end of the color spectrum. He sits next to his mother who leans into him. Mrs. Jaspers speaks next.

“Bruce gets picked on in school.”

Mr. Jaspers responds, “Well, if you didn’t run in there all the time and take him out, maybe he would learn how to deal with it better!”

“But they are mistreating him,” Mrs. Jaspers says.

The other children look away and play with their phones. Dr. Sally wonders whether this is a pattern: The parents fighting about how to deal with Bruce and his difficulties in the world – and the other siblings getting ignored and not included.

Dr. Sally asks Mrs. Jaspers for more details. She tells a narrative that is a strong thread in this family’s story.

“As you can see, Bruce is darker than the rest of our children. When we see the rest of our family, they all comment on what good skin and light coloring and good hair the other children have. Bruce just sits there. He is always being left out. He doesn’t speak up for himself. Maybe they think he can’t hear them, but I know he does and it affects him. They say the others are more intelligent, but I don’t think that is true. Bruce just gets picked on in school and he doesn’t feel like he matters. He doesn’t say anything, so maybe people think he doesn’t care, but I know he does.”

Dr. Sally turns to Bruce, who is still sitting silently next to his mother, his head down.

“Bruce, what do you have to say?”

Bruce shrugs his shoulders. His siblings still do not want to be drawn in and are otherwise occupied.

At this point, Dr. Sally might be thinking that she could see Bruce alone to assess his depression/self-esteem and maybe find ways to try to build him up. She does not want this to be an opportunity wasted. The goal is to work with the family to get Bruce where he needs to be faster and help the whole family.

Dr. Sally presses on. “Mr. Jaspers, what is your opinion?”

“She babies him. She treats him differently from the other kids. She is driving a wedge between him and his siblings. We fight about it all the time. She is driving a wedge between us, too.”

Mrs. Jaspers jumps in: “But you don’t know what it is like! When I was the only Black person in math class, I got picked on all the time! It made me self-conscious, and I couldn’t do my work. “

The other siblings look up briefly then back down at their devices. Dr. Sally asks them as a group:

“Can I ask you a question as a family? Can I ask the children a question?” They look up again. “Is this what goes on at home?” They all nod but offer no details.

Dr. Sally asks the oldest: “How does this affect your relationship with Bruce?”

They all look back and forth at each other. There is another long silence.

“See!” says Mr. Jaspers! “You can't protect him forever, and you are just ostracizing him from the rest of us! “

“But, but, he, he needs to learn different things. He is different. He faces different struggles. The police will stop him more. I am afraid for him.” Mrs. Jaspers starts to cry.

“You can’t protect him forever,” says her husband, gently reaching over to her.

Bruce has psychologically disappeared from the room, hiding behind his mother, who is now the largest and neediest presence in the room. Mr. Jaspers looks at Dr. Sally helplessly.

Dr. Sally asks the important question to the whole family.

“How do you all think this should work? If you don’t think Mrs. Jaspers is right, what do you think should be the way forward?”

This question is the turning point and indicates that Dr. Sally sees that the solution lies in how the family wants to manage things.

“I believe that your whole family has the answers, that you all have thought through this situation much more deeply and for much longer than I have. I am just hearing about it, and I am White and don’t have this experience. I have faith in your family, that with an opportunity to openly discuss this issue, that this knot can be unraveled. It does not mean that there are not more knots to unravel. For today, how to help you all help Bruce, is the work."

Dr. Sally talks to everyone but finishes up by looking at Mr. Jaspers, who has indicated that Bruce is part of the family and should not be treated differently from the other children.

Sean, the oldest sibling, now pipes up: “Bruce gets everything he wants. Mum spoils him; she always takes his side if there are arguments. Bruce knows this, and he steals our stuff because he knows he will get away with it.”

Bruce is quiet and leans in more to his mother. Dr. Sally motions to the mother not to speak.

“Is this true, Bruce?” Silence speaks that the answer is yes. The disparities in the family are aired for a while longer.

“Mrs. Jaspers, it is now your turn to respond.”

“Bruce is darker and faces more challenges than the others; he needs more protection and to know that he is loved.”

“Your family seems to think otherwise. They seem to think that your protection, while admirable, needs to be tempered to allow him to grow into a man who can stand on his own feet.”

Dr. Sally guides the family as a whole to a place where they can agree on the problem. The problem is now framed as a mother who cares too much and is too protective of Bruce but now her love and care need to be tempered. As a mother, she feels that it is her duty to protect her most vulnerable son. The family knows that Bruce will face more social scrutiny than the others, that he will have more internal struggles with self-worth than the others. How can the family help?

This conceptualization causes the family to look searchingly at one another. It is nothing they haven’t thought about privately, but this is the first time they are together thinking about it.

Dr. Sally says that she can help by providing time and space for them to wok through this together. They all agree to come back the following week with some thoughts about moving forward.
 

Offering perspective on colorism

In her book “Facing the Black Shadow,” couples and family therapist Marlene F. Watson, PhD, discusses colorism.

“African Americans still have a tough time talking about slavery – the origin of colorism. Seriously, what can we really expect to change without acknowledging and challenging the psychological residuals of slavery in our families and communities? What doesn’t get resolved in one generation is passed on to the next so our issues from slavery go from one generation to the next.”

Dr. Watson continues: “Confronting the secret about skin color in our families and communities is necessary for all Black girls to feel lovable, worthy, and deserving of care and for all Black boys to feel their value lies within them, not a dark, light, bright, near-white or White woman. African Americans need to get that preferring light over dark or dark over light is problematic for all of us. Skin color preferences in the African American community follow society’s racial hierarchy. African Americans as a group are at the bottom in the larger society and dark-skinned African Americans are at the bottom in the Black community.”

Dr. Watson suggests a way that we can help our patients. She encourages families to draw a family tree that tracks the family’s beliefs and patterns about skin color. Her advice is to ask each family member, from oldest to youngest, to identify the spoken and unspoken skin color beliefs he or she experiences in the family. Ask about skin color beliefs from outside that affect family members, and what each person thinks the family could do to stop promoting the “less than/better than” mentality that is often present with skin color assignment.



Thank you to Lynette Ramsingh Barros, who collaborated on creating the case.
 

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

The color hue of a person’s skin is the most obvious criteria for society to judge a person and has always been deeply rooted in racism. Discrimination based on skin color is called colorism and is usually meted out by members of the same race and in the same family. The general belief is that someone with a lighter complexion is more beautiful, intelligent, or valuable than someone with a darker complexion. The term colorism can be widely applied in our assessment of conflict within families and society. The following case example gives guidance for psychiatrists faced with a family where colorism fuels family conflict.

Meeting the family

The Jaspers, a Black family, arrive at the psychiatrist’s office. They come in and look around before they choose their seats. Dr. Sally watches who sits next to whom and how they organize themselves in the office. After brief introductions, Mr. Jaspers begins, explaining why they are there.

“We are always fighting. We need this to stop. She, my wife, contradicts me all the time. Our kids are getting frustrated, and Bruce is acting out in school. He got in a fight again last week.”

Everyone looks at Bruce. He is darker skinned than the other siblings and carries all the African features in a family that favors the lighter end of the color spectrum. He sits next to his mother who leans into him. Mrs. Jaspers speaks next.

“Bruce gets picked on in school.”

Mr. Jaspers responds, “Well, if you didn’t run in there all the time and take him out, maybe he would learn how to deal with it better!”

“But they are mistreating him,” Mrs. Jaspers says.

The other children look away and play with their phones. Dr. Sally wonders whether this is a pattern: The parents fighting about how to deal with Bruce and his difficulties in the world – and the other siblings getting ignored and not included.

Dr. Sally asks Mrs. Jaspers for more details. She tells a narrative that is a strong thread in this family’s story.

“As you can see, Bruce is darker than the rest of our children. When we see the rest of our family, they all comment on what good skin and light coloring and good hair the other children have. Bruce just sits there. He is always being left out. He doesn’t speak up for himself. Maybe they think he can’t hear them, but I know he does and it affects him. They say the others are more intelligent, but I don’t think that is true. Bruce just gets picked on in school and he doesn’t feel like he matters. He doesn’t say anything, so maybe people think he doesn’t care, but I know he does.”

Dr. Sally turns to Bruce, who is still sitting silently next to his mother, his head down.

“Bruce, what do you have to say?”

Bruce shrugs his shoulders. His siblings still do not want to be drawn in and are otherwise occupied.

At this point, Dr. Sally might be thinking that she could see Bruce alone to assess his depression/self-esteem and maybe find ways to try to build him up. She does not want this to be an opportunity wasted. The goal is to work with the family to get Bruce where he needs to be faster and help the whole family.

Dr. Sally presses on. “Mr. Jaspers, what is your opinion?”

“She babies him. She treats him differently from the other kids. She is driving a wedge between him and his siblings. We fight about it all the time. She is driving a wedge between us, too.”

Mrs. Jaspers jumps in: “But you don’t know what it is like! When I was the only Black person in math class, I got picked on all the time! It made me self-conscious, and I couldn’t do my work. “

The other siblings look up briefly then back down at their devices. Dr. Sally asks them as a group:

“Can I ask you a question as a family? Can I ask the children a question?” They look up again. “Is this what goes on at home?” They all nod but offer no details.

Dr. Sally asks the oldest: “How does this affect your relationship with Bruce?”

They all look back and forth at each other. There is another long silence.

“See!” says Mr. Jaspers! “You can't protect him forever, and you are just ostracizing him from the rest of us! “

“But, but, he, he needs to learn different things. He is different. He faces different struggles. The police will stop him more. I am afraid for him.” Mrs. Jaspers starts to cry.

“You can’t protect him forever,” says her husband, gently reaching over to her.

Bruce has psychologically disappeared from the room, hiding behind his mother, who is now the largest and neediest presence in the room. Mr. Jaspers looks at Dr. Sally helplessly.

Dr. Sally asks the important question to the whole family.

“How do you all think this should work? If you don’t think Mrs. Jaspers is right, what do you think should be the way forward?”

This question is the turning point and indicates that Dr. Sally sees that the solution lies in how the family wants to manage things.

“I believe that your whole family has the answers, that you all have thought through this situation much more deeply and for much longer than I have. I am just hearing about it, and I am White and don’t have this experience. I have faith in your family, that with an opportunity to openly discuss this issue, that this knot can be unraveled. It does not mean that there are not more knots to unravel. For today, how to help you all help Bruce, is the work."

Dr. Sally talks to everyone but finishes up by looking at Mr. Jaspers, who has indicated that Bruce is part of the family and should not be treated differently from the other children.

Sean, the oldest sibling, now pipes up: “Bruce gets everything he wants. Mum spoils him; she always takes his side if there are arguments. Bruce knows this, and he steals our stuff because he knows he will get away with it.”

Bruce is quiet and leans in more to his mother. Dr. Sally motions to the mother not to speak.

“Is this true, Bruce?” Silence speaks that the answer is yes. The disparities in the family are aired for a while longer.

“Mrs. Jaspers, it is now your turn to respond.”

“Bruce is darker and faces more challenges than the others; he needs more protection and to know that he is loved.”

“Your family seems to think otherwise. They seem to think that your protection, while admirable, needs to be tempered to allow him to grow into a man who can stand on his own feet.”

Dr. Sally guides the family as a whole to a place where they can agree on the problem. The problem is now framed as a mother who cares too much and is too protective of Bruce but now her love and care need to be tempered. As a mother, she feels that it is her duty to protect her most vulnerable son. The family knows that Bruce will face more social scrutiny than the others, that he will have more internal struggles with self-worth than the others. How can the family help?

This conceptualization causes the family to look searchingly at one another. It is nothing they haven’t thought about privately, but this is the first time they are together thinking about it.

Dr. Sally says that she can help by providing time and space for them to wok through this together. They all agree to come back the following week with some thoughts about moving forward.
 

Offering perspective on colorism

In her book “Facing the Black Shadow,” couples and family therapist Marlene F. Watson, PhD, discusses colorism.

“African Americans still have a tough time talking about slavery – the origin of colorism. Seriously, what can we really expect to change without acknowledging and challenging the psychological residuals of slavery in our families and communities? What doesn’t get resolved in one generation is passed on to the next so our issues from slavery go from one generation to the next.”

Dr. Watson continues: “Confronting the secret about skin color in our families and communities is necessary for all Black girls to feel lovable, worthy, and deserving of care and for all Black boys to feel their value lies within them, not a dark, light, bright, near-white or White woman. African Americans need to get that preferring light over dark or dark over light is problematic for all of us. Skin color preferences in the African American community follow society’s racial hierarchy. African Americans as a group are at the bottom in the larger society and dark-skinned African Americans are at the bottom in the Black community.”

Dr. Watson suggests a way that we can help our patients. She encourages families to draw a family tree that tracks the family’s beliefs and patterns about skin color. Her advice is to ask each family member, from oldest to youngest, to identify the spoken and unspoken skin color beliefs he or she experiences in the family. Ask about skin color beliefs from outside that affect family members, and what each person thinks the family could do to stop promoting the “less than/better than” mentality that is often present with skin color assignment.



Thank you to Lynette Ramsingh Barros, who collaborated on creating the case.
 

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

The color hue of a person’s skin is the most obvious criteria for society to judge a person and has always been deeply rooted in racism. Discrimination based on skin color is called colorism and is usually meted out by members of the same race and in the same family. The general belief is that someone with a lighter complexion is more beautiful, intelligent, or valuable than someone with a darker complexion. The term colorism can be widely applied in our assessment of conflict within families and society. The following case example gives guidance for psychiatrists faced with a family where colorism fuels family conflict.

Meeting the family

The Jaspers, a Black family, arrive at the psychiatrist’s office. They come in and look around before they choose their seats. Dr. Sally watches who sits next to whom and how they organize themselves in the office. After brief introductions, Mr. Jaspers begins, explaining why they are there.

“We are always fighting. We need this to stop. She, my wife, contradicts me all the time. Our kids are getting frustrated, and Bruce is acting out in school. He got in a fight again last week.”

Everyone looks at Bruce. He is darker skinned than the other siblings and carries all the African features in a family that favors the lighter end of the color spectrum. He sits next to his mother who leans into him. Mrs. Jaspers speaks next.

“Bruce gets picked on in school.”

Mr. Jaspers responds, “Well, if you didn’t run in there all the time and take him out, maybe he would learn how to deal with it better!”

“But they are mistreating him,” Mrs. Jaspers says.

The other children look away and play with their phones. Dr. Sally wonders whether this is a pattern: The parents fighting about how to deal with Bruce and his difficulties in the world – and the other siblings getting ignored and not included.

Dr. Sally asks Mrs. Jaspers for more details. She tells a narrative that is a strong thread in this family’s story.

“As you can see, Bruce is darker than the rest of our children. When we see the rest of our family, they all comment on what good skin and light coloring and good hair the other children have. Bruce just sits there. He is always being left out. He doesn’t speak up for himself. Maybe they think he can’t hear them, but I know he does and it affects him. They say the others are more intelligent, but I don’t think that is true. Bruce just gets picked on in school and he doesn’t feel like he matters. He doesn’t say anything, so maybe people think he doesn’t care, but I know he does.”

Dr. Sally turns to Bruce, who is still sitting silently next to his mother, his head down.

“Bruce, what do you have to say?”

Bruce shrugs his shoulders. His siblings still do not want to be drawn in and are otherwise occupied.

At this point, Dr. Sally might be thinking that she could see Bruce alone to assess his depression/self-esteem and maybe find ways to try to build him up. She does not want this to be an opportunity wasted. The goal is to work with the family to get Bruce where he needs to be faster and help the whole family.

Dr. Sally presses on. “Mr. Jaspers, what is your opinion?”

“She babies him. She treats him differently from the other kids. She is driving a wedge between him and his siblings. We fight about it all the time. She is driving a wedge between us, too.”

Mrs. Jaspers jumps in: “But you don’t know what it is like! When I was the only Black person in math class, I got picked on all the time! It made me self-conscious, and I couldn’t do my work. “

The other siblings look up briefly then back down at their devices. Dr. Sally asks them as a group:

“Can I ask you a question as a family? Can I ask the children a question?” They look up again. “Is this what goes on at home?” They all nod but offer no details.

Dr. Sally asks the oldest: “How does this affect your relationship with Bruce?”

They all look back and forth at each other. There is another long silence.

“See!” says Mr. Jaspers! “You can't protect him forever, and you are just ostracizing him from the rest of us! “

“But, but, he, he needs to learn different things. He is different. He faces different struggles. The police will stop him more. I am afraid for him.” Mrs. Jaspers starts to cry.

“You can’t protect him forever,” says her husband, gently reaching over to her.

Bruce has psychologically disappeared from the room, hiding behind his mother, who is now the largest and neediest presence in the room. Mr. Jaspers looks at Dr. Sally helplessly.

Dr. Sally asks the important question to the whole family.

“How do you all think this should work? If you don’t think Mrs. Jaspers is right, what do you think should be the way forward?”

This question is the turning point and indicates that Dr. Sally sees that the solution lies in how the family wants to manage things.

“I believe that your whole family has the answers, that you all have thought through this situation much more deeply and for much longer than I have. I am just hearing about it, and I am White and don’t have this experience. I have faith in your family, that with an opportunity to openly discuss this issue, that this knot can be unraveled. It does not mean that there are not more knots to unravel. For today, how to help you all help Bruce, is the work."

Dr. Sally talks to everyone but finishes up by looking at Mr. Jaspers, who has indicated that Bruce is part of the family and should not be treated differently from the other children.

Sean, the oldest sibling, now pipes up: “Bruce gets everything he wants. Mum spoils him; she always takes his side if there are arguments. Bruce knows this, and he steals our stuff because he knows he will get away with it.”

Bruce is quiet and leans in more to his mother. Dr. Sally motions to the mother not to speak.

“Is this true, Bruce?” Silence speaks that the answer is yes. The disparities in the family are aired for a while longer.

“Mrs. Jaspers, it is now your turn to respond.”

“Bruce is darker and faces more challenges than the others; he needs more protection and to know that he is loved.”

“Your family seems to think otherwise. They seem to think that your protection, while admirable, needs to be tempered to allow him to grow into a man who can stand on his own feet.”

Dr. Sally guides the family as a whole to a place where they can agree on the problem. The problem is now framed as a mother who cares too much and is too protective of Bruce but now her love and care need to be tempered. As a mother, she feels that it is her duty to protect her most vulnerable son. The family knows that Bruce will face more social scrutiny than the others, that he will have more internal struggles with self-worth than the others. How can the family help?

This conceptualization causes the family to look searchingly at one another. It is nothing they haven’t thought about privately, but this is the first time they are together thinking about it.

Dr. Sally says that she can help by providing time and space for them to wok through this together. They all agree to come back the following week with some thoughts about moving forward.
 

Offering perspective on colorism

In her book “Facing the Black Shadow,” couples and family therapist Marlene F. Watson, PhD, discusses colorism.

“African Americans still have a tough time talking about slavery – the origin of colorism. Seriously, what can we really expect to change without acknowledging and challenging the psychological residuals of slavery in our families and communities? What doesn’t get resolved in one generation is passed on to the next so our issues from slavery go from one generation to the next.”

Dr. Watson continues: “Confronting the secret about skin color in our families and communities is necessary for all Black girls to feel lovable, worthy, and deserving of care and for all Black boys to feel their value lies within them, not a dark, light, bright, near-white or White woman. African Americans need to get that preferring light over dark or dark over light is problematic for all of us. Skin color preferences in the African American community follow society’s racial hierarchy. African Americans as a group are at the bottom in the larger society and dark-skinned African Americans are at the bottom in the Black community.”

Dr. Watson suggests a way that we can help our patients. She encourages families to draw a family tree that tracks the family’s beliefs and patterns about skin color. Her advice is to ask each family member, from oldest to youngest, to identify the spoken and unspoken skin color beliefs he or she experiences in the family. Ask about skin color beliefs from outside that affect family members, and what each person thinks the family could do to stop promoting the “less than/better than” mentality that is often present with skin color assignment.



Thank you to Lynette Ramsingh Barros, who collaborated on creating the case.
 

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