Clinical Psychiatry News

Every person who received Moderna’s COVID-19 vaccine, mRNA-1273, developed an immune response to the virus that causes it, the company says in a news release.

Researchers also reported some side effects in the 45 people in the phase I study, but no significant safety issues, the news release says.

The vaccine is among hundreds being tested worldwide in an effort to halt the pandemic that has killed nearly 600,000 worldwide.

A researcher testing the vaccine called the results encouraging but cautioned more study is needed. “Importantly, the vaccine resulted in a robust immune response,” Evan Anderson, MD, principal investigator for the trial at Emory University, says in a news release. Emory and Kaiser Permanente Washington Health Research Institute were the two sites for the study.

The company is already testing the vaccine in a larger group of people, known as a phase II trial. It plans to begin phase III trials in late July. Phase III trials involve testing the vaccine on an even larger group and are the final step before FDA approval.

The study results are published in The New England Journal of Medicine. The study was led by the National Institute of Allergy and Infectious Diseases of the National Institutes of Health.

Moderna’s vaccine uses messenger RNA, also called mRNA. It carries the instruction for making the spike protein, a key protein on the surface of the virus that allows it to enter cells when a person is infected. After it’s injected, it goes to the immune cells and instructs them to make copies of the spike protein, acting as if the cells have been infected with the actual coronavirus. This allows other immune cells to develop immunity.

In the study, participants were divided into three groups of 15 people each. All groups received two vaccinations 28 days apart. Each group received a different strength of the vaccine – either 25, 100, or 250 micrograms.

Every person in the study developed antibodies that can block the infection. Most commonly reported side effects after the second vaccination in the 100-microgram group were fatigue, chills, headache, and muscle pains, ranging from mild to moderately severe.

The phase II study has 300 heathy adults ages 18-55, along with another 300 ages 55 and older

Moderna says it hopes to include about 30,000 participants at the 100-microgram dose level in the U.S. for the phase III trial. The estimated start date is July 27.

This article first appeared on WebMD.com.

Every person who received Moderna’s COVID-19 vaccine, mRNA-1273, developed an immune response to the virus that causes it, the company says in a news release.

Researchers also reported some side effects in the 45 people in the phase I study, but no significant safety issues, the news release says.

The vaccine is among hundreds being tested worldwide in an effort to halt the pandemic that has killed nearly 600,000 worldwide.

A researcher testing the vaccine called the results encouraging but cautioned more study is needed. “Importantly, the vaccine resulted in a robust immune response,” Evan Anderson, MD, principal investigator for the trial at Emory University, says in a news release. Emory and Kaiser Permanente Washington Health Research Institute were the two sites for the study.

The company is already testing the vaccine in a larger group of people, known as a phase II trial. It plans to begin phase III trials in late July. Phase III trials involve testing the vaccine on an even larger group and are the final step before FDA approval.

The study results are published in The New England Journal of Medicine. The study was led by the National Institute of Allergy and Infectious Diseases of the National Institutes of Health.

Moderna’s vaccine uses messenger RNA, also called mRNA. It carries the instruction for making the spike protein, a key protein on the surface of the virus that allows it to enter cells when a person is infected. After it’s injected, it goes to the immune cells and instructs them to make copies of the spike protein, acting as if the cells have been infected with the actual coronavirus. This allows other immune cells to develop immunity.

In the study, participants were divided into three groups of 15 people each. All groups received two vaccinations 28 days apart. Each group received a different strength of the vaccine – either 25, 100, or 250 micrograms.

Every person in the study developed antibodies that can block the infection. Most commonly reported side effects after the second vaccination in the 100-microgram group were fatigue, chills, headache, and muscle pains, ranging from mild to moderately severe.

The phase II study has 300 heathy adults ages 18-55, along with another 300 ages 55 and older

Moderna says it hopes to include about 30,000 participants at the 100-microgram dose level in the U.S. for the phase III trial. The estimated start date is July 27.

This article first appeared on WebMD.com.

Every person who received Moderna’s COVID-19 vaccine, mRNA-1273, developed an immune response to the virus that causes it, the company says in a news release.

Researchers also reported some side effects in the 45 people in the phase I study, but no significant safety issues, the news release says.

The vaccine is among hundreds being tested worldwide in an effort to halt the pandemic that has killed nearly 600,000 worldwide.

A researcher testing the vaccine called the results encouraging but cautioned more study is needed. “Importantly, the vaccine resulted in a robust immune response,” Evan Anderson, MD, principal investigator for the trial at Emory University, says in a news release. Emory and Kaiser Permanente Washington Health Research Institute were the two sites for the study.

The company is already testing the vaccine in a larger group of people, known as a phase II trial. It plans to begin phase III trials in late July. Phase III trials involve testing the vaccine on an even larger group and are the final step before FDA approval.

The study results are published in The New England Journal of Medicine. The study was led by the National Institute of Allergy and Infectious Diseases of the National Institutes of Health.

Moderna’s vaccine uses messenger RNA, also called mRNA. It carries the instruction for making the spike protein, a key protein on the surface of the virus that allows it to enter cells when a person is infected. After it’s injected, it goes to the immune cells and instructs them to make copies of the spike protein, acting as if the cells have been infected with the actual coronavirus. This allows other immune cells to develop immunity.

In the study, participants were divided into three groups of 15 people each. All groups received two vaccinations 28 days apart. Each group received a different strength of the vaccine – either 25, 100, or 250 micrograms.

Every person in the study developed antibodies that can block the infection. Most commonly reported side effects after the second vaccination in the 100-microgram group were fatigue, chills, headache, and muscle pains, ranging from mild to moderately severe.

The phase II study has 300 heathy adults ages 18-55, along with another 300 ages 55 and older

Moderna says it hopes to include about 30,000 participants at the 100-microgram dose level in the U.S. for the phase III trial. The estimated start date is July 27.

This article first appeared on WebMD.com.

We live in historic times. A worldwide pandemic is surging in the United States, with millions infected and the world’s highest death rate. Many of our hospitals are overwhelmed. Schools have been closed for months. Businesses are struggling, and unemployment is at record levels. The murder of George Floyd unleashed an outpouring of grief and rage over police brutality and structural racism.

Thinkstock

The value of knowing about these risk factors would seem self-evident; it would inform a patient’s health care from screening for cancer or heart disease, referral for mild depressive symptoms, and counseling about alcohol consumption. But this research did not lead to the establishment of routine screening for childhood adversity in primary care practices. There are multiple reasons for this, including growing pressure on physician time and discomfort with starting conversations about potentially traumatic material. But perhaps the greatest obstacle has been uncertainty about what to offer patients who screened in. What is the treatment for a high ACE score?

Even without treatments, we have learned much about childhood adversity since Dr. Anda and Dr. Felitti published their landmark study. Other more chronic adverse childhood experiences also contribute to adult health risk, such as poverty, homelessness, discrimination, community violence, parental chronic illness, or disability or placement in foster care. Having a high ACE score does not only affect health in adulthood. Children with an ACE score of 4 are 2 times as likely to have asthma^2,3 and allergies³, 2 times as likely to be obese⁴, 3 times as likely to have headaches³ and dental problems^5,6, 4 times as likely to have depression^7,8, 5 times as likely to have ADHD^8,9, 7 times as likely to have high rates of school absenteeism³ and aggression¹⁰, and over 30 times as likely to have learning or behavioral problems at school⁴. There is a growing body of knowledge about how chronic, severe stress in childhood affects can lead to pathological alterations in neuroendocrine and immune function. But this has not led to any concrete treatments that may be preventive or reparative.

Movement toward expanding screening nonetheless has accelerated. In California, Nadine Burke-Harris, MD, a pediatrician who studied ACEs and children’s health was named the state’s first Surgeon General in 2019 and spearheaded an effort to make screening for ACEs easier. Starting in 2020, MediCal will pay for annual screenings, and the state is offering training and resources on how to screen and what to do with the information to help patients and families.

The coronavirus pandemic has only highlighted the risks of childhood adversity. The burden of infection and mortality has been borne disproportionately by people of color and those with multiple chronic medical conditions (obesity, cardiovascular disease, diabetes, etc.). While viruses do not discriminate, they are more likely to infect those with higher risk of exposure and to kill those who are physiologically vulnerable.

And the pandemic increases the risk for adversity for today’s children and families. When children cannot attend school, financially vulnerable parents may have to choose between supervising them or feeding them. Families who suddenly are all in a small apartment together without school or other outside supports may be at higher risk for domestic violence and child abuse. Unemployment and financial uncertainty will increase the rates of substance abuse and depression amongst parents. And the serious illness or death of a parent will be a more common event for children in the year ahead. One of these risk factors may increase the likelihood of others.

Beyond the obvious need for substantial policy changes focused on housing, education, and health care, there are immediate and concrete strategies that can build resilience in children and their families. And resilience can build on itself, as children face subsequent challenges with the support of caring connected adults.

The critical first step is asking. Then listen calmly and supportively, normalizing for parents and children how common these experiences are. Explain how they affect health and well-being. Explain that adversity and its consequences are not their fault. Then educate them about what is in their control: the skills they can practice to buffer against the consequences of adversity and build resilience. They sound simple, but still require effort and work. And the pandemic has created some difficulty (social distancing) and opportunity (more family time, fewer school demands).
 

Sleep

Help parents establish and protect consistent, restful sleep for their children. They can set a consistent bedtime and a calm routine, with screens all off at least 30 minutes before sleep and reading before sleep. Restful sleep is physiologically and psychologically protective to everyone in a family.

Movement

Beyond directly improving physical health, establishing habits of exercise – especially outside – every day can effectively manage ongoing stress, build skills of self-regulation, and help with sleep.

Find out what parents and their children like to do together (walking the dog, shooting hoops, even dancing) and help them devise ways to create family routines around exercise.
 

Nutrition

Food should be a source of pleasure, but stress can make food into a source of comfort or escape. Help parents to create realistic ways to consistently offer healthy family meals and discourage unhealthy habits.

Even small changes like water instead of soda can help, and there are nutritional and emotional benefits to eating a healthy breakfast or dinner together as a family.
 

Connections

Nourishing social connections are protective. Help parents think about protecting time to spend with their children for talking, playing games, or even singing.

They should support their children’s connections to other caring adults, through community organizations (church, community centers, or sports), and they should know who their children’s reliable friends are. Parents will benefit from these supports for themselves, which in turn will benefit the full family.
 

Self-awareness

Activities that cultivate mindfulness are protective. Parents can simply ask how their children are feeling, physically or emotionally, and be able to bear it when it is uncomfortable. Work towards nonjudgmental awareness of how they are feeling. Learning what is relaxing or recharging for them (exercise, music, a hot bath, a good book, time with a friend) will protect against defaulting into maladaptive coping such as escape, numbing, or avoidance.

Of course, if you learn about symptoms that suggest PTSD, depression, or addiction, you should help your patient connect with effective treatment. The difficulty of referring to a mental health provider does not mean you should not try and bring as many people onto the team and into the orbit of the child and family at risk. It may be easier to access some therapy given the new availability of telemedicine visits across many more systems of care. Although the heaviest burdens of adversity are not being borne equally, the fact that adversity is currently a shared experience makes this a moment of promise.

Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Dr. Swick and Dr. Jellinek had no relevant financial disclosures. Email them at [email protected].

References
1. Am J Prev Med. 1998 May;14(4):245-58.
2. Ann Allergy Asthma Immunol. 2015;114: 379-84.
3. BMC Public Health. 2018. doi: 10.1186/s12889-018-5699-8.
4. Child Abuse Negl. 2011 Jun;35(6):408-13.
5. Community Dent Oral Epidemiol. 2015;43:193-9.
6. Community Dent Oral Epidemiol. 2018 Oct;46(5): 442-8.
7. Pediatrics 2016 Apr. doi: 10.1542/peds.2015-4016.
8. Matern Child Health J. 2016 Apr. doi: 10.1007/s10995-015-1915-7.
9. Acad Pediatr. 2017 May-Jun. doi: 10.1016/j.acap.2016.08.013.
10. Pediatrics. 2010 Apr. doi: 10.1542/peds.2009-0597.
 

This article was updated 7/27/2020.

We live in historic times. A worldwide pandemic is surging in the United States, with millions infected and the world’s highest death rate. Many of our hospitals are overwhelmed. Schools have been closed for months. Businesses are struggling, and unemployment is at record levels. The murder of George Floyd unleashed an outpouring of grief and rage over police brutality and structural racism.

Thinkstock

The value of knowing about these risk factors would seem self-evident; it would inform a patient’s health care from screening for cancer or heart disease, referral for mild depressive symptoms, and counseling about alcohol consumption. But this research did not lead to the establishment of routine screening for childhood adversity in primary care practices. There are multiple reasons for this, including growing pressure on physician time and discomfort with starting conversations about potentially traumatic material. But perhaps the greatest obstacle has been uncertainty about what to offer patients who screened in. What is the treatment for a high ACE score?

Even without treatments, we have learned much about childhood adversity since Dr. Anda and Dr. Felitti published their landmark study. Other more chronic adverse childhood experiences also contribute to adult health risk, such as poverty, homelessness, discrimination, community violence, parental chronic illness, or disability or placement in foster care. Having a high ACE score does not only affect health in adulthood. Children with an ACE score of 4 are 2 times as likely to have asthma^2,3 and allergies³, 2 times as likely to be obese⁴, 3 times as likely to have headaches³ and dental problems^5,6, 4 times as likely to have depression^7,8, 5 times as likely to have ADHD^8,9, 7 times as likely to have high rates of school absenteeism³ and aggression¹⁰, and over 30 times as likely to have learning or behavioral problems at school⁴. There is a growing body of knowledge about how chronic, severe stress in childhood affects can lead to pathological alterations in neuroendocrine and immune function. But this has not led to any concrete treatments that may be preventive or reparative.

Movement toward expanding screening nonetheless has accelerated. In California, Nadine Burke-Harris, MD, a pediatrician who studied ACEs and children’s health was named the state’s first Surgeon General in 2019 and spearheaded an effort to make screening for ACEs easier. Starting in 2020, MediCal will pay for annual screenings, and the state is offering training and resources on how to screen and what to do with the information to help patients and families.

The coronavirus pandemic has only highlighted the risks of childhood adversity. The burden of infection and mortality has been borne disproportionately by people of color and those with multiple chronic medical conditions (obesity, cardiovascular disease, diabetes, etc.). While viruses do not discriminate, they are more likely to infect those with higher risk of exposure and to kill those who are physiologically vulnerable.

And the pandemic increases the risk for adversity for today’s children and families. When children cannot attend school, financially vulnerable parents may have to choose between supervising them or feeding them. Families who suddenly are all in a small apartment together without school or other outside supports may be at higher risk for domestic violence and child abuse. Unemployment and financial uncertainty will increase the rates of substance abuse and depression amongst parents. And the serious illness or death of a parent will be a more common event for children in the year ahead. One of these risk factors may increase the likelihood of others.

Beyond the obvious need for substantial policy changes focused on housing, education, and health care, there are immediate and concrete strategies that can build resilience in children and their families. And resilience can build on itself, as children face subsequent challenges with the support of caring connected adults.

The critical first step is asking. Then listen calmly and supportively, normalizing for parents and children how common these experiences are. Explain how they affect health and well-being. Explain that adversity and its consequences are not their fault. Then educate them about what is in their control: the skills they can practice to buffer against the consequences of adversity and build resilience. They sound simple, but still require effort and work. And the pandemic has created some difficulty (social distancing) and opportunity (more family time, fewer school demands).
 

Sleep

Help parents establish and protect consistent, restful sleep for their children. They can set a consistent bedtime and a calm routine, with screens all off at least 30 minutes before sleep and reading before sleep. Restful sleep is physiologically and psychologically protective to everyone in a family.

Movement

Beyond directly improving physical health, establishing habits of exercise – especially outside – every day can effectively manage ongoing stress, build skills of self-regulation, and help with sleep.

Find out what parents and their children like to do together (walking the dog, shooting hoops, even dancing) and help them devise ways to create family routines around exercise.
 

Nutrition

Food should be a source of pleasure, but stress can make food into a source of comfort or escape. Help parents to create realistic ways to consistently offer healthy family meals and discourage unhealthy habits.

Even small changes like water instead of soda can help, and there are nutritional and emotional benefits to eating a healthy breakfast or dinner together as a family.
 

Connections

Nourishing social connections are protective. Help parents think about protecting time to spend with their children for talking, playing games, or even singing.

They should support their children’s connections to other caring adults, through community organizations (church, community centers, or sports), and they should know who their children’s reliable friends are. Parents will benefit from these supports for themselves, which in turn will benefit the full family.
 

Self-awareness

Activities that cultivate mindfulness are protective. Parents can simply ask how their children are feeling, physically or emotionally, and be able to bear it when it is uncomfortable. Work towards nonjudgmental awareness of how they are feeling. Learning what is relaxing or recharging for them (exercise, music, a hot bath, a good book, time with a friend) will protect against defaulting into maladaptive coping such as escape, numbing, or avoidance.

Of course, if you learn about symptoms that suggest PTSD, depression, or addiction, you should help your patient connect with effective treatment. The difficulty of referring to a mental health provider does not mean you should not try and bring as many people onto the team and into the orbit of the child and family at risk. It may be easier to access some therapy given the new availability of telemedicine visits across many more systems of care. Although the heaviest burdens of adversity are not being borne equally, the fact that adversity is currently a shared experience makes this a moment of promise.

Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Dr. Swick and Dr. Jellinek had no relevant financial disclosures. Email them at [email protected].

References
1. Am J Prev Med. 1998 May;14(4):245-58.
2. Ann Allergy Asthma Immunol. 2015;114: 379-84.
3. BMC Public Health. 2018. doi: 10.1186/s12889-018-5699-8.
4. Child Abuse Negl. 2011 Jun;35(6):408-13.
5. Community Dent Oral Epidemiol. 2015;43:193-9.
6. Community Dent Oral Epidemiol. 2018 Oct;46(5): 442-8.
7. Pediatrics 2016 Apr. doi: 10.1542/peds.2015-4016.
8. Matern Child Health J. 2016 Apr. doi: 10.1007/s10995-015-1915-7.
9. Acad Pediatr. 2017 May-Jun. doi: 10.1016/j.acap.2016.08.013.
10. Pediatrics. 2010 Apr. doi: 10.1542/peds.2009-0597.
 

This article was updated 7/27/2020.

We live in historic times. A worldwide pandemic is surging in the United States, with millions infected and the world’s highest death rate. Many of our hospitals are overwhelmed. Schools have been closed for months. Businesses are struggling, and unemployment is at record levels. The murder of George Floyd unleashed an outpouring of grief and rage over police brutality and structural racism.

Thinkstock

The value of knowing about these risk factors would seem self-evident; it would inform a patient’s health care from screening for cancer or heart disease, referral for mild depressive symptoms, and counseling about alcohol consumption. But this research did not lead to the establishment of routine screening for childhood adversity in primary care practices. There are multiple reasons for this, including growing pressure on physician time and discomfort with starting conversations about potentially traumatic material. But perhaps the greatest obstacle has been uncertainty about what to offer patients who screened in. What is the treatment for a high ACE score?

Even without treatments, we have learned much about childhood adversity since Dr. Anda and Dr. Felitti published their landmark study. Other more chronic adverse childhood experiences also contribute to adult health risk, such as poverty, homelessness, discrimination, community violence, parental chronic illness, or disability or placement in foster care. Having a high ACE score does not only affect health in adulthood. Children with an ACE score of 4 are 2 times as likely to have asthma^2,3 and allergies³, 2 times as likely to be obese⁴, 3 times as likely to have headaches³ and dental problems^5,6, 4 times as likely to have depression^7,8, 5 times as likely to have ADHD^8,9, 7 times as likely to have high rates of school absenteeism³ and aggression¹⁰, and over 30 times as likely to have learning or behavioral problems at school⁴. There is a growing body of knowledge about how chronic, severe stress in childhood affects can lead to pathological alterations in neuroendocrine and immune function. But this has not led to any concrete treatments that may be preventive or reparative.

Movement toward expanding screening nonetheless has accelerated. In California, Nadine Burke-Harris, MD, a pediatrician who studied ACEs and children’s health was named the state’s first Surgeon General in 2019 and spearheaded an effort to make screening for ACEs easier. Starting in 2020, MediCal will pay for annual screenings, and the state is offering training and resources on how to screen and what to do with the information to help patients and families.

The coronavirus pandemic has only highlighted the risks of childhood adversity. The burden of infection and mortality has been borne disproportionately by people of color and those with multiple chronic medical conditions (obesity, cardiovascular disease, diabetes, etc.). While viruses do not discriminate, they are more likely to infect those with higher risk of exposure and to kill those who are physiologically vulnerable.

And the pandemic increases the risk for adversity for today’s children and families. When children cannot attend school, financially vulnerable parents may have to choose between supervising them or feeding them. Families who suddenly are all in a small apartment together without school or other outside supports may be at higher risk for domestic violence and child abuse. Unemployment and financial uncertainty will increase the rates of substance abuse and depression amongst parents. And the serious illness or death of a parent will be a more common event for children in the year ahead. One of these risk factors may increase the likelihood of others.

Beyond the obvious need for substantial policy changes focused on housing, education, and health care, there are immediate and concrete strategies that can build resilience in children and their families. And resilience can build on itself, as children face subsequent challenges with the support of caring connected adults.

The critical first step is asking. Then listen calmly and supportively, normalizing for parents and children how common these experiences are. Explain how they affect health and well-being. Explain that adversity and its consequences are not their fault. Then educate them about what is in their control: the skills they can practice to buffer against the consequences of adversity and build resilience. They sound simple, but still require effort and work. And the pandemic has created some difficulty (social distancing) and opportunity (more family time, fewer school demands).
 

Sleep

Help parents establish and protect consistent, restful sleep for their children. They can set a consistent bedtime and a calm routine, with screens all off at least 30 minutes before sleep and reading before sleep. Restful sleep is physiologically and psychologically protective to everyone in a family.

Movement

Beyond directly improving physical health, establishing habits of exercise – especially outside – every day can effectively manage ongoing stress, build skills of self-regulation, and help with sleep.

Find out what parents and their children like to do together (walking the dog, shooting hoops, even dancing) and help them devise ways to create family routines around exercise.
 

Nutrition

Food should be a source of pleasure, but stress can make food into a source of comfort or escape. Help parents to create realistic ways to consistently offer healthy family meals and discourage unhealthy habits.

Even small changes like water instead of soda can help, and there are nutritional and emotional benefits to eating a healthy breakfast or dinner together as a family.
 

Connections

Nourishing social connections are protective. Help parents think about protecting time to spend with their children for talking, playing games, or even singing.

They should support their children’s connections to other caring adults, through community organizations (church, community centers, or sports), and they should know who their children’s reliable friends are. Parents will benefit from these supports for themselves, which in turn will benefit the full family.
 

Self-awareness

Activities that cultivate mindfulness are protective. Parents can simply ask how their children are feeling, physically or emotionally, and be able to bear it when it is uncomfortable. Work towards nonjudgmental awareness of how they are feeling. Learning what is relaxing or recharging for them (exercise, music, a hot bath, a good book, time with a friend) will protect against defaulting into maladaptive coping such as escape, numbing, or avoidance.

Of course, if you learn about symptoms that suggest PTSD, depression, or addiction, you should help your patient connect with effective treatment. The difficulty of referring to a mental health provider does not mean you should not try and bring as many people onto the team and into the orbit of the child and family at risk. It may be easier to access some therapy given the new availability of telemedicine visits across many more systems of care. Although the heaviest burdens of adversity are not being borne equally, the fact that adversity is currently a shared experience makes this a moment of promise.

Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Dr. Swick and Dr. Jellinek had no relevant financial disclosures. Email them at [email protected].

References
1. Am J Prev Med. 1998 May;14(4):245-58.
2. Ann Allergy Asthma Immunol. 2015;114: 379-84.
3. BMC Public Health. 2018. doi: 10.1186/s12889-018-5699-8.
4. Child Abuse Negl. 2011 Jun;35(6):408-13.
5. Community Dent Oral Epidemiol. 2015;43:193-9.
6. Community Dent Oral Epidemiol. 2018 Oct;46(5): 442-8.
7. Pediatrics 2016 Apr. doi: 10.1542/peds.2015-4016.
8. Matern Child Health J. 2016 Apr. doi: 10.1007/s10995-015-1915-7.
9. Acad Pediatr. 2017 May-Jun. doi: 10.1016/j.acap.2016.08.013.
10. Pediatrics. 2010 Apr. doi: 10.1542/peds.2009-0597.
 

This article was updated 7/27/2020.

For patients with psychotic depression, response to treatment, remission rates, and cognitive improvement are better following electroconvulsive therapy (ECT) than for patients with nonpsychotic depression, results from a new study suggest.

However, findings from another study suggest that at least some of these differences may be because psychotic patients are referred for ECT earlier in the disease course.

Both studies were presented at the European Psychiatric Association 2020 Congress, which was held online this year because of the COVID-19 pandemic.
 

Limited, old evidence

The first study was led by Christopher Yi Wen Chan, MD, Institute of Mental Health, Singapore. The investigators stated that they have “often observed” superior remission rates with ECT in psychotic versus nonpsychotic depression. However, the evidence base is “limited and mostly more than 10 years old.”

They conducted a retrospective case-control study that included 160 patients – 50 with psychotic depression, and 110 with nonpsychotic depression. All patients had a primary diagnosis of unipolar major depressive disorder and underwent ECT at a tertiary psychiatric institute between January 2016 and January 2018.

Baseline characteristics of the two groups were similar, although patients with psychosis were more likely to have had an involuntary hospital admission and to have had higher baseline scores on the Montreal Cognitive Assessment (MoCA) and Clinical Global Impression–Severity scale (CGI-S) than nonpsychotic patients.

Response rates to ECT were significantly higher for the patients with psychotic depression than for those with nonpsychotic depression (79% vs. 51%; P = .009), as were remission rates (71% vs. 36%; P = .001).

Both groups showed significant improvement following ECT in Montgomery-Åsberg Depression Rating Scale, CGI, and quality-of-life scores.

However, only the participants with psychotic depression showed a significant improvement in MoCA total score (P = .038), as well as on attention (P = .024), language (P = .008), and orientation (P = .021) subdomains.
 

Psychotic depression markers?

For the second study, a team led by Aida De Arriba Arnau, MD, Centro de Investigación Biomédica en Red de Salud Mental, Barcelona, Spain, retrospectively analyzed 66 patients with depression who had received ECT. Of these, 26 had psychotic depression, and 40 had nonpsychotic depression.

Response rates were again higher in patients with psychotic vs nonpsychotic depression (92.3% vs. 85.0%). A similar number of sessions was needed to achieve a response.

Improvements in Hamilton Depression Rating Scale scores were significant between the two groups from the start of treatment, although the difference became nonsignificant at week 6.

Arriba Arnau said that there were some notable differences between patients with psychotic depression and those with nonpsychotic depression. For example, the former had “poor functionality, shorter episode duration, and less pharmacological resistance before receiving ECT,” she said.

“So we hypothesized that they might be referred more promptly to ECT treatment,” she added.

The psychotic depression group was significantly older than the group with nonpsychotic depression, at an average of 67.81 years vs 58.96 years.

They also “showed more illness severity and cognitive disturbances at baseline and ... required less anesthetic doses and higher initial stimulus intensity,» Arriba Arnau noted.

“All these features could be the markers of psychotic depression as an entity,” she said. However, the potential impact of age on these differences should be “further studied.”

She added that other aspects, such as age at onset and number of previous episodes, were similar between the groups.
 

Confirmatory data

Commenting on the findings for Medscape Medical News, Georgios Petrides, MD, associate professor of psychiatry, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, East Garden City, New York, noted that differences in response to ECT between patients with psychotic depression and those with nonpsychotic depression are “well known.”

However, “it’s actually good to present more data that confirm what people are doing in clinical practice,” said Petrides, who was not involved with the research.

Petrides noted that some guidelines recommend ECT as first-line treatment for psychotic depression.

“For nonpsychotic depression, we’d try medications, psychotherapy, and everything else first,” he said. He noted that the current results are “a good replication of what is known so far.”

As to why ECT should be more effective for patients with psychotic depression, he said, “A lot of people think that the biology of psychotic depression is different from the biology of nonpsychotic depression.”

Many things that ECT “corrects” are disturbed in psychotic depression, including cortisol homeostasis, which is thought to be affected via the hypothalamic-pituitary-adrenal axis, Petrides added.

That ECT is more effective in psychotic depression is an “indirect point of evidence” to support that theory.

One aspect that has traditionally dogged the use of ECT has been the stigma that surrounds the procedure, Petrides noted. That’s “always an issue, but it’s getting less and less over time,” he said.

He added that ECT is extremely safe and that it is associated with the “lowest mortality for any procedure performed under general anesthesia,” which helps to reduce the stigma around it, he noted.

The study authors and Petrides have reported no relevant financial relationships.

This article first appeared on Medscape.com.

For patients with psychotic depression, response to treatment, remission rates, and cognitive improvement are better following electroconvulsive therapy (ECT) than for patients with nonpsychotic depression, results from a new study suggest.

However, findings from another study suggest that at least some of these differences may be because psychotic patients are referred for ECT earlier in the disease course.

Both studies were presented at the European Psychiatric Association 2020 Congress, which was held online this year because of the COVID-19 pandemic.
 

Limited, old evidence

The first study was led by Christopher Yi Wen Chan, MD, Institute of Mental Health, Singapore. The investigators stated that they have “often observed” superior remission rates with ECT in psychotic versus nonpsychotic depression. However, the evidence base is “limited and mostly more than 10 years old.”

They conducted a retrospective case-control study that included 160 patients – 50 with psychotic depression, and 110 with nonpsychotic depression. All patients had a primary diagnosis of unipolar major depressive disorder and underwent ECT at a tertiary psychiatric institute between January 2016 and January 2018.

Baseline characteristics of the two groups were similar, although patients with psychosis were more likely to have had an involuntary hospital admission and to have had higher baseline scores on the Montreal Cognitive Assessment (MoCA) and Clinical Global Impression–Severity scale (CGI-S) than nonpsychotic patients.

Response rates to ECT were significantly higher for the patients with psychotic depression than for those with nonpsychotic depression (79% vs. 51%; P = .009), as were remission rates (71% vs. 36%; P = .001).

Both groups showed significant improvement following ECT in Montgomery-Åsberg Depression Rating Scale, CGI, and quality-of-life scores.

However, only the participants with psychotic depression showed a significant improvement in MoCA total score (P = .038), as well as on attention (P = .024), language (P = .008), and orientation (P = .021) subdomains.
 

Psychotic depression markers?

For the second study, a team led by Aida De Arriba Arnau, MD, Centro de Investigación Biomédica en Red de Salud Mental, Barcelona, Spain, retrospectively analyzed 66 patients with depression who had received ECT. Of these, 26 had psychotic depression, and 40 had nonpsychotic depression.

Response rates were again higher in patients with psychotic vs nonpsychotic depression (92.3% vs. 85.0%). A similar number of sessions was needed to achieve a response.

Improvements in Hamilton Depression Rating Scale scores were significant between the two groups from the start of treatment, although the difference became nonsignificant at week 6.

Arriba Arnau said that there were some notable differences between patients with psychotic depression and those with nonpsychotic depression. For example, the former had “poor functionality, shorter episode duration, and less pharmacological resistance before receiving ECT,” she said.

“So we hypothesized that they might be referred more promptly to ECT treatment,” she added.

The psychotic depression group was significantly older than the group with nonpsychotic depression, at an average of 67.81 years vs 58.96 years.

They also “showed more illness severity and cognitive disturbances at baseline and ... required less anesthetic doses and higher initial stimulus intensity,» Arriba Arnau noted.

“All these features could be the markers of psychotic depression as an entity,” she said. However, the potential impact of age on these differences should be “further studied.”

She added that other aspects, such as age at onset and number of previous episodes, were similar between the groups.
 

Confirmatory data

Commenting on the findings for Medscape Medical News, Georgios Petrides, MD, associate professor of psychiatry, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, East Garden City, New York, noted that differences in response to ECT between patients with psychotic depression and those with nonpsychotic depression are “well known.”

However, “it’s actually good to present more data that confirm what people are doing in clinical practice,” said Petrides, who was not involved with the research.

Petrides noted that some guidelines recommend ECT as first-line treatment for psychotic depression.

“For nonpsychotic depression, we’d try medications, psychotherapy, and everything else first,” he said. He noted that the current results are “a good replication of what is known so far.”

As to why ECT should be more effective for patients with psychotic depression, he said, “A lot of people think that the biology of psychotic depression is different from the biology of nonpsychotic depression.”

Many things that ECT “corrects” are disturbed in psychotic depression, including cortisol homeostasis, which is thought to be affected via the hypothalamic-pituitary-adrenal axis, Petrides added.

That ECT is more effective in psychotic depression is an “indirect point of evidence” to support that theory.

One aspect that has traditionally dogged the use of ECT has been the stigma that surrounds the procedure, Petrides noted. That’s “always an issue, but it’s getting less and less over time,” he said.

He added that ECT is extremely safe and that it is associated with the “lowest mortality for any procedure performed under general anesthesia,” which helps to reduce the stigma around it, he noted.

The study authors and Petrides have reported no relevant financial relationships.

This article first appeared on Medscape.com.

For patients with psychotic depression, response to treatment, remission rates, and cognitive improvement are better following electroconvulsive therapy (ECT) than for patients with nonpsychotic depression, results from a new study suggest.

However, findings from another study suggest that at least some of these differences may be because psychotic patients are referred for ECT earlier in the disease course.

Both studies were presented at the European Psychiatric Association 2020 Congress, which was held online this year because of the COVID-19 pandemic.
 

Limited, old evidence

The first study was led by Christopher Yi Wen Chan, MD, Institute of Mental Health, Singapore. The investigators stated that they have “often observed” superior remission rates with ECT in psychotic versus nonpsychotic depression. However, the evidence base is “limited and mostly more than 10 years old.”

They conducted a retrospective case-control study that included 160 patients – 50 with psychotic depression, and 110 with nonpsychotic depression. All patients had a primary diagnosis of unipolar major depressive disorder and underwent ECT at a tertiary psychiatric institute between January 2016 and January 2018.

Baseline characteristics of the two groups were similar, although patients with psychosis were more likely to have had an involuntary hospital admission and to have had higher baseline scores on the Montreal Cognitive Assessment (MoCA) and Clinical Global Impression–Severity scale (CGI-S) than nonpsychotic patients.

Response rates to ECT were significantly higher for the patients with psychotic depression than for those with nonpsychotic depression (79% vs. 51%; P = .009), as were remission rates (71% vs. 36%; P = .001).

Both groups showed significant improvement following ECT in Montgomery-Åsberg Depression Rating Scale, CGI, and quality-of-life scores.

However, only the participants with psychotic depression showed a significant improvement in MoCA total score (P = .038), as well as on attention (P = .024), language (P = .008), and orientation (P = .021) subdomains.
 

Psychotic depression markers?

For the second study, a team led by Aida De Arriba Arnau, MD, Centro de Investigación Biomédica en Red de Salud Mental, Barcelona, Spain, retrospectively analyzed 66 patients with depression who had received ECT. Of these, 26 had psychotic depression, and 40 had nonpsychotic depression.

Response rates were again higher in patients with psychotic vs nonpsychotic depression (92.3% vs. 85.0%). A similar number of sessions was needed to achieve a response.

Improvements in Hamilton Depression Rating Scale scores were significant between the two groups from the start of treatment, although the difference became nonsignificant at week 6.

Arriba Arnau said that there were some notable differences between patients with psychotic depression and those with nonpsychotic depression. For example, the former had “poor functionality, shorter episode duration, and less pharmacological resistance before receiving ECT,” she said.

“So we hypothesized that they might be referred more promptly to ECT treatment,” she added.

The psychotic depression group was significantly older than the group with nonpsychotic depression, at an average of 67.81 years vs 58.96 years.

They also “showed more illness severity and cognitive disturbances at baseline and ... required less anesthetic doses and higher initial stimulus intensity,» Arriba Arnau noted.

“All these features could be the markers of psychotic depression as an entity,” she said. However, the potential impact of age on these differences should be “further studied.”

She added that other aspects, such as age at onset and number of previous episodes, were similar between the groups.
 

Confirmatory data

Commenting on the findings for Medscape Medical News, Georgios Petrides, MD, associate professor of psychiatry, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, East Garden City, New York, noted that differences in response to ECT between patients with psychotic depression and those with nonpsychotic depression are “well known.”

However, “it’s actually good to present more data that confirm what people are doing in clinical practice,” said Petrides, who was not involved with the research.

Petrides noted that some guidelines recommend ECT as first-line treatment for psychotic depression.

“For nonpsychotic depression, we’d try medications, psychotherapy, and everything else first,” he said. He noted that the current results are “a good replication of what is known so far.”

As to why ECT should be more effective for patients with psychotic depression, he said, “A lot of people think that the biology of psychotic depression is different from the biology of nonpsychotic depression.”

Many things that ECT “corrects” are disturbed in psychotic depression, including cortisol homeostasis, which is thought to be affected via the hypothalamic-pituitary-adrenal axis, Petrides added.

That ECT is more effective in psychotic depression is an “indirect point of evidence” to support that theory.

One aspect that has traditionally dogged the use of ECT has been the stigma that surrounds the procedure, Petrides noted. That’s “always an issue, but it’s getting less and less over time,” he said.

He added that ECT is extremely safe and that it is associated with the “lowest mortality for any procedure performed under general anesthesia,” which helps to reduce the stigma around it, he noted.

The study authors and Petrides have reported no relevant financial relationships.

This article first appeared on Medscape.com.

If US pharmacies were permitted to dispense methadone for opioid use disorder (OUD) it would improve national access to treatment and save costs, new research suggests.

Under current federal regulations, only opioid treatment programs (OTPs) are permitted to dispense methadone maintenance treatment. This stands in sharp contrast to how methadone is dispensed in Canada, Australia, and the United Kingdom, where patients can obtain daily doses of methadone maintenance from community pharmacies.

“It’s challenging for patients in many parts of the US to access methadone treatment,” Robert Kleinman, MD, of Stanford University School of Medicine, Stanford, California, said in a JAMA Psychiatry podcast.

“It’s important for policymakers to consider strategies that enhance access to methadone maintenance treatment, in that it’s associated with large reductions in mortality from opioid use disorder. One possibility is to use pharmacies as dispensing sites,” said Kleinman.

The study was published online July 15 in JAMA Psychiatry.

An Hour vs 10 Minutes

Kleinman examined how pharmacy-based dispensing would affect drive times to the nearest OTP for the general US population. The analysis included all 1682 OTP locations, 69,475 unique pharmacy locations, and 72,443 census tracts.

The average drive time to OTPs in the US is 20.4 minutes vs a drive time of 4.5 minutes to pharmacies.

Driving times to OTPs are particularly long in nonmetropolitan counties while pharmacies remain “relatively easily accessible” in nonmetropolitan counties, he said.

In “micropolitan” counties, for example, the drive time to OTPs was 48.4 minutes vs 7 minutes to pharmacies. In the most rural counties, the drive time to OTPs is 60.9 minutes vs 9.1 minutes to pharmacies.

“This suggests that pharmacy-based dispensing has the potential to reduce urban or rural inequities, and access to methadone treatment,” Kleinman said.

In a mileage cost analysis, Kleinman determined that the average cost of one-way trip to an OTP in the US is $3.12 compared with 45 cents to a pharmacy. In the most rural counties, the average cost one-way is $11.10 vs $1.27 to a pharmacy.

Kleinman says decreasing drive times, distance, and costs for patients seeking methadone treatment by allowing pharmacies to dispense the medication may help achieve several public health goals.

“Patients dissuaded from obtaining treatment because of extended travel, particularly patients with disabilities, unreliable access to transportation, or from rural regions, would have reduced barriers to care. Quality of life may be increased for the more than 380,000 individuals currently receiving methadone treatment if less time is spent commuting,” he writes.

Time for Change

The authors of an accompanying editorial, say the “regulatory burden” on methadone provision in the US “effectively prohibits the integration of methadone prescribing into primary care, even in rural communities where there may exist no specialty substance use treatment options.”

However, federal and state agencies are starting to take action to expand geographic access to methadone treatment, note Paul Joudrey, MD, MPH, and coauthors from Yale School of Medicine, New Haven, Connecticut.

The US Drug Enforcement Administration has proposed allowing mobile methadone units, and Ohio and Kentucky have passed laws to allow greater use of federally qualified health centers and other facilities for methadone dispensing.

“While these policies are welcomed, the results here by Kleinman and others suggest they fall short of needed expansion if patients’ rights to evidence-based care for OUD are to be ensured. Importantly, even with broad adoption of mobile or pharmacy-based dispensing, patients would still face a long drive time to a central OTP before starting methadone,” Joudrey and colleagues write.

In their view, the only way to address this barrier is to modify federal law, and this “should be urgently pursued in the context of the ongoing overdose epidemic. It is time for policies that truly support methadone treatment for OUD as opposed to focusing on diversion.”

This article first appeared on Medscape.com.

If US pharmacies were permitted to dispense methadone for opioid use disorder (OUD) it would improve national access to treatment and save costs, new research suggests.

Under current federal regulations, only opioid treatment programs (OTPs) are permitted to dispense methadone maintenance treatment. This stands in sharp contrast to how methadone is dispensed in Canada, Australia, and the United Kingdom, where patients can obtain daily doses of methadone maintenance from community pharmacies.

“It’s challenging for patients in many parts of the US to access methadone treatment,” Robert Kleinman, MD, of Stanford University School of Medicine, Stanford, California, said in a JAMA Psychiatry podcast.

“It’s important for policymakers to consider strategies that enhance access to methadone maintenance treatment, in that it’s associated with large reductions in mortality from opioid use disorder. One possibility is to use pharmacies as dispensing sites,” said Kleinman.

The study was published online July 15 in JAMA Psychiatry.

An Hour vs 10 Minutes

Kleinman examined how pharmacy-based dispensing would affect drive times to the nearest OTP for the general US population. The analysis included all 1682 OTP locations, 69,475 unique pharmacy locations, and 72,443 census tracts.

The average drive time to OTPs in the US is 20.4 minutes vs a drive time of 4.5 minutes to pharmacies.

Driving times to OTPs are particularly long in nonmetropolitan counties while pharmacies remain “relatively easily accessible” in nonmetropolitan counties, he said.

In “micropolitan” counties, for example, the drive time to OTPs was 48.4 minutes vs 7 minutes to pharmacies. In the most rural counties, the drive time to OTPs is 60.9 minutes vs 9.1 minutes to pharmacies.

“This suggests that pharmacy-based dispensing has the potential to reduce urban or rural inequities, and access to methadone treatment,” Kleinman said.

In a mileage cost analysis, Kleinman determined that the average cost of one-way trip to an OTP in the US is $3.12 compared with 45 cents to a pharmacy. In the most rural counties, the average cost one-way is $11.10 vs $1.27 to a pharmacy.

Kleinman says decreasing drive times, distance, and costs for patients seeking methadone treatment by allowing pharmacies to dispense the medication may help achieve several public health goals.

“Patients dissuaded from obtaining treatment because of extended travel, particularly patients with disabilities, unreliable access to transportation, or from rural regions, would have reduced barriers to care. Quality of life may be increased for the more than 380,000 individuals currently receiving methadone treatment if less time is spent commuting,” he writes.

Time for Change

The authors of an accompanying editorial, say the “regulatory burden” on methadone provision in the US “effectively prohibits the integration of methadone prescribing into primary care, even in rural communities where there may exist no specialty substance use treatment options.”

However, federal and state agencies are starting to take action to expand geographic access to methadone treatment, note Paul Joudrey, MD, MPH, and coauthors from Yale School of Medicine, New Haven, Connecticut.

The US Drug Enforcement Administration has proposed allowing mobile methadone units, and Ohio and Kentucky have passed laws to allow greater use of federally qualified health centers and other facilities for methadone dispensing.

“While these policies are welcomed, the results here by Kleinman and others suggest they fall short of needed expansion if patients’ rights to evidence-based care for OUD are to be ensured. Importantly, even with broad adoption of mobile or pharmacy-based dispensing, patients would still face a long drive time to a central OTP before starting methadone,” Joudrey and colleagues write.

In their view, the only way to address this barrier is to modify federal law, and this “should be urgently pursued in the context of the ongoing overdose epidemic. It is time for policies that truly support methadone treatment for OUD as opposed to focusing on diversion.”

This article first appeared on Medscape.com.

If US pharmacies were permitted to dispense methadone for opioid use disorder (OUD) it would improve national access to treatment and save costs, new research suggests.

Under current federal regulations, only opioid treatment programs (OTPs) are permitted to dispense methadone maintenance treatment. This stands in sharp contrast to how methadone is dispensed in Canada, Australia, and the United Kingdom, where patients can obtain daily doses of methadone maintenance from community pharmacies.

“It’s challenging for patients in many parts of the US to access methadone treatment,” Robert Kleinman, MD, of Stanford University School of Medicine, Stanford, California, said in a JAMA Psychiatry podcast.

“It’s important for policymakers to consider strategies that enhance access to methadone maintenance treatment, in that it’s associated with large reductions in mortality from opioid use disorder. One possibility is to use pharmacies as dispensing sites,” said Kleinman.

The study was published online July 15 in JAMA Psychiatry.

An Hour vs 10 Minutes

Kleinman examined how pharmacy-based dispensing would affect drive times to the nearest OTP for the general US population. The analysis included all 1682 OTP locations, 69,475 unique pharmacy locations, and 72,443 census tracts.

The average drive time to OTPs in the US is 20.4 minutes vs a drive time of 4.5 minutes to pharmacies.

Driving times to OTPs are particularly long in nonmetropolitan counties while pharmacies remain “relatively easily accessible” in nonmetropolitan counties, he said.

In “micropolitan” counties, for example, the drive time to OTPs was 48.4 minutes vs 7 minutes to pharmacies. In the most rural counties, the drive time to OTPs is 60.9 minutes vs 9.1 minutes to pharmacies.

“This suggests that pharmacy-based dispensing has the potential to reduce urban or rural inequities, and access to methadone treatment,” Kleinman said.

In a mileage cost analysis, Kleinman determined that the average cost of one-way trip to an OTP in the US is $3.12 compared with 45 cents to a pharmacy. In the most rural counties, the average cost one-way is $11.10 vs $1.27 to a pharmacy.

Kleinman says decreasing drive times, distance, and costs for patients seeking methadone treatment by allowing pharmacies to dispense the medication may help achieve several public health goals.

“Patients dissuaded from obtaining treatment because of extended travel, particularly patients with disabilities, unreliable access to transportation, or from rural regions, would have reduced barriers to care. Quality of life may be increased for the more than 380,000 individuals currently receiving methadone treatment if less time is spent commuting,” he writes.

Time for Change

The authors of an accompanying editorial, say the “regulatory burden” on methadone provision in the US “effectively prohibits the integration of methadone prescribing into primary care, even in rural communities where there may exist no specialty substance use treatment options.”

However, federal and state agencies are starting to take action to expand geographic access to methadone treatment, note Paul Joudrey, MD, MPH, and coauthors from Yale School of Medicine, New Haven, Connecticut.

The US Drug Enforcement Administration has proposed allowing mobile methadone units, and Ohio and Kentucky have passed laws to allow greater use of federally qualified health centers and other facilities for methadone dispensing.

“While these policies are welcomed, the results here by Kleinman and others suggest they fall short of needed expansion if patients’ rights to evidence-based care for OUD are to be ensured. Importantly, even with broad adoption of mobile or pharmacy-based dispensing, patients would still face a long drive time to a central OTP before starting methadone,” Joudrey and colleagues write.

In their view, the only way to address this barrier is to modify federal law, and this “should be urgently pursued in the context of the ongoing overdose epidemic. It is time for policies that truly support methadone treatment for OUD as opposed to focusing on diversion.”

This article first appeared on Medscape.com.

Given an opportunity to see physicians’ notes about their visits, patients mostly understand and agree with them, a survey shows.

Overall, 93% of respondents said the notes accurately described the visit; only 6% reported that something important was missing, write Suzanne G. Leveille, RN, PhD, of the University of Massachusetts, Boston, and colleagues in the Journal of General Internal Medicine.

“I think it’s wonderful news,” commented Howard Levy, MD, PhD, who spearheaded the implementation of open notes at Johns Hopkins University, Baltimore. “I’m thrilled with this report.”

Currently, 50 million Americans have access to their notes, the researchers report. Starting Nov. 2, 2020, the 21st Century Cures Act will require all US physicians to provide this access.

The regulation follows a movement to involve patients more actively in their care. Previous research has shown that access to visit notes improves patients’ feelings of control, helps them adhere to their medication regimens, and enables them to better understand their care plans.

Although physicians often feel that giving patients access to notes will lead to unnecessary conversations that will waste their time, previous studies have not borne that out. “Most clinical providers don’t notice a thing,” Levy told Medscape Medical News. “There was no change in the volume of work.”

Leveille and colleagues wanted to know how patients viewed the clarity, accuracy, and completeness of the notes they were reading and whether they had suggestions for improvements.

They surveyed all 136,815 adult outpatients affiliated with Beth Israel Deaconess Medical Center in Boston, Massachusetts; the University of Washington Medicine, in Seattle; and the Geisinger Health System, based in Danville, Pennsylvania. These systems all offer patients access to physicians’ notes.

The researchers asked the patients to recall one note written by a doctor, nurse practitioner, physician assistant, or mental health professional.

They received responses from 21,664 patients who had read at least one note. Of these, two thirds were women, three quarters were aged 45 years or older, and 85% were White.

Seventy-two percent had completed college. Although 85% reported being in good or excellent health, more of the respondents than nonrespondents had chronic health problems.

Ninety-seven percent of those with college educations understood their notes, compared with 92% of those who had not completed college, a finding that conflicted with the researchers’ expectations. “Good gracious, that’s wonderful,” Levy said. “In medicine we almost never get a 92% success rate in anything we do.”

Of the patients in fair or poor health, 88.6% said the note was accurate, compared with 94.4% of those in better health. Those in worse health were also more likely to say something important was missing.

When patients didn’t understand something, 35% searched the Internet, 27% asked a clinician, 7% asked a friend or family member, and 27% didn’t get help. (The researchers did not account for the other 4%.)

Of those patients whose note was written by a physician, 95% reported that the note accurately described the visit, compared with 92% of those whose note was written by a nurse practitioner and 90% of those whose note was written by a physician assistant.

Of patients reporting on a primary care note, 97% understood the note, compared with 94% of those reporting on a note from a visit to a specialist.

Ninety-three percent of those who understood their note were likely to recommend their clinician, compared with 77% of those who didn’t completely understand their note.

Asked how the notes could be improved, 3,812 people responded with comments of at least five words. These responses were included in the analysis.

Most commonly, patients wanted new information to be prominently featured at the top of the note, with clear instructions about next steps, referrals, and explanations of test results.

Often, they complained of old information or templates that felt impersonal. They stumbled over medical jargon and suggested links to glossaries. They bristled at such terms as “obese” and “patient denies.” Some wanted a way to comment on the notes.

Regarding the portals in which the notes were found, some patients said the notes were sometimes hard to find. Some said the notes were not posted quickly enough after the visits.

Levy said physicians should learn to write notes more succinctly, and he expects new regulations from the Centers for Medicare & Medicaid Services to encourage that. Previous regulations may have given physicians the impression that longer notes would allow them to bill at higher rates, he said. “The change in billing requirements will make it easier for healthcare providers to feel comfortable that they don’t have to restate information that had already been stated,” he said.

On the other hand, physicians should continue to use medical terminology, he said. “At times we use jargon, because it conveys rich, dense information in a few words,” he said. “That’s something that we should not have to give up.” Patients can research terms they don’t understand, he said.

Family physician Doug Iliff, MD, thinks it’s about time that his colleagues share their notes. He’s been doing it since he opened his solo practice in Topeka, Kansas, in 1984.

He still does it the way he always did, with carbonless copy paper. After each visit, he simply tears off the copy and hands it to the patient.

“It makes them know we’re on the same page,” he told Medscape Medical News. “It gives them confidence that I’m telling them what I really think.”

He has one comment on the work of Leveille and her colleagues. “Why are they studying this? Isn’t it obvious that it’s a good thing?”

The study was funded by the Robert Wood Johnson Foundation, the Gordon and Betty Moore Foundation, the Peterson Center on Healthcare, and the Cambia Health Foundation. The study authors, Iliff, and Levy have disclosed no relevant financial relationships.

This article first appeared on Medscape.com.

Given an opportunity to see physicians’ notes about their visits, patients mostly understand and agree with them, a survey shows.

Overall, 93% of respondents said the notes accurately described the visit; only 6% reported that something important was missing, write Suzanne G. Leveille, RN, PhD, of the University of Massachusetts, Boston, and colleagues in the Journal of General Internal Medicine.

“I think it’s wonderful news,” commented Howard Levy, MD, PhD, who spearheaded the implementation of open notes at Johns Hopkins University, Baltimore. “I’m thrilled with this report.”

Currently, 50 million Americans have access to their notes, the researchers report. Starting Nov. 2, 2020, the 21st Century Cures Act will require all US physicians to provide this access.

The regulation follows a movement to involve patients more actively in their care. Previous research has shown that access to visit notes improves patients’ feelings of control, helps them adhere to their medication regimens, and enables them to better understand their care plans.

Although physicians often feel that giving patients access to notes will lead to unnecessary conversations that will waste their time, previous studies have not borne that out. “Most clinical providers don’t notice a thing,” Levy told Medscape Medical News. “There was no change in the volume of work.”

Leveille and colleagues wanted to know how patients viewed the clarity, accuracy, and completeness of the notes they were reading and whether they had suggestions for improvements.

They surveyed all 136,815 adult outpatients affiliated with Beth Israel Deaconess Medical Center in Boston, Massachusetts; the University of Washington Medicine, in Seattle; and the Geisinger Health System, based in Danville, Pennsylvania. These systems all offer patients access to physicians’ notes.

The researchers asked the patients to recall one note written by a doctor, nurse practitioner, physician assistant, or mental health professional.

They received responses from 21,664 patients who had read at least one note. Of these, two thirds were women, three quarters were aged 45 years or older, and 85% were White.

Seventy-two percent had completed college. Although 85% reported being in good or excellent health, more of the respondents than nonrespondents had chronic health problems.

Ninety-seven percent of those with college educations understood their notes, compared with 92% of those who had not completed college, a finding that conflicted with the researchers’ expectations. “Good gracious, that’s wonderful,” Levy said. “In medicine we almost never get a 92% success rate in anything we do.”

Of the patients in fair or poor health, 88.6% said the note was accurate, compared with 94.4% of those in better health. Those in worse health were also more likely to say something important was missing.

When patients didn’t understand something, 35% searched the Internet, 27% asked a clinician, 7% asked a friend or family member, and 27% didn’t get help. (The researchers did not account for the other 4%.)

Of those patients whose note was written by a physician, 95% reported that the note accurately described the visit, compared with 92% of those whose note was written by a nurse practitioner and 90% of those whose note was written by a physician assistant.

Of patients reporting on a primary care note, 97% understood the note, compared with 94% of those reporting on a note from a visit to a specialist.

Ninety-three percent of those who understood their note were likely to recommend their clinician, compared with 77% of those who didn’t completely understand their note.

Asked how the notes could be improved, 3,812 people responded with comments of at least five words. These responses were included in the analysis.

Most commonly, patients wanted new information to be prominently featured at the top of the note, with clear instructions about next steps, referrals, and explanations of test results.

Often, they complained of old information or templates that felt impersonal. They stumbled over medical jargon and suggested links to glossaries. They bristled at such terms as “obese” and “patient denies.” Some wanted a way to comment on the notes.

Regarding the portals in which the notes were found, some patients said the notes were sometimes hard to find. Some said the notes were not posted quickly enough after the visits.

Levy said physicians should learn to write notes more succinctly, and he expects new regulations from the Centers for Medicare & Medicaid Services to encourage that. Previous regulations may have given physicians the impression that longer notes would allow them to bill at higher rates, he said. “The change in billing requirements will make it easier for healthcare providers to feel comfortable that they don’t have to restate information that had already been stated,” he said.

On the other hand, physicians should continue to use medical terminology, he said. “At times we use jargon, because it conveys rich, dense information in a few words,” he said. “That’s something that we should not have to give up.” Patients can research terms they don’t understand, he said.

Family physician Doug Iliff, MD, thinks it’s about time that his colleagues share their notes. He’s been doing it since he opened his solo practice in Topeka, Kansas, in 1984.

He still does it the way he always did, with carbonless copy paper. After each visit, he simply tears off the copy and hands it to the patient.

“It makes them know we’re on the same page,” he told Medscape Medical News. “It gives them confidence that I’m telling them what I really think.”

He has one comment on the work of Leveille and her colleagues. “Why are they studying this? Isn’t it obvious that it’s a good thing?”

The study was funded by the Robert Wood Johnson Foundation, the Gordon and Betty Moore Foundation, the Peterson Center on Healthcare, and the Cambia Health Foundation. The study authors, Iliff, and Levy have disclosed no relevant financial relationships.

This article first appeared on Medscape.com.

Given an opportunity to see physicians’ notes about their visits, patients mostly understand and agree with them, a survey shows.

Overall, 93% of respondents said the notes accurately described the visit; only 6% reported that something important was missing, write Suzanne G. Leveille, RN, PhD, of the University of Massachusetts, Boston, and colleagues in the Journal of General Internal Medicine.

“I think it’s wonderful news,” commented Howard Levy, MD, PhD, who spearheaded the implementation of open notes at Johns Hopkins University, Baltimore. “I’m thrilled with this report.”

Currently, 50 million Americans have access to their notes, the researchers report. Starting Nov. 2, 2020, the 21st Century Cures Act will require all US physicians to provide this access.

The regulation follows a movement to involve patients more actively in their care. Previous research has shown that access to visit notes improves patients’ feelings of control, helps them adhere to their medication regimens, and enables them to better understand their care plans.

Although physicians often feel that giving patients access to notes will lead to unnecessary conversations that will waste their time, previous studies have not borne that out. “Most clinical providers don’t notice a thing,” Levy told Medscape Medical News. “There was no change in the volume of work.”

Leveille and colleagues wanted to know how patients viewed the clarity, accuracy, and completeness of the notes they were reading and whether they had suggestions for improvements.

They surveyed all 136,815 adult outpatients affiliated with Beth Israel Deaconess Medical Center in Boston, Massachusetts; the University of Washington Medicine, in Seattle; and the Geisinger Health System, based in Danville, Pennsylvania. These systems all offer patients access to physicians’ notes.

The researchers asked the patients to recall one note written by a doctor, nurse practitioner, physician assistant, or mental health professional.

They received responses from 21,664 patients who had read at least one note. Of these, two thirds were women, three quarters were aged 45 years or older, and 85% were White.

Seventy-two percent had completed college. Although 85% reported being in good or excellent health, more of the respondents than nonrespondents had chronic health problems.

Ninety-seven percent of those with college educations understood their notes, compared with 92% of those who had not completed college, a finding that conflicted with the researchers’ expectations. “Good gracious, that’s wonderful,” Levy said. “In medicine we almost never get a 92% success rate in anything we do.”

Of the patients in fair or poor health, 88.6% said the note was accurate, compared with 94.4% of those in better health. Those in worse health were also more likely to say something important was missing.

When patients didn’t understand something, 35% searched the Internet, 27% asked a clinician, 7% asked a friend or family member, and 27% didn’t get help. (The researchers did not account for the other 4%.)

Of those patients whose note was written by a physician, 95% reported that the note accurately described the visit, compared with 92% of those whose note was written by a nurse practitioner and 90% of those whose note was written by a physician assistant.

Of patients reporting on a primary care note, 97% understood the note, compared with 94% of those reporting on a note from a visit to a specialist.

Ninety-three percent of those who understood their note were likely to recommend their clinician, compared with 77% of those who didn’t completely understand their note.

Asked how the notes could be improved, 3,812 people responded with comments of at least five words. These responses were included in the analysis.

Most commonly, patients wanted new information to be prominently featured at the top of the note, with clear instructions about next steps, referrals, and explanations of test results.

Often, they complained of old information or templates that felt impersonal. They stumbled over medical jargon and suggested links to glossaries. They bristled at such terms as “obese” and “patient denies.” Some wanted a way to comment on the notes.

Regarding the portals in which the notes were found, some patients said the notes were sometimes hard to find. Some said the notes were not posted quickly enough after the visits.

Levy said physicians should learn to write notes more succinctly, and he expects new regulations from the Centers for Medicare & Medicaid Services to encourage that. Previous regulations may have given physicians the impression that longer notes would allow them to bill at higher rates, he said. “The change in billing requirements will make it easier for healthcare providers to feel comfortable that they don’t have to restate information that had already been stated,” he said.

On the other hand, physicians should continue to use medical terminology, he said. “At times we use jargon, because it conveys rich, dense information in a few words,” he said. “That’s something that we should not have to give up.” Patients can research terms they don’t understand, he said.

Family physician Doug Iliff, MD, thinks it’s about time that his colleagues share their notes. He’s been doing it since he opened his solo practice in Topeka, Kansas, in 1984.

He still does it the way he always did, with carbonless copy paper. After each visit, he simply tears off the copy and hands it to the patient.

“It makes them know we’re on the same page,” he told Medscape Medical News. “It gives them confidence that I’m telling them what I really think.”

He has one comment on the work of Leveille and her colleagues. “Why are they studying this? Isn’t it obvious that it’s a good thing?”

The study was funded by the Robert Wood Johnson Foundation, the Gordon and Betty Moore Foundation, the Peterson Center on Healthcare, and the Cambia Health Foundation. The study authors, Iliff, and Levy have disclosed no relevant financial relationships.

This article first appeared on Medscape.com.

A former nursing assistant and Army veteran pleaded guilty to federal murder charges this week in connection with the 2017-2018 deaths of seven patients in a West Virginia veteran’s hospital, according to news reports.

Prosecutors said in court documents filed on July 13 that Reta Mays, 46, injected lethal doses of insulin into seven veterans at the Louis A. Johnson VA Medical Center (VAMC) in rural Clarksburg, W.Va.

Their blood glucose levels plummeted, and each died shortly after their injections, according to the Tennessean.

An eighth patient, a 92-year-old man whom Mays is accused of assaulting with an insulin injection, initially survived after staff were able to stabilize him but died 2 weeks later at a nursing home, NPR reports.

According to NPR, US Attorney Jarod Douglas told the court Tuesday that the medical investigator could not determine whether the insulin contributed to the man’s death but that it was Mays’ intention to kill him.

“No one watched while she injected them with lethal doses of insulin during an 11-month killing rampage,” the Washington Post reported.
 

No motive offered

The Post article said no motive has been established, but after a 2-year investigation into a pattern of suspicious deaths that took the hospital almost a year to detect, Mays, who had denied any wrongdoing in multiple interviews with investigators, told a federal judge she preyed on some of the country›s most vulnerable service members.

An attorney for Mays, Brian Kornbrath, contacted by Medscape Medical News, said: “The defense team decided that we would have no public comment at this time.”

According to court documents from the Northern District of West Virginia, Mays was charged with seven counts of second-degree murder and one count of assault with intent to commit murder in connection with the patient who died later.

Mays was hired at the VAMC in Clarksburg in June 2015. She worked from 7:30 PM to 8:00 AM in the medical surgical unit, court documents say.

According to the documents, “VAMC Clarksburg did not require a nursing assistant to have a certification or licensure for initial appointment or as a condition of continuing employment.”

The documents indicate that in June 2018, a hospitalist employed by VAMC Clarksburg reported concern about several deaths from unexplained hypoglycemic events in the same ward and noted that many of the affected patients did not have diabetes.

By that time, according to the Tennessean, “at least eight patients had died under suspicious circumstances. Several had been embalmed and buried, destroying potential evidence. One veteran had been cremated.”

An internal investigation began, followed by a criminal investigation, and in July 2018, Mays was removed from patient care.
 

Mays fired in 2019 because of lies on resume; claims suffers from PTSD

The Post reports that Mays was fired from the hospital in 2019, 7 months after she was banned from patient care, «after it was discovered she had lied about her qualifications on her resume.»

Court documents indicate that her duties included acting as a sitter for patients, checking vital signs, intake and output, and testing blood glucose levels, but she was not qualified to administer medications, including insulin.

Similarities in the deaths were evident, the Post reported. Citing sources familiar with the case, the report said, “elderly patients in private rooms were injected in their abdomen and limbs with insulin the hospital had not ordered.”

The Post reported that Mays sobbed by the end of the hearing on Tuesday.

The article notes that Mays has three sons and served in the Army National Guard from November 2000 to April 2001 and again from February 2003 to May 2004, when she was deployed to Iraq and Kuwait. She told the judge she was taking medication for posttraumatic stress disorder.

By pleading guilty, she waived her right to have the case presented to a grand jury. A sentencing hearing has not been scheduled, the Post reports.

NPR notes that prosecutors have requested that Mays serve seven consecutive life sentences and an additional 20 years in prison.
 

“Our hearts go out to those affected by these tragic deaths”

A spokesman for VAMC Clarksburg said in a statement to Medscape Medical News: “Our hearts go out to those affected by these tragic deaths. Clarksburg VA Medical Center discovered these allegations and reported them to VA›s independent inspector general more than 2 years ago. Clarksburg VA Medical Center also fired the individual at the center of the allegations.

“We’re glad the Department of Justice stepped in to push this investigation across the finish line and hopeful our court system will deliver the justice Clarksburg-area Veterans and families deserve.”

According to the Tennessean, Michael Missal, inspector general for the Department of Veteran Affairs, said the agency is investigating the hospital’s practices, “including medication management and communications among staffers.”

This article first appeared on Medscape.com.

A former nursing assistant and Army veteran pleaded guilty to federal murder charges this week in connection with the 2017-2018 deaths of seven patients in a West Virginia veteran’s hospital, according to news reports.

Prosecutors said in court documents filed on July 13 that Reta Mays, 46, injected lethal doses of insulin into seven veterans at the Louis A. Johnson VA Medical Center (VAMC) in rural Clarksburg, W.Va.

Their blood glucose levels plummeted, and each died shortly after their injections, according to the Tennessean.

An eighth patient, a 92-year-old man whom Mays is accused of assaulting with an insulin injection, initially survived after staff were able to stabilize him but died 2 weeks later at a nursing home, NPR reports.

According to NPR, US Attorney Jarod Douglas told the court Tuesday that the medical investigator could not determine whether the insulin contributed to the man’s death but that it was Mays’ intention to kill him.

“No one watched while she injected them with lethal doses of insulin during an 11-month killing rampage,” the Washington Post reported.
 

No motive offered

The Post article said no motive has been established, but after a 2-year investigation into a pattern of suspicious deaths that took the hospital almost a year to detect, Mays, who had denied any wrongdoing in multiple interviews with investigators, told a federal judge she preyed on some of the country›s most vulnerable service members.

An attorney for Mays, Brian Kornbrath, contacted by Medscape Medical News, said: “The defense team decided that we would have no public comment at this time.”

According to court documents from the Northern District of West Virginia, Mays was charged with seven counts of second-degree murder and one count of assault with intent to commit murder in connection with the patient who died later.

Mays was hired at the VAMC in Clarksburg in June 2015. She worked from 7:30 PM to 8:00 AM in the medical surgical unit, court documents say.

According to the documents, “VAMC Clarksburg did not require a nursing assistant to have a certification or licensure for initial appointment or as a condition of continuing employment.”

The documents indicate that in June 2018, a hospitalist employed by VAMC Clarksburg reported concern about several deaths from unexplained hypoglycemic events in the same ward and noted that many of the affected patients did not have diabetes.

By that time, according to the Tennessean, “at least eight patients had died under suspicious circumstances. Several had been embalmed and buried, destroying potential evidence. One veteran had been cremated.”

An internal investigation began, followed by a criminal investigation, and in July 2018, Mays was removed from patient care.
 

Mays fired in 2019 because of lies on resume; claims suffers from PTSD

The Post reports that Mays was fired from the hospital in 2019, 7 months after she was banned from patient care, «after it was discovered she had lied about her qualifications on her resume.»

Court documents indicate that her duties included acting as a sitter for patients, checking vital signs, intake and output, and testing blood glucose levels, but she was not qualified to administer medications, including insulin.

Similarities in the deaths were evident, the Post reported. Citing sources familiar with the case, the report said, “elderly patients in private rooms were injected in their abdomen and limbs with insulin the hospital had not ordered.”

The Post reported that Mays sobbed by the end of the hearing on Tuesday.

The article notes that Mays has three sons and served in the Army National Guard from November 2000 to April 2001 and again from February 2003 to May 2004, when she was deployed to Iraq and Kuwait. She told the judge she was taking medication for posttraumatic stress disorder.

By pleading guilty, she waived her right to have the case presented to a grand jury. A sentencing hearing has not been scheduled, the Post reports.

NPR notes that prosecutors have requested that Mays serve seven consecutive life sentences and an additional 20 years in prison.
 

“Our hearts go out to those affected by these tragic deaths”

A spokesman for VAMC Clarksburg said in a statement to Medscape Medical News: “Our hearts go out to those affected by these tragic deaths. Clarksburg VA Medical Center discovered these allegations and reported them to VA›s independent inspector general more than 2 years ago. Clarksburg VA Medical Center also fired the individual at the center of the allegations.

“We’re glad the Department of Justice stepped in to push this investigation across the finish line and hopeful our court system will deliver the justice Clarksburg-area Veterans and families deserve.”

According to the Tennessean, Michael Missal, inspector general for the Department of Veteran Affairs, said the agency is investigating the hospital’s practices, “including medication management and communications among staffers.”

This article first appeared on Medscape.com.

A former nursing assistant and Army veteran pleaded guilty to federal murder charges this week in connection with the 2017-2018 deaths of seven patients in a West Virginia veteran’s hospital, according to news reports.

Prosecutors said in court documents filed on July 13 that Reta Mays, 46, injected lethal doses of insulin into seven veterans at the Louis A. Johnson VA Medical Center (VAMC) in rural Clarksburg, W.Va.

Their blood glucose levels plummeted, and each died shortly after their injections, according to the Tennessean.

An eighth patient, a 92-year-old man whom Mays is accused of assaulting with an insulin injection, initially survived after staff were able to stabilize him but died 2 weeks later at a nursing home, NPR reports.

According to NPR, US Attorney Jarod Douglas told the court Tuesday that the medical investigator could not determine whether the insulin contributed to the man’s death but that it was Mays’ intention to kill him.

“No one watched while she injected them with lethal doses of insulin during an 11-month killing rampage,” the Washington Post reported.
 

No motive offered

The Post article said no motive has been established, but after a 2-year investigation into a pattern of suspicious deaths that took the hospital almost a year to detect, Mays, who had denied any wrongdoing in multiple interviews with investigators, told a federal judge she preyed on some of the country›s most vulnerable service members.

An attorney for Mays, Brian Kornbrath, contacted by Medscape Medical News, said: “The defense team decided that we would have no public comment at this time.”

According to court documents from the Northern District of West Virginia, Mays was charged with seven counts of second-degree murder and one count of assault with intent to commit murder in connection with the patient who died later.

Mays was hired at the VAMC in Clarksburg in June 2015. She worked from 7:30 PM to 8:00 AM in the medical surgical unit, court documents say.

According to the documents, “VAMC Clarksburg did not require a nursing assistant to have a certification or licensure for initial appointment or as a condition of continuing employment.”

The documents indicate that in June 2018, a hospitalist employed by VAMC Clarksburg reported concern about several deaths from unexplained hypoglycemic events in the same ward and noted that many of the affected patients did not have diabetes.

By that time, according to the Tennessean, “at least eight patients had died under suspicious circumstances. Several had been embalmed and buried, destroying potential evidence. One veteran had been cremated.”

An internal investigation began, followed by a criminal investigation, and in July 2018, Mays was removed from patient care.
 

Mays fired in 2019 because of lies on resume; claims suffers from PTSD

The Post reports that Mays was fired from the hospital in 2019, 7 months after she was banned from patient care, «after it was discovered she had lied about her qualifications on her resume.»

Court documents indicate that her duties included acting as a sitter for patients, checking vital signs, intake and output, and testing blood glucose levels, but she was not qualified to administer medications, including insulin.

Similarities in the deaths were evident, the Post reported. Citing sources familiar with the case, the report said, “elderly patients in private rooms were injected in their abdomen and limbs with insulin the hospital had not ordered.”

The Post reported that Mays sobbed by the end of the hearing on Tuesday.

The article notes that Mays has three sons and served in the Army National Guard from November 2000 to April 2001 and again from February 2003 to May 2004, when she was deployed to Iraq and Kuwait. She told the judge she was taking medication for posttraumatic stress disorder.

By pleading guilty, she waived her right to have the case presented to a grand jury. A sentencing hearing has not been scheduled, the Post reports.

NPR notes that prosecutors have requested that Mays serve seven consecutive life sentences and an additional 20 years in prison.
 

“Our hearts go out to those affected by these tragic deaths”

A spokesman for VAMC Clarksburg said in a statement to Medscape Medical News: “Our hearts go out to those affected by these tragic deaths. Clarksburg VA Medical Center discovered these allegations and reported them to VA›s independent inspector general more than 2 years ago. Clarksburg VA Medical Center also fired the individual at the center of the allegations.

“We’re glad the Department of Justice stepped in to push this investigation across the finish line and hopeful our court system will deliver the justice Clarksburg-area Veterans and families deserve.”

According to the Tennessean, Michael Missal, inspector general for the Department of Veteran Affairs, said the agency is investigating the hospital’s practices, “including medication management and communications among staffers.”

This article first appeared on Medscape.com.

Over the past months, society has reflected on the role of law enforcement. The shocking murder of George Floyd has forced Americans to reconsider the place of police officers in maintaining order.

The death of Mr. Floyd is certainly not a lone incident; in 2019, 1,098 people were killed by those tasked with protecting us.¹ The United States holds 25% of the world’s incarcerated, though it makes up only 5% of the world’s population.² Society is demanding a newer and better system.

The phrase “defund the police” can easily be dismissed because, to many, it implies an appeal to lawlessness. While we certainly cannot speak for any one protester, we think that many of the necessary changes are painfully obvious.³ Society wants law enforcement where force is not the default position but the last option. Society wants law enforcement where verbal conflict resolution is the primary focus of training and intervention. Society wants a correctional system that is more rehabilitative than it is punitive.⁴

Major U.S. cities spend up to 40% of their funds on police budgeting, much more than what is dedicated to community resources and infrastructure. This trend continues to increase between 1986 and 2013, state spending for correctional facilities increased by 141%.⁵ Yet, as psychiatrists, we are well aware that social determinants are a strong factor in future criminality.⁶ Increasing police budgets without addressing structural root causes and risk factors for future asocial behavior is not a wise approach to reducing unlawful behavior. Investing more into programs and policies that reduce these risks is essential.

Using the adverse childhood experiences (ACE) questionnaires, researchers have supported the idea that social programs are a key player in an improved criminal system. The ACE study identified 10 forms of childhood trauma in 17,000 patients, including abuse, neglect, abandonment, household dysfunction, and exposure to violence, that were strongly associated with negative psychological outcomes, engagement in high-risk behaviors, significant medical consequences, and even early death.⁷ More recent research has shown that those ACEs were four times more prevalent in a criminal offender group than in the general population.⁸ Psychiatry is in a unique position to address and provide education about ACEs as a tool to identify and help at-risk youths.

Many protesters have asked for mental health providers to have a primary role in this societal reflection and in providing a solution.⁹ This makes particular sense when considering that almost 20% of calls to law enforcement are for persons with impaired judgment from mental illness or intoxication, and one in four patients with mental illness has been arrested.^10,11 We are humbled by this public trust and request. We believe psychiatry can provide many answers to this societal angst. After all, psychiatry is a specialty dedicated to addressing behavioral problems in an evidence-based way.

Yet, we should not forget psychiatry’s imperfect past and our own role in the creation of this system. While this article does not attempt to catalog psychiatry’s faults, one can start by recognizing that mass incarceration is partly a response to how poorly human beings were treated in asylums. Psychiatry was at one time a main enforcer of societal disenfranchisement. After most asylums were closed in 1963 with the Community Mental Health Act, correctional facilities became the largest purveyors of mental health care, often with damaging results.¹² If psychiatry were to advocate for the reestablishment of asylums as a solution, we fear that psychiatry would have missed the point. We wonder whether the psychiatrists who have railed against deinstitutionalization since the 1970s do not realize that violence, unethical experimentation, and even racism were at times attributes of asylums.¹³

Psychiatry can and should be much more than what it once was. Instead of indirectly and inaccurately suggesting that our patients commit mass murders, we should improve research in the field of violence risk assessment and management. As many have already pointed out, violence risk assessment is permeated with overestimation of its potential and, more concerningly, tainted by evidence of implicit racism.¹⁴ Implicit racism extends to rights-limiting treatments as well. As previously studied, involuntary outpatient programs often referred to as assisted outpatient treatment are disproportionately levied on Black Americans.¹⁵ Instead of routinely seeking to expand abilities to involuntary treat and limit the rights of our patients, we should strive to be a violence-free alternative to law enforcement, not the medical version of police.

Psychiatrists should start actively training, practicing, and researching how to address nonviolent emergency calls. Training should include more robust deescalation training, techniques on the evaluation of patients outside of health care facilities (for example, the street), and a broadening of interventions to include proficiency in the treatment of subclinical populations seeking emergency care without the need to be formally labeled with a psychiatric disorder. Ride-alongs with police officers, volunteering at crisis hotlines, and home calls should not be volunteer or elective experiences for psychiatrists but a required part of training.

Thankfully, some local jurisdictions already have started promising practices that merit replication or at least academic review. Austin, Tex., recently implemented the capability of requesting mental health emergency calls when contacting 911.¹⁷ Eugene, Ore., has had the CAHOOTS (Crisis Assistance Helping Out On The Streets) program since 1989, where a medical provider and a mental health provider respond to calls without any law enforcement officers.¹⁸ Our own San Diego County has an innovative PERT (Psychiatric Emergency Response Team) program, which partners a mental health provider to a police patrol, allowing an ability to quickly provide different types of services.¹⁹ Programs like these show us what is possible. At this time, there is little research to evaluate many programs’ effectiveness.²⁰ Psychiatry should seize this moment to be at the forefront of studying, then educating the public on what works and how to reproduce it.

Police officers have a difficult profession. They are tasked with preventing and predicting crime, often to the point of risking their own lives. Historically, police have been the first call to handle issues for which they are not equipped, ranging from fixing homelessness to arresting violent people using nonviolent means. The idea that police should be able to protect us in all situations has been mistakenly ingrained in our minds. Officers themselves do not feel adequately trained to handle mental health crises.²¹ “Defund the police” also means a recognition by governments, the public, and police themselves that officers should not be on the front lines for every emergency situation. We must diversify our first responders. Psychiatry should hear this call and be ready.

Since the death of Mr. Floyd, mental health professionals have attempted to voice empathy and warmth to those feeling left out and disenfranchised. Mental health professionals have voiced a desire to educate themselves on systemic biases and antiracism. However, we argue that psychiatry is not and has never been a bystander to the societal debate on the management of different and criminal behavior. While it may be enough for many fields to express sympathy from the sidelines, psychiatry has been and continues to be an active player in the disenfranchisement of minority populations in the criminal justice system. Society appears to be offering us a chance at repairing our past and helping the future. Let’s take it with honor and humility.
 

References

1. Collins S. Police killings can be captured in data. The terror police create cannot. Vox.com. 2020 Jun 19.

2. Lee MYH. Yes, U.S. locks people up at a higher rate than any other country. The Washington Post. 2015 Jul 7.

3. McDowell MG, Fernandez LA. Critical Criminology. 2018;26(3):373-91.

4. Thielo AJ et al. Criminology & Public Policy. 2016;15(1):137-70.

5. The Center for Popular Democracy. Freedom to Thrive.

6. Hipp JR. Criminology. 2007;45(3):665-97.

7. Felitti VJ et al. Am J Prev Med. 1998;14(4):245-58.

8. Reavis JA. Perm J. 2013 Spring;17(2):44-8.

9. McHarris PV, McHarris T. No more money for the police. The New York Times. 2020 May 20.

10. Kaminski RJ et al. Police Quarterly. 2004;7(3):311-38.

11. Livington JD. Psychiatr Serv. 2016 Aug 1;67(8):850-7.

12. Galanek JD. Cult Med Psychiatry. 2013 Mar;37(1):195-225.

13. Raz M. Nature. Book Review. 2020 Apr 21.

14. Dressel J, Farid H. Sci Adv. 2018 J 17;4(1):eaao5580.

15. Swartz MS et al. New York State assisted outpatient treatment program evaluation. 2009 Jun 30.

16. Barnes SS and Badre N. Psychiatr Serv. 2016 Jul 1;67(7):784-6.

17. Fox A. Austin budget adds millions for mental health response in 911 services. efficientgov.com. 2019 Sep 13.

18. Elinson Z. When mental health experts, not police, are the first responders. The Wall Street Journal. 2018 Nov 14.

19. Improved responses in psychiatric crises: The Psychiatric Emergency Response Team.

20. Kane E et al. Crim Behav Ment Health. 2018 Apr;28(2):108-19.

21. Wells W, Schafer JA. Officer perceptions of police responses to persons with a mental illness, in “Policing: An International Journal of Police Strategies & Management,” 2006 Oct;29(4):578-61.

Dr. Malik is a first-year psychiatry resident at the University of California, San Diego. She has a background in policy and grassroots organizing through her time working at the National Coalition for the Homeless and the Women’s Law Project. Dr. Malik has no disclosures.

Dr. Amendolara is a first-year psychiatry resident at University of California, San Diego. He spent years advocating for survivors of rape and domestic violence at the Crime Victims Treatment Center in New York and conducted public health research at Lourdes Center for Public Health in Camden, N.J. Dr. Amendolara has no disclosures.

Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Among his writings is chapter 7 in the book “Critical Psychiatry: Controversies and Clinical Implications” (Cham, Switzerland: Springer, 2019). He has no disclosures.

Over the past months, society has reflected on the role of law enforcement. The shocking murder of George Floyd has forced Americans to reconsider the place of police officers in maintaining order.

The death of Mr. Floyd is certainly not a lone incident; in 2019, 1,098 people were killed by those tasked with protecting us.¹ The United States holds 25% of the world’s incarcerated, though it makes up only 5% of the world’s population.² Society is demanding a newer and better system.

The phrase “defund the police” can easily be dismissed because, to many, it implies an appeal to lawlessness. While we certainly cannot speak for any one protester, we think that many of the necessary changes are painfully obvious.³ Society wants law enforcement where force is not the default position but the last option. Society wants law enforcement where verbal conflict resolution is the primary focus of training and intervention. Society wants a correctional system that is more rehabilitative than it is punitive.⁴

Major U.S. cities spend up to 40% of their funds on police budgeting, much more than what is dedicated to community resources and infrastructure. This trend continues to increase between 1986 and 2013, state spending for correctional facilities increased by 141%.⁵ Yet, as psychiatrists, we are well aware that social determinants are a strong factor in future criminality.⁶ Increasing police budgets without addressing structural root causes and risk factors for future asocial behavior is not a wise approach to reducing unlawful behavior. Investing more into programs and policies that reduce these risks is essential.

Using the adverse childhood experiences (ACE) questionnaires, researchers have supported the idea that social programs are a key player in an improved criminal system. The ACE study identified 10 forms of childhood trauma in 17,000 patients, including abuse, neglect, abandonment, household dysfunction, and exposure to violence, that were strongly associated with negative psychological outcomes, engagement in high-risk behaviors, significant medical consequences, and even early death.⁷ More recent research has shown that those ACEs were four times more prevalent in a criminal offender group than in the general population.⁸ Psychiatry is in a unique position to address and provide education about ACEs as a tool to identify and help at-risk youths.

Many protesters have asked for mental health providers to have a primary role in this societal reflection and in providing a solution.⁹ This makes particular sense when considering that almost 20% of calls to law enforcement are for persons with impaired judgment from mental illness or intoxication, and one in four patients with mental illness has been arrested.^10,11 We are humbled by this public trust and request. We believe psychiatry can provide many answers to this societal angst. After all, psychiatry is a specialty dedicated to addressing behavioral problems in an evidence-based way.

Yet, we should not forget psychiatry’s imperfect past and our own role in the creation of this system. While this article does not attempt to catalog psychiatry’s faults, one can start by recognizing that mass incarceration is partly a response to how poorly human beings were treated in asylums. Psychiatry was at one time a main enforcer of societal disenfranchisement. After most asylums were closed in 1963 with the Community Mental Health Act, correctional facilities became the largest purveyors of mental health care, often with damaging results.¹² If psychiatry were to advocate for the reestablishment of asylums as a solution, we fear that psychiatry would have missed the point. We wonder whether the psychiatrists who have railed against deinstitutionalization since the 1970s do not realize that violence, unethical experimentation, and even racism were at times attributes of asylums.¹³

Psychiatry can and should be much more than what it once was. Instead of indirectly and inaccurately suggesting that our patients commit mass murders, we should improve research in the field of violence risk assessment and management. As many have already pointed out, violence risk assessment is permeated with overestimation of its potential and, more concerningly, tainted by evidence of implicit racism.¹⁴ Implicit racism extends to rights-limiting treatments as well. As previously studied, involuntary outpatient programs often referred to as assisted outpatient treatment are disproportionately levied on Black Americans.¹⁵ Instead of routinely seeking to expand abilities to involuntary treat and limit the rights of our patients, we should strive to be a violence-free alternative to law enforcement, not the medical version of police.

Psychiatrists should start actively training, practicing, and researching how to address nonviolent emergency calls. Training should include more robust deescalation training, techniques on the evaluation of patients outside of health care facilities (for example, the street), and a broadening of interventions to include proficiency in the treatment of subclinical populations seeking emergency care without the need to be formally labeled with a psychiatric disorder. Ride-alongs with police officers, volunteering at crisis hotlines, and home calls should not be volunteer or elective experiences for psychiatrists but a required part of training.

Thankfully, some local jurisdictions already have started promising practices that merit replication or at least academic review. Austin, Tex., recently implemented the capability of requesting mental health emergency calls when contacting 911.¹⁷ Eugene, Ore., has had the CAHOOTS (Crisis Assistance Helping Out On The Streets) program since 1989, where a medical provider and a mental health provider respond to calls without any law enforcement officers.¹⁸ Our own San Diego County has an innovative PERT (Psychiatric Emergency Response Team) program, which partners a mental health provider to a police patrol, allowing an ability to quickly provide different types of services.¹⁹ Programs like these show us what is possible. At this time, there is little research to evaluate many programs’ effectiveness.²⁰ Psychiatry should seize this moment to be at the forefront of studying, then educating the public on what works and how to reproduce it.

Police officers have a difficult profession. They are tasked with preventing and predicting crime, often to the point of risking their own lives. Historically, police have been the first call to handle issues for which they are not equipped, ranging from fixing homelessness to arresting violent people using nonviolent means. The idea that police should be able to protect us in all situations has been mistakenly ingrained in our minds. Officers themselves do not feel adequately trained to handle mental health crises.²¹ “Defund the police” also means a recognition by governments, the public, and police themselves that officers should not be on the front lines for every emergency situation. We must diversify our first responders. Psychiatry should hear this call and be ready.

Since the death of Mr. Floyd, mental health professionals have attempted to voice empathy and warmth to those feeling left out and disenfranchised. Mental health professionals have voiced a desire to educate themselves on systemic biases and antiracism. However, we argue that psychiatry is not and has never been a bystander to the societal debate on the management of different and criminal behavior. While it may be enough for many fields to express sympathy from the sidelines, psychiatry has been and continues to be an active player in the disenfranchisement of minority populations in the criminal justice system. Society appears to be offering us a chance at repairing our past and helping the future. Let’s take it with honor and humility.
 

References

1. Collins S. Police killings can be captured in data. The terror police create cannot. Vox.com. 2020 Jun 19.

2. Lee MYH. Yes, U.S. locks people up at a higher rate than any other country. The Washington Post. 2015 Jul 7.

3. McDowell MG, Fernandez LA. Critical Criminology. 2018;26(3):373-91.

4. Thielo AJ et al. Criminology & Public Policy. 2016;15(1):137-70.

5. The Center for Popular Democracy. Freedom to Thrive.

6. Hipp JR. Criminology. 2007;45(3):665-97.

7. Felitti VJ et al. Am J Prev Med. 1998;14(4):245-58.

8. Reavis JA. Perm J. 2013 Spring;17(2):44-8.

9. McHarris PV, McHarris T. No more money for the police. The New York Times. 2020 May 20.

10. Kaminski RJ et al. Police Quarterly. 2004;7(3):311-38.

11. Livington JD. Psychiatr Serv. 2016 Aug 1;67(8):850-7.

12. Galanek JD. Cult Med Psychiatry. 2013 Mar;37(1):195-225.

13. Raz M. Nature. Book Review. 2020 Apr 21.

14. Dressel J, Farid H. Sci Adv. 2018 J 17;4(1):eaao5580.

15. Swartz MS et al. New York State assisted outpatient treatment program evaluation. 2009 Jun 30.

16. Barnes SS and Badre N. Psychiatr Serv. 2016 Jul 1;67(7):784-6.

17. Fox A. Austin budget adds millions for mental health response in 911 services. efficientgov.com. 2019 Sep 13.

18. Elinson Z. When mental health experts, not police, are the first responders. The Wall Street Journal. 2018 Nov 14.

19. Improved responses in psychiatric crises: The Psychiatric Emergency Response Team.

20. Kane E et al. Crim Behav Ment Health. 2018 Apr;28(2):108-19.

21. Wells W, Schafer JA. Officer perceptions of police responses to persons with a mental illness, in “Policing: An International Journal of Police Strategies & Management,” 2006 Oct;29(4):578-61.

Dr. Malik is a first-year psychiatry resident at the University of California, San Diego. She has a background in policy and grassroots organizing through her time working at the National Coalition for the Homeless and the Women’s Law Project. Dr. Malik has no disclosures.

Dr. Amendolara is a first-year psychiatry resident at University of California, San Diego. He spent years advocating for survivors of rape and domestic violence at the Crime Victims Treatment Center in New York and conducted public health research at Lourdes Center for Public Health in Camden, N.J. Dr. Amendolara has no disclosures.

Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Among his writings is chapter 7 in the book “Critical Psychiatry: Controversies and Clinical Implications” (Cham, Switzerland: Springer, 2019). He has no disclosures.

Over the past months, society has reflected on the role of law enforcement. The shocking murder of George Floyd has forced Americans to reconsider the place of police officers in maintaining order.

The death of Mr. Floyd is certainly not a lone incident; in 2019, 1,098 people were killed by those tasked with protecting us.¹ The United States holds 25% of the world’s incarcerated, though it makes up only 5% of the world’s population.² Society is demanding a newer and better system.

The phrase “defund the police” can easily be dismissed because, to many, it implies an appeal to lawlessness. While we certainly cannot speak for any one protester, we think that many of the necessary changes are painfully obvious.³ Society wants law enforcement where force is not the default position but the last option. Society wants law enforcement where verbal conflict resolution is the primary focus of training and intervention. Society wants a correctional system that is more rehabilitative than it is punitive.⁴

Major U.S. cities spend up to 40% of their funds on police budgeting, much more than what is dedicated to community resources and infrastructure. This trend continues to increase between 1986 and 2013, state spending for correctional facilities increased by 141%.⁵ Yet, as psychiatrists, we are well aware that social determinants are a strong factor in future criminality.⁶ Increasing police budgets without addressing structural root causes and risk factors for future asocial behavior is not a wise approach to reducing unlawful behavior. Investing more into programs and policies that reduce these risks is essential.

Using the adverse childhood experiences (ACE) questionnaires, researchers have supported the idea that social programs are a key player in an improved criminal system. The ACE study identified 10 forms of childhood trauma in 17,000 patients, including abuse, neglect, abandonment, household dysfunction, and exposure to violence, that were strongly associated with negative psychological outcomes, engagement in high-risk behaviors, significant medical consequences, and even early death.⁷ More recent research has shown that those ACEs were four times more prevalent in a criminal offender group than in the general population.⁸ Psychiatry is in a unique position to address and provide education about ACEs as a tool to identify and help at-risk youths.

Many protesters have asked for mental health providers to have a primary role in this societal reflection and in providing a solution.⁹ This makes particular sense when considering that almost 20% of calls to law enforcement are for persons with impaired judgment from mental illness or intoxication, and one in four patients with mental illness has been arrested.^10,11 We are humbled by this public trust and request. We believe psychiatry can provide many answers to this societal angst. After all, psychiatry is a specialty dedicated to addressing behavioral problems in an evidence-based way.

Yet, we should not forget psychiatry’s imperfect past and our own role in the creation of this system. While this article does not attempt to catalog psychiatry’s faults, one can start by recognizing that mass incarceration is partly a response to how poorly human beings were treated in asylums. Psychiatry was at one time a main enforcer of societal disenfranchisement. After most asylums were closed in 1963 with the Community Mental Health Act, correctional facilities became the largest purveyors of mental health care, often with damaging results.¹² If psychiatry were to advocate for the reestablishment of asylums as a solution, we fear that psychiatry would have missed the point. We wonder whether the psychiatrists who have railed against deinstitutionalization since the 1970s do not realize that violence, unethical experimentation, and even racism were at times attributes of asylums.¹³

Psychiatry can and should be much more than what it once was. Instead of indirectly and inaccurately suggesting that our patients commit mass murders, we should improve research in the field of violence risk assessment and management. As many have already pointed out, violence risk assessment is permeated with overestimation of its potential and, more concerningly, tainted by evidence of implicit racism.¹⁴ Implicit racism extends to rights-limiting treatments as well. As previously studied, involuntary outpatient programs often referred to as assisted outpatient treatment are disproportionately levied on Black Americans.¹⁵ Instead of routinely seeking to expand abilities to involuntary treat and limit the rights of our patients, we should strive to be a violence-free alternative to law enforcement, not the medical version of police.

Psychiatrists should start actively training, practicing, and researching how to address nonviolent emergency calls. Training should include more robust deescalation training, techniques on the evaluation of patients outside of health care facilities (for example, the street), and a broadening of interventions to include proficiency in the treatment of subclinical populations seeking emergency care without the need to be formally labeled with a psychiatric disorder. Ride-alongs with police officers, volunteering at crisis hotlines, and home calls should not be volunteer or elective experiences for psychiatrists but a required part of training.

Thankfully, some local jurisdictions already have started promising practices that merit replication or at least academic review. Austin, Tex., recently implemented the capability of requesting mental health emergency calls when contacting 911.¹⁷ Eugene, Ore., has had the CAHOOTS (Crisis Assistance Helping Out On The Streets) program since 1989, where a medical provider and a mental health provider respond to calls without any law enforcement officers.¹⁸ Our own San Diego County has an innovative PERT (Psychiatric Emergency Response Team) program, which partners a mental health provider to a police patrol, allowing an ability to quickly provide different types of services.¹⁹ Programs like these show us what is possible. At this time, there is little research to evaluate many programs’ effectiveness.²⁰ Psychiatry should seize this moment to be at the forefront of studying, then educating the public on what works and how to reproduce it.

Police officers have a difficult profession. They are tasked with preventing and predicting crime, often to the point of risking their own lives. Historically, police have been the first call to handle issues for which they are not equipped, ranging from fixing homelessness to arresting violent people using nonviolent means. The idea that police should be able to protect us in all situations has been mistakenly ingrained in our minds. Officers themselves do not feel adequately trained to handle mental health crises.²¹ “Defund the police” also means a recognition by governments, the public, and police themselves that officers should not be on the front lines for every emergency situation. We must diversify our first responders. Psychiatry should hear this call and be ready.

Since the death of Mr. Floyd, mental health professionals have attempted to voice empathy and warmth to those feeling left out and disenfranchised. Mental health professionals have voiced a desire to educate themselves on systemic biases and antiracism. However, we argue that psychiatry is not and has never been a bystander to the societal debate on the management of different and criminal behavior. While it may be enough for many fields to express sympathy from the sidelines, psychiatry has been and continues to be an active player in the disenfranchisement of minority populations in the criminal justice system. Society appears to be offering us a chance at repairing our past and helping the future. Let’s take it with honor and humility.
 

References

1. Collins S. Police killings can be captured in data. The terror police create cannot. Vox.com. 2020 Jun 19.

2. Lee MYH. Yes, U.S. locks people up at a higher rate than any other country. The Washington Post. 2015 Jul 7.

3. McDowell MG, Fernandez LA. Critical Criminology. 2018;26(3):373-91.

4. Thielo AJ et al. Criminology & Public Policy. 2016;15(1):137-70.

5. The Center for Popular Democracy. Freedom to Thrive.

6. Hipp JR. Criminology. 2007;45(3):665-97.

7. Felitti VJ et al. Am J Prev Med. 1998;14(4):245-58.

8. Reavis JA. Perm J. 2013 Spring;17(2):44-8.

9. McHarris PV, McHarris T. No more money for the police. The New York Times. 2020 May 20.

10. Kaminski RJ et al. Police Quarterly. 2004;7(3):311-38.

11. Livington JD. Psychiatr Serv. 2016 Aug 1;67(8):850-7.

12. Galanek JD. Cult Med Psychiatry. 2013 Mar;37(1):195-225.

13. Raz M. Nature. Book Review. 2020 Apr 21.

14. Dressel J, Farid H. Sci Adv. 2018 J 17;4(1):eaao5580.

15. Swartz MS et al. New York State assisted outpatient treatment program evaluation. 2009 Jun 30.

16. Barnes SS and Badre N. Psychiatr Serv. 2016 Jul 1;67(7):784-6.

17. Fox A. Austin budget adds millions for mental health response in 911 services. efficientgov.com. 2019 Sep 13.

18. Elinson Z. When mental health experts, not police, are the first responders. The Wall Street Journal. 2018 Nov 14.

19. Improved responses in psychiatric crises: The Psychiatric Emergency Response Team.

20. Kane E et al. Crim Behav Ment Health. 2018 Apr;28(2):108-19.

21. Wells W, Schafer JA. Officer perceptions of police responses to persons with a mental illness, in “Policing: An International Journal of Police Strategies & Management,” 2006 Oct;29(4):578-61.

Dr. Malik is a first-year psychiatry resident at the University of California, San Diego. She has a background in policy and grassroots organizing through her time working at the National Coalition for the Homeless and the Women’s Law Project. Dr. Malik has no disclosures.

Dr. Amendolara is a first-year psychiatry resident at University of California, San Diego. He spent years advocating for survivors of rape and domestic violence at the Crime Victims Treatment Center in New York and conducted public health research at Lourdes Center for Public Health in Camden, N.J. Dr. Amendolara has no disclosures.

Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Among his writings is chapter 7 in the book “Critical Psychiatry: Controversies and Clinical Implications” (Cham, Switzerland: Springer, 2019). He has no disclosures.

The absence of in-person school has harmed children in ways beyond loss of academic learning, according to Josh Sharfstein, MD, vice dean for public health practice and community engagement at the Johns Hopkins Bloomberg School of Public Health, Baltimore. In addition to learning, school is a place where many children receive breakfast and lunch every day, as well as support services and the benefits of being in a safe and secure environment, Dr. Sharfstein said in a press briefing sponsored by Johns Hopkins University.

However, although it is an important priority for children to return to school, “we are in the midst of a pandemic that poses real risk,” he said.

In the press briefing, several experts shared ideas and considerations for safely reopening K-12 schools in the fall of 2020.

Data from other countries where schools have reopened, notably Austria and Denmark, have been reassuring about the lack of transmission of SARS-CoV-2 among children in a school setting, said Jennifer Nuzzo, DrPH, an epidemiologist at the Johns Hopkins Center for Health Security. However, other countries where schools have reopened successfully have reported low levels of viral transmission locally, and a responsible strategy for school reopening in the United States should follow a similar plan, she said. In areas where transmission and infection rates are increasing “it may not be safe to reopen,” but in areas where rates are declining or stable, schools could potentially reopen if they follow safety measures.

Dr. Nuzzo suggested that schools should prioritize students who will benefit most from in-person learning, such as younger children and those with special needs. Considerations include protocols for handwashing and sanitation, and maintaining physical distance by creative use of outdoor classrooms (weather permitting) or other spaces within school buildings. Transportation to and from school also will be an issue to address, she noted.

None of the strategies being considered will completely eliminate risk of SARS-CoV-2 infection in school settings, so allowing parents and students to opt out and choose distance learning will be important as well, said Dr. Nuzzo. In addition, schools may need to consider alternative roles for teachers and staff who don’t feel comfortable being in contact with students and fellow staff members. “All of these things are going to be hard,” Dr. Nuzzo acknowledged. “Hard should not be a deterrent,” to reopening schools, but “we acknowledge the resources that schools will need in order to do this.”

At present, all 50 states and the District of Columbia have released some type of plan for reopening schools, said Megan Collins, MD, MPH, codirector the Johns Hopkins Consortium for School-Based Health Solutions.

Dr. Collins and colleagues have developed a school reopening tracker, which is “a national snapshot of current reopening plans that have been released,” she said. The tracker is being updated continuously as plans evolve. The eSchool+ K-12 School Reopening Tracker identifies 12 reopening categories that states could potentially address in the plans. These categories are divided into Operational and Ethics/Equity. The operational categories include:

• Core academics
• SARS-CoV-2 protection
• Before and after school programs
• School access and transportation
• Student health services
• Food and nutrition.

Ethics/equity categories include the following:

• Parent choice
• Teacher and staff choice
• Children of poverty and systemic disadvantage
• Children with special needs/English as second language/gifted and twice exceptional
• Privacy
• Engagement and transparency.

As of July 15, 2020, 16 states (Arizona, Colorado, Connecticut, Georgia, Maryland, Minnesota, New Mexico, North Carolina, North Dakota, Ohio, Rhode Island, Tennessee, Texas, Virginia, Washington, and Wisconsin) had addressed all 12 categories in their reopening plans, Dr. Collins said.

School reopening plans must take equity issues into account, said Annette Anderson, PhD, of the Johns Hopkins University School of Education.

Specifically, developing learning plans for special education students and others at the most risk for learning loss will be essential. “The digital divide has become a digital canyon” in some areas, Dr. Anderson noted, and schools need to rethink eligibility and work to provide access to devices for online learning for all students.

In addition, schools need to convince parents that schools are safe. She recommended that schools consider inviting parents and families to visit buildings in advance of reopening so they can see the safety measures, such as space between desks, cleaning stations, and other protective strategies.

The message to pediatricians and health care professionals when counseling families about returning individual children to school is to consider the risk to the child and the family directly in the context of the local plans, Dr. Sharfstein said during a question and answer session. “One school system’s plan is one school system’s plan,” he said, and added that families who are concerned about the risk should have an online option. However, “if you see a thoughtful approach” to reopening, with safety steps taken and parents informed, with protocols such as keeping small groups of children together to reduce transmission, “it is a pretty good trade-off,” and that is why the American Academy of Pediatrics currently favors children returning to school, he said.

The briefing participants had no relevant financial conflicts to disclose.

The absence of in-person school has harmed children in ways beyond loss of academic learning, according to Josh Sharfstein, MD, vice dean for public health practice and community engagement at the Johns Hopkins Bloomberg School of Public Health, Baltimore. In addition to learning, school is a place where many children receive breakfast and lunch every day, as well as support services and the benefits of being in a safe and secure environment, Dr. Sharfstein said in a press briefing sponsored by Johns Hopkins University.

However, although it is an important priority for children to return to school, “we are in the midst of a pandemic that poses real risk,” he said.

In the press briefing, several experts shared ideas and considerations for safely reopening K-12 schools in the fall of 2020.

Data from other countries where schools have reopened, notably Austria and Denmark, have been reassuring about the lack of transmission of SARS-CoV-2 among children in a school setting, said Jennifer Nuzzo, DrPH, an epidemiologist at the Johns Hopkins Center for Health Security. However, other countries where schools have reopened successfully have reported low levels of viral transmission locally, and a responsible strategy for school reopening in the United States should follow a similar plan, she said. In areas where transmission and infection rates are increasing “it may not be safe to reopen,” but in areas where rates are declining or stable, schools could potentially reopen if they follow safety measures.

Dr. Nuzzo suggested that schools should prioritize students who will benefit most from in-person learning, such as younger children and those with special needs. Considerations include protocols for handwashing and sanitation, and maintaining physical distance by creative use of outdoor classrooms (weather permitting) or other spaces within school buildings. Transportation to and from school also will be an issue to address, she noted.

None of the strategies being considered will completely eliminate risk of SARS-CoV-2 infection in school settings, so allowing parents and students to opt out and choose distance learning will be important as well, said Dr. Nuzzo. In addition, schools may need to consider alternative roles for teachers and staff who don’t feel comfortable being in contact with students and fellow staff members. “All of these things are going to be hard,” Dr. Nuzzo acknowledged. “Hard should not be a deterrent,” to reopening schools, but “we acknowledge the resources that schools will need in order to do this.”

At present, all 50 states and the District of Columbia have released some type of plan for reopening schools, said Megan Collins, MD, MPH, codirector the Johns Hopkins Consortium for School-Based Health Solutions.

Dr. Collins and colleagues have developed a school reopening tracker, which is “a national snapshot of current reopening plans that have been released,” she said. The tracker is being updated continuously as plans evolve. The eSchool+ K-12 School Reopening Tracker identifies 12 reopening categories that states could potentially address in the plans. These categories are divided into Operational and Ethics/Equity. The operational categories include:

• Core academics
• SARS-CoV-2 protection
• Before and after school programs
• School access and transportation
• Student health services
• Food and nutrition.

Ethics/equity categories include the following:

• Parent choice
• Teacher and staff choice
• Children of poverty and systemic disadvantage
• Children with special needs/English as second language/gifted and twice exceptional
• Privacy
• Engagement and transparency.

As of July 15, 2020, 16 states (Arizona, Colorado, Connecticut, Georgia, Maryland, Minnesota, New Mexico, North Carolina, North Dakota, Ohio, Rhode Island, Tennessee, Texas, Virginia, Washington, and Wisconsin) had addressed all 12 categories in their reopening plans, Dr. Collins said.

School reopening plans must take equity issues into account, said Annette Anderson, PhD, of the Johns Hopkins University School of Education.

Specifically, developing learning plans for special education students and others at the most risk for learning loss will be essential. “The digital divide has become a digital canyon” in some areas, Dr. Anderson noted, and schools need to rethink eligibility and work to provide access to devices for online learning for all students.

In addition, schools need to convince parents that schools are safe. She recommended that schools consider inviting parents and families to visit buildings in advance of reopening so they can see the safety measures, such as space between desks, cleaning stations, and other protective strategies.

The message to pediatricians and health care professionals when counseling families about returning individual children to school is to consider the risk to the child and the family directly in the context of the local plans, Dr. Sharfstein said during a question and answer session. “One school system’s plan is one school system’s plan,” he said, and added that families who are concerned about the risk should have an online option. However, “if you see a thoughtful approach” to reopening, with safety steps taken and parents informed, with protocols such as keeping small groups of children together to reduce transmission, “it is a pretty good trade-off,” and that is why the American Academy of Pediatrics currently favors children returning to school, he said.

The briefing participants had no relevant financial conflicts to disclose.

The absence of in-person school has harmed children in ways beyond loss of academic learning, according to Josh Sharfstein, MD, vice dean for public health practice and community engagement at the Johns Hopkins Bloomberg School of Public Health, Baltimore. In addition to learning, school is a place where many children receive breakfast and lunch every day, as well as support services and the benefits of being in a safe and secure environment, Dr. Sharfstein said in a press briefing sponsored by Johns Hopkins University.

However, although it is an important priority for children to return to school, “we are in the midst of a pandemic that poses real risk,” he said.

In the press briefing, several experts shared ideas and considerations for safely reopening K-12 schools in the fall of 2020.

Data from other countries where schools have reopened, notably Austria and Denmark, have been reassuring about the lack of transmission of SARS-CoV-2 among children in a school setting, said Jennifer Nuzzo, DrPH, an epidemiologist at the Johns Hopkins Center for Health Security. However, other countries where schools have reopened successfully have reported low levels of viral transmission locally, and a responsible strategy for school reopening in the United States should follow a similar plan, she said. In areas where transmission and infection rates are increasing “it may not be safe to reopen,” but in areas where rates are declining or stable, schools could potentially reopen if they follow safety measures.

Dr. Nuzzo suggested that schools should prioritize students who will benefit most from in-person learning, such as younger children and those with special needs. Considerations include protocols for handwashing and sanitation, and maintaining physical distance by creative use of outdoor classrooms (weather permitting) or other spaces within school buildings. Transportation to and from school also will be an issue to address, she noted.

None of the strategies being considered will completely eliminate risk of SARS-CoV-2 infection in school settings, so allowing parents and students to opt out and choose distance learning will be important as well, said Dr. Nuzzo. In addition, schools may need to consider alternative roles for teachers and staff who don’t feel comfortable being in contact with students and fellow staff members. “All of these things are going to be hard,” Dr. Nuzzo acknowledged. “Hard should not be a deterrent,” to reopening schools, but “we acknowledge the resources that schools will need in order to do this.”

At present, all 50 states and the District of Columbia have released some type of plan for reopening schools, said Megan Collins, MD, MPH, codirector the Johns Hopkins Consortium for School-Based Health Solutions.

Dr. Collins and colleagues have developed a school reopening tracker, which is “a national snapshot of current reopening plans that have been released,” she said. The tracker is being updated continuously as plans evolve. The eSchool+ K-12 School Reopening Tracker identifies 12 reopening categories that states could potentially address in the plans. These categories are divided into Operational and Ethics/Equity. The operational categories include:

• Core academics
• SARS-CoV-2 protection
• Before and after school programs
• School access and transportation
• Student health services
• Food and nutrition.

Ethics/equity categories include the following:

• Parent choice
• Teacher and staff choice
• Children of poverty and systemic disadvantage
• Children with special needs/English as second language/gifted and twice exceptional
• Privacy
• Engagement and transparency.

As of July 15, 2020, 16 states (Arizona, Colorado, Connecticut, Georgia, Maryland, Minnesota, New Mexico, North Carolina, North Dakota, Ohio, Rhode Island, Tennessee, Texas, Virginia, Washington, and Wisconsin) had addressed all 12 categories in their reopening plans, Dr. Collins said.

School reopening plans must take equity issues into account, said Annette Anderson, PhD, of the Johns Hopkins University School of Education.

Specifically, developing learning plans for special education students and others at the most risk for learning loss will be essential. “The digital divide has become a digital canyon” in some areas, Dr. Anderson noted, and schools need to rethink eligibility and work to provide access to devices for online learning for all students.

In addition, schools need to convince parents that schools are safe. She recommended that schools consider inviting parents and families to visit buildings in advance of reopening so they can see the safety measures, such as space between desks, cleaning stations, and other protective strategies.

The message to pediatricians and health care professionals when counseling families about returning individual children to school is to consider the risk to the child and the family directly in the context of the local plans, Dr. Sharfstein said during a question and answer session. “One school system’s plan is one school system’s plan,” he said, and added that families who are concerned about the risk should have an online option. However, “if you see a thoughtful approach” to reopening, with safety steps taken and parents informed, with protocols such as keeping small groups of children together to reduce transmission, “it is a pretty good trade-off,” and that is why the American Academy of Pediatrics currently favors children returning to school, he said.

The briefing participants had no relevant financial conflicts to disclose.

Cardiovascular risk factors (CVRFs), including hypertension, diabetes, and smoking, are linked to a significantly increased risk for cognitive decline in midlife in a dose-dependent manner, new research shows. The findings suggest that the relationship between CVRFs and cognition becomes evident much earlier than previously realized. Investigators found that individuals who smoked were 65% more likely to have accelerated cognitive decline, those with hypertension were 87% more likely, and individuals with diabetes had nearly a 200% increased risk.

“What is new here is that almost no one has looked at cardiovascular risk factors in such a young age [mean, 50 years] and cognitive change in middle age from 50 to 55 or so. Almost all other studies have looked at mid- or late-life cardiovascular risk factors and late-life cognition or dementia,” said study investigator Kristine Yaffe, MD.

The research was published online July 15 in Neurology.
 

New insight

Previous research has shown a strong association between CVRFs and a greater risk for cognitive decline and dementia in late life, but the investigators note that data about the influence of CVRFs on cognition in midlife are “sparse.” Longitudinal studies have also shown that several cognitive domains – particularly processing speed and executive function – may start to decline in midlife, but whether CVRFs, many of which also emerge in midlife, contribute to these changes is unclear.

To assess the effect of CVRFs on cognitive changes in midlife, the investigators analyzed data from the ongoing Coronary Artery Risk Development in Young Adults (CARDIA) study. CARDIA is a multicenter longitudinal study designed to measure risk factors for coronary artery disease in a large cohort of Black and White men and women.

The analysis was based on data from 2,675 participants who underwent CVRF assessment and cognitive testing at baseline and 5 years later. At baseline, participants’ mean age was 50.2 years. Approximately 57% of participants were women, 55% were White, and the mean number of years of education was 15. At study outset, 43% (n = 1,133) of participants were considered obese, 31% (n = 826) had hypertension, 15% (n = 701) were current smokers, 11% (n = 290) had diabetes, and 9% (n = 248) had high cholesterol.

Cognition was assessed using the Digit Symbol Substitution Test, which measures processing speed and executive function; the Stroop Test, which measures executive function; and the Rey Auditory Verbal Learning Test, which measures verbal memory.
 

Dose-dependent effect

Overall results showed that, for 5% of participants, cognitive decline was accelerated at 5 years. In unadjusted models, the odds of developing accelerated cognitive decline over 5 years was associated with hypertension (7.5% vs. 4.3%; odds ratio, 1.79, 95% confidence interval, 1.27-2.52), diabetes (10.3% vs. 4.7%; OR, 2.33; 95% CI, 1.53-3.56), and smoking (7.7% current smokers vs. 4.3% never smokers; OR, 1.87; 95% CI, 1.21-2.90). After adjusting for age, sex, and race, the associations remained significant.

The researchers found no significant effect of high cholesterol (6.9% vs. 5.2%; OR, 1.35; 95% CI, 0.80-2.28) or obesity (6.1% vs. 4.8%; OR, 1.29; 95% CI, 0.92-1.82) on accelerated cognitive decline.

Compared with participants with no CVRFs, the likelihood of accelerated cognitive decline was higher for individuals with one or two risk factors (OR, 1.94; 95% CI, 1.16-3.25) and was higher still for those with three or more risk factors (OR, 3.51; 95% CI, 2.05-6.00).

The fact that there was no association between midlife cognitive decline and obesity or high cholesterol did not come as a surprise, said Dr. Yaffe. “Most studies have not shown a consistent finding with high cholesterol and later-life cognition, so it is not surprising we did not see one in midlife, when there is not as much cognitive change.”

The study’s results, said Dr. Yaffe, provide physicians with another good reason to help patients address CVRFs and to work with them to lower blood pressure, stop smoking, reduce diabetes incidence, or control diabetes.

Dr. Yaffe said she and her colleagues plan further research into CVRFs and accelerated cognitive decline. “We want to know if this earlier cognitive decline [in midlife] is connected to greater decline later in life. We also want to know if improving these risk factors in midlife might prevent or slow dementia later.”
 

More to explore

Commenting on the findings, Michelle M. Mielke, PhD, professor of epidemiology and neurology at Mayo Clinic, Rochester, Minn., said one of the study’s main implications “is that the prevention and treatment of midlife hypertension and diabetes and smoking cessation directly impacts shorter-term changes in cognition.”

She added that the study also provides a foundation for answering further questions about the effects of CVRFs on cognition in midlife. For example, questions about sex differences remain unanswered. Men develop CVRFs earlier than women, but the investigators did not provide the prevalence of cardiovascular risk factors by sex.

“It was also not reported whether a specific midlife cardiovascular risk factor was more strongly associated with accelerated cognitive decline for women or for men,” she said. In addition, the mean age of the population at baseline is the approximate age of the onset of menopause, after which cardiovascular risk factors increase among women.

“Additional research is needed to understand the emergence of cardiovascular risk factors pre- versus post menopause on subsequent cognition and also consider the use of menopausal hormone therapy,” said Dr. Mielke.

“Another future research avenue is to further understand the impact of antihypertensive and diabetes medications,” she continued. “For example, in the current study, it was not clear how many [participants] with hypertension were treated versus untreated and whether this impacted subsequent cognition. Similarly, it is not known whether specific antihypertensives are more beneficial for cognition in midlife.”

CARDIA is supported by the National Heart, Lung, and Blood Institute; the University of Alabama at Birmingham; Northwestern University, Chicago; the University of Minnesota; and the Kaiser Foundation Research Institute. Dr. Yaffe serves on data safety monitoring boards for Eli Lilly and studies sponsored by the National Institute on Aging. She is a board member of Alector and is a member of the Beeson Scientific Advisory Board and the Global Council on Brain Health. Dr. Mielke has disclosed no relevant financial relationships.

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

Cardiovascular risk factors (CVRFs), including hypertension, diabetes, and smoking, are linked to a significantly increased risk for cognitive decline in midlife in a dose-dependent manner, new research shows. The findings suggest that the relationship between CVRFs and cognition becomes evident much earlier than previously realized. Investigators found that individuals who smoked were 65% more likely to have accelerated cognitive decline, those with hypertension were 87% more likely, and individuals with diabetes had nearly a 200% increased risk.

“What is new here is that almost no one has looked at cardiovascular risk factors in such a young age [mean, 50 years] and cognitive change in middle age from 50 to 55 or so. Almost all other studies have looked at mid- or late-life cardiovascular risk factors and late-life cognition or dementia,” said study investigator Kristine Yaffe, MD.

The research was published online July 15 in Neurology.
 

New insight

Previous research has shown a strong association between CVRFs and a greater risk for cognitive decline and dementia in late life, but the investigators note that data about the influence of CVRFs on cognition in midlife are “sparse.” Longitudinal studies have also shown that several cognitive domains – particularly processing speed and executive function – may start to decline in midlife, but whether CVRFs, many of which also emerge in midlife, contribute to these changes is unclear.

To assess the effect of CVRFs on cognitive changes in midlife, the investigators analyzed data from the ongoing Coronary Artery Risk Development in Young Adults (CARDIA) study. CARDIA is a multicenter longitudinal study designed to measure risk factors for coronary artery disease in a large cohort of Black and White men and women.

The analysis was based on data from 2,675 participants who underwent CVRF assessment and cognitive testing at baseline and 5 years later. At baseline, participants’ mean age was 50.2 years. Approximately 57% of participants were women, 55% were White, and the mean number of years of education was 15. At study outset, 43% (n = 1,133) of participants were considered obese, 31% (n = 826) had hypertension, 15% (n = 701) were current smokers, 11% (n = 290) had diabetes, and 9% (n = 248) had high cholesterol.

Cognition was assessed using the Digit Symbol Substitution Test, which measures processing speed and executive function; the Stroop Test, which measures executive function; and the Rey Auditory Verbal Learning Test, which measures verbal memory.
 

Dose-dependent effect

Overall results showed that, for 5% of participants, cognitive decline was accelerated at 5 years. In unadjusted models, the odds of developing accelerated cognitive decline over 5 years was associated with hypertension (7.5% vs. 4.3%; odds ratio, 1.79, 95% confidence interval, 1.27-2.52), diabetes (10.3% vs. 4.7%; OR, 2.33; 95% CI, 1.53-3.56), and smoking (7.7% current smokers vs. 4.3% never smokers; OR, 1.87; 95% CI, 1.21-2.90). After adjusting for age, sex, and race, the associations remained significant.

The researchers found no significant effect of high cholesterol (6.9% vs. 5.2%; OR, 1.35; 95% CI, 0.80-2.28) or obesity (6.1% vs. 4.8%; OR, 1.29; 95% CI, 0.92-1.82) on accelerated cognitive decline.

Compared with participants with no CVRFs, the likelihood of accelerated cognitive decline was higher for individuals with one or two risk factors (OR, 1.94; 95% CI, 1.16-3.25) and was higher still for those with three or more risk factors (OR, 3.51; 95% CI, 2.05-6.00).

The fact that there was no association between midlife cognitive decline and obesity or high cholesterol did not come as a surprise, said Dr. Yaffe. “Most studies have not shown a consistent finding with high cholesterol and later-life cognition, so it is not surprising we did not see one in midlife, when there is not as much cognitive change.”

The study’s results, said Dr. Yaffe, provide physicians with another good reason to help patients address CVRFs and to work with them to lower blood pressure, stop smoking, reduce diabetes incidence, or control diabetes.

Dr. Yaffe said she and her colleagues plan further research into CVRFs and accelerated cognitive decline. “We want to know if this earlier cognitive decline [in midlife] is connected to greater decline later in life. We also want to know if improving these risk factors in midlife might prevent or slow dementia later.”
 

More to explore

Commenting on the findings, Michelle M. Mielke, PhD, professor of epidemiology and neurology at Mayo Clinic, Rochester, Minn., said one of the study’s main implications “is that the prevention and treatment of midlife hypertension and diabetes and smoking cessation directly impacts shorter-term changes in cognition.”

She added that the study also provides a foundation for answering further questions about the effects of CVRFs on cognition in midlife. For example, questions about sex differences remain unanswered. Men develop CVRFs earlier than women, but the investigators did not provide the prevalence of cardiovascular risk factors by sex.

“It was also not reported whether a specific midlife cardiovascular risk factor was more strongly associated with accelerated cognitive decline for women or for men,” she said. In addition, the mean age of the population at baseline is the approximate age of the onset of menopause, after which cardiovascular risk factors increase among women.

“Additional research is needed to understand the emergence of cardiovascular risk factors pre- versus post menopause on subsequent cognition and also consider the use of menopausal hormone therapy,” said Dr. Mielke.

“Another future research avenue is to further understand the impact of antihypertensive and diabetes medications,” she continued. “For example, in the current study, it was not clear how many [participants] with hypertension were treated versus untreated and whether this impacted subsequent cognition. Similarly, it is not known whether specific antihypertensives are more beneficial for cognition in midlife.”

CARDIA is supported by the National Heart, Lung, and Blood Institute; the University of Alabama at Birmingham; Northwestern University, Chicago; the University of Minnesota; and the Kaiser Foundation Research Institute. Dr. Yaffe serves on data safety monitoring boards for Eli Lilly and studies sponsored by the National Institute on Aging. She is a board member of Alector and is a member of the Beeson Scientific Advisory Board and the Global Council on Brain Health. Dr. Mielke has disclosed no relevant financial relationships.

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

Cardiovascular risk factors (CVRFs), including hypertension, diabetes, and smoking, are linked to a significantly increased risk for cognitive decline in midlife in a dose-dependent manner, new research shows. The findings suggest that the relationship between CVRFs and cognition becomes evident much earlier than previously realized. Investigators found that individuals who smoked were 65% more likely to have accelerated cognitive decline, those with hypertension were 87% more likely, and individuals with diabetes had nearly a 200% increased risk.

“What is new here is that almost no one has looked at cardiovascular risk factors in such a young age [mean, 50 years] and cognitive change in middle age from 50 to 55 or so. Almost all other studies have looked at mid- or late-life cardiovascular risk factors and late-life cognition or dementia,” said study investigator Kristine Yaffe, MD.

The research was published online July 15 in Neurology.
 

New insight

Previous research has shown a strong association between CVRFs and a greater risk for cognitive decline and dementia in late life, but the investigators note that data about the influence of CVRFs on cognition in midlife are “sparse.” Longitudinal studies have also shown that several cognitive domains – particularly processing speed and executive function – may start to decline in midlife, but whether CVRFs, many of which also emerge in midlife, contribute to these changes is unclear.

To assess the effect of CVRFs on cognitive changes in midlife, the investigators analyzed data from the ongoing Coronary Artery Risk Development in Young Adults (CARDIA) study. CARDIA is a multicenter longitudinal study designed to measure risk factors for coronary artery disease in a large cohort of Black and White men and women.

The analysis was based on data from 2,675 participants who underwent CVRF assessment and cognitive testing at baseline and 5 years later. At baseline, participants’ mean age was 50.2 years. Approximately 57% of participants were women, 55% were White, and the mean number of years of education was 15. At study outset, 43% (n = 1,133) of participants were considered obese, 31% (n = 826) had hypertension, 15% (n = 701) were current smokers, 11% (n = 290) had diabetes, and 9% (n = 248) had high cholesterol.

Cognition was assessed using the Digit Symbol Substitution Test, which measures processing speed and executive function; the Stroop Test, which measures executive function; and the Rey Auditory Verbal Learning Test, which measures verbal memory.
 

Dose-dependent effect

Overall results showed that, for 5% of participants, cognitive decline was accelerated at 5 years. In unadjusted models, the odds of developing accelerated cognitive decline over 5 years was associated with hypertension (7.5% vs. 4.3%; odds ratio, 1.79, 95% confidence interval, 1.27-2.52), diabetes (10.3% vs. 4.7%; OR, 2.33; 95% CI, 1.53-3.56), and smoking (7.7% current smokers vs. 4.3% never smokers; OR, 1.87; 95% CI, 1.21-2.90). After adjusting for age, sex, and race, the associations remained significant.

The researchers found no significant effect of high cholesterol (6.9% vs. 5.2%; OR, 1.35; 95% CI, 0.80-2.28) or obesity (6.1% vs. 4.8%; OR, 1.29; 95% CI, 0.92-1.82) on accelerated cognitive decline.

Compared with participants with no CVRFs, the likelihood of accelerated cognitive decline was higher for individuals with one or two risk factors (OR, 1.94; 95% CI, 1.16-3.25) and was higher still for those with three or more risk factors (OR, 3.51; 95% CI, 2.05-6.00).

The fact that there was no association between midlife cognitive decline and obesity or high cholesterol did not come as a surprise, said Dr. Yaffe. “Most studies have not shown a consistent finding with high cholesterol and later-life cognition, so it is not surprising we did not see one in midlife, when there is not as much cognitive change.”

The study’s results, said Dr. Yaffe, provide physicians with another good reason to help patients address CVRFs and to work with them to lower blood pressure, stop smoking, reduce diabetes incidence, or control diabetes.

Dr. Yaffe said she and her colleagues plan further research into CVRFs and accelerated cognitive decline. “We want to know if this earlier cognitive decline [in midlife] is connected to greater decline later in life. We also want to know if improving these risk factors in midlife might prevent or slow dementia later.”
 

More to explore

Commenting on the findings, Michelle M. Mielke, PhD, professor of epidemiology and neurology at Mayo Clinic, Rochester, Minn., said one of the study’s main implications “is that the prevention and treatment of midlife hypertension and diabetes and smoking cessation directly impacts shorter-term changes in cognition.”

She added that the study also provides a foundation for answering further questions about the effects of CVRFs on cognition in midlife. For example, questions about sex differences remain unanswered. Men develop CVRFs earlier than women, but the investigators did not provide the prevalence of cardiovascular risk factors by sex.

“It was also not reported whether a specific midlife cardiovascular risk factor was more strongly associated with accelerated cognitive decline for women or for men,” she said. In addition, the mean age of the population at baseline is the approximate age of the onset of menopause, after which cardiovascular risk factors increase among women.

“Additional research is needed to understand the emergence of cardiovascular risk factors pre- versus post menopause on subsequent cognition and also consider the use of menopausal hormone therapy,” said Dr. Mielke.

“Another future research avenue is to further understand the impact of antihypertensive and diabetes medications,” she continued. “For example, in the current study, it was not clear how many [participants] with hypertension were treated versus untreated and whether this impacted subsequent cognition. Similarly, it is not known whether specific antihypertensives are more beneficial for cognition in midlife.”

CARDIA is supported by the National Heart, Lung, and Blood Institute; the University of Alabama at Birmingham; Northwestern University, Chicago; the University of Minnesota; and the Kaiser Foundation Research Institute. Dr. Yaffe serves on data safety monitoring boards for Eli Lilly and studies sponsored by the National Institute on Aging. She is a board member of Alector and is a member of the Beeson Scientific Advisory Board and the Global Council on Brain Health. Dr. Mielke has disclosed no relevant financial relationships.

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

Using a simple point-of-care (POC) finger prick device to measure blood glucose and lipid levels significantly increases rates of physical health checkups for patients with severe mental illness, new research shows.

In a UK pilot study, use of the Afinion 2 device (Abbott) was associated with a doubling of completed physical health checkups.

However, the effect only occurred in early-intervention services, in which clinicians may feel physical health checkups are most beneficial. This underlines the importance of staff training and payment incentives, the researchers note.

“Clearly, convenience is a great thing about these devices” for both the patient and the mental health clinician, Joseph Butler, MD, a psychiatry trainee at the University of Oxford, United Kingdom, told Medscape Medical News.

He noted that blood test results are rapid, which facilitates immediate discussion of a health management plan.

These tests are “independent from the lab, they’re independent from the general practitioner, and so in terms of convenience, we think it wins on both fronts,” Butler said.

The findings were scheduled to be presented at the Congress of the Schizophrenia International Research Society (SIRS) 2020, but the meeting was canceled because of the coronavirus pandemic.

Poor heart health

Previous research has shown that life expectancy of patients with severe mental illness is 15 to 20 years less than that of the general population, mostly because of complications from poor cardiovascular health.

In the United Kingdom, physical healthcare for patients with serious mental illness is provided by primary care clinicians and community mental health teams (CMHTs). The National Institute for Health and Care Excellence recommends an annual physical examination.

However, a recent audit in the south of England indicated that only 38% of patients with severe mental illness underwent complete physical examinations, primarily because blood glucose and lipid test panels had been omitted.

The researchers note that patients are typically advised to visit their general practitioner for blood tests, “which can be a challenge” for those with severe mental illness.

The Cardiovascular Monitoring in Mental Health (CARMEN) project involved distributing the Afinion 2 device for use in two CMHTs in Oxfordshire, United Kingdom, for 6 months. One CMHT was an early-intervention service, and the other was an adult mental health service.

Care coordinators received training on how to use the device as well as ongoing support to facilitate engagement with the device.

Rates of completion of blood testing and full physical examinations were compared between the intervention CMHTs and two matched control services – an early-intervention group, and an adult metal health services group in Buckinghamshire, a neighboring county.

Better completion rates

The investigators found that after the introduction of the POC, physical examination completion rates for the early-intervention service increased from 22.6% to 40.3% over 6 months.

In contrast, the percentage of physical examinations that were completed remained low in the control CMHT early-intervention service, at just 7.8%.

Direct comparison between the two services showed that use of the POC device was associated with a significant increase in the number of complete physical examinations, at a relative rate of 5.18 (P < .001).

Results were similar when the investigators examined rates at which A1c and lipid panels were completed.

However, there was no difference in completion of physical examinations in the adult mental health service group, for which rates were comparable to those in the control service.

Butler speculated that the way health checkups are funded in the United Kingdom might have contributed to the poor results with the device in the adult mental health service.

In early-intervention services, there is increased awareness of the importance of physical examinations, and funding is contingent on whether clinicians persuade patients to have the examinations.

Overall, the findings show that use of a POC device for physical examinations is acceptable to patients who have severe mental illness as well as to mental health care clinicians, the investigators note.

“In teams where it is well adopted, POC testing can improve physical health check completion...although our qualitative findings highlight important considerations for maximizing clinician engagement,” they add.

The researchers plan to repeat the study across the whole of the south of England, with early-intervention services in the west equipped with POC devices and those in the east serving as controls.

Similar findings

Commenting on the findings for Medscape Medical News, Joe Parks, MD, vice president and practice improvement and medical director at the National Council for Behavioral Health, Washington, DC, noted that he and his colleagues conducted a similar study in the mid-2000s.

Starting in 2004, they distributed a POC finger prick test device for use by community mental health teams to measure blood glucose and lipid levels.

“We required as a condition of payment that the providers get these lab results for everybody they served and report them centrally. Then, we databased them and benchmarked them, and we were able to show significant reductions in HbA1c’s over time,” said Parks, who was not involved with the current research.

Moreover, that program achieved corresponding savings of $23 to $24 million, he noted.

Although his study and the current study show that POC devices work, he emphasized that it’s not enough to make the devices available to clinicians.

“You also have to ensure the providers put it in their clinic workflows and use it with everybody. To do that, it really helps if you have the providers report the results, then give them report cards so they can see who’s doing it and who isn’t,” Parks said.

It wasn’t surprising that in the current study, the introduction of the POC device made less of an impact in the adult community services, he noted.

Although weight reduction is much slower in that setting, “you can still get better control of their lipids and HbA1c›s, and you get at their weight over time. You just have to program for that, too,» said Parks.

He added that it’s hard to achieve weight reduction of more than 5% or 10%, but many of these patients need a 25% to 30% reduction. “The only thing that’s going to get that is bariatric surgery,” he noted.

POC devices are not widely used in the United States.

“The payer paying for the care basically has to insist that [it] be used and then provide the machine and train the staff to use it,” Parks said.

It requires payers “to get actually involved in how providers organize and manage care, which they tend to not like to do. It’s silly because the only way any payer has to make anybody better is through the provider,” he noted.

Parks added that to increase uptake beyond the “motivated few” requires that it be made part of the workflow and not left up to clinician discretion.

The study was funded by the National Institute for Health Research. Butler and Parks have reported no relevant financial relationships.

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

Using a simple point-of-care (POC) finger prick device to measure blood glucose and lipid levels significantly increases rates of physical health checkups for patients with severe mental illness, new research shows.

In a UK pilot study, use of the Afinion 2 device (Abbott) was associated with a doubling of completed physical health checkups.

However, the effect only occurred in early-intervention services, in which clinicians may feel physical health checkups are most beneficial. This underlines the importance of staff training and payment incentives, the researchers note.

“Clearly, convenience is a great thing about these devices” for both the patient and the mental health clinician, Joseph Butler, MD, a psychiatry trainee at the University of Oxford, United Kingdom, told Medscape Medical News.

He noted that blood test results are rapid, which facilitates immediate discussion of a health management plan.

These tests are “independent from the lab, they’re independent from the general practitioner, and so in terms of convenience, we think it wins on both fronts,” Butler said.

The findings were scheduled to be presented at the Congress of the Schizophrenia International Research Society (SIRS) 2020, but the meeting was canceled because of the coronavirus pandemic.

Poor heart health

Previous research has shown that life expectancy of patients with severe mental illness is 15 to 20 years less than that of the general population, mostly because of complications from poor cardiovascular health.

In the United Kingdom, physical healthcare for patients with serious mental illness is provided by primary care clinicians and community mental health teams (CMHTs). The National Institute for Health and Care Excellence recommends an annual physical examination.

However, a recent audit in the south of England indicated that only 38% of patients with severe mental illness underwent complete physical examinations, primarily because blood glucose and lipid test panels had been omitted.

The researchers note that patients are typically advised to visit their general practitioner for blood tests, “which can be a challenge” for those with severe mental illness.

The Cardiovascular Monitoring in Mental Health (CARMEN) project involved distributing the Afinion 2 device for use in two CMHTs in Oxfordshire, United Kingdom, for 6 months. One CMHT was an early-intervention service, and the other was an adult mental health service.

Care coordinators received training on how to use the device as well as ongoing support to facilitate engagement with the device.

Rates of completion of blood testing and full physical examinations were compared between the intervention CMHTs and two matched control services – an early-intervention group, and an adult metal health services group in Buckinghamshire, a neighboring county.

Better completion rates

The investigators found that after the introduction of the POC, physical examination completion rates for the early-intervention service increased from 22.6% to 40.3% over 6 months.

In contrast, the percentage of physical examinations that were completed remained low in the control CMHT early-intervention service, at just 7.8%.

Direct comparison between the two services showed that use of the POC device was associated with a significant increase in the number of complete physical examinations, at a relative rate of 5.18 (P < .001).

Results were similar when the investigators examined rates at which A1c and lipid panels were completed.

However, there was no difference in completion of physical examinations in the adult mental health service group, for which rates were comparable to those in the control service.

Butler speculated that the way health checkups are funded in the United Kingdom might have contributed to the poor results with the device in the adult mental health service.

In early-intervention services, there is increased awareness of the importance of physical examinations, and funding is contingent on whether clinicians persuade patients to have the examinations.

Overall, the findings show that use of a POC device for physical examinations is acceptable to patients who have severe mental illness as well as to mental health care clinicians, the investigators note.

“In teams where it is well adopted, POC testing can improve physical health check completion...although our qualitative findings highlight important considerations for maximizing clinician engagement,” they add.

The researchers plan to repeat the study across the whole of the south of England, with early-intervention services in the west equipped with POC devices and those in the east serving as controls.

Similar findings

Commenting on the findings for Medscape Medical News, Joe Parks, MD, vice president and practice improvement and medical director at the National Council for Behavioral Health, Washington, DC, noted that he and his colleagues conducted a similar study in the mid-2000s.

Starting in 2004, they distributed a POC finger prick test device for use by community mental health teams to measure blood glucose and lipid levels.

“We required as a condition of payment that the providers get these lab results for everybody they served and report them centrally. Then, we databased them and benchmarked them, and we were able to show significant reductions in HbA1c’s over time,” said Parks, who was not involved with the current research.

Moreover, that program achieved corresponding savings of $23 to $24 million, he noted.

Although his study and the current study show that POC devices work, he emphasized that it’s not enough to make the devices available to clinicians.

“You also have to ensure the providers put it in their clinic workflows and use it with everybody. To do that, it really helps if you have the providers report the results, then give them report cards so they can see who’s doing it and who isn’t,” Parks said.

It wasn’t surprising that in the current study, the introduction of the POC device made less of an impact in the adult community services, he noted.

Although weight reduction is much slower in that setting, “you can still get better control of their lipids and HbA1c›s, and you get at their weight over time. You just have to program for that, too,» said Parks.

He added that it’s hard to achieve weight reduction of more than 5% or 10%, but many of these patients need a 25% to 30% reduction. “The only thing that’s going to get that is bariatric surgery,” he noted.

POC devices are not widely used in the United States.

“The payer paying for the care basically has to insist that [it] be used and then provide the machine and train the staff to use it,” Parks said.

It requires payers “to get actually involved in how providers organize and manage care, which they tend to not like to do. It’s silly because the only way any payer has to make anybody better is through the provider,” he noted.

Parks added that to increase uptake beyond the “motivated few” requires that it be made part of the workflow and not left up to clinician discretion.

The study was funded by the National Institute for Health Research. Butler and Parks have reported no relevant financial relationships.

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

Using a simple point-of-care (POC) finger prick device to measure blood glucose and lipid levels significantly increases rates of physical health checkups for patients with severe mental illness, new research shows.

In a UK pilot study, use of the Afinion 2 device (Abbott) was associated with a doubling of completed physical health checkups.

However, the effect only occurred in early-intervention services, in which clinicians may feel physical health checkups are most beneficial. This underlines the importance of staff training and payment incentives, the researchers note.

“Clearly, convenience is a great thing about these devices” for both the patient and the mental health clinician, Joseph Butler, MD, a psychiatry trainee at the University of Oxford, United Kingdom, told Medscape Medical News.

He noted that blood test results are rapid, which facilitates immediate discussion of a health management plan.

These tests are “independent from the lab, they’re independent from the general practitioner, and so in terms of convenience, we think it wins on both fronts,” Butler said.

The findings were scheduled to be presented at the Congress of the Schizophrenia International Research Society (SIRS) 2020, but the meeting was canceled because of the coronavirus pandemic.

Poor heart health

Previous research has shown that life expectancy of patients with severe mental illness is 15 to 20 years less than that of the general population, mostly because of complications from poor cardiovascular health.

In the United Kingdom, physical healthcare for patients with serious mental illness is provided by primary care clinicians and community mental health teams (CMHTs). The National Institute for Health and Care Excellence recommends an annual physical examination.

However, a recent audit in the south of England indicated that only 38% of patients with severe mental illness underwent complete physical examinations, primarily because blood glucose and lipid test panels had been omitted.

The researchers note that patients are typically advised to visit their general practitioner for blood tests, “which can be a challenge” for those with severe mental illness.

The Cardiovascular Monitoring in Mental Health (CARMEN) project involved distributing the Afinion 2 device for use in two CMHTs in Oxfordshire, United Kingdom, for 6 months. One CMHT was an early-intervention service, and the other was an adult mental health service.

Care coordinators received training on how to use the device as well as ongoing support to facilitate engagement with the device.

Rates of completion of blood testing and full physical examinations were compared between the intervention CMHTs and two matched control services – an early-intervention group, and an adult metal health services group in Buckinghamshire, a neighboring county.

Better completion rates

The investigators found that after the introduction of the POC, physical examination completion rates for the early-intervention service increased from 22.6% to 40.3% over 6 months.

In contrast, the percentage of physical examinations that were completed remained low in the control CMHT early-intervention service, at just 7.8%.

Direct comparison between the two services showed that use of the POC device was associated with a significant increase in the number of complete physical examinations, at a relative rate of 5.18 (P < .001).

Results were similar when the investigators examined rates at which A1c and lipid panels were completed.

However, there was no difference in completion of physical examinations in the adult mental health service group, for which rates were comparable to those in the control service.

Butler speculated that the way health checkups are funded in the United Kingdom might have contributed to the poor results with the device in the adult mental health service.

In early-intervention services, there is increased awareness of the importance of physical examinations, and funding is contingent on whether clinicians persuade patients to have the examinations.

Overall, the findings show that use of a POC device for physical examinations is acceptable to patients who have severe mental illness as well as to mental health care clinicians, the investigators note.

“In teams where it is well adopted, POC testing can improve physical health check completion...although our qualitative findings highlight important considerations for maximizing clinician engagement,” they add.

The researchers plan to repeat the study across the whole of the south of England, with early-intervention services in the west equipped with POC devices and those in the east serving as controls.

Similar findings

Commenting on the findings for Medscape Medical News, Joe Parks, MD, vice president and practice improvement and medical director at the National Council for Behavioral Health, Washington, DC, noted that he and his colleagues conducted a similar study in the mid-2000s.

Starting in 2004, they distributed a POC finger prick test device for use by community mental health teams to measure blood glucose and lipid levels.

“We required as a condition of payment that the providers get these lab results for everybody they served and report them centrally. Then, we databased them and benchmarked them, and we were able to show significant reductions in HbA1c’s over time,” said Parks, who was not involved with the current research.

Moreover, that program achieved corresponding savings of $23 to $24 million, he noted.

Although his study and the current study show that POC devices work, he emphasized that it’s not enough to make the devices available to clinicians.

“You also have to ensure the providers put it in their clinic workflows and use it with everybody. To do that, it really helps if you have the providers report the results, then give them report cards so they can see who’s doing it and who isn’t,” Parks said.

It wasn’t surprising that in the current study, the introduction of the POC device made less of an impact in the adult community services, he noted.

Although weight reduction is much slower in that setting, “you can still get better control of their lipids and HbA1c›s, and you get at their weight over time. You just have to program for that, too,» said Parks.

He added that it’s hard to achieve weight reduction of more than 5% or 10%, but many of these patients need a 25% to 30% reduction. “The only thing that’s going to get that is bariatric surgery,” he noted.

POC devices are not widely used in the United States.

“The payer paying for the care basically has to insist that [it] be used and then provide the machine and train the staff to use it,” Parks said.

It requires payers “to get actually involved in how providers organize and manage care, which they tend to not like to do. It’s silly because the only way any payer has to make anybody better is through the provider,” he noted.

Parks added that to increase uptake beyond the “motivated few” requires that it be made part of the workflow and not left up to clinician discretion.

The study was funded by the National Institute for Health Research. Butler and Parks have reported no relevant financial relationships.

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