Clinical Psychiatry News

ACE levels are lower in individuals with first episode psychosis (FEP) and even lower in those with resistant disease, suggesting the enzyme may be a biomarker of disease severity.

In a longitudinal cohort study, investigators found patients with FEP had significantly reduced ACE levels compared with their healthy peers.

With blood concentrations of the enzyme significantly reduced in those who were treatment-resistant, “ACE alterations appear to be already present at the disease onset” and results suggest “a possible relationship with disease severity,” noted the researchers, led by investigator Luisa Longo, MD, a resident in psychiatry, University of Bari Aldo Moro in Italy.

Moreover, the finding that lower ACE levels were associated with greater cognitive impairment on neuropsychological tests indicates the enzyme plays a role in “the alteration of neurocognitive abilities” in patients with FEP.

Taken together, the results “highlight ACE as a promising peripheral biomarker to identify patients at risk of treatment resistance to antipsychotics,” the investigators reported.

The findings were presented at the annual congress of the Schizophrenia International Research Society.
 

Mechanisms “poorly understood”

Previous studies suggest ACE may play a role in neurologic and psychiatric conditions, including schizophrenia, through alterations in function or blood concentrations.

However, the molecular mechanisms underlying disease onset and response to antipsychotics in patients with FEP “remain poorly understood,” the researchers noted. In addition, “despite adequate antipsychotic treatment, 20% of patients have persistent symptoms.”

To determine whether ACE levels are already altered in FEP patients, the investigators examined data on 138 patients with FEP and 115 healthy controls.

After measuring blood concentrations in 122 of the patients and 78 controls, they found that ACE levels were significantly lower in FEP patients (P = 4.1x10-13) after controlling for age, sex, ethnicity, duration of illness, smoking status, and chlorpromazine equivalents.

Cerebrospinal fluid (CSF) levels, which were measured in 19 patients and 18 controls, were also significantly lower in individuals with FEP (P = .01), with a strong correlation observed between blood and CSF levels (P = .0005).

Next, the team used Treatment Response and Resistance in Psychosis criteria to compare ACE levels in 32 treatment-resistant patients and 106 non–treatment-resistant patients. Results showed that ACE blood levels were significantly lower in the treatment-resistant patients (P = .03).

Finally, the association between ACE blood levels and range of clinical and neurocognitive variables were examined across all FEP patients.

The Scale for the Assessment of Negative and Positive Symptoms was administered, along with a battery of tests looking at processing speed, working memory, verbal learning and memory, visual learning and memory, ideational fluency, and executive function. All were combined into a composite score.

While there was no association between ACE blood levels and symptom severity in the patients, there was a significant association between levels and verbal memory (P = .007) and composite cognitive score (P = .04).
 

Notable finding

In an interview, Thomas W. Sedlak, MD, PhD, assistant professor of psychiatry and behavioral health, Johns Hopkins University, Baltimore, said the finding that ACE levels were associated with lower cognition scores is “notable in that we don’t really have any treatments for cognition.

“Antipsychotic drugs treat more of the famous symptoms of hallucinations and delusions and disordered speech, but they don›t really help cognition a whole lot — and too much medicine might even make that worse,” said Dr. Sedlak, who was not involved with the research.

“So it’s interesting to have another biomarker that might relate a symptom of schizophrenia that we don’t really have a good grip on addressing,” he said.

However, he noted that this study is “preliminary,” has not looked at longitudinal changes in ACE in the same patients, and is one of “many” correlation studies.

“I like to say you can pretty much Google any chemical in the body and somebody has a claim about it and schizophrenia,” Dr. Sedlak said.

Nevertheless, the current analysis is “convergent” with past studies on ACE, including those that have found associations between polymorphisms in the enzyme and schizophrenia, he noted.

Moreover, research has shown that ACE facilitates glutamate transmission, specifically via N-methyl-D-aspartate (NMDA) receptors in the prefrontal cortex, “which is probably the brain region most tied to schizophrenia abnormalities,” Dr. Sedlak said.
 

No tie to inflammation

The findings do contrast, however, with the increasing body of evidence linking schizophrenia to inflammation.

Dr. Sedlak said that is not surprising, as the more that is learned about schizophrenia, “the less it is likely to be a single homogeneous entity but something more akin to intellectual disability.

“We’re finding that there are different subtypes of schizophrenia, some of which might have more of an inflammatory tie and others which don’t.”

He added that it might be possible over the longer term to cluster patients by ACE levels and other biomarkers and then follow them long term to “see if we can predict outcomes better than purely clinical terms.”

In this way, Dr. Sedlak said he believes that psychiatry may become more like rheumatology, “which I’d say is the area of medicine, at least in terms of making diagnoses, most similar.”

The etiology of conditions such as lupus and rheumatoid arthritis is “not absolutely known” and there is “probably no single cause,” with the diagnosis relying on clinical findings alongside biomarker tests.

“I think psychiatry is, long term, hoping to discover some biomarkers ... that would be used together with the clinical findings to help come to more clinical agreement on how to define cases – and would be predictive long term in terms of the course of illness,” Dr. Sedlak concluded.

The study had no specific funding. The study investigators and Dr. Sedlak have disclosed no relevant financial relationships.
 

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

ACE levels are lower in individuals with first episode psychosis (FEP) and even lower in those with resistant disease, suggesting the enzyme may be a biomarker of disease severity.

In a longitudinal cohort study, investigators found patients with FEP had significantly reduced ACE levels compared with their healthy peers.

With blood concentrations of the enzyme significantly reduced in those who were treatment-resistant, “ACE alterations appear to be already present at the disease onset” and results suggest “a possible relationship with disease severity,” noted the researchers, led by investigator Luisa Longo, MD, a resident in psychiatry, University of Bari Aldo Moro in Italy.

Moreover, the finding that lower ACE levels were associated with greater cognitive impairment on neuropsychological tests indicates the enzyme plays a role in “the alteration of neurocognitive abilities” in patients with FEP.

Taken together, the results “highlight ACE as a promising peripheral biomarker to identify patients at risk of treatment resistance to antipsychotics,” the investigators reported.

The findings were presented at the annual congress of the Schizophrenia International Research Society.
 

Mechanisms “poorly understood”

Previous studies suggest ACE may play a role in neurologic and psychiatric conditions, including schizophrenia, through alterations in function or blood concentrations.

However, the molecular mechanisms underlying disease onset and response to antipsychotics in patients with FEP “remain poorly understood,” the researchers noted. In addition, “despite adequate antipsychotic treatment, 20% of patients have persistent symptoms.”

To determine whether ACE levels are already altered in FEP patients, the investigators examined data on 138 patients with FEP and 115 healthy controls.

After measuring blood concentrations in 122 of the patients and 78 controls, they found that ACE levels were significantly lower in FEP patients (P = 4.1x10-13) after controlling for age, sex, ethnicity, duration of illness, smoking status, and chlorpromazine equivalents.

Cerebrospinal fluid (CSF) levels, which were measured in 19 patients and 18 controls, were also significantly lower in individuals with FEP (P = .01), with a strong correlation observed between blood and CSF levels (P = .0005).

Next, the team used Treatment Response and Resistance in Psychosis criteria to compare ACE levels in 32 treatment-resistant patients and 106 non–treatment-resistant patients. Results showed that ACE blood levels were significantly lower in the treatment-resistant patients (P = .03).

Finally, the association between ACE blood levels and range of clinical and neurocognitive variables were examined across all FEP patients.

The Scale for the Assessment of Negative and Positive Symptoms was administered, along with a battery of tests looking at processing speed, working memory, verbal learning and memory, visual learning and memory, ideational fluency, and executive function. All were combined into a composite score.

While there was no association between ACE blood levels and symptom severity in the patients, there was a significant association between levels and verbal memory (P = .007) and composite cognitive score (P = .04).
 

Notable finding

In an interview, Thomas W. Sedlak, MD, PhD, assistant professor of psychiatry and behavioral health, Johns Hopkins University, Baltimore, said the finding that ACE levels were associated with lower cognition scores is “notable in that we don’t really have any treatments for cognition.

“Antipsychotic drugs treat more of the famous symptoms of hallucinations and delusions and disordered speech, but they don›t really help cognition a whole lot — and too much medicine might even make that worse,” said Dr. Sedlak, who was not involved with the research.

“So it’s interesting to have another biomarker that might relate a symptom of schizophrenia that we don’t really have a good grip on addressing,” he said.

However, he noted that this study is “preliminary,” has not looked at longitudinal changes in ACE in the same patients, and is one of “many” correlation studies.

“I like to say you can pretty much Google any chemical in the body and somebody has a claim about it and schizophrenia,” Dr. Sedlak said.

Nevertheless, the current analysis is “convergent” with past studies on ACE, including those that have found associations between polymorphisms in the enzyme and schizophrenia, he noted.

Moreover, research has shown that ACE facilitates glutamate transmission, specifically via N-methyl-D-aspartate (NMDA) receptors in the prefrontal cortex, “which is probably the brain region most tied to schizophrenia abnormalities,” Dr. Sedlak said.
 

No tie to inflammation

The findings do contrast, however, with the increasing body of evidence linking schizophrenia to inflammation.

Dr. Sedlak said that is not surprising, as the more that is learned about schizophrenia, “the less it is likely to be a single homogeneous entity but something more akin to intellectual disability.

“We’re finding that there are different subtypes of schizophrenia, some of which might have more of an inflammatory tie and others which don’t.”

He added that it might be possible over the longer term to cluster patients by ACE levels and other biomarkers and then follow them long term to “see if we can predict outcomes better than purely clinical terms.”

In this way, Dr. Sedlak said he believes that psychiatry may become more like rheumatology, “which I’d say is the area of medicine, at least in terms of making diagnoses, most similar.”

The etiology of conditions such as lupus and rheumatoid arthritis is “not absolutely known” and there is “probably no single cause,” with the diagnosis relying on clinical findings alongside biomarker tests.

“I think psychiatry is, long term, hoping to discover some biomarkers ... that would be used together with the clinical findings to help come to more clinical agreement on how to define cases – and would be predictive long term in terms of the course of illness,” Dr. Sedlak concluded.

The study had no specific funding. The study investigators and Dr. Sedlak have disclosed no relevant financial relationships.
 

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

ACE levels are lower in individuals with first episode psychosis (FEP) and even lower in those with resistant disease, suggesting the enzyme may be a biomarker of disease severity.

In a longitudinal cohort study, investigators found patients with FEP had significantly reduced ACE levels compared with their healthy peers.

With blood concentrations of the enzyme significantly reduced in those who were treatment-resistant, “ACE alterations appear to be already present at the disease onset” and results suggest “a possible relationship with disease severity,” noted the researchers, led by investigator Luisa Longo, MD, a resident in psychiatry, University of Bari Aldo Moro in Italy.

Moreover, the finding that lower ACE levels were associated with greater cognitive impairment on neuropsychological tests indicates the enzyme plays a role in “the alteration of neurocognitive abilities” in patients with FEP.

Taken together, the results “highlight ACE as a promising peripheral biomarker to identify patients at risk of treatment resistance to antipsychotics,” the investigators reported.

The findings were presented at the annual congress of the Schizophrenia International Research Society.
 

Mechanisms “poorly understood”

Previous studies suggest ACE may play a role in neurologic and psychiatric conditions, including schizophrenia, through alterations in function or blood concentrations.

However, the molecular mechanisms underlying disease onset and response to antipsychotics in patients with FEP “remain poorly understood,” the researchers noted. In addition, “despite adequate antipsychotic treatment, 20% of patients have persistent symptoms.”

To determine whether ACE levels are already altered in FEP patients, the investigators examined data on 138 patients with FEP and 115 healthy controls.

After measuring blood concentrations in 122 of the patients and 78 controls, they found that ACE levels were significantly lower in FEP patients (P = 4.1x10-13) after controlling for age, sex, ethnicity, duration of illness, smoking status, and chlorpromazine equivalents.

Cerebrospinal fluid (CSF) levels, which were measured in 19 patients and 18 controls, were also significantly lower in individuals with FEP (P = .01), with a strong correlation observed between blood and CSF levels (P = .0005).

Next, the team used Treatment Response and Resistance in Psychosis criteria to compare ACE levels in 32 treatment-resistant patients and 106 non–treatment-resistant patients. Results showed that ACE blood levels were significantly lower in the treatment-resistant patients (P = .03).

Finally, the association between ACE blood levels and range of clinical and neurocognitive variables were examined across all FEP patients.

The Scale for the Assessment of Negative and Positive Symptoms was administered, along with a battery of tests looking at processing speed, working memory, verbal learning and memory, visual learning and memory, ideational fluency, and executive function. All were combined into a composite score.

While there was no association between ACE blood levels and symptom severity in the patients, there was a significant association between levels and verbal memory (P = .007) and composite cognitive score (P = .04).
 

Notable finding

In an interview, Thomas W. Sedlak, MD, PhD, assistant professor of psychiatry and behavioral health, Johns Hopkins University, Baltimore, said the finding that ACE levels were associated with lower cognition scores is “notable in that we don’t really have any treatments for cognition.

“Antipsychotic drugs treat more of the famous symptoms of hallucinations and delusions and disordered speech, but they don›t really help cognition a whole lot — and too much medicine might even make that worse,” said Dr. Sedlak, who was not involved with the research.

“So it’s interesting to have another biomarker that might relate a symptom of schizophrenia that we don’t really have a good grip on addressing,” he said.

However, he noted that this study is “preliminary,” has not looked at longitudinal changes in ACE in the same patients, and is one of “many” correlation studies.

“I like to say you can pretty much Google any chemical in the body and somebody has a claim about it and schizophrenia,” Dr. Sedlak said.

Nevertheless, the current analysis is “convergent” with past studies on ACE, including those that have found associations between polymorphisms in the enzyme and schizophrenia, he noted.

Moreover, research has shown that ACE facilitates glutamate transmission, specifically via N-methyl-D-aspartate (NMDA) receptors in the prefrontal cortex, “which is probably the brain region most tied to schizophrenia abnormalities,” Dr. Sedlak said.
 

No tie to inflammation

The findings do contrast, however, with the increasing body of evidence linking schizophrenia to inflammation.

Dr. Sedlak said that is not surprising, as the more that is learned about schizophrenia, “the less it is likely to be a single homogeneous entity but something more akin to intellectual disability.

“We’re finding that there are different subtypes of schizophrenia, some of which might have more of an inflammatory tie and others which don’t.”

He added that it might be possible over the longer term to cluster patients by ACE levels and other biomarkers and then follow them long term to “see if we can predict outcomes better than purely clinical terms.”

In this way, Dr. Sedlak said he believes that psychiatry may become more like rheumatology, “which I’d say is the area of medicine, at least in terms of making diagnoses, most similar.”

The etiology of conditions such as lupus and rheumatoid arthritis is “not absolutely known” and there is “probably no single cause,” with the diagnosis relying on clinical findings alongside biomarker tests.

“I think psychiatry is, long term, hoping to discover some biomarkers ... that would be used together with the clinical findings to help come to more clinical agreement on how to define cases – and would be predictive long term in terms of the course of illness,” Dr. Sedlak concluded.

The study had no specific funding. The study investigators and Dr. Sedlak have disclosed no relevant financial relationships.
 

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

There are at least five dermatologic patterns in patients who are suspected or confirmed of having COVID-19, and the knowledge base continues to evolve, according to Christine Ko, MD.

“Things are very fluid,” Dr. Ko, professor of dermatology and pathology at Yale University, New Haven, Conn., said during the virtual annual meeting of the American Academy of Dermatology. “New studies are coming out daily. Due to the need for rapid dissemination, a lot of the studies are case reports, but there are some nice case series. Another caveat for the literature is that a lot of these cases were not necessarily confirmed with testing for SARS-CoV-2, but some were.”

Dr. Ko framed her remarks largely on a case collection survey of images and clinical data from 375 patients in Spain with suspected or confirmed COVID-19 that was published online April 29, 2020, in the British Journal of Dermatology (doi: 10.1111/bjd.19163). Cutaneous manifestations included early vesicular eruptions mainly on the trunk or limbs (9%), maculopapular (47%) to urticarial lesions (19%) mainly on the trunk, and acral areas of erythema sometimes with vesicles or erosion (perniosis-like) (19%) that seemed to be a later manifestation of COVID-19. Retiform purpura or necrosis (6%) was most concerning in terms of skin disease, with an associated with a mortality of 10%.

On histology, the early vesicular eruptions are typically marked by dyskeratotic keratinocytes, Dr. Ko said, while urticarial lesions are characterized by a mixed dermal infiltrate; maculopapular lesions were a broad category. “There are some case reports that show spongiotic dermatitis or parakeratosis with a lymphocytic infiltrate,” she said. “A caveat to keep in mind is that, although these patients may definitely have COVID-19 and be confirmed to have it by testing, hypersensitivity reactions may be due to the multiple medications they’re on.”

Patients can develop a spectrum of lesions that are suggestive of vascular damage or occlusion, Dr. Ko continued. Livedoid lesions may remain static and not eventuate into necrosis or purpura but will self-resolve. Purpuric lesions and acral gangrene have been described, and these lesions correspond to vascular occlusion on biopsy.

A later manifestation are the so-called “COVID toes” with a superficial and deep lymphocytic infiltrate, as published June 1, 2020, in JAAD Case Reports: (doi: 10.1016/j.jdcr.2020.04.011).

“There are patients in the literature that have slightly different pathology, with lymphocytic inflammation as well as occlusion of vessels,” Dr. Ko said. A paper published June 20, 2020, in the British Journal of Dermatology used immunohistochemical staining against the SARS-CoV-2 spike protein, and biopsies of “COVID toes” had positive staining of endothelial cells, supporting the notion that “COVID toes” are a direct manifestation of viral infection (doi: 10.1111/bjd.19327).

“There’s a lot that we still don’t know, and some patterns are going to be outliers,” Dr. Ko concluded. “[As for] determining which skin manifestations are directly from coronavirus infection within the skin, more study is needed and likely time will tell.” She reported having no financial disclosures relevant to her talk.

[email protected]

There are at least five dermatologic patterns in patients who are suspected or confirmed of having COVID-19, and the knowledge base continues to evolve, according to Christine Ko, MD.

“Things are very fluid,” Dr. Ko, professor of dermatology and pathology at Yale University, New Haven, Conn., said during the virtual annual meeting of the American Academy of Dermatology. “New studies are coming out daily. Due to the need for rapid dissemination, a lot of the studies are case reports, but there are some nice case series. Another caveat for the literature is that a lot of these cases were not necessarily confirmed with testing for SARS-CoV-2, but some were.”

Dr. Ko framed her remarks largely on a case collection survey of images and clinical data from 375 patients in Spain with suspected or confirmed COVID-19 that was published online April 29, 2020, in the British Journal of Dermatology (doi: 10.1111/bjd.19163). Cutaneous manifestations included early vesicular eruptions mainly on the trunk or limbs (9%), maculopapular (47%) to urticarial lesions (19%) mainly on the trunk, and acral areas of erythema sometimes with vesicles or erosion (perniosis-like) (19%) that seemed to be a later manifestation of COVID-19. Retiform purpura or necrosis (6%) was most concerning in terms of skin disease, with an associated with a mortality of 10%.

On histology, the early vesicular eruptions are typically marked by dyskeratotic keratinocytes, Dr. Ko said, while urticarial lesions are characterized by a mixed dermal infiltrate; maculopapular lesions were a broad category. “There are some case reports that show spongiotic dermatitis or parakeratosis with a lymphocytic infiltrate,” she said. “A caveat to keep in mind is that, although these patients may definitely have COVID-19 and be confirmed to have it by testing, hypersensitivity reactions may be due to the multiple medications they’re on.”

Patients can develop a spectrum of lesions that are suggestive of vascular damage or occlusion, Dr. Ko continued. Livedoid lesions may remain static and not eventuate into necrosis or purpura but will self-resolve. Purpuric lesions and acral gangrene have been described, and these lesions correspond to vascular occlusion on biopsy.

A later manifestation are the so-called “COVID toes” with a superficial and deep lymphocytic infiltrate, as published June 1, 2020, in JAAD Case Reports: (doi: 10.1016/j.jdcr.2020.04.011).

“There are patients in the literature that have slightly different pathology, with lymphocytic inflammation as well as occlusion of vessels,” Dr. Ko said. A paper published June 20, 2020, in the British Journal of Dermatology used immunohistochemical staining against the SARS-CoV-2 spike protein, and biopsies of “COVID toes” had positive staining of endothelial cells, supporting the notion that “COVID toes” are a direct manifestation of viral infection (doi: 10.1111/bjd.19327).

“There’s a lot that we still don’t know, and some patterns are going to be outliers,” Dr. Ko concluded. “[As for] determining which skin manifestations are directly from coronavirus infection within the skin, more study is needed and likely time will tell.” She reported having no financial disclosures relevant to her talk.

[email protected]

There are at least five dermatologic patterns in patients who are suspected or confirmed of having COVID-19, and the knowledge base continues to evolve, according to Christine Ko, MD.

“Things are very fluid,” Dr. Ko, professor of dermatology and pathology at Yale University, New Haven, Conn., said during the virtual annual meeting of the American Academy of Dermatology. “New studies are coming out daily. Due to the need for rapid dissemination, a lot of the studies are case reports, but there are some nice case series. Another caveat for the literature is that a lot of these cases were not necessarily confirmed with testing for SARS-CoV-2, but some were.”

Dr. Ko framed her remarks largely on a case collection survey of images and clinical data from 375 patients in Spain with suspected or confirmed COVID-19 that was published online April 29, 2020, in the British Journal of Dermatology (doi: 10.1111/bjd.19163). Cutaneous manifestations included early vesicular eruptions mainly on the trunk or limbs (9%), maculopapular (47%) to urticarial lesions (19%) mainly on the trunk, and acral areas of erythema sometimes with vesicles or erosion (perniosis-like) (19%) that seemed to be a later manifestation of COVID-19. Retiform purpura or necrosis (6%) was most concerning in terms of skin disease, with an associated with a mortality of 10%.

On histology, the early vesicular eruptions are typically marked by dyskeratotic keratinocytes, Dr. Ko said, while urticarial lesions are characterized by a mixed dermal infiltrate; maculopapular lesions were a broad category. “There are some case reports that show spongiotic dermatitis or parakeratosis with a lymphocytic infiltrate,” she said. “A caveat to keep in mind is that, although these patients may definitely have COVID-19 and be confirmed to have it by testing, hypersensitivity reactions may be due to the multiple medications they’re on.”

Patients can develop a spectrum of lesions that are suggestive of vascular damage or occlusion, Dr. Ko continued. Livedoid lesions may remain static and not eventuate into necrosis or purpura but will self-resolve. Purpuric lesions and acral gangrene have been described, and these lesions correspond to vascular occlusion on biopsy.

A later manifestation are the so-called “COVID toes” with a superficial and deep lymphocytic infiltrate, as published June 1, 2020, in JAAD Case Reports: (doi: 10.1016/j.jdcr.2020.04.011).

“There are patients in the literature that have slightly different pathology, with lymphocytic inflammation as well as occlusion of vessels,” Dr. Ko said. A paper published June 20, 2020, in the British Journal of Dermatology used immunohistochemical staining against the SARS-CoV-2 spike protein, and biopsies of “COVID toes” had positive staining of endothelial cells, supporting the notion that “COVID toes” are a direct manifestation of viral infection (doi: 10.1111/bjd.19327).

“There’s a lot that we still don’t know, and some patterns are going to be outliers,” Dr. Ko concluded. “[As for] determining which skin manifestations are directly from coronavirus infection within the skin, more study is needed and likely time will tell.” She reported having no financial disclosures relevant to her talk.

[email protected]

Here are the stories our MDedge editors across specialties think you need to know about today:

Ignored by doctors, transgender patients turn to DIY treatments

Without access to quality medical care, trans people around the world are seeking hormones from friends or through illegal online markets, even when the cost exceeds what it would through insurance. Although rare, others are resorting to self-surgery by cutting off their own penis and testicles or breasts.

ACIP plans priority groups in advance of COVID-19 vaccine

Early plans for prioritizing vaccination when a COVID-19 vaccine becomes available include placing critical health care workers in the first tier, according to Sarah Mbaeyi, MD, MPH, of the CDC’s National Center for Immunization and Respiratory Diseases.

A COVID-19 vaccine work group is developing strategies and identifying priority groups for vaccination to help inform discussions about the use of COVID-19 vaccines, Dr. Mbaeyi said at a virtual meeting of the CDC’s Advisory Committee on Immunization Practices.

Based on current information, the work group has proposed that vaccine priority be given to health care personnel, essential workers, adults aged 65 years and older, long-term care facility residents, and persons with high-risk medical conditions.

Among these groups “a subset of critical health care and other workers should receive initial doses,” Dr. Mbaeyi said. Read more.

‘Nietzsche was wrong’: Past stressors do not create psychological resilience.

The famous quote from the German philosopher Friedrich Nietzsche, “That which does not kill us makes us stronger,” may not be true after all – at least when it comes to mental health.

Results of a new study show that individuals who have a history of a stressful life events are more likely to develop PTSD and/or major depressive disorder (MDD) following a major natural disaster than their counterparts who do not have such a history.

The investigation of more than a thousand Chilean residents – all of whom experienced one of the most powerful earthquakes in the country’s history – showed that the odds of developing postdisaster PTSD or MDD increased according to the number of predisaster stressors participants had experienced.

“At the clinical level, these findings help the clinician know which patients are more likely to need more intensive services,” said Stephen L. Buka, PhD. “And the more trauma and hardship they’ve experienced, the more attention they need and the less likely they’re going to be able to cope and manage on their own.” Read more.

High-impact training can build bone in older women

Older adults, particularly postmenopausal women, are often advised to pursue low-impact, low-intensity exercise as a way to preserve joint health, but that approach might actually contribute to a decline in bone mineral density, researchers report. 

Concerns about falls and fracture risk have led many clinicians to advise against higher-impact activities, like jumping, but that is exactly the type of activity that improves bone density and physical function, said Belinda Beck, PhD, professor at the Griffith University School of Allied Health Sciences in Southport, Australia. But new findings show that high-intensity resistance and impact training was a safe and effective way to improve bone mass.

“Once women hit 60, they’re somehow regarded as frail, but that becomes a self-fulfilling prophecy when we take this kinder, gentler approach to exercise,” said Vanessa Yingling, PhD. Read more.

For more on COVID-19, visit our Resource Center. All of our latest news is available on MDedge.com.






 

Here are the stories our MDedge editors across specialties think you need to know about today:

Ignored by doctors, transgender patients turn to DIY treatments

Without access to quality medical care, trans people around the world are seeking hormones from friends or through illegal online markets, even when the cost exceeds what it would through insurance. Although rare, others are resorting to self-surgery by cutting off their own penis and testicles or breasts.

ACIP plans priority groups in advance of COVID-19 vaccine

Early plans for prioritizing vaccination when a COVID-19 vaccine becomes available include placing critical health care workers in the first tier, according to Sarah Mbaeyi, MD, MPH, of the CDC’s National Center for Immunization and Respiratory Diseases.

A COVID-19 vaccine work group is developing strategies and identifying priority groups for vaccination to help inform discussions about the use of COVID-19 vaccines, Dr. Mbaeyi said at a virtual meeting of the CDC’s Advisory Committee on Immunization Practices.

Based on current information, the work group has proposed that vaccine priority be given to health care personnel, essential workers, adults aged 65 years and older, long-term care facility residents, and persons with high-risk medical conditions.

Among these groups “a subset of critical health care and other workers should receive initial doses,” Dr. Mbaeyi said. Read more.

‘Nietzsche was wrong’: Past stressors do not create psychological resilience.

The famous quote from the German philosopher Friedrich Nietzsche, “That which does not kill us makes us stronger,” may not be true after all – at least when it comes to mental health.

Results of a new study show that individuals who have a history of a stressful life events are more likely to develop PTSD and/or major depressive disorder (MDD) following a major natural disaster than their counterparts who do not have such a history.

The investigation of more than a thousand Chilean residents – all of whom experienced one of the most powerful earthquakes in the country’s history – showed that the odds of developing postdisaster PTSD or MDD increased according to the number of predisaster stressors participants had experienced.

“At the clinical level, these findings help the clinician know which patients are more likely to need more intensive services,” said Stephen L. Buka, PhD. “And the more trauma and hardship they’ve experienced, the more attention they need and the less likely they’re going to be able to cope and manage on their own.” Read more.

High-impact training can build bone in older women

Older adults, particularly postmenopausal women, are often advised to pursue low-impact, low-intensity exercise as a way to preserve joint health, but that approach might actually contribute to a decline in bone mineral density, researchers report. 

Concerns about falls and fracture risk have led many clinicians to advise against higher-impact activities, like jumping, but that is exactly the type of activity that improves bone density and physical function, said Belinda Beck, PhD, professor at the Griffith University School of Allied Health Sciences in Southport, Australia. But new findings show that high-intensity resistance and impact training was a safe and effective way to improve bone mass.

“Once women hit 60, they’re somehow regarded as frail, but that becomes a self-fulfilling prophecy when we take this kinder, gentler approach to exercise,” said Vanessa Yingling, PhD. Read more.

For more on COVID-19, visit our Resource Center. All of our latest news is available on MDedge.com.






 

Here are the stories our MDedge editors across specialties think you need to know about today:

Ignored by doctors, transgender patients turn to DIY treatments

Without access to quality medical care, trans people around the world are seeking hormones from friends or through illegal online markets, even when the cost exceeds what it would through insurance. Although rare, others are resorting to self-surgery by cutting off their own penis and testicles or breasts.

ACIP plans priority groups in advance of COVID-19 vaccine

Early plans for prioritizing vaccination when a COVID-19 vaccine becomes available include placing critical health care workers in the first tier, according to Sarah Mbaeyi, MD, MPH, of the CDC’s National Center for Immunization and Respiratory Diseases.

A COVID-19 vaccine work group is developing strategies and identifying priority groups for vaccination to help inform discussions about the use of COVID-19 vaccines, Dr. Mbaeyi said at a virtual meeting of the CDC’s Advisory Committee on Immunization Practices.

Based on current information, the work group has proposed that vaccine priority be given to health care personnel, essential workers, adults aged 65 years and older, long-term care facility residents, and persons with high-risk medical conditions.

Among these groups “a subset of critical health care and other workers should receive initial doses,” Dr. Mbaeyi said. Read more.

‘Nietzsche was wrong’: Past stressors do not create psychological resilience.

The famous quote from the German philosopher Friedrich Nietzsche, “That which does not kill us makes us stronger,” may not be true after all – at least when it comes to mental health.

Results of a new study show that individuals who have a history of a stressful life events are more likely to develop PTSD and/or major depressive disorder (MDD) following a major natural disaster than their counterparts who do not have such a history.

The investigation of more than a thousand Chilean residents – all of whom experienced one of the most powerful earthquakes in the country’s history – showed that the odds of developing postdisaster PTSD or MDD increased according to the number of predisaster stressors participants had experienced.

“At the clinical level, these findings help the clinician know which patients are more likely to need more intensive services,” said Stephen L. Buka, PhD. “And the more trauma and hardship they’ve experienced, the more attention they need and the less likely they’re going to be able to cope and manage on their own.” Read more.

High-impact training can build bone in older women

Older adults, particularly postmenopausal women, are often advised to pursue low-impact, low-intensity exercise as a way to preserve joint health, but that approach might actually contribute to a decline in bone mineral density, researchers report. 

Concerns about falls and fracture risk have led many clinicians to advise against higher-impact activities, like jumping, but that is exactly the type of activity that improves bone density and physical function, said Belinda Beck, PhD, professor at the Griffith University School of Allied Health Sciences in Southport, Australia. But new findings show that high-intensity resistance and impact training was a safe and effective way to improve bone mass.

“Once women hit 60, they’re somehow regarded as frail, but that becomes a self-fulfilling prophecy when we take this kinder, gentler approach to exercise,” said Vanessa Yingling, PhD. Read more.

For more on COVID-19, visit our Resource Center. All of our latest news is available on MDedge.com.






 

It’s been about two months since I volunteered in a hospital in Brooklyn, working in an ICU taking care of patients with COVID-19. I’m back home in California now but with new perspectives, not only on the pandemic, but on those who are affected by it the most.

Courtesy Dr. Arghavan Salles

Everyone seems to have forgotten the early days of the pandemic – the time when the ICUs were overrun, we were using FEMA ventilators, and endocrinologists and psychiatrists were acting as intensivists.

Even though things are opening up and people are taking summer vacations in a seemingly amnestic state, having witnessed multiple daily deaths remains a part of my daily consciousness. As I see the case numbers climbing juxtaposed against people being out and about without masks, my anxiety level is rising.

A virus doesn’t discriminate. It can fly through the air, landing on the next available surface. If that virus is SARS-CoV-2 and that surface is a human mucosal membrane, the virus makes itself at home. It orders furniture, buys a fancy mattress and a large high definition TV, hangs art on the walls, and settles in for the long haul. It’s not going anywhere anytime soon.

Even as an equal opportunity virus, what SARS-CoV-2 has done is to hold a mirror up to the healthcare system. It has shown us what was here all along. When people first started noticing that underrepresented minorities were more likely to contract the virus and get sick from it, I heard musings that this was likely because of their preexisting health conditions. For example, commentators on cable news were quick to point out that black people are more likely than other people to have hypertension or diabetes. So doesn’t that explain why they are more affected by this virus?

That certainly is part of the story, but it doesn’t entirely explain the discrepancies we’ve seen. For example, in New York 14% of the population is black, and 25% of those who had a COVID-related death were black patients. Similarly, 19% of the population is Hispanic or Latino, and they made up 26% of COVID-related deaths. On the other hand, 55% of the population in New York is white, and white people account for only 34% of COVID-related deaths.

Working in Brooklyn, I didn’t need to be a keen observer to notice that, out of our entire unit of about 20-25 patients, there was only one patient in a 2-week period who was neither black nor Hispanic.

As others have written, there are other factors at play. I’m not sure how many of those commentators back in March stopped to think about why black patients are more likely to have hypertension and diabetes, but the chronic stress of facing racism on a daily basis surely contributes. Beyond those medical problems, minorities are more likely to live in multigenerational housing, which means that it is harder for them to isolate from others. In addition, their living quarters tend to be further from health care centers and grocery stores, which makes it harder for them to access medical care and healthy food.

As if that weren’t enough to put their health at risk, people of color are also affected by environmental racism . Factories with toxic waste are more likely to be built in or near neighborhoods filled with people of color than in other communities. On top of that, black and Hispanic people are also more likely to be under- or uninsured, meaning they often delay seeking care in order to avoid astronomic healthcare costs.

Black and Hispanic people are also more likely than others to be working in the service industry or other essential services, which means they are less likely to be able to work from home. Consequently, they have to risk more exposures to other people and the virus than do those who have the privilege of working safely from home. They also are less likely to have available paid leave and, therefore, are more likely to work while sick.

With the deck completely stacked against them, underrepresented minorities also face systemic bias and racism when interacting with the health care system. Physicians mistakenly believe black patients experience less pain than other patients, according to some research. Black mothers have significantly worse health care outcomes than do their non-black counterparts, and the infant mortality rate for Black infants is much higher as well.

Dr. Salles is a bariatric surgeon and is currently a Scholar in Residence at Stanford (Calif.) University. Find her on Twitter @arghavan_salles.

It’s been about two months since I volunteered in a hospital in Brooklyn, working in an ICU taking care of patients with COVID-19. I’m back home in California now but with new perspectives, not only on the pandemic, but on those who are affected by it the most.

Courtesy Dr. Arghavan Salles

Everyone seems to have forgotten the early days of the pandemic – the time when the ICUs were overrun, we were using FEMA ventilators, and endocrinologists and psychiatrists were acting as intensivists.

Even though things are opening up and people are taking summer vacations in a seemingly amnestic state, having witnessed multiple daily deaths remains a part of my daily consciousness. As I see the case numbers climbing juxtaposed against people being out and about without masks, my anxiety level is rising.

A virus doesn’t discriminate. It can fly through the air, landing on the next available surface. If that virus is SARS-CoV-2 and that surface is a human mucosal membrane, the virus makes itself at home. It orders furniture, buys a fancy mattress and a large high definition TV, hangs art on the walls, and settles in for the long haul. It’s not going anywhere anytime soon.

Even as an equal opportunity virus, what SARS-CoV-2 has done is to hold a mirror up to the healthcare system. It has shown us what was here all along. When people first started noticing that underrepresented minorities were more likely to contract the virus and get sick from it, I heard musings that this was likely because of their preexisting health conditions. For example, commentators on cable news were quick to point out that black people are more likely than other people to have hypertension or diabetes. So doesn’t that explain why they are more affected by this virus?

That certainly is part of the story, but it doesn’t entirely explain the discrepancies we’ve seen. For example, in New York 14% of the population is black, and 25% of those who had a COVID-related death were black patients. Similarly, 19% of the population is Hispanic or Latino, and they made up 26% of COVID-related deaths. On the other hand, 55% of the population in New York is white, and white people account for only 34% of COVID-related deaths.

Working in Brooklyn, I didn’t need to be a keen observer to notice that, out of our entire unit of about 20-25 patients, there was only one patient in a 2-week period who was neither black nor Hispanic.

As others have written, there are other factors at play. I’m not sure how many of those commentators back in March stopped to think about why black patients are more likely to have hypertension and diabetes, but the chronic stress of facing racism on a daily basis surely contributes. Beyond those medical problems, minorities are more likely to live in multigenerational housing, which means that it is harder for them to isolate from others. In addition, their living quarters tend to be further from health care centers and grocery stores, which makes it harder for them to access medical care and healthy food.

As if that weren’t enough to put their health at risk, people of color are also affected by environmental racism . Factories with toxic waste are more likely to be built in or near neighborhoods filled with people of color than in other communities. On top of that, black and Hispanic people are also more likely to be under- or uninsured, meaning they often delay seeking care in order to avoid astronomic healthcare costs.

Black and Hispanic people are also more likely than others to be working in the service industry or other essential services, which means they are less likely to be able to work from home. Consequently, they have to risk more exposures to other people and the virus than do those who have the privilege of working safely from home. They also are less likely to have available paid leave and, therefore, are more likely to work while sick.

With the deck completely stacked against them, underrepresented minorities also face systemic bias and racism when interacting with the health care system. Physicians mistakenly believe black patients experience less pain than other patients, according to some research. Black mothers have significantly worse health care outcomes than do their non-black counterparts, and the infant mortality rate for Black infants is much higher as well.

Dr. Salles is a bariatric surgeon and is currently a Scholar in Residence at Stanford (Calif.) University. Find her on Twitter @arghavan_salles.

It’s been about two months since I volunteered in a hospital in Brooklyn, working in an ICU taking care of patients with COVID-19. I’m back home in California now but with new perspectives, not only on the pandemic, but on those who are affected by it the most.

Courtesy Dr. Arghavan Salles

Everyone seems to have forgotten the early days of the pandemic – the time when the ICUs were overrun, we were using FEMA ventilators, and endocrinologists and psychiatrists were acting as intensivists.

Even though things are opening up and people are taking summer vacations in a seemingly amnestic state, having witnessed multiple daily deaths remains a part of my daily consciousness. As I see the case numbers climbing juxtaposed against people being out and about without masks, my anxiety level is rising.

A virus doesn’t discriminate. It can fly through the air, landing on the next available surface. If that virus is SARS-CoV-2 and that surface is a human mucosal membrane, the virus makes itself at home. It orders furniture, buys a fancy mattress and a large high definition TV, hangs art on the walls, and settles in for the long haul. It’s not going anywhere anytime soon.

Even as an equal opportunity virus, what SARS-CoV-2 has done is to hold a mirror up to the healthcare system. It has shown us what was here all along. When people first started noticing that underrepresented minorities were more likely to contract the virus and get sick from it, I heard musings that this was likely because of their preexisting health conditions. For example, commentators on cable news were quick to point out that black people are more likely than other people to have hypertension or diabetes. So doesn’t that explain why they are more affected by this virus?

That certainly is part of the story, but it doesn’t entirely explain the discrepancies we’ve seen. For example, in New York 14% of the population is black, and 25% of those who had a COVID-related death were black patients. Similarly, 19% of the population is Hispanic or Latino, and they made up 26% of COVID-related deaths. On the other hand, 55% of the population in New York is white, and white people account for only 34% of COVID-related deaths.

Working in Brooklyn, I didn’t need to be a keen observer to notice that, out of our entire unit of about 20-25 patients, there was only one patient in a 2-week period who was neither black nor Hispanic.

As others have written, there are other factors at play. I’m not sure how many of those commentators back in March stopped to think about why black patients are more likely to have hypertension and diabetes, but the chronic stress of facing racism on a daily basis surely contributes. Beyond those medical problems, minorities are more likely to live in multigenerational housing, which means that it is harder for them to isolate from others. In addition, their living quarters tend to be further from health care centers and grocery stores, which makes it harder for them to access medical care and healthy food.

As if that weren’t enough to put their health at risk, people of color are also affected by environmental racism . Factories with toxic waste are more likely to be built in or near neighborhoods filled with people of color than in other communities. On top of that, black and Hispanic people are also more likely to be under- or uninsured, meaning they often delay seeking care in order to avoid astronomic healthcare costs.

Black and Hispanic people are also more likely than others to be working in the service industry or other essential services, which means they are less likely to be able to work from home. Consequently, they have to risk more exposures to other people and the virus than do those who have the privilege of working safely from home. They also are less likely to have available paid leave and, therefore, are more likely to work while sick.

With the deck completely stacked against them, underrepresented minorities also face systemic bias and racism when interacting with the health care system. Physicians mistakenly believe black patients experience less pain than other patients, according to some research. Black mothers have significantly worse health care outcomes than do their non-black counterparts, and the infant mortality rate for Black infants is much higher as well.

Dr. Salles is a bariatric surgeon and is currently a Scholar in Residence at Stanford (Calif.) University. Find her on Twitter @arghavan_salles.

For the first 10 months of Christine’s gender transition, a progressive LGBT health clinic in Boston made getting on hormones easy. But after a year or so on estrogen and a testosterone-blocker, she found herself in financial trouble. She had just recently moved to the city, where she was unable to find a job, and her savings were starting to wear thin.

Finding employment as a transgender person, she says, was overwhelmingly difficult: “I was turned down for more jobs than I can count — 20 or 40 different positions in a couple of months.” She would land an interview, then wouldn’t hear back, she says, which she suspects happened because the company noticed she was “not like their other potential hires.”

Christine, a transgender woman, had been enrolled in the state’s Medicaid program, MassHealth, for four months, and her copay for hormone therapy was only $5. But without a job, she found herself torn between food, rent, and medication. For a while, she juggled all three expenses with donations from friends. But after several months, she felt guilty about asking for help and stopped treatment. (Undark has agreed to use only Christine's chosen name because she said she feared both online and in-person harassment for sharing her story.)

At first, Christine didn’t mind being off hormones. She marched in political protests alongside older trans people who assured her that starting and stopping hormones was a normal part of the trans experience. But eventually, Christine felt her body reverting back to the way it had been before her transition; her chest flattened and her fat moved from her hips to her stomach. She stopped wearing dresses and makeup.

“I wasn't looking at myself in the mirror anymore,” she says. “I existed for 10 months, and then I was gone.”

People who are visibly transgender often have trouble finding a job. Nearly a third live in poverty. Many don’t have health insurance, and those who do may have a plan that doesn’t cover hormones. Although testosterone and estrogen only cost $5 to $30 a month for patients with an insurance plan (and typically less than $100 per month for the uninsured), doctors often require consistent therapy and blood work, which ratchets up the cost. Even when trans people have the money, finding doctors willing to treat them can prove impossible. Trans people are also likely to have had bad experiences with the health care system and want to avoid it altogether.

Without access to quality medical care, trans people around the world are seeking hormones from friends or through illegal online markets, even when the cost exceeds what it would through insurance. Although rare, others are resorting to self-surgery by cutting off their own penis and testicles or breasts.

Even with a doctor’s oversight, the health risks of transgender hormone therapy remain unclear, but without formal medical care, the do-it-yourself transition may be downright dangerous. To minimize these risks, some experts suggest health care reforms such as making it easier for primary care physicians to assess trans patients and prescribe hormones or creating specialized clinics where doctors prescribe hormones on demand.

But those solutions aren’t available to most people who are seeking DIY treatments right now. Many doctors aren’t even aware that DIY transitioning exists, although the few experts who are following the community aren’t surprised. Self-treatment is “the reality for most trans people in the world,” says Ayden Scheim, an epidemiologist focusing on transgender health at Drexel University who is trans himself.

While there isn’t a lot of other existing research on DIY hormone treatment, and some of it may be outdated, the available studies suggest it is fairly common and researchers may in fact be underestimating the prevalence of DIY hormone use because they miss people who avoid the medical system completely. In 2014, researchers in the U.K. found that at the time of their first gender clinic visit, 17 percent of transgender people were already taking hormones that they had bought online or from a friend. In Canada, a quarter of trans people on hormones had self-medicated, according to a 2013 study in the American Journal of Public Health. And in a survey of trans people in Washington, D.C. in 2000, 58 percent said they used non-prescribed hormones.

People cite all sorts of reasons for ordering the drugs online or acquiring them by other means. In addition to distrust of doctors and a lack of insurance or access to health care, some simply don’t want to endure long waits for medications. That’s the case for Emma, a trans woman in college in the Netherlands, where it can take two to three years to receive a physician prescription. (Emma is only using her first name to avoid online harassment, which she says she’s experienced in the past.)

As for surgery, far fewer people turn to DIY versions compared to those who try hormones. A 2012 study in the Journal of Sexual Medicine reported that only 109 cases of self-castration or self-mutilation of the genitals appear in the scientific literature, and not all are related to gender identity. “But one is too many,” Scheim says. “No one should be in a position where they feel like they need to do that.”

The individual cases reveal a practice that is dangerous and devastating. In Hangzhou, China, a 30-year-old transgender woman feared rejection from her family, so she hid her true gender, according to a 2019 Amnesty International report. She also tried to transition in secret. At first, the woman tried putting ice on her genitals to stop them from functioning. When that didn’t work, she booked an appointment with a black-market surgeon, but the doctor was arrested before her session. She attempted surgery on herself, the report says, and after losing a profuse amount of blood, hailed a taxi to the emergency room. There, she asked the doctor to tell her family she had been in an accident.

When it comes to self-surgery, the dangers of DIY transitioning are obvious. The dangers of DIY hormones are more far-ranging, from “not ideal to serious,” Scheim says. Some DIY users take a more-is-better approach, but taking too much testosterone too quickly can fry the vocal cords. Even buying hormones from an online pharmacy is risky. In 2010, more than half of all treatments from illicit websites — not only of hormones, but of any drug — were counterfeit, according to a bulletin from the World Health Organization.

Still, Charley isn’t worried about the legitimacy of the drugs he’s taking. The packaging his estrogen comes in matches what he would get from a pharmacy with a doctor’s prescription, he says. He’s also unconcerned about the side effects. “I just did a metric century” — a 100-kilometer bike ride — “in under four hours and walked away from it feeling great. I’m healthy,” he says. “So, yeah, there might be a few side effects. But I know where the local hospital is.”

Yet waiting to see if a seemingly minor side effect leads to a health emergency may mean a patient gets help too late. “I don’t want to say that the risks are incredibly high and there is a high mortality,” Metastasio says. “I am saying, though, that this is a procedure best to be monitored.” Metastasio and others recommend seeing a doctor regularly to catch any health issues that arise as quickly as possible.

But even when doctors prescribe the drugs, the risks are unclear because of a lack of research on trans health, says Scheim: “There’s so much we don’t know about hormone use.”

Researchers do know a little bit, though. Even when a doctor weighs in on the proper dosages, there is an increased risk of heart attack. Taking testosterone increases the chances of developing acne, headaches and migraines, and anger and irritability, according to the Trans Care Project, a program of the Transcend Transgender Support and Education Society and Vancouver Coastal Health’s Transgender Health Program in Canada. Testosterone also increases the risk of having abnormally high levels of red blood cells, or polycythemia, which thickens the blood and can lead to clotting. Meanwhile, studies suggest estrogen can up the risk for breast cancer, stroke, blood clots, gallstones, and a range of heart issues. And the most common testosterone-blocker, spironolactone, can cause dehydration and weaken the kidneys.

All of these risks make it especially important for trans people to have the support of a medical provider, Metastasio says. Specialists are in short supply, but general practitioners and family doctors should be able to fill the gap. After all, they already sign off on the hormone medications for cisgender people for birth control and conditions such as menopause and male pattern baldness — which come with similar side effects and warnings as when trans people use them.

Some doctors have already realized the connection. “People can increasingly get hormone therapy from their pre-existing family doctor,” Scheim says, “which is really ideal because people should be able to have a sort of continuity of health care.”

Zil Goldstein, associate medical director for transgender and gender non-binary health at the Callen-Lorde Community Health Center in New York City, would like to see more of this. Treating gender dysphoria, she says, should be just like treating a patient for any other condition. “It wouldn't be acceptable for someone to come into a primary care provider’s office with diabetes” and for the doctor to say “‘I can't actually treat you. Please leave,’” she says. Primary care providers need to see transgender care, she adds, “as a regular part of their practice.”

Another way to increase access to hormones is through informed consent, a system which received a green light from the newest WPATH guidelines. That’s how Christine received her hormones from Fenway Health before she moved from Boston to Cape Cod. Under informed consent, if someone has a blood test to assess personal health risks of treatment, they can receive a diagnosis of gender dysphoria, sign off on knowing the risks and benefits of hormone therapy, and get a prescription — all in one day.

And Jaime Lynn Gilmour, a trans woman using the full name she chose to match her gender identity, turned to informed consent after struggling to find DIY hormones. In 2017, Jaime realized she was trans while serving in the military, and says she felt she had to keep her gender a secret. When her service ended, she was ready to start taking hormones right away. So she tried to find them online, but her order wouldn’t go through on three different websites. Instead, she visited a Planned Parenthood clinic. After blood work and a few questions, she walked out with three months of estrogen and spironolactone.

But Goldstein says even informed consent doesn’t go far enough: “If I have someone who's diabetic, I don't make them sign a document eliciting their informed consent before starting insulin.”

For trans people, hormone treatments “are life-saving therapies,” Goldstein adds, “and we shouldn’t delay or stigmatize.”

For now Christine still lives with her parents in Cape Cod. She’s also still off hormones. But she found a job. After she stashes a bit more cash in the bank, she plans to move closer to Boston and find a physician.

Despite the positive shifts in her life, it’s been a difficult few months. After moving to Cape Cod, Christine lost most of her social life and support system — particularly since her parents don’t understand or accept her gender identity. Though she has reconnected with a few friends in the past several weeks, she says she’s in a tough place emotionally. In public, she typically dresses and styles herself to look more masculine to avoid rude stares, and she is experiencing self-hatred that she fears won’t go away when she restarts treatment. Transitioning again isn’t going to be easy, as she explained to Undark in a private message on Facebook: “I've been beaten down enough that now I don't wanna get back up most of the time.”

Even worse is the fear that she might not be able to restart treatment at all. Earlier this year, Christine suffered two health emergencies within the span of a week, in which she says her blood pressure spiked, potentially causing organ damage. Christine has had one similar episode in the past and her family has a history of heart issues.

Christine may not be able to get back on estrogen despite the hard work she’s done to be able to afford it, she says, since it can increase the risk of heart attack and stroke. Because she has so far resisted trying DIY treatments again, she may have saved herself from additional health problems.

But Christine doesn’t see it that way. “Even if it was unsafe, even if I risked health concerns making myself a guinea pig, I wish I followed through,” she wrote. “Being off hormones is hell. And now that I face potentially never taking them again, I wish I had.”

Tara Santora is a science journalist based out of Denver. They have written for Psychology Today, Live Science, Fatherly, Audubon, and more.

This article was originally published on Undark. Read the original article.

For the first 10 months of Christine’s gender transition, a progressive LGBT health clinic in Boston made getting on hormones easy. But after a year or so on estrogen and a testosterone-blocker, she found herself in financial trouble. She had just recently moved to the city, where she was unable to find a job, and her savings were starting to wear thin.

Finding employment as a transgender person, she says, was overwhelmingly difficult: “I was turned down for more jobs than I can count — 20 or 40 different positions in a couple of months.” She would land an interview, then wouldn’t hear back, she says, which she suspects happened because the company noticed she was “not like their other potential hires.”

Christine, a transgender woman, had been enrolled in the state’s Medicaid program, MassHealth, for four months, and her copay for hormone therapy was only $5. But without a job, she found herself torn between food, rent, and medication. For a while, she juggled all three expenses with donations from friends. But after several months, she felt guilty about asking for help and stopped treatment. (Undark has agreed to use only Christine's chosen name because she said she feared both online and in-person harassment for sharing her story.)

At first, Christine didn’t mind being off hormones. She marched in political protests alongside older trans people who assured her that starting and stopping hormones was a normal part of the trans experience. But eventually, Christine felt her body reverting back to the way it had been before her transition; her chest flattened and her fat moved from her hips to her stomach. She stopped wearing dresses and makeup.

“I wasn't looking at myself in the mirror anymore,” she says. “I existed for 10 months, and then I was gone.”

People who are visibly transgender often have trouble finding a job. Nearly a third live in poverty. Many don’t have health insurance, and those who do may have a plan that doesn’t cover hormones. Although testosterone and estrogen only cost $5 to $30 a month for patients with an insurance plan (and typically less than $100 per month for the uninsured), doctors often require consistent therapy and blood work, which ratchets up the cost. Even when trans people have the money, finding doctors willing to treat them can prove impossible. Trans people are also likely to have had bad experiences with the health care system and want to avoid it altogether.

Without access to quality medical care, trans people around the world are seeking hormones from friends or through illegal online markets, even when the cost exceeds what it would through insurance. Although rare, others are resorting to self-surgery by cutting off their own penis and testicles or breasts.

Even with a doctor’s oversight, the health risks of transgender hormone therapy remain unclear, but without formal medical care, the do-it-yourself transition may be downright dangerous. To minimize these risks, some experts suggest health care reforms such as making it easier for primary care physicians to assess trans patients and prescribe hormones or creating specialized clinics where doctors prescribe hormones on demand.

But those solutions aren’t available to most people who are seeking DIY treatments right now. Many doctors aren’t even aware that DIY transitioning exists, although the few experts who are following the community aren’t surprised. Self-treatment is “the reality for most trans people in the world,” says Ayden Scheim, an epidemiologist focusing on transgender health at Drexel University who is trans himself.

While there isn’t a lot of other existing research on DIY hormone treatment, and some of it may be outdated, the available studies suggest it is fairly common and researchers may in fact be underestimating the prevalence of DIY hormone use because they miss people who avoid the medical system completely. In 2014, researchers in the U.K. found that at the time of their first gender clinic visit, 17 percent of transgender people were already taking hormones that they had bought online or from a friend. In Canada, a quarter of trans people on hormones had self-medicated, according to a 2013 study in the American Journal of Public Health. And in a survey of trans people in Washington, D.C. in 2000, 58 percent said they used non-prescribed hormones.

People cite all sorts of reasons for ordering the drugs online or acquiring them by other means. In addition to distrust of doctors and a lack of insurance or access to health care, some simply don’t want to endure long waits for medications. That’s the case for Emma, a trans woman in college in the Netherlands, where it can take two to three years to receive a physician prescription. (Emma is only using her first name to avoid online harassment, which she says she’s experienced in the past.)

As for surgery, far fewer people turn to DIY versions compared to those who try hormones. A 2012 study in the Journal of Sexual Medicine reported that only 109 cases of self-castration or self-mutilation of the genitals appear in the scientific literature, and not all are related to gender identity. “But one is too many,” Scheim says. “No one should be in a position where they feel like they need to do that.”

The individual cases reveal a practice that is dangerous and devastating. In Hangzhou, China, a 30-year-old transgender woman feared rejection from her family, so she hid her true gender, according to a 2019 Amnesty International report. She also tried to transition in secret. At first, the woman tried putting ice on her genitals to stop them from functioning. When that didn’t work, she booked an appointment with a black-market surgeon, but the doctor was arrested before her session. She attempted surgery on herself, the report says, and after losing a profuse amount of blood, hailed a taxi to the emergency room. There, she asked the doctor to tell her family she had been in an accident.

When it comes to self-surgery, the dangers of DIY transitioning are obvious. The dangers of DIY hormones are more far-ranging, from “not ideal to serious,” Scheim says. Some DIY users take a more-is-better approach, but taking too much testosterone too quickly can fry the vocal cords. Even buying hormones from an online pharmacy is risky. In 2010, more than half of all treatments from illicit websites — not only of hormones, but of any drug — were counterfeit, according to a bulletin from the World Health Organization.

Still, Charley isn’t worried about the legitimacy of the drugs he’s taking. The packaging his estrogen comes in matches what he would get from a pharmacy with a doctor’s prescription, he says. He’s also unconcerned about the side effects. “I just did a metric century” — a 100-kilometer bike ride — “in under four hours and walked away from it feeling great. I’m healthy,” he says. “So, yeah, there might be a few side effects. But I know where the local hospital is.”

Yet waiting to see if a seemingly minor side effect leads to a health emergency may mean a patient gets help too late. “I don’t want to say that the risks are incredibly high and there is a high mortality,” Metastasio says. “I am saying, though, that this is a procedure best to be monitored.” Metastasio and others recommend seeing a doctor regularly to catch any health issues that arise as quickly as possible.

But even when doctors prescribe the drugs, the risks are unclear because of a lack of research on trans health, says Scheim: “There’s so much we don’t know about hormone use.”

Researchers do know a little bit, though. Even when a doctor weighs in on the proper dosages, there is an increased risk of heart attack. Taking testosterone increases the chances of developing acne, headaches and migraines, and anger and irritability, according to the Trans Care Project, a program of the Transcend Transgender Support and Education Society and Vancouver Coastal Health’s Transgender Health Program in Canada. Testosterone also increases the risk of having abnormally high levels of red blood cells, or polycythemia, which thickens the blood and can lead to clotting. Meanwhile, studies suggest estrogen can up the risk for breast cancer, stroke, blood clots, gallstones, and a range of heart issues. And the most common testosterone-blocker, spironolactone, can cause dehydration and weaken the kidneys.

All of these risks make it especially important for trans people to have the support of a medical provider, Metastasio says. Specialists are in short supply, but general practitioners and family doctors should be able to fill the gap. After all, they already sign off on the hormone medications for cisgender people for birth control and conditions such as menopause and male pattern baldness — which come with similar side effects and warnings as when trans people use them.

Some doctors have already realized the connection. “People can increasingly get hormone therapy from their pre-existing family doctor,” Scheim says, “which is really ideal because people should be able to have a sort of continuity of health care.”

Zil Goldstein, associate medical director for transgender and gender non-binary health at the Callen-Lorde Community Health Center in New York City, would like to see more of this. Treating gender dysphoria, she says, should be just like treating a patient for any other condition. “It wouldn't be acceptable for someone to come into a primary care provider’s office with diabetes” and for the doctor to say “‘I can't actually treat you. Please leave,’” she says. Primary care providers need to see transgender care, she adds, “as a regular part of their practice.”

Another way to increase access to hormones is through informed consent, a system which received a green light from the newest WPATH guidelines. That’s how Christine received her hormones from Fenway Health before she moved from Boston to Cape Cod. Under informed consent, if someone has a blood test to assess personal health risks of treatment, they can receive a diagnosis of gender dysphoria, sign off on knowing the risks and benefits of hormone therapy, and get a prescription — all in one day.

And Jaime Lynn Gilmour, a trans woman using the full name she chose to match her gender identity, turned to informed consent after struggling to find DIY hormones. In 2017, Jaime realized she was trans while serving in the military, and says she felt she had to keep her gender a secret. When her service ended, she was ready to start taking hormones right away. So she tried to find them online, but her order wouldn’t go through on three different websites. Instead, she visited a Planned Parenthood clinic. After blood work and a few questions, she walked out with three months of estrogen and spironolactone.

But Goldstein says even informed consent doesn’t go far enough: “If I have someone who's diabetic, I don't make them sign a document eliciting their informed consent before starting insulin.”

For trans people, hormone treatments “are life-saving therapies,” Goldstein adds, “and we shouldn’t delay or stigmatize.”

For now Christine still lives with her parents in Cape Cod. She’s also still off hormones. But she found a job. After she stashes a bit more cash in the bank, she plans to move closer to Boston and find a physician.

Despite the positive shifts in her life, it’s been a difficult few months. After moving to Cape Cod, Christine lost most of her social life and support system — particularly since her parents don’t understand or accept her gender identity. Though she has reconnected with a few friends in the past several weeks, she says she’s in a tough place emotionally. In public, she typically dresses and styles herself to look more masculine to avoid rude stares, and she is experiencing self-hatred that she fears won’t go away when she restarts treatment. Transitioning again isn’t going to be easy, as she explained to Undark in a private message on Facebook: “I've been beaten down enough that now I don't wanna get back up most of the time.”

Even worse is the fear that she might not be able to restart treatment at all. Earlier this year, Christine suffered two health emergencies within the span of a week, in which she says her blood pressure spiked, potentially causing organ damage. Christine has had one similar episode in the past and her family has a history of heart issues.

Christine may not be able to get back on estrogen despite the hard work she’s done to be able to afford it, she says, since it can increase the risk of heart attack and stroke. Because she has so far resisted trying DIY treatments again, she may have saved herself from additional health problems.

But Christine doesn’t see it that way. “Even if it was unsafe, even if I risked health concerns making myself a guinea pig, I wish I followed through,” she wrote. “Being off hormones is hell. And now that I face potentially never taking them again, I wish I had.”

Tara Santora is a science journalist based out of Denver. They have written for Psychology Today, Live Science, Fatherly, Audubon, and more.

This article was originally published on Undark. Read the original article.

For the first 10 months of Christine’s gender transition, a progressive LGBT health clinic in Boston made getting on hormones easy. But after a year or so on estrogen and a testosterone-blocker, she found herself in financial trouble. She had just recently moved to the city, where she was unable to find a job, and her savings were starting to wear thin.

Finding employment as a transgender person, she says, was overwhelmingly difficult: “I was turned down for more jobs than I can count — 20 or 40 different positions in a couple of months.” She would land an interview, then wouldn’t hear back, she says, which she suspects happened because the company noticed she was “not like their other potential hires.”

Christine, a transgender woman, had been enrolled in the state’s Medicaid program, MassHealth, for four months, and her copay for hormone therapy was only $5. But without a job, she found herself torn between food, rent, and medication. For a while, she juggled all three expenses with donations from friends. But after several months, she felt guilty about asking for help and stopped treatment. (Undark has agreed to use only Christine's chosen name because she said she feared both online and in-person harassment for sharing her story.)

At first, Christine didn’t mind being off hormones. She marched in political protests alongside older trans people who assured her that starting and stopping hormones was a normal part of the trans experience. But eventually, Christine felt her body reverting back to the way it had been before her transition; her chest flattened and her fat moved from her hips to her stomach. She stopped wearing dresses and makeup.

“I wasn't looking at myself in the mirror anymore,” she says. “I existed for 10 months, and then I was gone.”

People who are visibly transgender often have trouble finding a job. Nearly a third live in poverty. Many don’t have health insurance, and those who do may have a plan that doesn’t cover hormones. Although testosterone and estrogen only cost $5 to $30 a month for patients with an insurance plan (and typically less than $100 per month for the uninsured), doctors often require consistent therapy and blood work, which ratchets up the cost. Even when trans people have the money, finding doctors willing to treat them can prove impossible. Trans people are also likely to have had bad experiences with the health care system and want to avoid it altogether.

Without access to quality medical care, trans people around the world are seeking hormones from friends or through illegal online markets, even when the cost exceeds what it would through insurance. Although rare, others are resorting to self-surgery by cutting off their own penis and testicles or breasts.

Even with a doctor’s oversight, the health risks of transgender hormone therapy remain unclear, but without formal medical care, the do-it-yourself transition may be downright dangerous. To minimize these risks, some experts suggest health care reforms such as making it easier for primary care physicians to assess trans patients and prescribe hormones or creating specialized clinics where doctors prescribe hormones on demand.

But those solutions aren’t available to most people who are seeking DIY treatments right now. Many doctors aren’t even aware that DIY transitioning exists, although the few experts who are following the community aren’t surprised. Self-treatment is “the reality for most trans people in the world,” says Ayden Scheim, an epidemiologist focusing on transgender health at Drexel University who is trans himself.

While there isn’t a lot of other existing research on DIY hormone treatment, and some of it may be outdated, the available studies suggest it is fairly common and researchers may in fact be underestimating the prevalence of DIY hormone use because they miss people who avoid the medical system completely. In 2014, researchers in the U.K. found that at the time of their first gender clinic visit, 17 percent of transgender people were already taking hormones that they had bought online or from a friend. In Canada, a quarter of trans people on hormones had self-medicated, according to a 2013 study in the American Journal of Public Health. And in a survey of trans people in Washington, D.C. in 2000, 58 percent said they used non-prescribed hormones.

People cite all sorts of reasons for ordering the drugs online or acquiring them by other means. In addition to distrust of doctors and a lack of insurance or access to health care, some simply don’t want to endure long waits for medications. That’s the case for Emma, a trans woman in college in the Netherlands, where it can take two to three years to receive a physician prescription. (Emma is only using her first name to avoid online harassment, which she says she’s experienced in the past.)

As for surgery, far fewer people turn to DIY versions compared to those who try hormones. A 2012 study in the Journal of Sexual Medicine reported that only 109 cases of self-castration or self-mutilation of the genitals appear in the scientific literature, and not all are related to gender identity. “But one is too many,” Scheim says. “No one should be in a position where they feel like they need to do that.”

The individual cases reveal a practice that is dangerous and devastating. In Hangzhou, China, a 30-year-old transgender woman feared rejection from her family, so she hid her true gender, according to a 2019 Amnesty International report. She also tried to transition in secret. At first, the woman tried putting ice on her genitals to stop them from functioning. When that didn’t work, she booked an appointment with a black-market surgeon, but the doctor was arrested before her session. She attempted surgery on herself, the report says, and after losing a profuse amount of blood, hailed a taxi to the emergency room. There, she asked the doctor to tell her family she had been in an accident.

When it comes to self-surgery, the dangers of DIY transitioning are obvious. The dangers of DIY hormones are more far-ranging, from “not ideal to serious,” Scheim says. Some DIY users take a more-is-better approach, but taking too much testosterone too quickly can fry the vocal cords. Even buying hormones from an online pharmacy is risky. In 2010, more than half of all treatments from illicit websites — not only of hormones, but of any drug — were counterfeit, according to a bulletin from the World Health Organization.

Still, Charley isn’t worried about the legitimacy of the drugs he’s taking. The packaging his estrogen comes in matches what he would get from a pharmacy with a doctor’s prescription, he says. He’s also unconcerned about the side effects. “I just did a metric century” — a 100-kilometer bike ride — “in under four hours and walked away from it feeling great. I’m healthy,” he says. “So, yeah, there might be a few side effects. But I know where the local hospital is.”

Yet waiting to see if a seemingly minor side effect leads to a health emergency may mean a patient gets help too late. “I don’t want to say that the risks are incredibly high and there is a high mortality,” Metastasio says. “I am saying, though, that this is a procedure best to be monitored.” Metastasio and others recommend seeing a doctor regularly to catch any health issues that arise as quickly as possible.

But even when doctors prescribe the drugs, the risks are unclear because of a lack of research on trans health, says Scheim: “There’s so much we don’t know about hormone use.”

Researchers do know a little bit, though. Even when a doctor weighs in on the proper dosages, there is an increased risk of heart attack. Taking testosterone increases the chances of developing acne, headaches and migraines, and anger and irritability, according to the Trans Care Project, a program of the Transcend Transgender Support and Education Society and Vancouver Coastal Health’s Transgender Health Program in Canada. Testosterone also increases the risk of having abnormally high levels of red blood cells, or polycythemia, which thickens the blood and can lead to clotting. Meanwhile, studies suggest estrogen can up the risk for breast cancer, stroke, blood clots, gallstones, and a range of heart issues. And the most common testosterone-blocker, spironolactone, can cause dehydration and weaken the kidneys.

All of these risks make it especially important for trans people to have the support of a medical provider, Metastasio says. Specialists are in short supply, but general practitioners and family doctors should be able to fill the gap. After all, they already sign off on the hormone medications for cisgender people for birth control and conditions such as menopause and male pattern baldness — which come with similar side effects and warnings as when trans people use them.

Some doctors have already realized the connection. “People can increasingly get hormone therapy from their pre-existing family doctor,” Scheim says, “which is really ideal because people should be able to have a sort of continuity of health care.”

Zil Goldstein, associate medical director for transgender and gender non-binary health at the Callen-Lorde Community Health Center in New York City, would like to see more of this. Treating gender dysphoria, she says, should be just like treating a patient for any other condition. “It wouldn't be acceptable for someone to come into a primary care provider’s office with diabetes” and for the doctor to say “‘I can't actually treat you. Please leave,’” she says. Primary care providers need to see transgender care, she adds, “as a regular part of their practice.”

Another way to increase access to hormones is through informed consent, a system which received a green light from the newest WPATH guidelines. That’s how Christine received her hormones from Fenway Health before she moved from Boston to Cape Cod. Under informed consent, if someone has a blood test to assess personal health risks of treatment, they can receive a diagnosis of gender dysphoria, sign off on knowing the risks and benefits of hormone therapy, and get a prescription — all in one day.

And Jaime Lynn Gilmour, a trans woman using the full name she chose to match her gender identity, turned to informed consent after struggling to find DIY hormones. In 2017, Jaime realized she was trans while serving in the military, and says she felt she had to keep her gender a secret. When her service ended, she was ready to start taking hormones right away. So she tried to find them online, but her order wouldn’t go through on three different websites. Instead, she visited a Planned Parenthood clinic. After blood work and a few questions, she walked out with three months of estrogen and spironolactone.

But Goldstein says even informed consent doesn’t go far enough: “If I have someone who's diabetic, I don't make them sign a document eliciting their informed consent before starting insulin.”

For trans people, hormone treatments “are life-saving therapies,” Goldstein adds, “and we shouldn’t delay or stigmatize.”

For now Christine still lives with her parents in Cape Cod. She’s also still off hormones. But she found a job. After she stashes a bit more cash in the bank, she plans to move closer to Boston and find a physician.

Despite the positive shifts in her life, it’s been a difficult few months. After moving to Cape Cod, Christine lost most of her social life and support system — particularly since her parents don’t understand or accept her gender identity. Though she has reconnected with a few friends in the past several weeks, she says she’s in a tough place emotionally. In public, she typically dresses and styles herself to look more masculine to avoid rude stares, and she is experiencing self-hatred that she fears won’t go away when she restarts treatment. Transitioning again isn’t going to be easy, as she explained to Undark in a private message on Facebook: “I've been beaten down enough that now I don't wanna get back up most of the time.”

Even worse is the fear that she might not be able to restart treatment at all. Earlier this year, Christine suffered two health emergencies within the span of a week, in which she says her blood pressure spiked, potentially causing organ damage. Christine has had one similar episode in the past and her family has a history of heart issues.

Christine may not be able to get back on estrogen despite the hard work she’s done to be able to afford it, she says, since it can increase the risk of heart attack and stroke. Because she has so far resisted trying DIY treatments again, she may have saved herself from additional health problems.

But Christine doesn’t see it that way. “Even if it was unsafe, even if I risked health concerns making myself a guinea pig, I wish I followed through,” she wrote. “Being off hormones is hell. And now that I face potentially never taking them again, I wish I had.”

Tara Santora is a science journalist based out of Denver. They have written for Psychology Today, Live Science, Fatherly, Audubon, and more.

This article was originally published on Undark. Read the original article.

Early plans for prioritizing vaccination when a COVID-19 vaccine becomes available include placing critical health care workers in the first tier, according to Sarah Mbaeyi, MD, MPH, of the Centers for Disease Control and Prevention’s National Center for Immunization and Respiratory Diseases.

A COVID-19 vaccine work group is developing strategies and identifying priority groups for vaccination to help inform discussions about the use of COVID-19 vaccines, Dr. Mbaeyi said at a virtual meeting of the CDC’s Advisory Committee on Immunization Practices.

“Preparing for vaccination during a pandemic has long been a priority of the CDC and the U.S. government,” said Dr. Mbaeyi. The work group is building on a tiered approach to vaccination that was updated in 2018 after the H1N1 flu pandemic, with occupational and high-risk populations placed in the highest-priority groups, Dr. Mbaeyi said.

There are important differences between COVID-19 and influenza, Dr. Mbaeyi said. “Vaccine prioritization is challenging due to incomplete information on COVID-19 epidemiology and vaccines, including characteristics, timing, and number of doses.”

However, guidance for vaccine prioritization developed after the H1N1 outbreak in 2018 can be adapted for COVID-19.

To help inform ACIP deliberations, the work group reviewed the epidemiology of COVID-19. A large proportion of the population remains susceptible, and prioritizations should be based on data to date and continually refined, she said.

The work group defined the objectives of the COVID-19 vaccine program as follows: “Ensure safety and effectiveness of COVID-19 vaccines; reduce transmission, morbidity, and mortality in the population; help minimize disruption to society and economy, including maintaining health care capacity; and ensure equity in vaccine allocation and distribution.”

Based on current information, the work group has proposed that vaccine priority be given to health care personnel, essential workers, adults aged 65 years and older, long-term care facility residents, and persons with high-risk medical conditions.

Among these groups “a subset of critical health care and other workers should receive initial doses,” Dr. Mbaeyi said.

However, vaccines will not be administered until safety and efficacy have been demonstrated, she emphasized. The timing and number of vaccine doses are unknown, and subprioritization may be needed, assuming the vaccine becomes available in incremental quantities over several months.

Next steps for the work group are refinement of priority groups based on ACIP feedback, and assignment of tiers to other groups such as children, pregnant women, and racial/ethnic groups at high risk, Dr. Mbaeyi said.

The goal of the work group is to have a prioritization framework for COVID-19 vaccination to present at the next ACIP meeting.

Committee member Helen Keipp Talbot, MD, of Vanderbilt University, Nashville, Tenn., emphasized that “one of the things we need to know is how is the virus [is] transmitted and who is transmitting,” and that this information will be key to developing strategies for vaccination.

Sarah E. Oliver, MD, an epidemiologist at the National Center for Immunization and Respiratory Diseases, responded that household transmission studies are in progress that will help inform the prioritization process.

Dr. Mbaeyi and Dr. Oliver had no financial conflicts to disclose.

Early plans for prioritizing vaccination when a COVID-19 vaccine becomes available include placing critical health care workers in the first tier, according to Sarah Mbaeyi, MD, MPH, of the Centers for Disease Control and Prevention’s National Center for Immunization and Respiratory Diseases.

A COVID-19 vaccine work group is developing strategies and identifying priority groups for vaccination to help inform discussions about the use of COVID-19 vaccines, Dr. Mbaeyi said at a virtual meeting of the CDC’s Advisory Committee on Immunization Practices.

“Preparing for vaccination during a pandemic has long been a priority of the CDC and the U.S. government,” said Dr. Mbaeyi. The work group is building on a tiered approach to vaccination that was updated in 2018 after the H1N1 flu pandemic, with occupational and high-risk populations placed in the highest-priority groups, Dr. Mbaeyi said.

There are important differences between COVID-19 and influenza, Dr. Mbaeyi said. “Vaccine prioritization is challenging due to incomplete information on COVID-19 epidemiology and vaccines, including characteristics, timing, and number of doses.”

However, guidance for vaccine prioritization developed after the H1N1 outbreak in 2018 can be adapted for COVID-19.

To help inform ACIP deliberations, the work group reviewed the epidemiology of COVID-19. A large proportion of the population remains susceptible, and prioritizations should be based on data to date and continually refined, she said.

The work group defined the objectives of the COVID-19 vaccine program as follows: “Ensure safety and effectiveness of COVID-19 vaccines; reduce transmission, morbidity, and mortality in the population; help minimize disruption to society and economy, including maintaining health care capacity; and ensure equity in vaccine allocation and distribution.”

Based on current information, the work group has proposed that vaccine priority be given to health care personnel, essential workers, adults aged 65 years and older, long-term care facility residents, and persons with high-risk medical conditions.

Among these groups “a subset of critical health care and other workers should receive initial doses,” Dr. Mbaeyi said.

However, vaccines will not be administered until safety and efficacy have been demonstrated, she emphasized. The timing and number of vaccine doses are unknown, and subprioritization may be needed, assuming the vaccine becomes available in incremental quantities over several months.

Next steps for the work group are refinement of priority groups based on ACIP feedback, and assignment of tiers to other groups such as children, pregnant women, and racial/ethnic groups at high risk, Dr. Mbaeyi said.

The goal of the work group is to have a prioritization framework for COVID-19 vaccination to present at the next ACIP meeting.

Committee member Helen Keipp Talbot, MD, of Vanderbilt University, Nashville, Tenn., emphasized that “one of the things we need to know is how is the virus [is] transmitted and who is transmitting,” and that this information will be key to developing strategies for vaccination.

Sarah E. Oliver, MD, an epidemiologist at the National Center for Immunization and Respiratory Diseases, responded that household transmission studies are in progress that will help inform the prioritization process.

Dr. Mbaeyi and Dr. Oliver had no financial conflicts to disclose.

Early plans for prioritizing vaccination when a COVID-19 vaccine becomes available include placing critical health care workers in the first tier, according to Sarah Mbaeyi, MD, MPH, of the Centers for Disease Control and Prevention’s National Center for Immunization and Respiratory Diseases.

A COVID-19 vaccine work group is developing strategies and identifying priority groups for vaccination to help inform discussions about the use of COVID-19 vaccines, Dr. Mbaeyi said at a virtual meeting of the CDC’s Advisory Committee on Immunization Practices.

“Preparing for vaccination during a pandemic has long been a priority of the CDC and the U.S. government,” said Dr. Mbaeyi. The work group is building on a tiered approach to vaccination that was updated in 2018 after the H1N1 flu pandemic, with occupational and high-risk populations placed in the highest-priority groups, Dr. Mbaeyi said.

There are important differences between COVID-19 and influenza, Dr. Mbaeyi said. “Vaccine prioritization is challenging due to incomplete information on COVID-19 epidemiology and vaccines, including characteristics, timing, and number of doses.”

However, guidance for vaccine prioritization developed after the H1N1 outbreak in 2018 can be adapted for COVID-19.

To help inform ACIP deliberations, the work group reviewed the epidemiology of COVID-19. A large proportion of the population remains susceptible, and prioritizations should be based on data to date and continually refined, she said.

The work group defined the objectives of the COVID-19 vaccine program as follows: “Ensure safety and effectiveness of COVID-19 vaccines; reduce transmission, morbidity, and mortality in the population; help minimize disruption to society and economy, including maintaining health care capacity; and ensure equity in vaccine allocation and distribution.”

Based on current information, the work group has proposed that vaccine priority be given to health care personnel, essential workers, adults aged 65 years and older, long-term care facility residents, and persons with high-risk medical conditions.

Among these groups “a subset of critical health care and other workers should receive initial doses,” Dr. Mbaeyi said.

However, vaccines will not be administered until safety and efficacy have been demonstrated, she emphasized. The timing and number of vaccine doses are unknown, and subprioritization may be needed, assuming the vaccine becomes available in incremental quantities over several months.

Next steps for the work group are refinement of priority groups based on ACIP feedback, and assignment of tiers to other groups such as children, pregnant women, and racial/ethnic groups at high risk, Dr. Mbaeyi said.

The goal of the work group is to have a prioritization framework for COVID-19 vaccination to present at the next ACIP meeting.

Committee member Helen Keipp Talbot, MD, of Vanderbilt University, Nashville, Tenn., emphasized that “one of the things we need to know is how is the virus [is] transmitted and who is transmitting,” and that this information will be key to developing strategies for vaccination.

Sarah E. Oliver, MD, an epidemiologist at the National Center for Immunization and Respiratory Diseases, responded that household transmission studies are in progress that will help inform the prioritization process.

Dr. Mbaeyi and Dr. Oliver had no financial conflicts to disclose.

The famous quote from the German philosopher Friedrich Nietzsche, “That which does not kill us makes us stronger,” may not be true after all – at least when it comes to mental health.

Results of a new study show that individuals who have a history of a stressful life events are more likely to develop posttraumatic stress disorder (PTSD) and/or major depressive disorder (MDD) following a major natural disaster than their counterparts who do not have such a history.

The investigation of more than a thousand Chilean residents – all of whom experienced one of the most powerful earthquakes in the country’s history – showed that the odds of developing postdisaster PTSD or MDD increased according to the number of predisaster stressors participants had experienced.

“We’ve learned that Nietzsche was wrong in this case and that the people who have had prior stressful and traumatic histories were more likely to develop PTSD and depression than those with fewer, study investigator Stephen L. Buka, PhD, professor of epidemiology at Brown University, Providence, Rhode Island, said in an interview.

The study was published online June 11 in the British Journal of Psychiatry.

Stress inoculation hypothesis

The so-called stress inoculation hypothesis proposes that individuals who experience manageable stressors may be able to better cope with subsequent stressors, inasmuch as such experience affords them opportunities to practice effective coping skills and develop a sense of mastery over stressors.

It’s unclear whether the theory is true for individuals who are exposed to subsequent trauma, particularly with respect to such common mental health disorders as MDD and PTSD. Although less severe day-to-day stressors may be easier to cope with, major trauma can overwhelm an individual’s coping mechanisms.

Findings from previous research have been mixed. Some studiessuggest that prior stressors can increase the risk of developing later psychiatric disorders. On the other hand, previous research has also shown that exposure to prior trauma alone does not predict subsequent PTSD.

Given these contradictions, the investigators wanted to determine whether a history of prior stressors was associated with psychiatric resilience among individuals who had no psychiatric history of MDD or PTSD.

“Only a small minority of people who have experienced a traumatic event go on to develop PTSD or MDD,” said lead author Cristina Fernandez, PhD, a psychiatric epidemiologist at the PAHO/WHO Collaborating Center for Research on Psychiatric Epidemiology and Mental Health, Brown University, Providence, R.I.

“So most people are resilient and move on without developing these disorders. But what is unique about this minority of individuals that makes them more susceptible to developing these disorders?” she continued. “It’s one of the most significant questions in the PTSD literature,” she added.

The analysis included data from 10 sites in the Chilean cities of Concepción and Talcahuano that had participated in the PREDICT investigation, a prospective cohort study that sought to predict mental health outcomes among primary care patients.

While the PREDICT study was being conducted, in February 2010, a major earthquake struck the coast of central Chile, killing more than 500 people and displacing 800,000. Concepción and Talcahuano experienced the most damage from the earthquake and its subsequent effects, including a tsunami that ravaged Talcahuano.

Dose-dependent effect

At baseline and 1 year after the disaster, all participants completed the Composite International Diagnostic Interview, which assesses for the presence of PTSD and/or MDD. Participants also completed the List of Threatening Experiences, a 12-item questionnaire that measures major stressful life events.

Of 3,000 participants who initially agreed to take part in the trial, 1708 completed both the predisaster assessment in 2003 and the postdisaster assessment in 2011, 1 year after the earthquake and tsunami occurred. After excluding for a variety other criteria, 1,160 individuals were included in the final analysis.

“As it turns out, it was a very natural experiment,” said Dr. Buka. “We had a group of people whose past traumatic experiences we knew about, and then they were all subjected to this terrible earthquake, and then we were able to look forward into time and see who did and didn’t develop PTSD and MDD.”

When the study began in 2003, none of the 1,160 participants had a history of PTSD or MDD. After the 2010 earthquake, 9.1% of the survivors (n = 106) were diagnosed with PTSD, and 14.4% were diagnosed with MDD (n = 167).

Further analyses showed that prior disaster exposure was not a significant predictor of postdisaster PTSD. Nevertheless, for every unit increase in prior nondisaster stressors, the odds of developing postdisaster PTSD increased (odds ratio, 1.21; 95% confidence interval, 1.08-1.37; P = .001).

When categorizing predisaster stressors, the investigators found that individuals who had four or more predisaster stressors had a significantly greater chance of developing postdisaster PTSD than those with no predisaster stressors (OR, 2.77; 95% CI, 1.52 – 5.04).

Similar logistic regression analyses were performed for MDD, with comparable results. Although prior disaster exposure was not a significant predictor of postdisaster MDD, each one-unit increase in prior nondisaster stressors increased the odds of developing postdisaster MDD by 16% (OR, 1.16; 95% CI, 1.06-1.27; P = .001).

Categorization of these stressors revealed that experiencing any number of stressors significantly increased the odds of developing postdisaster MDD in a dose-response fashion.

In other words, every predisaster stressor – even a single one – increased an individual’s risk of developing postdisaster MDD, and each additional stressor further increased the risk.

Predisaster stressors

Interestingly, the study also showed that the risk of developing both PTSD and MDD was particularly high among those who had experienced multiple predisaster stressors, such as serious illness or injury, death of a loved one, divorce, unemployment, financial struggles, legal troubles, or the loss of a valuable possession.

These findings, the researchers note, demonstrate that a history of stressors increases what they called “stress sensitization,” which may make individuals more vulnerable to the negative effects of subsequent stressors rather than more resilient.

As such, individuals who have experienced several stressors over the course of a lifetime are at higher risk of developing a psychiatric disorder.

This was the case with PTSD, in which exposure to at least four previous manageable stressors was associated with greater odds of developing postdisaster PTSD. For MDD, on the other hand, there was a distinct dose-response relationship between the number of manageable predisaster stressors and the risk for postdisaster MDD.

The investigators explain that these findings are particularly relevant in light of the COVID-19 pandemic and the current focus on racial and economic inequality in the United States. “The findings highlight the sectors of the population that are at greatest risk,” Dr. Buka said. “And those are the ones who’ve had more challenging and traumatic lives and more hardship.

“So it certainly calls for greater concentration of psychiatric services in traditionally underserved areas, because those are also areas that have greater histories of trauma.”
 

“Fascinating” research

Commenting on the findings fin an interview, Patricia A. Resick, PhD, who was not involved in the study, said she found the research fascinating.

“The fact that they had preexisting data and then had the wherewithal to go back after the earthquake is quite amazing,” she said.

The findings came as little surprise to Dr. Resick, professor of psychiatry and behavioral sciences at Duke University Medical Center in Durham, N.C.

“I think most people are in agreement that the more stress you have, the more likely you are to get PTSD when you experience a traumatic stressor,” she said.

Treating these individuals remains a challenge, Dr. Resick noted, though knowing their history of stressors and traumas is an important starting point.

“We have to get a good history and figure out where to start treating them, because we always want to start with the event that causes the most PTSD symptoms,” she explained.

She also characterized the issue as being as much a public health concern as one for psychiatrists. “These are people you will want to have surveillance on and encourage them to get help,” Dr. Resick added.

Dr. Fernandez agreed.

“In the face of a disaster,” she said, “there needs to be more attention paid to vulnerable populations, because they likely don’t have the support they need.

“At the clinical level, these findings help the clinician know which patients are more likely to need more intensive services,” Dr. Buka added. “And the more trauma and hardship they’ve experienced, the more attention they need and the less likely they’re going to be able to cope and manage on their own.”

The study was funded by the U.S. National Institute of Mental Health and FONDEF Chile. Dr. Fernandez, Dr. Buka, and Dr. Resick have disclosed no relevant financial relationships.
 

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

The famous quote from the German philosopher Friedrich Nietzsche, “That which does not kill us makes us stronger,” may not be true after all – at least when it comes to mental health.

Results of a new study show that individuals who have a history of a stressful life events are more likely to develop posttraumatic stress disorder (PTSD) and/or major depressive disorder (MDD) following a major natural disaster than their counterparts who do not have such a history.

The investigation of more than a thousand Chilean residents – all of whom experienced one of the most powerful earthquakes in the country’s history – showed that the odds of developing postdisaster PTSD or MDD increased according to the number of predisaster stressors participants had experienced.

“We’ve learned that Nietzsche was wrong in this case and that the people who have had prior stressful and traumatic histories were more likely to develop PTSD and depression than those with fewer, study investigator Stephen L. Buka, PhD, professor of epidemiology at Brown University, Providence, Rhode Island, said in an interview.

The study was published online June 11 in the British Journal of Psychiatry.

Stress inoculation hypothesis

The so-called stress inoculation hypothesis proposes that individuals who experience manageable stressors may be able to better cope with subsequent stressors, inasmuch as such experience affords them opportunities to practice effective coping skills and develop a sense of mastery over stressors.

It’s unclear whether the theory is true for individuals who are exposed to subsequent trauma, particularly with respect to such common mental health disorders as MDD and PTSD. Although less severe day-to-day stressors may be easier to cope with, major trauma can overwhelm an individual’s coping mechanisms.

Findings from previous research have been mixed. Some studiessuggest that prior stressors can increase the risk of developing later psychiatric disorders. On the other hand, previous research has also shown that exposure to prior trauma alone does not predict subsequent PTSD.

Given these contradictions, the investigators wanted to determine whether a history of prior stressors was associated with psychiatric resilience among individuals who had no psychiatric history of MDD or PTSD.

“Only a small minority of people who have experienced a traumatic event go on to develop PTSD or MDD,” said lead author Cristina Fernandez, PhD, a psychiatric epidemiologist at the PAHO/WHO Collaborating Center for Research on Psychiatric Epidemiology and Mental Health, Brown University, Providence, R.I.

“So most people are resilient and move on without developing these disorders. But what is unique about this minority of individuals that makes them more susceptible to developing these disorders?” she continued. “It’s one of the most significant questions in the PTSD literature,” she added.

The analysis included data from 10 sites in the Chilean cities of Concepción and Talcahuano that had participated in the PREDICT investigation, a prospective cohort study that sought to predict mental health outcomes among primary care patients.

While the PREDICT study was being conducted, in February 2010, a major earthquake struck the coast of central Chile, killing more than 500 people and displacing 800,000. Concepción and Talcahuano experienced the most damage from the earthquake and its subsequent effects, including a tsunami that ravaged Talcahuano.

Dose-dependent effect

At baseline and 1 year after the disaster, all participants completed the Composite International Diagnostic Interview, which assesses for the presence of PTSD and/or MDD. Participants also completed the List of Threatening Experiences, a 12-item questionnaire that measures major stressful life events.

Of 3,000 participants who initially agreed to take part in the trial, 1708 completed both the predisaster assessment in 2003 and the postdisaster assessment in 2011, 1 year after the earthquake and tsunami occurred. After excluding for a variety other criteria, 1,160 individuals were included in the final analysis.

“As it turns out, it was a very natural experiment,” said Dr. Buka. “We had a group of people whose past traumatic experiences we knew about, and then they were all subjected to this terrible earthquake, and then we were able to look forward into time and see who did and didn’t develop PTSD and MDD.”

When the study began in 2003, none of the 1,160 participants had a history of PTSD or MDD. After the 2010 earthquake, 9.1% of the survivors (n = 106) were diagnosed with PTSD, and 14.4% were diagnosed with MDD (n = 167).

Further analyses showed that prior disaster exposure was not a significant predictor of postdisaster PTSD. Nevertheless, for every unit increase in prior nondisaster stressors, the odds of developing postdisaster PTSD increased (odds ratio, 1.21; 95% confidence interval, 1.08-1.37; P = .001).

When categorizing predisaster stressors, the investigators found that individuals who had four or more predisaster stressors had a significantly greater chance of developing postdisaster PTSD than those with no predisaster stressors (OR, 2.77; 95% CI, 1.52 – 5.04).

Similar logistic regression analyses were performed for MDD, with comparable results. Although prior disaster exposure was not a significant predictor of postdisaster MDD, each one-unit increase in prior nondisaster stressors increased the odds of developing postdisaster MDD by 16% (OR, 1.16; 95% CI, 1.06-1.27; P = .001).

Categorization of these stressors revealed that experiencing any number of stressors significantly increased the odds of developing postdisaster MDD in a dose-response fashion.

In other words, every predisaster stressor – even a single one – increased an individual’s risk of developing postdisaster MDD, and each additional stressor further increased the risk.

Predisaster stressors

Interestingly, the study also showed that the risk of developing both PTSD and MDD was particularly high among those who had experienced multiple predisaster stressors, such as serious illness or injury, death of a loved one, divorce, unemployment, financial struggles, legal troubles, or the loss of a valuable possession.

These findings, the researchers note, demonstrate that a history of stressors increases what they called “stress sensitization,” which may make individuals more vulnerable to the negative effects of subsequent stressors rather than more resilient.

As such, individuals who have experienced several stressors over the course of a lifetime are at higher risk of developing a psychiatric disorder.

This was the case with PTSD, in which exposure to at least four previous manageable stressors was associated with greater odds of developing postdisaster PTSD. For MDD, on the other hand, there was a distinct dose-response relationship between the number of manageable predisaster stressors and the risk for postdisaster MDD.

The investigators explain that these findings are particularly relevant in light of the COVID-19 pandemic and the current focus on racial and economic inequality in the United States. “The findings highlight the sectors of the population that are at greatest risk,” Dr. Buka said. “And those are the ones who’ve had more challenging and traumatic lives and more hardship.

“So it certainly calls for greater concentration of psychiatric services in traditionally underserved areas, because those are also areas that have greater histories of trauma.”
 

“Fascinating” research

Commenting on the findings fin an interview, Patricia A. Resick, PhD, who was not involved in the study, said she found the research fascinating.

“The fact that they had preexisting data and then had the wherewithal to go back after the earthquake is quite amazing,” she said.

The findings came as little surprise to Dr. Resick, professor of psychiatry and behavioral sciences at Duke University Medical Center in Durham, N.C.

“I think most people are in agreement that the more stress you have, the more likely you are to get PTSD when you experience a traumatic stressor,” she said.

Treating these individuals remains a challenge, Dr. Resick noted, though knowing their history of stressors and traumas is an important starting point.

“We have to get a good history and figure out where to start treating them, because we always want to start with the event that causes the most PTSD symptoms,” she explained.

She also characterized the issue as being as much a public health concern as one for psychiatrists. “These are people you will want to have surveillance on and encourage them to get help,” Dr. Resick added.

Dr. Fernandez agreed.

“In the face of a disaster,” she said, “there needs to be more attention paid to vulnerable populations, because they likely don’t have the support they need.

“At the clinical level, these findings help the clinician know which patients are more likely to need more intensive services,” Dr. Buka added. “And the more trauma and hardship they’ve experienced, the more attention they need and the less likely they’re going to be able to cope and manage on their own.”

The study was funded by the U.S. National Institute of Mental Health and FONDEF Chile. Dr. Fernandez, Dr. Buka, and Dr. Resick have disclosed no relevant financial relationships.
 

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

The famous quote from the German philosopher Friedrich Nietzsche, “That which does not kill us makes us stronger,” may not be true after all – at least when it comes to mental health.

Results of a new study show that individuals who have a history of a stressful life events are more likely to develop posttraumatic stress disorder (PTSD) and/or major depressive disorder (MDD) following a major natural disaster than their counterparts who do not have such a history.

The investigation of more than a thousand Chilean residents – all of whom experienced one of the most powerful earthquakes in the country’s history – showed that the odds of developing postdisaster PTSD or MDD increased according to the number of predisaster stressors participants had experienced.

“We’ve learned that Nietzsche was wrong in this case and that the people who have had prior stressful and traumatic histories were more likely to develop PTSD and depression than those with fewer, study investigator Stephen L. Buka, PhD, professor of epidemiology at Brown University, Providence, Rhode Island, said in an interview.

The study was published online June 11 in the British Journal of Psychiatry.

Stress inoculation hypothesis

The so-called stress inoculation hypothesis proposes that individuals who experience manageable stressors may be able to better cope with subsequent stressors, inasmuch as such experience affords them opportunities to practice effective coping skills and develop a sense of mastery over stressors.

It’s unclear whether the theory is true for individuals who are exposed to subsequent trauma, particularly with respect to such common mental health disorders as MDD and PTSD. Although less severe day-to-day stressors may be easier to cope with, major trauma can overwhelm an individual’s coping mechanisms.

Findings from previous research have been mixed. Some studiessuggest that prior stressors can increase the risk of developing later psychiatric disorders. On the other hand, previous research has also shown that exposure to prior trauma alone does not predict subsequent PTSD.

Given these contradictions, the investigators wanted to determine whether a history of prior stressors was associated with psychiatric resilience among individuals who had no psychiatric history of MDD or PTSD.

“Only a small minority of people who have experienced a traumatic event go on to develop PTSD or MDD,” said lead author Cristina Fernandez, PhD, a psychiatric epidemiologist at the PAHO/WHO Collaborating Center for Research on Psychiatric Epidemiology and Mental Health, Brown University, Providence, R.I.

“So most people are resilient and move on without developing these disorders. But what is unique about this minority of individuals that makes them more susceptible to developing these disorders?” she continued. “It’s one of the most significant questions in the PTSD literature,” she added.

The analysis included data from 10 sites in the Chilean cities of Concepción and Talcahuano that had participated in the PREDICT investigation, a prospective cohort study that sought to predict mental health outcomes among primary care patients.

While the PREDICT study was being conducted, in February 2010, a major earthquake struck the coast of central Chile, killing more than 500 people and displacing 800,000. Concepción and Talcahuano experienced the most damage from the earthquake and its subsequent effects, including a tsunami that ravaged Talcahuano.

Dose-dependent effect

At baseline and 1 year after the disaster, all participants completed the Composite International Diagnostic Interview, which assesses for the presence of PTSD and/or MDD. Participants also completed the List of Threatening Experiences, a 12-item questionnaire that measures major stressful life events.

Of 3,000 participants who initially agreed to take part in the trial, 1708 completed both the predisaster assessment in 2003 and the postdisaster assessment in 2011, 1 year after the earthquake and tsunami occurred. After excluding for a variety other criteria, 1,160 individuals were included in the final analysis.

“As it turns out, it was a very natural experiment,” said Dr. Buka. “We had a group of people whose past traumatic experiences we knew about, and then they were all subjected to this terrible earthquake, and then we were able to look forward into time and see who did and didn’t develop PTSD and MDD.”

When the study began in 2003, none of the 1,160 participants had a history of PTSD or MDD. After the 2010 earthquake, 9.1% of the survivors (n = 106) were diagnosed with PTSD, and 14.4% were diagnosed with MDD (n = 167).

Further analyses showed that prior disaster exposure was not a significant predictor of postdisaster PTSD. Nevertheless, for every unit increase in prior nondisaster stressors, the odds of developing postdisaster PTSD increased (odds ratio, 1.21; 95% confidence interval, 1.08-1.37; P = .001).

When categorizing predisaster stressors, the investigators found that individuals who had four or more predisaster stressors had a significantly greater chance of developing postdisaster PTSD than those with no predisaster stressors (OR, 2.77; 95% CI, 1.52 – 5.04).

Similar logistic regression analyses were performed for MDD, with comparable results. Although prior disaster exposure was not a significant predictor of postdisaster MDD, each one-unit increase in prior nondisaster stressors increased the odds of developing postdisaster MDD by 16% (OR, 1.16; 95% CI, 1.06-1.27; P = .001).

Categorization of these stressors revealed that experiencing any number of stressors significantly increased the odds of developing postdisaster MDD in a dose-response fashion.

In other words, every predisaster stressor – even a single one – increased an individual’s risk of developing postdisaster MDD, and each additional stressor further increased the risk.

Predisaster stressors

Interestingly, the study also showed that the risk of developing both PTSD and MDD was particularly high among those who had experienced multiple predisaster stressors, such as serious illness or injury, death of a loved one, divorce, unemployment, financial struggles, legal troubles, or the loss of a valuable possession.

These findings, the researchers note, demonstrate that a history of stressors increases what they called “stress sensitization,” which may make individuals more vulnerable to the negative effects of subsequent stressors rather than more resilient.

As such, individuals who have experienced several stressors over the course of a lifetime are at higher risk of developing a psychiatric disorder.

This was the case with PTSD, in which exposure to at least four previous manageable stressors was associated with greater odds of developing postdisaster PTSD. For MDD, on the other hand, there was a distinct dose-response relationship between the number of manageable predisaster stressors and the risk for postdisaster MDD.

The investigators explain that these findings are particularly relevant in light of the COVID-19 pandemic and the current focus on racial and economic inequality in the United States. “The findings highlight the sectors of the population that are at greatest risk,” Dr. Buka said. “And those are the ones who’ve had more challenging and traumatic lives and more hardship.

“So it certainly calls for greater concentration of psychiatric services in traditionally underserved areas, because those are also areas that have greater histories of trauma.”
 

“Fascinating” research

Commenting on the findings fin an interview, Patricia A. Resick, PhD, who was not involved in the study, said she found the research fascinating.

“The fact that they had preexisting data and then had the wherewithal to go back after the earthquake is quite amazing,” she said.

The findings came as little surprise to Dr. Resick, professor of psychiatry and behavioral sciences at Duke University Medical Center in Durham, N.C.

“I think most people are in agreement that the more stress you have, the more likely you are to get PTSD when you experience a traumatic stressor,” she said.

Treating these individuals remains a challenge, Dr. Resick noted, though knowing their history of stressors and traumas is an important starting point.

“We have to get a good history and figure out where to start treating them, because we always want to start with the event that causes the most PTSD symptoms,” she explained.

She also characterized the issue as being as much a public health concern as one for psychiatrists. “These are people you will want to have surveillance on and encourage them to get help,” Dr. Resick added.

Dr. Fernandez agreed.

“In the face of a disaster,” she said, “there needs to be more attention paid to vulnerable populations, because they likely don’t have the support they need.

“At the clinical level, these findings help the clinician know which patients are more likely to need more intensive services,” Dr. Buka added. “And the more trauma and hardship they’ve experienced, the more attention they need and the less likely they’re going to be able to cope and manage on their own.”

The study was funded by the U.S. National Institute of Mental Health and FONDEF Chile. Dr. Fernandez, Dr. Buka, and Dr. Resick have disclosed no relevant financial relationships.
 

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

Six Oregon teenagers ingested flualprazolam, a designer benzodiazepine, and developed symptoms of central nervous system depression. When evaluated at local emergency departments, lethargy and slurred speech were the most common clinical findings.

Nick Matthews/CC BY-SA 2.0

One student had mild respiratory depression with a respiratory rate of 10 breaths per minute.

“All patients had sufficient clinical improvement within 6 hours such that they could be discharged from the hospital,” according to a description of the cases that was published online in Pediatrics.

The report is the first to detail clinical toxicity from flualprazolam, and “it is likely that physicians will again encounter patients” with intoxication from this new psychoactive drug, said Adam Blumenberg, MD, of Oregon Health & Science University in Portland and colleagues.

Internet purchasing has increased rates of exposure to new psychoactive substances since the early 2000s, and law enforcement agents have seized tons of these drugs. “In the United States, the incidence of exposures to designer benzodiazepines in particular has been rising since 2014,” the authors said.

According to an addiction researcher, the COVID-19 pandemic may exacerbate abuse of designer benzodiazepines.

“This is an important paper describing what medical examiners, pathologists, and emergency rooms have been seeing recently – an increase in designer benzodiazepines,” commented Mark S. Gold, MD, adjunct professor of psychiatry at Washington University in St. Louis. “Recent increases in these drugs have started to be seen in many locations as the traditional drugs of abuse, grown and distributed in bulk, have been disrupted” by the pandemic, he said in an interview. Although it may be too early for such cases to appear in Centers for Disease Control and Prevention reports, they can be described in studies like this one and, “I suspect, sadly, in medical examiner case reports.”

Flualprazolam, known colloquially as Hulk, is structurally related to the Food and Drug Administration–approved drugs alprazolam and triazolam. During 1 week in June 2019, the patients in Oregon received the drug as a free sample from another student from their Oregon high school. They believed it was commercial Xanax (alprazolam). “The flualprazolam tablets were identical in appearance and labeling to 2-mg tablets of alprazolam,” according to the report. “This indicates an intentionally counterfeit product entering the drug supply chain.”

Five of the six patients were boys, and they ranged in age from 14 to 16 years. The patient with mild respiratory depression received 0.4-mg naloxone, which physicians gave empirically because of the unknown identity of the drug, but did not respond. Two of the six patients initially felt drowsy but were asymptomatic during the clinical evaluation.

A urine immunoassay was performed in five of the patients, and all tested positive for benzodiazepines. One patient also tested positive for cannabinoids. Analysis of a tablet fragment revealed that it contained flualprazolam.

“Although flualprazolam intoxication cannot be clinically differentiated from that of other benzodiazepines without advanced testing, patient management should be the same,” Dr. Blumenberg and coauthors said. “For mild to moderate intoxication, patients should be treated with close monitoring and supportive care until symptom resolution. The benzodiazepine antidote flumazenil may be considered a safe and effective antidote in pediatric patients with significant CNS or respiratory depression. In patients for whom there is a concern of benzodiazepine dependence and flumazenil-induced seizures, airway protection and mechanical ventilation may be considered.”

Although patients rarely die from isolated benzodiazepine toxicity, death from respiratory depression or aspiration is more common when benzodiazepine toxicity occurs “in combination with alcohol, opioids, or other sedatives,” the authors noted. In addition, counterfeit alprazolam tablets have contained adulterants such as fentanyl and the opioid U-47700, which can be deadly.

The authors had no relevant financial disclosures, and there was no external funding for the study.

[email protected]

SOURCE: Blumenberg A et al. Pediatrics. 2020 Jun 24. doi: 10.1542/peds.2019-2953.

Six Oregon teenagers ingested flualprazolam, a designer benzodiazepine, and developed symptoms of central nervous system depression. When evaluated at local emergency departments, lethargy and slurred speech were the most common clinical findings.

Nick Matthews/CC BY-SA 2.0

One student had mild respiratory depression with a respiratory rate of 10 breaths per minute.

“All patients had sufficient clinical improvement within 6 hours such that they could be discharged from the hospital,” according to a description of the cases that was published online in Pediatrics.

The report is the first to detail clinical toxicity from flualprazolam, and “it is likely that physicians will again encounter patients” with intoxication from this new psychoactive drug, said Adam Blumenberg, MD, of Oregon Health & Science University in Portland and colleagues.

Internet purchasing has increased rates of exposure to new psychoactive substances since the early 2000s, and law enforcement agents have seized tons of these drugs. “In the United States, the incidence of exposures to designer benzodiazepines in particular has been rising since 2014,” the authors said.

According to an addiction researcher, the COVID-19 pandemic may exacerbate abuse of designer benzodiazepines.

“This is an important paper describing what medical examiners, pathologists, and emergency rooms have been seeing recently – an increase in designer benzodiazepines,” commented Mark S. Gold, MD, adjunct professor of psychiatry at Washington University in St. Louis. “Recent increases in these drugs have started to be seen in many locations as the traditional drugs of abuse, grown and distributed in bulk, have been disrupted” by the pandemic, he said in an interview. Although it may be too early for such cases to appear in Centers for Disease Control and Prevention reports, they can be described in studies like this one and, “I suspect, sadly, in medical examiner case reports.”

Flualprazolam, known colloquially as Hulk, is structurally related to the Food and Drug Administration–approved drugs alprazolam and triazolam. During 1 week in June 2019, the patients in Oregon received the drug as a free sample from another student from their Oregon high school. They believed it was commercial Xanax (alprazolam). “The flualprazolam tablets were identical in appearance and labeling to 2-mg tablets of alprazolam,” according to the report. “This indicates an intentionally counterfeit product entering the drug supply chain.”

Five of the six patients were boys, and they ranged in age from 14 to 16 years. The patient with mild respiratory depression received 0.4-mg naloxone, which physicians gave empirically because of the unknown identity of the drug, but did not respond. Two of the six patients initially felt drowsy but were asymptomatic during the clinical evaluation.

A urine immunoassay was performed in five of the patients, and all tested positive for benzodiazepines. One patient also tested positive for cannabinoids. Analysis of a tablet fragment revealed that it contained flualprazolam.

“Although flualprazolam intoxication cannot be clinically differentiated from that of other benzodiazepines without advanced testing, patient management should be the same,” Dr. Blumenberg and coauthors said. “For mild to moderate intoxication, patients should be treated with close monitoring and supportive care until symptom resolution. The benzodiazepine antidote flumazenil may be considered a safe and effective antidote in pediatric patients with significant CNS or respiratory depression. In patients for whom there is a concern of benzodiazepine dependence and flumazenil-induced seizures, airway protection and mechanical ventilation may be considered.”

Although patients rarely die from isolated benzodiazepine toxicity, death from respiratory depression or aspiration is more common when benzodiazepine toxicity occurs “in combination with alcohol, opioids, or other sedatives,” the authors noted. In addition, counterfeit alprazolam tablets have contained adulterants such as fentanyl and the opioid U-47700, which can be deadly.

The authors had no relevant financial disclosures, and there was no external funding for the study.

[email protected]

SOURCE: Blumenberg A et al. Pediatrics. 2020 Jun 24. doi: 10.1542/peds.2019-2953.

Six Oregon teenagers ingested flualprazolam, a designer benzodiazepine, and developed symptoms of central nervous system depression. When evaluated at local emergency departments, lethargy and slurred speech were the most common clinical findings.

Nick Matthews/CC BY-SA 2.0

One student had mild respiratory depression with a respiratory rate of 10 breaths per minute.

“All patients had sufficient clinical improvement within 6 hours such that they could be discharged from the hospital,” according to a description of the cases that was published online in Pediatrics.

The report is the first to detail clinical toxicity from flualprazolam, and “it is likely that physicians will again encounter patients” with intoxication from this new psychoactive drug, said Adam Blumenberg, MD, of Oregon Health & Science University in Portland and colleagues.

Internet purchasing has increased rates of exposure to new psychoactive substances since the early 2000s, and law enforcement agents have seized tons of these drugs. “In the United States, the incidence of exposures to designer benzodiazepines in particular has been rising since 2014,” the authors said.

According to an addiction researcher, the COVID-19 pandemic may exacerbate abuse of designer benzodiazepines.

“This is an important paper describing what medical examiners, pathologists, and emergency rooms have been seeing recently – an increase in designer benzodiazepines,” commented Mark S. Gold, MD, adjunct professor of psychiatry at Washington University in St. Louis. “Recent increases in these drugs have started to be seen in many locations as the traditional drugs of abuse, grown and distributed in bulk, have been disrupted” by the pandemic, he said in an interview. Although it may be too early for such cases to appear in Centers for Disease Control and Prevention reports, they can be described in studies like this one and, “I suspect, sadly, in medical examiner case reports.”

Flualprazolam, known colloquially as Hulk, is structurally related to the Food and Drug Administration–approved drugs alprazolam and triazolam. During 1 week in June 2019, the patients in Oregon received the drug as a free sample from another student from their Oregon high school. They believed it was commercial Xanax (alprazolam). “The flualprazolam tablets were identical in appearance and labeling to 2-mg tablets of alprazolam,” according to the report. “This indicates an intentionally counterfeit product entering the drug supply chain.”

Five of the six patients were boys, and they ranged in age from 14 to 16 years. The patient with mild respiratory depression received 0.4-mg naloxone, which physicians gave empirically because of the unknown identity of the drug, but did not respond. Two of the six patients initially felt drowsy but were asymptomatic during the clinical evaluation.

A urine immunoassay was performed in five of the patients, and all tested positive for benzodiazepines. One patient also tested positive for cannabinoids. Analysis of a tablet fragment revealed that it contained flualprazolam.

“Although flualprazolam intoxication cannot be clinically differentiated from that of other benzodiazepines without advanced testing, patient management should be the same,” Dr. Blumenberg and coauthors said. “For mild to moderate intoxication, patients should be treated with close monitoring and supportive care until symptom resolution. The benzodiazepine antidote flumazenil may be considered a safe and effective antidote in pediatric patients with significant CNS or respiratory depression. In patients for whom there is a concern of benzodiazepine dependence and flumazenil-induced seizures, airway protection and mechanical ventilation may be considered.”

Although patients rarely die from isolated benzodiazepine toxicity, death from respiratory depression or aspiration is more common when benzodiazepine toxicity occurs “in combination with alcohol, opioids, or other sedatives,” the authors noted. In addition, counterfeit alprazolam tablets have contained adulterants such as fentanyl and the opioid U-47700, which can be deadly.

The authors had no relevant financial disclosures, and there was no external funding for the study.

[email protected]

SOURCE: Blumenberg A et al. Pediatrics. 2020 Jun 24. doi: 10.1542/peds.2019-2953.

Here are the stories our MDedge editors across specialties think you need to know about today:

Pregnant women at higher risk for severe COVID-19

Pregnant women may be at increased risk for severe COVID-19 illness, according to a report published online June 26 in Morbidity and Mortality Weekly Report.

Among reproductive-aged women (15-44 years) infected with SARS-CoV-2, pregnancy was associated with a greater likelihood of hospitalization, admission to the intensive care unit (ICU), and mechanical ventilation, but not death. Pregnant women were 5.4 times more likely to be hospitalized, 1.5 times more likely to be admitted to the ICU, and 1.7 times more likely to need mechanical ventilation, after adjustment for age, underlying conditions, and race/ethnicity.  

CDC researchers said that preventing COVID-19 infection in pregnant women should be a priority and any potential barriers to compliance with preventive measures need to be removed.

“During pregnancy, women experience immunologic and physiologic changes that could increase their risk for more severe illness from respiratory infections,” they wrote. Read more.

Going out of business: Primary care practices at risk

In a recently published editorial, Tom Frieden, MD, MPH, former head of the Centers for Disease Control and Prevention, argued that primary care is in deep trouble, its long-standing financial problems exacerbated by the fallout from the COVID-19 pandemic. In an interview with Kenny Lin, MD, MPH, a family physician, Dr. Frieden discussed the future of primary care.

Here is a sample of Dr. Frieden’s observations:

“When I’ve looked around the United States, I’ve been extremely concerned about both the risk that primary care practitioners are subjected to in their everyday practice and the economic risk that we could lose many of our primary care practices around the country. It’s really striking to see that the number of visits has plummeted. Because of our payment structure, that means incomes have plummeted. We’re hearing about doctors’ offices getting boarded up and shuttering. As I write in the piece, it’s one thing for a theater or a restaurant or another important community entity to shut because of economic downturn, and these are real losses, but to lose their only primary care practice or one of the few in an area really is a matter of life and death for many communities.” Read more.
 

Surge in out-of-hospital cardiac arrests

The COVID-19 pandemic in New York City led to a surge in out-of-hospital cardiac arrests that placed a huge burden on first responders, according to a new analysis.

During the height of the pandemic in New York, there was a “dramatic increase in cardiopulmonary arrests, nearly all presented in non-shockable cardiac rhythms (> 90% fatality rate) and vulnerable patient populations were most affected,” David J. Prezant, MD, chief medical officer, Fire Department of New York (FDNY), said in an interview.

In a news release, Dr. Prezant noted that “relatively few, if any, patients were tested to confirm the presence of COVID-19,” making it impossible to distinguish between cardiac arrests as a result of COVID-19 and those that may have resulted from other health conditions.

“We also can’t rule out the possibility that some people may have died from delays in seeking or receiving treatment for non–COVID-19-related conditions. However, the dramatic increase in cardiac arrests compared to the same period in 2019 strongly indicates that the pandemic was directly or indirectly responsible for that surge in cardiac arrests and deaths,” said Dr. Prezant.

The study was published online June 19 in JAMA Cardiology.

Read more.

Fenfluramine approved for Dravet syndrome

The U.S. Food and Drug Administration has approved fenfluramine (Fintepla, Zogenix) oral solution, a Schedule IV controlled substance, for the treatment of seizures associated with Dravet syndrome in children age 2 years and older.

Dravet syndrome is a rare childhood-onset epilepsy characterized by frequent, drug-resistant convulsive seizures that may contribute to intellectual disability and impairments in motor control, behavior, and cognition, as well as an increased risk of sudden unexpected death in epilepsy.

Dravet syndrome takes a “tremendous toll on both patients and their families. Fintepla offers an additional effective treatment option for the treatment of seizures associated with Dravet syndrome,” Billy Dunn, MD, director, Office of Neuroscience in the FDA’s Center for Drug Evaluation and Research, said in a news release. Read more.

For more on COVID-19, visit our Resource Center. All of our latest news is available on MDedge.com.






 

Here are the stories our MDedge editors across specialties think you need to know about today:

Pregnant women at higher risk for severe COVID-19

Pregnant women may be at increased risk for severe COVID-19 illness, according to a report published online June 26 in Morbidity and Mortality Weekly Report.

Among reproductive-aged women (15-44 years) infected with SARS-CoV-2, pregnancy was associated with a greater likelihood of hospitalization, admission to the intensive care unit (ICU), and mechanical ventilation, but not death. Pregnant women were 5.4 times more likely to be hospitalized, 1.5 times more likely to be admitted to the ICU, and 1.7 times more likely to need mechanical ventilation, after adjustment for age, underlying conditions, and race/ethnicity.  

CDC researchers said that preventing COVID-19 infection in pregnant women should be a priority and any potential barriers to compliance with preventive measures need to be removed.

“During pregnancy, women experience immunologic and physiologic changes that could increase their risk for more severe illness from respiratory infections,” they wrote. Read more.

Going out of business: Primary care practices at risk

In a recently published editorial, Tom Frieden, MD, MPH, former head of the Centers for Disease Control and Prevention, argued that primary care is in deep trouble, its long-standing financial problems exacerbated by the fallout from the COVID-19 pandemic. In an interview with Kenny Lin, MD, MPH, a family physician, Dr. Frieden discussed the future of primary care.

Here is a sample of Dr. Frieden’s observations:

“When I’ve looked around the United States, I’ve been extremely concerned about both the risk that primary care practitioners are subjected to in their everyday practice and the economic risk that we could lose many of our primary care practices around the country. It’s really striking to see that the number of visits has plummeted. Because of our payment structure, that means incomes have plummeted. We’re hearing about doctors’ offices getting boarded up and shuttering. As I write in the piece, it’s one thing for a theater or a restaurant or another important community entity to shut because of economic downturn, and these are real losses, but to lose their only primary care practice or one of the few in an area really is a matter of life and death for many communities.” Read more.
 

Surge in out-of-hospital cardiac arrests

The COVID-19 pandemic in New York City led to a surge in out-of-hospital cardiac arrests that placed a huge burden on first responders, according to a new analysis.

During the height of the pandemic in New York, there was a “dramatic increase in cardiopulmonary arrests, nearly all presented in non-shockable cardiac rhythms (> 90% fatality rate) and vulnerable patient populations were most affected,” David J. Prezant, MD, chief medical officer, Fire Department of New York (FDNY), said in an interview.

In a news release, Dr. Prezant noted that “relatively few, if any, patients were tested to confirm the presence of COVID-19,” making it impossible to distinguish between cardiac arrests as a result of COVID-19 and those that may have resulted from other health conditions.

“We also can’t rule out the possibility that some people may have died from delays in seeking or receiving treatment for non–COVID-19-related conditions. However, the dramatic increase in cardiac arrests compared to the same period in 2019 strongly indicates that the pandemic was directly or indirectly responsible for that surge in cardiac arrests and deaths,” said Dr. Prezant.

The study was published online June 19 in JAMA Cardiology.

Read more.

Fenfluramine approved for Dravet syndrome

The U.S. Food and Drug Administration has approved fenfluramine (Fintepla, Zogenix) oral solution, a Schedule IV controlled substance, for the treatment of seizures associated with Dravet syndrome in children age 2 years and older.

Dravet syndrome is a rare childhood-onset epilepsy characterized by frequent, drug-resistant convulsive seizures that may contribute to intellectual disability and impairments in motor control, behavior, and cognition, as well as an increased risk of sudden unexpected death in epilepsy.

Dravet syndrome takes a “tremendous toll on both patients and their families. Fintepla offers an additional effective treatment option for the treatment of seizures associated with Dravet syndrome,” Billy Dunn, MD, director, Office of Neuroscience in the FDA’s Center for Drug Evaluation and Research, said in a news release. Read more.

For more on COVID-19, visit our Resource Center. All of our latest news is available on MDedge.com.






 

Here are the stories our MDedge editors across specialties think you need to know about today:

Pregnant women at higher risk for severe COVID-19

Pregnant women may be at increased risk for severe COVID-19 illness, according to a report published online June 26 in Morbidity and Mortality Weekly Report.

Among reproductive-aged women (15-44 years) infected with SARS-CoV-2, pregnancy was associated with a greater likelihood of hospitalization, admission to the intensive care unit (ICU), and mechanical ventilation, but not death. Pregnant women were 5.4 times more likely to be hospitalized, 1.5 times more likely to be admitted to the ICU, and 1.7 times more likely to need mechanical ventilation, after adjustment for age, underlying conditions, and race/ethnicity.  

CDC researchers said that preventing COVID-19 infection in pregnant women should be a priority and any potential barriers to compliance with preventive measures need to be removed.

“During pregnancy, women experience immunologic and physiologic changes that could increase their risk for more severe illness from respiratory infections,” they wrote. Read more.

Going out of business: Primary care practices at risk

In a recently published editorial, Tom Frieden, MD, MPH, former head of the Centers for Disease Control and Prevention, argued that primary care is in deep trouble, its long-standing financial problems exacerbated by the fallout from the COVID-19 pandemic. In an interview with Kenny Lin, MD, MPH, a family physician, Dr. Frieden discussed the future of primary care.

Here is a sample of Dr. Frieden’s observations:

“When I’ve looked around the United States, I’ve been extremely concerned about both the risk that primary care practitioners are subjected to in their everyday practice and the economic risk that we could lose many of our primary care practices around the country. It’s really striking to see that the number of visits has plummeted. Because of our payment structure, that means incomes have plummeted. We’re hearing about doctors’ offices getting boarded up and shuttering. As I write in the piece, it’s one thing for a theater or a restaurant or another important community entity to shut because of economic downturn, and these are real losses, but to lose their only primary care practice or one of the few in an area really is a matter of life and death for many communities.” Read more.
 

Surge in out-of-hospital cardiac arrests

The COVID-19 pandemic in New York City led to a surge in out-of-hospital cardiac arrests that placed a huge burden on first responders, according to a new analysis.

During the height of the pandemic in New York, there was a “dramatic increase in cardiopulmonary arrests, nearly all presented in non-shockable cardiac rhythms (> 90% fatality rate) and vulnerable patient populations were most affected,” David J. Prezant, MD, chief medical officer, Fire Department of New York (FDNY), said in an interview.

In a news release, Dr. Prezant noted that “relatively few, if any, patients were tested to confirm the presence of COVID-19,” making it impossible to distinguish between cardiac arrests as a result of COVID-19 and those that may have resulted from other health conditions.

“We also can’t rule out the possibility that some people may have died from delays in seeking or receiving treatment for non–COVID-19-related conditions. However, the dramatic increase in cardiac arrests compared to the same period in 2019 strongly indicates that the pandemic was directly or indirectly responsible for that surge in cardiac arrests and deaths,” said Dr. Prezant.

The study was published online June 19 in JAMA Cardiology.

Read more.

Fenfluramine approved for Dravet syndrome

The U.S. Food and Drug Administration has approved fenfluramine (Fintepla, Zogenix) oral solution, a Schedule IV controlled substance, for the treatment of seizures associated with Dravet syndrome in children age 2 years and older.

Dravet syndrome is a rare childhood-onset epilepsy characterized by frequent, drug-resistant convulsive seizures that may contribute to intellectual disability and impairments in motor control, behavior, and cognition, as well as an increased risk of sudden unexpected death in epilepsy.

Dravet syndrome takes a “tremendous toll on both patients and their families. Fintepla offers an additional effective treatment option for the treatment of seizures associated with Dravet syndrome,” Billy Dunn, MD, director, Office of Neuroscience in the FDA’s Center for Drug Evaluation and Research, said in a news release. Read more.

For more on COVID-19, visit our Resource Center. All of our latest news is available on MDedge.com.






 

Patients with schizophrenia appear to prefer long-acting injectable (LAI) antipsychotics, compared with oral versions of these medications, primarily because injectables are more convenient and give individuals more control over their lives, new research shows.

Patients also prefer injections once every 3 months to monthly injections, citing the need for fewer doctor visits and less pain as key reasons. They also reported a preference for deltoid versus gluteal injections, as they were faster and easier to administer, and less embarrassing.

Study investigator Srihari Gopal, MD, senior director at Janssen Research and Development in Titusville, N.J., said in an interview that stigma, which is a “is a really powerful force in mental health treatment,” underlies these findings in terms of the disease itself and its management.

“It’s one of the [key] reasons that schizophrenia patients decide to abandon their drugs and not go to the doctor,” he added.

The study was scheduled to be presented at the Congress of the Schizophrenia International Research Society 2020, but the meeting was canceled because of the coronavirus pandemic.
 

Outdated perceptions

The investigators noted that there is limited information on patient preference with regard to LAI versus oral antipsychotics in the management of schizophrenia.

They also noted that LAIs have been shown to reduce the risk of relapse and rehospitalization because of treatment discontinuation and may help to improve to medication adherence.

However, these medications are still underutilized in clinical practice. Dr. Gopal estimated that only around 1 in 10 patients with schizophrenia in the United States take an LAI, although that figure varies considerably at a global level and is as high as 1 in 2 in Spain.

This is the result of a number of factors that act as potential barriers to LAI use, not the least of which is misconceptions among caregiver and health care professionals about the drugs.

“When I first was in medical school, this was in the 1990s ... there were really only first-generation antipsychotics available in a depot or a long-acting form, and those had very severe side effects,” said Dr. Gopal.

“They would tend to cause all sorts of movement disorders and would make patients feel really drowsy throughout the day, so they really hated taking them,” he said, noting that these depot medications were oil based, which was painful on injection and caused reactions.

While the newer generations of LAIs are water based and have a much-improved adverse effect profile, doctors “on my end of the age spectrum have all those negative connotations and memories in their minds about what these older LAIs were like, ” Dr. Gopal said

“It’s only the newer generation of doctors who were not around at the time that have a more forward-thinking attitude about the newer long-actings.”
 

Differences by country

To assess factors that determine patients’ medication preferences in order to better understand expectations and reduce potential barriers to treatment, the researchers analyzed data on 1,429 patients with schizophrenia who were participants in a double-blind, randomized, noninferiority study of paliperidone palmitate taken monthly versus once every 3 months.

Participants had a mean age of 38.4 years, and 55% were men. The majority (54%) were white, 8% were black or African American, and 38% were from other races. About one-eighth (12%) of the patients were from the United States.

LAIs were preferred by 77% of patients, ranging from 84.2% among whites, 57.7% among blacks, and 71.2% from other races. The highest preference for LAIs was in Europe, at 88%, vs 59.1% in the United States and 70.7% in the rest of the world.

Interestingly, the preference for LAIs in the United States was comparable across different races, at 59.6% among black patients, 58.8% among whites, and 57.1% for other races.

All study participants had a confirmed diagnosis of schizophrenia and a Positive and Negative Syndrome Scale total score of between 70 and 120 at baseline, with worsening symptoms.

They completed the Medication Preference Questionnaire on day 1, day 120, and at the end of the study, with the current analysis focusing on day 1 responses, as that was the only time when patients would not have received any study medication.
 

Patient empowerment key

The most common reason patients cited for preferring LAIs over oral antipsychotics were that they felt healthier (57%), could get back to their favorite activities (56%), and didn’t have to think about taking their medication (54%).

In terms of their personal experiences, patients preferred LAIs to pills because they “are easier for me” (67% vs. 18%) and offered a greater sense of control and relieved them from having to think about taking medication (64% vs. 14%).

Finally, 50% of patients preferred LAI injections once every 3 months versus 38% for monthly and 3% for daily injections. Main reason cited were fewer injections (96%), less pain (84%), and fewer doctor visits (80%).

The preferred site for LAI injection was deltoid muscle over gluteal muscle, at 59%, with faster administration (63%), easier use (51%), and the location being less embarrassing (44%) cited as the primary reasons.

“Overall, patient empowerment and quality of life–related goals were important for patients who preferred LAI antipsychotics,” the investigators noted.

Logistic regression analysis indicated that only race and country were significantly associated with medication preferences, with white patients significantly more likely than others to prefer LAIs versus oral medications (adjusted odds ratio, 2.39; P < .001). U.S. patients were significantly less likely to prefer the drugs than those from other countries (aOR, 0.41; P < .001).

Dr. Gopal added that significant differences in patient preference for LAIs likely have a lot to do with the prevailing attitudes of doctors from different countries, with low LAI use corresponding to “more negative attitudes.”

“Better understanding of patients’ treatment priorities and perspective could help overcome barriers to LAI use and inform best course of personalized schizophrenia treatment for improved patient satisfaction and medication adherence,” the investigators noted.

Approached for comment, Matej Markota, MD, a psychiatrist at the Mayo Clinic in Rochester, Minn., who was not involved with the research, said that he agreed with the findings of the study.

He said in an interview that, in his clinical experience, the convenience of not having to take medications daily is an important factor that drives patient preference for LAI use over oral medications.

The study was funded by Janssen Research & Development. Dr. Gopal reports he is an employee of Janssen Research & Developmentand owns stock/equity in Johnson & Johnson. Dr. Markota has disclosed no relevant financial relationships.

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

Patients with schizophrenia appear to prefer long-acting injectable (LAI) antipsychotics, compared with oral versions of these medications, primarily because injectables are more convenient and give individuals more control over their lives, new research shows.

Patients also prefer injections once every 3 months to monthly injections, citing the need for fewer doctor visits and less pain as key reasons. They also reported a preference for deltoid versus gluteal injections, as they were faster and easier to administer, and less embarrassing.

Study investigator Srihari Gopal, MD, senior director at Janssen Research and Development in Titusville, N.J., said in an interview that stigma, which is a “is a really powerful force in mental health treatment,” underlies these findings in terms of the disease itself and its management.

“It’s one of the [key] reasons that schizophrenia patients decide to abandon their drugs and not go to the doctor,” he added.

The study was scheduled to be presented at the Congress of the Schizophrenia International Research Society 2020, but the meeting was canceled because of the coronavirus pandemic.
 

Outdated perceptions

The investigators noted that there is limited information on patient preference with regard to LAI versus oral antipsychotics in the management of schizophrenia.

They also noted that LAIs have been shown to reduce the risk of relapse and rehospitalization because of treatment discontinuation and may help to improve to medication adherence.

However, these medications are still underutilized in clinical practice. Dr. Gopal estimated that only around 1 in 10 patients with schizophrenia in the United States take an LAI, although that figure varies considerably at a global level and is as high as 1 in 2 in Spain.

This is the result of a number of factors that act as potential barriers to LAI use, not the least of which is misconceptions among caregiver and health care professionals about the drugs.

“When I first was in medical school, this was in the 1990s ... there were really only first-generation antipsychotics available in a depot or a long-acting form, and those had very severe side effects,” said Dr. Gopal.

“They would tend to cause all sorts of movement disorders and would make patients feel really drowsy throughout the day, so they really hated taking them,” he said, noting that these depot medications were oil based, which was painful on injection and caused reactions.

While the newer generations of LAIs are water based and have a much-improved adverse effect profile, doctors “on my end of the age spectrum have all those negative connotations and memories in their minds about what these older LAIs were like, ” Dr. Gopal said

“It’s only the newer generation of doctors who were not around at the time that have a more forward-thinking attitude about the newer long-actings.”
 

Differences by country

To assess factors that determine patients’ medication preferences in order to better understand expectations and reduce potential barriers to treatment, the researchers analyzed data on 1,429 patients with schizophrenia who were participants in a double-blind, randomized, noninferiority study of paliperidone palmitate taken monthly versus once every 3 months.

Participants had a mean age of 38.4 years, and 55% were men. The majority (54%) were white, 8% were black or African American, and 38% were from other races. About one-eighth (12%) of the patients were from the United States.

LAIs were preferred by 77% of patients, ranging from 84.2% among whites, 57.7% among blacks, and 71.2% from other races. The highest preference for LAIs was in Europe, at 88%, vs 59.1% in the United States and 70.7% in the rest of the world.

Interestingly, the preference for LAIs in the United States was comparable across different races, at 59.6% among black patients, 58.8% among whites, and 57.1% for other races.

All study participants had a confirmed diagnosis of schizophrenia and a Positive and Negative Syndrome Scale total score of between 70 and 120 at baseline, with worsening symptoms.

They completed the Medication Preference Questionnaire on day 1, day 120, and at the end of the study, with the current analysis focusing on day 1 responses, as that was the only time when patients would not have received any study medication.
 

Patient empowerment key

The most common reason patients cited for preferring LAIs over oral antipsychotics were that they felt healthier (57%), could get back to their favorite activities (56%), and didn’t have to think about taking their medication (54%).

In terms of their personal experiences, patients preferred LAIs to pills because they “are easier for me” (67% vs. 18%) and offered a greater sense of control and relieved them from having to think about taking medication (64% vs. 14%).

Finally, 50% of patients preferred LAI injections once every 3 months versus 38% for monthly and 3% for daily injections. Main reason cited were fewer injections (96%), less pain (84%), and fewer doctor visits (80%).

The preferred site for LAI injection was deltoid muscle over gluteal muscle, at 59%, with faster administration (63%), easier use (51%), and the location being less embarrassing (44%) cited as the primary reasons.

“Overall, patient empowerment and quality of life–related goals were important for patients who preferred LAI antipsychotics,” the investigators noted.

Logistic regression analysis indicated that only race and country were significantly associated with medication preferences, with white patients significantly more likely than others to prefer LAIs versus oral medications (adjusted odds ratio, 2.39; P < .001). U.S. patients were significantly less likely to prefer the drugs than those from other countries (aOR, 0.41; P < .001).

Dr. Gopal added that significant differences in patient preference for LAIs likely have a lot to do with the prevailing attitudes of doctors from different countries, with low LAI use corresponding to “more negative attitudes.”

“Better understanding of patients’ treatment priorities and perspective could help overcome barriers to LAI use and inform best course of personalized schizophrenia treatment for improved patient satisfaction and medication adherence,” the investigators noted.

Approached for comment, Matej Markota, MD, a psychiatrist at the Mayo Clinic in Rochester, Minn., who was not involved with the research, said that he agreed with the findings of the study.

He said in an interview that, in his clinical experience, the convenience of not having to take medications daily is an important factor that drives patient preference for LAI use over oral medications.

The study was funded by Janssen Research & Development. Dr. Gopal reports he is an employee of Janssen Research & Developmentand owns stock/equity in Johnson & Johnson. Dr. Markota has disclosed no relevant financial relationships.

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

Patients with schizophrenia appear to prefer long-acting injectable (LAI) antipsychotics, compared with oral versions of these medications, primarily because injectables are more convenient and give individuals more control over their lives, new research shows.

Patients also prefer injections once every 3 months to monthly injections, citing the need for fewer doctor visits and less pain as key reasons. They also reported a preference for deltoid versus gluteal injections, as they were faster and easier to administer, and less embarrassing.

Study investigator Srihari Gopal, MD, senior director at Janssen Research and Development in Titusville, N.J., said in an interview that stigma, which is a “is a really powerful force in mental health treatment,” underlies these findings in terms of the disease itself and its management.

“It’s one of the [key] reasons that schizophrenia patients decide to abandon their drugs and not go to the doctor,” he added.

The study was scheduled to be presented at the Congress of the Schizophrenia International Research Society 2020, but the meeting was canceled because of the coronavirus pandemic.
 

Outdated perceptions

The investigators noted that there is limited information on patient preference with regard to LAI versus oral antipsychotics in the management of schizophrenia.

They also noted that LAIs have been shown to reduce the risk of relapse and rehospitalization because of treatment discontinuation and may help to improve to medication adherence.

However, these medications are still underutilized in clinical practice. Dr. Gopal estimated that only around 1 in 10 patients with schizophrenia in the United States take an LAI, although that figure varies considerably at a global level and is as high as 1 in 2 in Spain.

This is the result of a number of factors that act as potential barriers to LAI use, not the least of which is misconceptions among caregiver and health care professionals about the drugs.

“When I first was in medical school, this was in the 1990s ... there were really only first-generation antipsychotics available in a depot or a long-acting form, and those had very severe side effects,” said Dr. Gopal.

“They would tend to cause all sorts of movement disorders and would make patients feel really drowsy throughout the day, so they really hated taking them,” he said, noting that these depot medications were oil based, which was painful on injection and caused reactions.

While the newer generations of LAIs are water based and have a much-improved adverse effect profile, doctors “on my end of the age spectrum have all those negative connotations and memories in their minds about what these older LAIs were like, ” Dr. Gopal said

“It’s only the newer generation of doctors who were not around at the time that have a more forward-thinking attitude about the newer long-actings.”
 

Differences by country

To assess factors that determine patients’ medication preferences in order to better understand expectations and reduce potential barriers to treatment, the researchers analyzed data on 1,429 patients with schizophrenia who were participants in a double-blind, randomized, noninferiority study of paliperidone palmitate taken monthly versus once every 3 months.

Participants had a mean age of 38.4 years, and 55% were men. The majority (54%) were white, 8% were black or African American, and 38% were from other races. About one-eighth (12%) of the patients were from the United States.

LAIs were preferred by 77% of patients, ranging from 84.2% among whites, 57.7% among blacks, and 71.2% from other races. The highest preference for LAIs was in Europe, at 88%, vs 59.1% in the United States and 70.7% in the rest of the world.

Interestingly, the preference for LAIs in the United States was comparable across different races, at 59.6% among black patients, 58.8% among whites, and 57.1% for other races.

All study participants had a confirmed diagnosis of schizophrenia and a Positive and Negative Syndrome Scale total score of between 70 and 120 at baseline, with worsening symptoms.

They completed the Medication Preference Questionnaire on day 1, day 120, and at the end of the study, with the current analysis focusing on day 1 responses, as that was the only time when patients would not have received any study medication.
 

Patient empowerment key

The most common reason patients cited for preferring LAIs over oral antipsychotics were that they felt healthier (57%), could get back to their favorite activities (56%), and didn’t have to think about taking their medication (54%).

In terms of their personal experiences, patients preferred LAIs to pills because they “are easier for me” (67% vs. 18%) and offered a greater sense of control and relieved them from having to think about taking medication (64% vs. 14%).

Finally, 50% of patients preferred LAI injections once every 3 months versus 38% for monthly and 3% for daily injections. Main reason cited were fewer injections (96%), less pain (84%), and fewer doctor visits (80%).

The preferred site for LAI injection was deltoid muscle over gluteal muscle, at 59%, with faster administration (63%), easier use (51%), and the location being less embarrassing (44%) cited as the primary reasons.

“Overall, patient empowerment and quality of life–related goals were important for patients who preferred LAI antipsychotics,” the investigators noted.

Logistic regression analysis indicated that only race and country were significantly associated with medication preferences, with white patients significantly more likely than others to prefer LAIs versus oral medications (adjusted odds ratio, 2.39; P < .001). U.S. patients were significantly less likely to prefer the drugs than those from other countries (aOR, 0.41; P < .001).

Dr. Gopal added that significant differences in patient preference for LAIs likely have a lot to do with the prevailing attitudes of doctors from different countries, with low LAI use corresponding to “more negative attitudes.”

“Better understanding of patients’ treatment priorities and perspective could help overcome barriers to LAI use and inform best course of personalized schizophrenia treatment for improved patient satisfaction and medication adherence,” the investigators noted.

Approached for comment, Matej Markota, MD, a psychiatrist at the Mayo Clinic in Rochester, Minn., who was not involved with the research, said that he agreed with the findings of the study.

He said in an interview that, in his clinical experience, the convenience of not having to take medications daily is an important factor that drives patient preference for LAI use over oral medications.

The study was funded by Janssen Research & Development. Dr. Gopal reports he is an employee of Janssen Research & Developmentand owns stock/equity in Johnson & Johnson. Dr. Markota has disclosed no relevant financial relationships.

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