Clinical Psychiatry News

Early evidence suggests that opioid overdoses and deaths are on the rise this year, the director of the National Institute on Drug Abuse warned colleagues, although it’s not clear whether the coronavirus pandemic is responsible for the trend.

The picture is complicated since COVID-19 could have both positive and negative effects on substance use, Nora D. Volkow, MD, said in a plenary session at the virtual annual meeting of the College on Problems of Drug Dependence. However, she said, one thing is clear: The pandemic marks an opportunity to investigate new strategies and potentially reform treatment.

“We are being faced with an unknown world, and the lack of information curtails our capacity to implement interventions in the most effective way,” Dr. Volkow said. “There’s an urgency to obtain these data. All of you out there in the trenches have an opportunity to help gather this information in a way that can be integrated and deployed rapidly for us to guide practices and treatment.”

It’s too early to know for certain how the pandemic is affecting substance use in the United States, since statistics are sparse and COVID-19 is still relatively new. Still, local news reports have suggested overdose deaths have risen, Dr. Volkow said.

And, she noted, the Office of National Drug Control Policy’s Overdose Detection Mapping Application Program – which tracks overdoses nationwide – issued 191% more “spike alerts” from January to April this year, compared with the same time period in 2019. However, the spike alerts started going up in January, several weeks before mass numbers of COVID-19 cases began to be diagnosed.

Dr. Volkow noted the uncertainty about the numbers but said several factors could cause the pandemic to boost overdoses:

• Stress and isolation. “My first fear was that overdoses are going to go up because the stress is actually extraordinarily difficult,” she said. “Social distancing is making it very difficult for individuals with substance use disorder or opioid use disorder to get the community support that keeps them from relapsing,” such as methadone clinics and syringe exchange programs.
• Unwitnessed opioid overdoses. Social distancing could “lead to overdoses that nobody has observed, so no one can administer naloxone,” she said.
• Treatment decisions affected by stigma. “Our health systems will be overburdened, and they have to make decisions about which patients to treat,” she said. Stigma could play a very important role in interfering with the treatment of individuals with substance use disorders.”
• Drug-related vulnerabilities. On another front, she said, substance users may be especially vulnerable to the pandemic, because the drugs target multiple body systems that worsen COVID-19 outcomes. These include not only the lungs but also the cardiac and metabolic systems, she said.

For example, “if you have a long history of drug use, you’re going to be much more likely to have a pulmonary disease,” she said. “We know that pulmonary disease is a risk factor for getting COVID and for much worse outcomes.”

But the pandemic could also help in the fight against substance use. For one thing, she said, the pandemic could disrupt drug markets and make it harder for users to get illicit products.

In yet another complication, there is an ongoing debate over whether tobacco use could actually be protective against COVID-19. Research into nicotine patches as a treatment is in the works, she said.

What now? Dr. Volkow said one priority going forward should be an evaluation of virtual medicine. “We have virtual technologies that have enabled us to do telemedicine to provide mental health support and hotlines, as well as virtual support meetings,” she said. “These have proliferated and have served to a certain extent to compensate for some of the deficit from the erosion of the community support systems that exist.”

Now, she said, we should evaluate which interventions are effective, which patients they help, and the components that make them work.

There are other opportunities for useful investigations, she said. For example, researchers could examine the effects of COVID-related changes in policy, such as the federal government allowing more methadone users to take doses home and expanded telemedicine policy allowing more remote prescriptions.

“If we can show that the outcomes are as good or better [than before] then we may be able to transform these practices that make it so very difficult for so many patients to get access to treatment and to sustain treatment – but have not been questioned for years and years.”

Dr. Volkow reported no relevant disclosures.

Early evidence suggests that opioid overdoses and deaths are on the rise this year, the director of the National Institute on Drug Abuse warned colleagues, although it’s not clear whether the coronavirus pandemic is responsible for the trend.

The picture is complicated since COVID-19 could have both positive and negative effects on substance use, Nora D. Volkow, MD, said in a plenary session at the virtual annual meeting of the College on Problems of Drug Dependence. However, she said, one thing is clear: The pandemic marks an opportunity to investigate new strategies and potentially reform treatment.

“We are being faced with an unknown world, and the lack of information curtails our capacity to implement interventions in the most effective way,” Dr. Volkow said. “There’s an urgency to obtain these data. All of you out there in the trenches have an opportunity to help gather this information in a way that can be integrated and deployed rapidly for us to guide practices and treatment.”

It’s too early to know for certain how the pandemic is affecting substance use in the United States, since statistics are sparse and COVID-19 is still relatively new. Still, local news reports have suggested overdose deaths have risen, Dr. Volkow said.

And, she noted, the Office of National Drug Control Policy’s Overdose Detection Mapping Application Program – which tracks overdoses nationwide – issued 191% more “spike alerts” from January to April this year, compared with the same time period in 2019. However, the spike alerts started going up in January, several weeks before mass numbers of COVID-19 cases began to be diagnosed.

Dr. Volkow noted the uncertainty about the numbers but said several factors could cause the pandemic to boost overdoses:

• Stress and isolation. “My first fear was that overdoses are going to go up because the stress is actually extraordinarily difficult,” she said. “Social distancing is making it very difficult for individuals with substance use disorder or opioid use disorder to get the community support that keeps them from relapsing,” such as methadone clinics and syringe exchange programs.
• Unwitnessed opioid overdoses. Social distancing could “lead to overdoses that nobody has observed, so no one can administer naloxone,” she said.
• Treatment decisions affected by stigma. “Our health systems will be overburdened, and they have to make decisions about which patients to treat,” she said. Stigma could play a very important role in interfering with the treatment of individuals with substance use disorders.”
• Drug-related vulnerabilities. On another front, she said, substance users may be especially vulnerable to the pandemic, because the drugs target multiple body systems that worsen COVID-19 outcomes. These include not only the lungs but also the cardiac and metabolic systems, she said.

For example, “if you have a long history of drug use, you’re going to be much more likely to have a pulmonary disease,” she said. “We know that pulmonary disease is a risk factor for getting COVID and for much worse outcomes.”

But the pandemic could also help in the fight against substance use. For one thing, she said, the pandemic could disrupt drug markets and make it harder for users to get illicit products.

In yet another complication, there is an ongoing debate over whether tobacco use could actually be protective against COVID-19. Research into nicotine patches as a treatment is in the works, she said.

What now? Dr. Volkow said one priority going forward should be an evaluation of virtual medicine. “We have virtual technologies that have enabled us to do telemedicine to provide mental health support and hotlines, as well as virtual support meetings,” she said. “These have proliferated and have served to a certain extent to compensate for some of the deficit from the erosion of the community support systems that exist.”

Now, she said, we should evaluate which interventions are effective, which patients they help, and the components that make them work.

There are other opportunities for useful investigations, she said. For example, researchers could examine the effects of COVID-related changes in policy, such as the federal government allowing more methadone users to take doses home and expanded telemedicine policy allowing more remote prescriptions.

“If we can show that the outcomes are as good or better [than before] then we may be able to transform these practices that make it so very difficult for so many patients to get access to treatment and to sustain treatment – but have not been questioned for years and years.”

Dr. Volkow reported no relevant disclosures.

Early evidence suggests that opioid overdoses and deaths are on the rise this year, the director of the National Institute on Drug Abuse warned colleagues, although it’s not clear whether the coronavirus pandemic is responsible for the trend.

The picture is complicated since COVID-19 could have both positive and negative effects on substance use, Nora D. Volkow, MD, said in a plenary session at the virtual annual meeting of the College on Problems of Drug Dependence. However, she said, one thing is clear: The pandemic marks an opportunity to investigate new strategies and potentially reform treatment.

“We are being faced with an unknown world, and the lack of information curtails our capacity to implement interventions in the most effective way,” Dr. Volkow said. “There’s an urgency to obtain these data. All of you out there in the trenches have an opportunity to help gather this information in a way that can be integrated and deployed rapidly for us to guide practices and treatment.”

It’s too early to know for certain how the pandemic is affecting substance use in the United States, since statistics are sparse and COVID-19 is still relatively new. Still, local news reports have suggested overdose deaths have risen, Dr. Volkow said.

And, she noted, the Office of National Drug Control Policy’s Overdose Detection Mapping Application Program – which tracks overdoses nationwide – issued 191% more “spike alerts” from January to April this year, compared with the same time period in 2019. However, the spike alerts started going up in January, several weeks before mass numbers of COVID-19 cases began to be diagnosed.

Dr. Volkow noted the uncertainty about the numbers but said several factors could cause the pandemic to boost overdoses:

• Stress and isolation. “My first fear was that overdoses are going to go up because the stress is actually extraordinarily difficult,” she said. “Social distancing is making it very difficult for individuals with substance use disorder or opioid use disorder to get the community support that keeps them from relapsing,” such as methadone clinics and syringe exchange programs.
• Unwitnessed opioid overdoses. Social distancing could “lead to overdoses that nobody has observed, so no one can administer naloxone,” she said.
• Treatment decisions affected by stigma. “Our health systems will be overburdened, and they have to make decisions about which patients to treat,” she said. Stigma could play a very important role in interfering with the treatment of individuals with substance use disorders.”
• Drug-related vulnerabilities. On another front, she said, substance users may be especially vulnerable to the pandemic, because the drugs target multiple body systems that worsen COVID-19 outcomes. These include not only the lungs but also the cardiac and metabolic systems, she said.

For example, “if you have a long history of drug use, you’re going to be much more likely to have a pulmonary disease,” she said. “We know that pulmonary disease is a risk factor for getting COVID and for much worse outcomes.”

But the pandemic could also help in the fight against substance use. For one thing, she said, the pandemic could disrupt drug markets and make it harder for users to get illicit products.

In yet another complication, there is an ongoing debate over whether tobacco use could actually be protective against COVID-19. Research into nicotine patches as a treatment is in the works, she said.

What now? Dr. Volkow said one priority going forward should be an evaluation of virtual medicine. “We have virtual technologies that have enabled us to do telemedicine to provide mental health support and hotlines, as well as virtual support meetings,” she said. “These have proliferated and have served to a certain extent to compensate for some of the deficit from the erosion of the community support systems that exist.”

Now, she said, we should evaluate which interventions are effective, which patients they help, and the components that make them work.

There are other opportunities for useful investigations, she said. For example, researchers could examine the effects of COVID-related changes in policy, such as the federal government allowing more methadone users to take doses home and expanded telemedicine policy allowing more remote prescriptions.

“If we can show that the outcomes are as good or better [than before] then we may be able to transform these practices that make it so very difficult for so many patients to get access to treatment and to sustain treatment – but have not been questioned for years and years.”

Dr. Volkow reported no relevant disclosures.

Combining four of five healthy lifestyle choices has been linked to up to a 60% reduced risk for Alzheimer’s dementia in new research that strengthens ties between healthy behaviors and lower dementia risk. “I hope this study will motivate people to engage in a healthy lifestyle by not smoking, being physically and cognitively active, and having a high-quality diet,” lead investigator Klodian Dhana, MD, PhD, department of internal medicine, Rush University Medical Center, Chicago, said in an interview.

The study was published online June 17 in Neurology.
 

Risk-modifying behaviors

To help quantify the impact of a healthy life on risk for Alzheimer’s dementia, Dr. Dhana and colleagues reviewed data from two longitudinal study populations: the Chicago Health and Aging Project (CHAP), with 1,845 participants, and the Memory and Aging Project (MAP), with 920 participants.

They defined a healthy lifestyle score on the basis of the following factors: not smoking; engaging in 150 min/wk or more of physical exercise of moderate to vigorous intensity; light to moderate alcohol consumption (between 1 and less than 15 g/day for women and between 1 and less than 30 g/day for men); consuming a high-quality Mediterranean-DASH Diet Intervention for Neurodegenerative Delay diet (upper 40%); and engaging in late-life cognitive activities (upper 40%). The overall score ranged from 0 to 5.

At baseline, the mean age of participants was 73.2 years in the CHAP study and 81.1 years in the MAP study; 62.4% of the CHAP participants and 75.2% of the MAP participants were women.

During a median follow-up of 5.8 years in CHAP and 6.0 years in MAP, a total of 379 and 229 participants, respectively, developed Alzheimer’s dementia. Rates of dementia decreased with an increasing number of healthy lifestyle behaviors.

In multivariable-adjusted models across the two cohorts, the risk for Alzheimer’s dementia was 27% lower with each additional healthy lifestyle factor (pooled hazard ratio, 0.73; 95% confidence interval, 0.66-0.80).

Compared with individuals with a healthy lifestyle score of 0-1, the risk was 37% lower (pooled HR, 0.63; 95% CI, 0.47-0.84) for those with two or three healthy lifestyle factors and 60% lower (pooled HR, 0.40; 95% CI, 0.28-0.56) for those with four or five healthy lifestyle factors.

“From these findings and the fact that the lifestyle factors we studied are modifiable and in direct control of the individual, it is imperative to promote them concurrently among older adults as a strategy to delay or prevent Alzheimer’s dementia,” Dr. Dhana and colleagues concluded.

In a statement, Dallas Anderson, PhD, program director, division of neuroscience, National Institute on Aging, said the findings help “paint the picture of how multiple factors are likely playing parts in Alzheimer’s disease risk.”

“It’s not a clear cause-and-effect result, but a strong finding because of the dual data sets and combination of modifiable lifestyle factors that appear to lead to risk reduction,” Dr. Anderson added.

Essential questions remain

Commenting on the new study, Luca Giliberto, MD, PhD, neurologist with the Litwin-Zucker Research Center for Alzheimer’s Disease and Memory Disorders at the Feinstein Institutes for Medical Research in Manhasset, N.Y., said this analysis is “further demonstration that a healthy lifestyle is essential to overcome or curb” the risk for Alzheimer’s disease.

“What needs to be determined is how early should we start ‘behaving.’ We should all aim to score four to five factors across our entire lifespan, but this is not always feasible. So, when is the time to behave? Also, what is the relative weight of each of these factors?” said Dr. Giliberto.

Of note, he added, although addressing vascular risk factors such as hypertension, hyperlipidemia, and diabetes “may require an extensive mindful and logistic effort, a healthy diet is effortlessly achieved in some countries, where both the DASH and MIND diets do not need to be ‘prescribed’ but are rather culturally engraved in the population.

“This is, in part, related to the wide availability of high-quality food in these countries, which is not the same in the U.S. This work is one more demonstration of the need to revisit our take on quality of food in the U.S.,” said Dr. Giliberto.

Numerous clinical trials testing lifestyle interventions for dementia prevention are currently underway. The MIND Diet Intervention to Prevent Alzheimer’s Disease, for example, is an interventional clinical trial comparing parallel groups with two different diets. MIND has enrolled more than 600 participants and is ongoing. The anticipated completion date is 2021. Another is the U.S. Study to Protect Brain Health Through Lifestyle Intervention to Reduce Risk (U.S. POINTER), a multisite randomized clinical trial evaluating whether lifestyle interventions – including exercise, cognitively stimulating activities, and the MIND diet – may protect cognitive function in older adults who are at increased risk for cognitive decline.

Funding for the current study was provided by the National Institutes of Health and the National Institute on Aging. Dr. Dhana and Dr. Giliberto have disclosed no relevant financial relationships.

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

Combining four of five healthy lifestyle choices has been linked to up to a 60% reduced risk for Alzheimer’s dementia in new research that strengthens ties between healthy behaviors and lower dementia risk. “I hope this study will motivate people to engage in a healthy lifestyle by not smoking, being physically and cognitively active, and having a high-quality diet,” lead investigator Klodian Dhana, MD, PhD, department of internal medicine, Rush University Medical Center, Chicago, said in an interview.

The study was published online June 17 in Neurology.
 

Risk-modifying behaviors

To help quantify the impact of a healthy life on risk for Alzheimer’s dementia, Dr. Dhana and colleagues reviewed data from two longitudinal study populations: the Chicago Health and Aging Project (CHAP), with 1,845 participants, and the Memory and Aging Project (MAP), with 920 participants.

They defined a healthy lifestyle score on the basis of the following factors: not smoking; engaging in 150 min/wk or more of physical exercise of moderate to vigorous intensity; light to moderate alcohol consumption (between 1 and less than 15 g/day for women and between 1 and less than 30 g/day for men); consuming a high-quality Mediterranean-DASH Diet Intervention for Neurodegenerative Delay diet (upper 40%); and engaging in late-life cognitive activities (upper 40%). The overall score ranged from 0 to 5.

At baseline, the mean age of participants was 73.2 years in the CHAP study and 81.1 years in the MAP study; 62.4% of the CHAP participants and 75.2% of the MAP participants were women.

During a median follow-up of 5.8 years in CHAP and 6.0 years in MAP, a total of 379 and 229 participants, respectively, developed Alzheimer’s dementia. Rates of dementia decreased with an increasing number of healthy lifestyle behaviors.

In multivariable-adjusted models across the two cohorts, the risk for Alzheimer’s dementia was 27% lower with each additional healthy lifestyle factor (pooled hazard ratio, 0.73; 95% confidence interval, 0.66-0.80).

Compared with individuals with a healthy lifestyle score of 0-1, the risk was 37% lower (pooled HR, 0.63; 95% CI, 0.47-0.84) for those with two or three healthy lifestyle factors and 60% lower (pooled HR, 0.40; 95% CI, 0.28-0.56) for those with four or five healthy lifestyle factors.

“From these findings and the fact that the lifestyle factors we studied are modifiable and in direct control of the individual, it is imperative to promote them concurrently among older adults as a strategy to delay or prevent Alzheimer’s dementia,” Dr. Dhana and colleagues concluded.

In a statement, Dallas Anderson, PhD, program director, division of neuroscience, National Institute on Aging, said the findings help “paint the picture of how multiple factors are likely playing parts in Alzheimer’s disease risk.”

“It’s not a clear cause-and-effect result, but a strong finding because of the dual data sets and combination of modifiable lifestyle factors that appear to lead to risk reduction,” Dr. Anderson added.

Essential questions remain

Commenting on the new study, Luca Giliberto, MD, PhD, neurologist with the Litwin-Zucker Research Center for Alzheimer’s Disease and Memory Disorders at the Feinstein Institutes for Medical Research in Manhasset, N.Y., said this analysis is “further demonstration that a healthy lifestyle is essential to overcome or curb” the risk for Alzheimer’s disease.

“What needs to be determined is how early should we start ‘behaving.’ We should all aim to score four to five factors across our entire lifespan, but this is not always feasible. So, when is the time to behave? Also, what is the relative weight of each of these factors?” said Dr. Giliberto.

Of note, he added, although addressing vascular risk factors such as hypertension, hyperlipidemia, and diabetes “may require an extensive mindful and logistic effort, a healthy diet is effortlessly achieved in some countries, where both the DASH and MIND diets do not need to be ‘prescribed’ but are rather culturally engraved in the population.

“This is, in part, related to the wide availability of high-quality food in these countries, which is not the same in the U.S. This work is one more demonstration of the need to revisit our take on quality of food in the U.S.,” said Dr. Giliberto.

Numerous clinical trials testing lifestyle interventions for dementia prevention are currently underway. The MIND Diet Intervention to Prevent Alzheimer’s Disease, for example, is an interventional clinical trial comparing parallel groups with two different diets. MIND has enrolled more than 600 participants and is ongoing. The anticipated completion date is 2021. Another is the U.S. Study to Protect Brain Health Through Lifestyle Intervention to Reduce Risk (U.S. POINTER), a multisite randomized clinical trial evaluating whether lifestyle interventions – including exercise, cognitively stimulating activities, and the MIND diet – may protect cognitive function in older adults who are at increased risk for cognitive decline.

Funding for the current study was provided by the National Institutes of Health and the National Institute on Aging. Dr. Dhana and Dr. Giliberto have disclosed no relevant financial relationships.

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

Combining four of five healthy lifestyle choices has been linked to up to a 60% reduced risk for Alzheimer’s dementia in new research that strengthens ties between healthy behaviors and lower dementia risk. “I hope this study will motivate people to engage in a healthy lifestyle by not smoking, being physically and cognitively active, and having a high-quality diet,” lead investigator Klodian Dhana, MD, PhD, department of internal medicine, Rush University Medical Center, Chicago, said in an interview.

The study was published online June 17 in Neurology.
 

Risk-modifying behaviors

To help quantify the impact of a healthy life on risk for Alzheimer’s dementia, Dr. Dhana and colleagues reviewed data from two longitudinal study populations: the Chicago Health and Aging Project (CHAP), with 1,845 participants, and the Memory and Aging Project (MAP), with 920 participants.

They defined a healthy lifestyle score on the basis of the following factors: not smoking; engaging in 150 min/wk or more of physical exercise of moderate to vigorous intensity; light to moderate alcohol consumption (between 1 and less than 15 g/day for women and between 1 and less than 30 g/day for men); consuming a high-quality Mediterranean-DASH Diet Intervention for Neurodegenerative Delay diet (upper 40%); and engaging in late-life cognitive activities (upper 40%). The overall score ranged from 0 to 5.

At baseline, the mean age of participants was 73.2 years in the CHAP study and 81.1 years in the MAP study; 62.4% of the CHAP participants and 75.2% of the MAP participants were women.

During a median follow-up of 5.8 years in CHAP and 6.0 years in MAP, a total of 379 and 229 participants, respectively, developed Alzheimer’s dementia. Rates of dementia decreased with an increasing number of healthy lifestyle behaviors.

In multivariable-adjusted models across the two cohorts, the risk for Alzheimer’s dementia was 27% lower with each additional healthy lifestyle factor (pooled hazard ratio, 0.73; 95% confidence interval, 0.66-0.80).

Compared with individuals with a healthy lifestyle score of 0-1, the risk was 37% lower (pooled HR, 0.63; 95% CI, 0.47-0.84) for those with two or three healthy lifestyle factors and 60% lower (pooled HR, 0.40; 95% CI, 0.28-0.56) for those with four or five healthy lifestyle factors.

“From these findings and the fact that the lifestyle factors we studied are modifiable and in direct control of the individual, it is imperative to promote them concurrently among older adults as a strategy to delay or prevent Alzheimer’s dementia,” Dr. Dhana and colleagues concluded.

In a statement, Dallas Anderson, PhD, program director, division of neuroscience, National Institute on Aging, said the findings help “paint the picture of how multiple factors are likely playing parts in Alzheimer’s disease risk.”

“It’s not a clear cause-and-effect result, but a strong finding because of the dual data sets and combination of modifiable lifestyle factors that appear to lead to risk reduction,” Dr. Anderson added.

Essential questions remain

Commenting on the new study, Luca Giliberto, MD, PhD, neurologist with the Litwin-Zucker Research Center for Alzheimer’s Disease and Memory Disorders at the Feinstein Institutes for Medical Research in Manhasset, N.Y., said this analysis is “further demonstration that a healthy lifestyle is essential to overcome or curb” the risk for Alzheimer’s disease.

“What needs to be determined is how early should we start ‘behaving.’ We should all aim to score four to five factors across our entire lifespan, but this is not always feasible. So, when is the time to behave? Also, what is the relative weight of each of these factors?” said Dr. Giliberto.

Of note, he added, although addressing vascular risk factors such as hypertension, hyperlipidemia, and diabetes “may require an extensive mindful and logistic effort, a healthy diet is effortlessly achieved in some countries, where both the DASH and MIND diets do not need to be ‘prescribed’ but are rather culturally engraved in the population.

“This is, in part, related to the wide availability of high-quality food in these countries, which is not the same in the U.S. This work is one more demonstration of the need to revisit our take on quality of food in the U.S.,” said Dr. Giliberto.

Numerous clinical trials testing lifestyle interventions for dementia prevention are currently underway. The MIND Diet Intervention to Prevent Alzheimer’s Disease, for example, is an interventional clinical trial comparing parallel groups with two different diets. MIND has enrolled more than 600 participants and is ongoing. The anticipated completion date is 2021. Another is the U.S. Study to Protect Brain Health Through Lifestyle Intervention to Reduce Risk (U.S. POINTER), a multisite randomized clinical trial evaluating whether lifestyle interventions – including exercise, cognitively stimulating activities, and the MIND diet – may protect cognitive function in older adults who are at increased risk for cognitive decline.

Funding for the current study was provided by the National Institutes of Health and the National Institute on Aging. Dr. Dhana and Dr. Giliberto have disclosed no relevant financial relationships.

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

As we reopen our offices we are faced with the challenge of determining the best way to do it safely – protecting ourselves, our staff, and our patients. The Infectious Diseases Society of America recently issued an evidence-based guideline to help clinicians in developing a sound approach to this issue, and this guideline, along with recommendations from the Centers for Disease Control and Prevention, should allow us to move ahead safely.

In this column we will focus on selected details of the recommendations from IDSA and the CDC that may be helpful in primary care offices.
 

Face masks

Many clinicians have asked whether a physician should use a mask while seeing patients without COVID-19 in the office, and if yes, which type. The IDSA guideline states that mask usage is imperative for reducing the risk of health care workers contracting COVID-19.¹ The evidence is derived from a number of sources, including a retrospective study from Wuhan (China) University that examined two groups of health care workers during the outbreak. The first group wore N95 masks and washed their hands frequently, while the second group did not wear masks and washed their hands less frequently. In the group that took greater actions to protect themselves, none of the 493 staff members contracted COVID-19, compared with 10 of 213 staff members in the other group. The decrease in infection rate occurred in the group that wore masks despite the fact that this group had 733% more exposure to COVID-19 patients.² Further evidence came from a case-control study done in hospitals in Hong Kong during the 2003 SARS-CoV outbreak.³ This study showed that mask wearing was the most significant intervention for reducing infection, followed by gowning, and then handwashing. These findings make it clear that mask usage is a must for all health care providers who may be caring for patients who could have COVID-19.

The guideline also reviews evidence about the use of surgical masks versus N95 masks. On reviewing indirect evidence from the SARS-CoV epidemic, IDSA found that wearing any mask – surgical or N95 – led to a large reduction in the risk of developing an infection. In this systematic review of five observational studies in health care personnel, for those wearing surgical masks, the odds ratio for developing an infection was 0.13 (95% CI, 0.03-0.62), and for those wearing N95 masks, the odds ratio was 0.12 (95% CI, 0.06-0.26). There was not a significant difference between risk reductions for those who wore surgical masks and N95 masks, respectively.^1,4 The IDSA guideline panel recommended “that health care personnel caring for patients with suspected or known COVID-19 use either a surgical mask or N95 respirator ... as part of appropriate PPE.” Since there is not a significant difference in outcomes between those who use surgical masks and those who use N95 respirators, and the IDSA guideline states either type of mask is considered appropriate when taking care of patients with suspected or known COVID-19, in our opinion, use of surgical masks rather than N95s is sufficient when performing low-risk activities. Such activities include seeing patients who do not have a high likelihood of COVID-19 in the office setting.

The IDSA recommendation also discusses universal masking, defined as both patients and clinicians wearing masks. The recommendation is supported by the findings of a study in which universal mask usage was used to prevent the spread of H1N 1 during the 2009 outbreak. In this study of staff members and patients exposed to H1N1 who all wore masks, only 0.48% of 836 acquired infection. In the same study, not wearing a mask by either the provider or patient increased the risk of infection.⁵ Also, in a prospective study of hematopoietic stem cell transplant patients, universal masking caused infection rates to drop from 10.3% to 4.4%.⁶

The IDSA guideline states the following: “There may be some, albeit uncertain, benefit to universal masking in the absence of resource constraints. However, the benefits of universal masking with surgical masks should be weighed against the risk of increasing the PPE burn rate and contextualized to the background COVID-19 prevalence rate for asymptomatic or minimally symptomatic HCPs [health care providers] and visitors.”¹

The CDC’s guidance statement says the following: “Continued community transmission has increased the number of individuals potentially exposed to and infectious with SARS-CoV-2. Fever and symptom screening have proven to be relatively ineffective in identifying all infected individuals, including HCPs. Symptom screening also will not identify individuals who are infected but otherwise asymptomatic or pre-symptomatic; additional interventions are needed to limit the unrecognized introduction of SARS-CoV-2 into healthcare settings by these individuals. As part of aggressive source control measures, healthcare facilities should consider implementing policies requiring everyone entering the facility to wear a cloth face covering (if tolerated) while in the building, regardless of symptoms.”⁷

It is our opinion, based on the CDC and IDSA recommendations, that both clinicians and patients should be required to wear masks when patients are seen in the office if possible. Many offices have instituted a policy that says, if a patient refuses to wear a mask during an office visit, then the patient will not be seen.
 

Eye protection

Many clinicians are uncertain about whether eye protection needs to be used when seeing asymptomatic patients. The IDSA acknowledges that there are not studies that have looked critically at eye protection, but the society also acknowledges “appropriate personal protective equipment includes, in addition to a mask or respirator, eye protection, gown and gloves.”¹ In addition, the CDC recommends that, for healthcare workers located in areas with moderate or higher prevalence of COVID-19, HCPs should wear eye protection in addition to facemasks since they may encounter asymptomatic individuals with COVID-19.

Gowns and gloves

Gowns and gloves are recommended as a part of personal protective gear when caring for patients who have COVID-19. The IDSA guideline is clear in its recommendations, but does not cite evidence for having no gloves versus having gloves. Furthermore, they state that the evidence is insufficient to recommend double gloves, with the top glove used to take off a personal protective gown, and the inner glove discarded after the gown is removed. The CDC do not make recommendations for routine use of gloves in the care of patients who do not have COVID-19, even in areas where there may be asymptomatic COVID-19, and recommends standard precautions, specifically practicing hand hygiene before and after patient contact.⁸
 

The Bottom Line

When seeing patients with COVID-19, N-95 masks, goggles or face shields, gowns, and gloves should be used, with hand hygiene routinely practiced before and after seeing patients. For offices seeing patients not suspected of having COVID-19, the IDSA guideline clarifies that there is not a statistical difference in acquisition of infection with the use of surgical face masks vs N95 respirators. According to the CDC recommendations, eye protection in addition to facemasks should be used by the health care provider, and masks should be worn by patients. Hand hygiene should be used routinely before and after all patient contact. With use of these approaches, it should be safe for offices to reopen and see patients.
 

Neil Skolnik, MD, is professor of family and community medicine at the Thomas Jefferson University, Philadelphia, and associate director of the Family Medicine Residency Program at Abington (Pa.) Jefferson Health. Jeffrey Matthews, DO, is a second-year resident in the Family Medicine Residency at Abington Jefferson Health. For questions or comments, feel free to contact Dr. Skolnik on Twitter @NeilSkolnik.

References

1. Lynch JB, Davitkov P, Anderson DJ, et al. COVID-19 Guideline, Part 2: Infection Prevention. IDSA Home. https://www.idsociety.org/practice-guideline/covid-19-guideline-infection-prevention/. April 27, 2020. Accessed June 10, 2020.

2. J Hosp Infect. 2020 May;105(1):104-5.

3. Lancet. 2003;361(9368):1519-20.

4. Influenza Other Respir Viruses. 2020 Apr 4. doi: 2020;10.1111/irv.12745.

5. J Hosp Infect. 2010;74(3):271-7.

6. Clin Infect Dis. 2016;63(8):999-1006.

7. Centers for Disease Control and Prevention. Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html. Accessed Jun 16, 2020.

8. Centers for Disease Control and Prevention. Healthcare Infection Prevention and Control FAQs for COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-faq.html. Accessed June 15, 2020.
 

As we reopen our offices we are faced with the challenge of determining the best way to do it safely – protecting ourselves, our staff, and our patients. The Infectious Diseases Society of America recently issued an evidence-based guideline to help clinicians in developing a sound approach to this issue, and this guideline, along with recommendations from the Centers for Disease Control and Prevention, should allow us to move ahead safely.

In this column we will focus on selected details of the recommendations from IDSA and the CDC that may be helpful in primary care offices.
 

Face masks

Many clinicians have asked whether a physician should use a mask while seeing patients without COVID-19 in the office, and if yes, which type. The IDSA guideline states that mask usage is imperative for reducing the risk of health care workers contracting COVID-19.¹ The evidence is derived from a number of sources, including a retrospective study from Wuhan (China) University that examined two groups of health care workers during the outbreak. The first group wore N95 masks and washed their hands frequently, while the second group did not wear masks and washed their hands less frequently. In the group that took greater actions to protect themselves, none of the 493 staff members contracted COVID-19, compared with 10 of 213 staff members in the other group. The decrease in infection rate occurred in the group that wore masks despite the fact that this group had 733% more exposure to COVID-19 patients.² Further evidence came from a case-control study done in hospitals in Hong Kong during the 2003 SARS-CoV outbreak.³ This study showed that mask wearing was the most significant intervention for reducing infection, followed by gowning, and then handwashing. These findings make it clear that mask usage is a must for all health care providers who may be caring for patients who could have COVID-19.

The guideline also reviews evidence about the use of surgical masks versus N95 masks. On reviewing indirect evidence from the SARS-CoV epidemic, IDSA found that wearing any mask – surgical or N95 – led to a large reduction in the risk of developing an infection. In this systematic review of five observational studies in health care personnel, for those wearing surgical masks, the odds ratio for developing an infection was 0.13 (95% CI, 0.03-0.62), and for those wearing N95 masks, the odds ratio was 0.12 (95% CI, 0.06-0.26). There was not a significant difference between risk reductions for those who wore surgical masks and N95 masks, respectively.^1,4 The IDSA guideline panel recommended “that health care personnel caring for patients with suspected or known COVID-19 use either a surgical mask or N95 respirator ... as part of appropriate PPE.” Since there is not a significant difference in outcomes between those who use surgical masks and those who use N95 respirators, and the IDSA guideline states either type of mask is considered appropriate when taking care of patients with suspected or known COVID-19, in our opinion, use of surgical masks rather than N95s is sufficient when performing low-risk activities. Such activities include seeing patients who do not have a high likelihood of COVID-19 in the office setting.

The IDSA recommendation also discusses universal masking, defined as both patients and clinicians wearing masks. The recommendation is supported by the findings of a study in which universal mask usage was used to prevent the spread of H1N 1 during the 2009 outbreak. In this study of staff members and patients exposed to H1N1 who all wore masks, only 0.48% of 836 acquired infection. In the same study, not wearing a mask by either the provider or patient increased the risk of infection.⁵ Also, in a prospective study of hematopoietic stem cell transplant patients, universal masking caused infection rates to drop from 10.3% to 4.4%.⁶

The IDSA guideline states the following: “There may be some, albeit uncertain, benefit to universal masking in the absence of resource constraints. However, the benefits of universal masking with surgical masks should be weighed against the risk of increasing the PPE burn rate and contextualized to the background COVID-19 prevalence rate for asymptomatic or minimally symptomatic HCPs [health care providers] and visitors.”¹

The CDC’s guidance statement says the following: “Continued community transmission has increased the number of individuals potentially exposed to and infectious with SARS-CoV-2. Fever and symptom screening have proven to be relatively ineffective in identifying all infected individuals, including HCPs. Symptom screening also will not identify individuals who are infected but otherwise asymptomatic or pre-symptomatic; additional interventions are needed to limit the unrecognized introduction of SARS-CoV-2 into healthcare settings by these individuals. As part of aggressive source control measures, healthcare facilities should consider implementing policies requiring everyone entering the facility to wear a cloth face covering (if tolerated) while in the building, regardless of symptoms.”⁷

It is our opinion, based on the CDC and IDSA recommendations, that both clinicians and patients should be required to wear masks when patients are seen in the office if possible. Many offices have instituted a policy that says, if a patient refuses to wear a mask during an office visit, then the patient will not be seen.
 

Eye protection

Many clinicians are uncertain about whether eye protection needs to be used when seeing asymptomatic patients. The IDSA acknowledges that there are not studies that have looked critically at eye protection, but the society also acknowledges “appropriate personal protective equipment includes, in addition to a mask or respirator, eye protection, gown and gloves.”¹ In addition, the CDC recommends that, for healthcare workers located in areas with moderate or higher prevalence of COVID-19, HCPs should wear eye protection in addition to facemasks since they may encounter asymptomatic individuals with COVID-19.

Gowns and gloves

Gowns and gloves are recommended as a part of personal protective gear when caring for patients who have COVID-19. The IDSA guideline is clear in its recommendations, but does not cite evidence for having no gloves versus having gloves. Furthermore, they state that the evidence is insufficient to recommend double gloves, with the top glove used to take off a personal protective gown, and the inner glove discarded after the gown is removed. The CDC do not make recommendations for routine use of gloves in the care of patients who do not have COVID-19, even in areas where there may be asymptomatic COVID-19, and recommends standard precautions, specifically practicing hand hygiene before and after patient contact.⁸
 

The Bottom Line

When seeing patients with COVID-19, N-95 masks, goggles or face shields, gowns, and gloves should be used, with hand hygiene routinely practiced before and after seeing patients. For offices seeing patients not suspected of having COVID-19, the IDSA guideline clarifies that there is not a statistical difference in acquisition of infection with the use of surgical face masks vs N95 respirators. According to the CDC recommendations, eye protection in addition to facemasks should be used by the health care provider, and masks should be worn by patients. Hand hygiene should be used routinely before and after all patient contact. With use of these approaches, it should be safe for offices to reopen and see patients.
 

Neil Skolnik, MD, is professor of family and community medicine at the Thomas Jefferson University, Philadelphia, and associate director of the Family Medicine Residency Program at Abington (Pa.) Jefferson Health. Jeffrey Matthews, DO, is a second-year resident in the Family Medicine Residency at Abington Jefferson Health. For questions or comments, feel free to contact Dr. Skolnik on Twitter @NeilSkolnik.

References

1. Lynch JB, Davitkov P, Anderson DJ, et al. COVID-19 Guideline, Part 2: Infection Prevention. IDSA Home. https://www.idsociety.org/practice-guideline/covid-19-guideline-infection-prevention/. April 27, 2020. Accessed June 10, 2020.

2. J Hosp Infect. 2020 May;105(1):104-5.

3. Lancet. 2003;361(9368):1519-20.

4. Influenza Other Respir Viruses. 2020 Apr 4. doi: 2020;10.1111/irv.12745.

5. J Hosp Infect. 2010;74(3):271-7.

6. Clin Infect Dis. 2016;63(8):999-1006.

7. Centers for Disease Control and Prevention. Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html. Accessed Jun 16, 2020.

8. Centers for Disease Control and Prevention. Healthcare Infection Prevention and Control FAQs for COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-faq.html. Accessed June 15, 2020.
 

As we reopen our offices we are faced with the challenge of determining the best way to do it safely – protecting ourselves, our staff, and our patients. The Infectious Diseases Society of America recently issued an evidence-based guideline to help clinicians in developing a sound approach to this issue, and this guideline, along with recommendations from the Centers for Disease Control and Prevention, should allow us to move ahead safely.

In this column we will focus on selected details of the recommendations from IDSA and the CDC that may be helpful in primary care offices.
 

Face masks

Many clinicians have asked whether a physician should use a mask while seeing patients without COVID-19 in the office, and if yes, which type. The IDSA guideline states that mask usage is imperative for reducing the risk of health care workers contracting COVID-19.¹ The evidence is derived from a number of sources, including a retrospective study from Wuhan (China) University that examined two groups of health care workers during the outbreak. The first group wore N95 masks and washed their hands frequently, while the second group did not wear masks and washed their hands less frequently. In the group that took greater actions to protect themselves, none of the 493 staff members contracted COVID-19, compared with 10 of 213 staff members in the other group. The decrease in infection rate occurred in the group that wore masks despite the fact that this group had 733% more exposure to COVID-19 patients.² Further evidence came from a case-control study done in hospitals in Hong Kong during the 2003 SARS-CoV outbreak.³ This study showed that mask wearing was the most significant intervention for reducing infection, followed by gowning, and then handwashing. These findings make it clear that mask usage is a must for all health care providers who may be caring for patients who could have COVID-19.

The guideline also reviews evidence about the use of surgical masks versus N95 masks. On reviewing indirect evidence from the SARS-CoV epidemic, IDSA found that wearing any mask – surgical or N95 – led to a large reduction in the risk of developing an infection. In this systematic review of five observational studies in health care personnel, for those wearing surgical masks, the odds ratio for developing an infection was 0.13 (95% CI, 0.03-0.62), and for those wearing N95 masks, the odds ratio was 0.12 (95% CI, 0.06-0.26). There was not a significant difference between risk reductions for those who wore surgical masks and N95 masks, respectively.^1,4 The IDSA guideline panel recommended “that health care personnel caring for patients with suspected or known COVID-19 use either a surgical mask or N95 respirator ... as part of appropriate PPE.” Since there is not a significant difference in outcomes between those who use surgical masks and those who use N95 respirators, and the IDSA guideline states either type of mask is considered appropriate when taking care of patients with suspected or known COVID-19, in our opinion, use of surgical masks rather than N95s is sufficient when performing low-risk activities. Such activities include seeing patients who do not have a high likelihood of COVID-19 in the office setting.

The IDSA recommendation also discusses universal masking, defined as both patients and clinicians wearing masks. The recommendation is supported by the findings of a study in which universal mask usage was used to prevent the spread of H1N 1 during the 2009 outbreak. In this study of staff members and patients exposed to H1N1 who all wore masks, only 0.48% of 836 acquired infection. In the same study, not wearing a mask by either the provider or patient increased the risk of infection.⁵ Also, in a prospective study of hematopoietic stem cell transplant patients, universal masking caused infection rates to drop from 10.3% to 4.4%.⁶

The IDSA guideline states the following: “There may be some, albeit uncertain, benefit to universal masking in the absence of resource constraints. However, the benefits of universal masking with surgical masks should be weighed against the risk of increasing the PPE burn rate and contextualized to the background COVID-19 prevalence rate for asymptomatic or minimally symptomatic HCPs [health care providers] and visitors.”¹

The CDC’s guidance statement says the following: “Continued community transmission has increased the number of individuals potentially exposed to and infectious with SARS-CoV-2. Fever and symptom screening have proven to be relatively ineffective in identifying all infected individuals, including HCPs. Symptom screening also will not identify individuals who are infected but otherwise asymptomatic or pre-symptomatic; additional interventions are needed to limit the unrecognized introduction of SARS-CoV-2 into healthcare settings by these individuals. As part of aggressive source control measures, healthcare facilities should consider implementing policies requiring everyone entering the facility to wear a cloth face covering (if tolerated) while in the building, regardless of symptoms.”⁷

It is our opinion, based on the CDC and IDSA recommendations, that both clinicians and patients should be required to wear masks when patients are seen in the office if possible. Many offices have instituted a policy that says, if a patient refuses to wear a mask during an office visit, then the patient will not be seen.
 

Eye protection

Many clinicians are uncertain about whether eye protection needs to be used when seeing asymptomatic patients. The IDSA acknowledges that there are not studies that have looked critically at eye protection, but the society also acknowledges “appropriate personal protective equipment includes, in addition to a mask or respirator, eye protection, gown and gloves.”¹ In addition, the CDC recommends that, for healthcare workers located in areas with moderate or higher prevalence of COVID-19, HCPs should wear eye protection in addition to facemasks since they may encounter asymptomatic individuals with COVID-19.

Gowns and gloves

Gowns and gloves are recommended as a part of personal protective gear when caring for patients who have COVID-19. The IDSA guideline is clear in its recommendations, but does not cite evidence for having no gloves versus having gloves. Furthermore, they state that the evidence is insufficient to recommend double gloves, with the top glove used to take off a personal protective gown, and the inner glove discarded after the gown is removed. The CDC do not make recommendations for routine use of gloves in the care of patients who do not have COVID-19, even in areas where there may be asymptomatic COVID-19, and recommends standard precautions, specifically practicing hand hygiene before and after patient contact.⁸
 

The Bottom Line

When seeing patients with COVID-19, N-95 masks, goggles or face shields, gowns, and gloves should be used, with hand hygiene routinely practiced before and after seeing patients. For offices seeing patients not suspected of having COVID-19, the IDSA guideline clarifies that there is not a statistical difference in acquisition of infection with the use of surgical face masks vs N95 respirators. According to the CDC recommendations, eye protection in addition to facemasks should be used by the health care provider, and masks should be worn by patients. Hand hygiene should be used routinely before and after all patient contact. With use of these approaches, it should be safe for offices to reopen and see patients.
 

Neil Skolnik, MD, is professor of family and community medicine at the Thomas Jefferson University, Philadelphia, and associate director of the Family Medicine Residency Program at Abington (Pa.) Jefferson Health. Jeffrey Matthews, DO, is a second-year resident in the Family Medicine Residency at Abington Jefferson Health. For questions or comments, feel free to contact Dr. Skolnik on Twitter @NeilSkolnik.

References

1. Lynch JB, Davitkov P, Anderson DJ, et al. COVID-19 Guideline, Part 2: Infection Prevention. IDSA Home. https://www.idsociety.org/practice-guideline/covid-19-guideline-infection-prevention/. April 27, 2020. Accessed June 10, 2020.

2. J Hosp Infect. 2020 May;105(1):104-5.

3. Lancet. 2003;361(9368):1519-20.

4. Influenza Other Respir Viruses. 2020 Apr 4. doi: 2020;10.1111/irv.12745.

5. J Hosp Infect. 2010;74(3):271-7.

6. Clin Infect Dis. 2016;63(8):999-1006.

7. Centers for Disease Control and Prevention. Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html. Accessed Jun 16, 2020.

8. Centers for Disease Control and Prevention. Healthcare Infection Prevention and Control FAQs for COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-faq.html. Accessed June 15, 2020.
 

Selective serotonin reuptake inhibitors (SSRIs) are associated with an increased risk of committing a violent crime, an effect that may linger up to 12 weeks after treatment discontinuation, new research suggests. However, investigators say the finding should be interpreted with caution.

A large population-based study of more than 800,000 individuals showed those taking these antidepressants had an overall 2.7% increased risk of committing a violent crime while on the medications compared with when they were not taking them.

The increased risk persisted up to 12 weeks after discontinuing SSRIs and then returned to pretreatment levels. The risk was highest in younger individuals and those with a history of a prior violent crime.

“Our findings should be interpreted with caution [because] we do not know how far the association between SSRI medication and violent crime reflect causation,” lead author Tyra Lagerberg, MSc, a PhD candidate at Karolinska Institute, Sweden, said in an interview.

“Our findings should not be used as grounds for individuals to go off their [SSRI] medication or for clinicians to withhold medication from those who might benefit from it,” Ms. Lagerberg said.

The study was published online May 29 in European Neuropsychopharmacology.
 

Previous concerns

There has been “apprehension” about a possible association between SSRIs and elevated risk of aggression and violence, especially in young people, but it “remains unclear” if there is a similar risk in middle-aged and older adults, the authors noted. Moreover, it is unclear whether the risk of violence varies with time after initiating and discontinuing SSRI treatment.

To assess how the risk of violent crime might vary by age and time after SSRI treatment initiation and discontinuation, the researchers calculated absolute rates of violent crime per 1000 person-years during on- and off-treatment periods and also conducted within-group analyses.

The cohort, which was derived from several Swedish national registers, included all individuals in Sweden prescribed an SSRI between Jan. 1, 2006, and Dec. 31, 2013 (n = 785,337, 64.2% female) over an average follow-up of 7.3 years.

Some of the covariates used in the analyses included age, recent or previous violent crime, use of non-SSRI medications, sex, family income, education, county of residence, birth country, and lifetime diagnoses.
 

“Rare” effect

Almost the entire study cohort (99%) changed their SSRI treatment over the follow-up period. During this time, of the full study cohort, 2.7% committed violent crimes (21,203 crimes in 5,707,293 person-years).

More men than women were convicted of a violent crime (5.7% vs 1.0%, respectively).

Absolute rates of violent crime were lower in treated versus nontreated periods across all age categories (other than those between 15 and 24 years) when covariates were not taken into account.

However, when hazards during the on- and off-treatment periods were compared and adjusted for covariables, SSRI treatment was associated with a “modest increased” risk of violent crime (HR, 1.10) – particularly in those ages 15-25 years and ages 25–34 years (HR, 1.19 and 1.16, respectively).

Moreover, further analysis stratifying the cohort according to previous violent crime revealed that the elevated risk for violent crime convictions “seemed to be confined to the individuals with previous criminality,” compared to those with no criminal history (HR, 1.13 vs. 1.07).

The within-individual analysis included 2.6% of the overall cohort who experienced SSRI treatment switching as well as ≥1 violent event.

These individuals differed from the overall cohort in that they tended to be younger (close to half were aged 15-24 years compared with one quarter in the overall cohort) and predominantly male (77% vs. 36%, respectively).

When the hazard of violent crime was compared between individuals’ periods on and off medication, there was a significantly increased hazard during treatment in the whole cohort (HR, 1.26), but in particular, in those aged 25-34 years and 35-44 years (HR, 1.35 and 1.15, respectively).

The within-individual HRs remained elevated for up to 12 weeks post discontinuation of the SSRI (HR, 1.37 during the first 28 days; HR, 1.20 during days 29-84). Although women had a significantly elevated on-treatment hazard in the youngest age category, they had a lower incidence of crime across ages.

Treatment with benzodiazepines was associated with a significantly higher hazard of violent crime and treatment with non-SSRI antidepressants was associated with a “modest but nonsignificantly elevated” hazard.

By contrast, treatment with other psychotropic drugs was not associated with elevated risk.
 

Warn patients

Commenting on the study, Eduard Vieta, MD, PhD, professor of psychiatry, Institute of Neuroscience, University of Barcelona, Spain, and author of an accompanying editorial, said it’s still not known if the mediating factor in the increased risk of violent crime was the SSRI or the underlying mental condition that prompted the prescription.

Dr. Vieta, who was not involved with the study, added that the results “raise a note of caution in terms of making a very accurate diagnosis and treatment in patients with a history of conviction, violence, or criminality, and opting ideally for psychosocial therapies whenever possible in this population.”

Also commenting on the study, Michael Thase, MD, professor of psychiatry, University of Pennsylvania, Philadelphia, said the findings are “not easy to brush away or explain away.”

Dr. Thase, who was not involved with the study, continued, “although it is a small finding, it is also a serious problem.”

He suggested the risk should be treated in a similar way to the risk for suicidal thoughts or behaviors.

“Just as you might caution patients [initiating treatment with SSRIs] regarding that risk, you might broaden your counsel to include other types of violent behavior because the same process that provokes the risk of self-harm for a given person may be externalized and provoke harm or violence toward others.”

Ms. Lagerberg added that further research is needed to confirm their findings and “inform whether – and if so, how – clinical practice should change.”

The study was supported by the Swedish Research Council, Horizon 2020 ACTION project, Stockholm County Council, and Thurings Foundation. Ms. Lagerberg has reported no relevant financial relationships. Other author disclosures are listed in the article. Dr. Vieta and coauthors have reported no relevant financial relationships. Dr. Thase has reported consulting with and receiving research funding from many of the companies that manufacture/sell antidepressants.

This article first appeared on Medscape.com.

Selective serotonin reuptake inhibitors (SSRIs) are associated with an increased risk of committing a violent crime, an effect that may linger up to 12 weeks after treatment discontinuation, new research suggests. However, investigators say the finding should be interpreted with caution.

A large population-based study of more than 800,000 individuals showed those taking these antidepressants had an overall 2.7% increased risk of committing a violent crime while on the medications compared with when they were not taking them.

The increased risk persisted up to 12 weeks after discontinuing SSRIs and then returned to pretreatment levels. The risk was highest in younger individuals and those with a history of a prior violent crime.

“Our findings should be interpreted with caution [because] we do not know how far the association between SSRI medication and violent crime reflect causation,” lead author Tyra Lagerberg, MSc, a PhD candidate at Karolinska Institute, Sweden, said in an interview.

“Our findings should not be used as grounds for individuals to go off their [SSRI] medication or for clinicians to withhold medication from those who might benefit from it,” Ms. Lagerberg said.

The study was published online May 29 in European Neuropsychopharmacology.
 

Previous concerns

There has been “apprehension” about a possible association between SSRIs and elevated risk of aggression and violence, especially in young people, but it “remains unclear” if there is a similar risk in middle-aged and older adults, the authors noted. Moreover, it is unclear whether the risk of violence varies with time after initiating and discontinuing SSRI treatment.

To assess how the risk of violent crime might vary by age and time after SSRI treatment initiation and discontinuation, the researchers calculated absolute rates of violent crime per 1000 person-years during on- and off-treatment periods and also conducted within-group analyses.

The cohort, which was derived from several Swedish national registers, included all individuals in Sweden prescribed an SSRI between Jan. 1, 2006, and Dec. 31, 2013 (n = 785,337, 64.2% female) over an average follow-up of 7.3 years.

Some of the covariates used in the analyses included age, recent or previous violent crime, use of non-SSRI medications, sex, family income, education, county of residence, birth country, and lifetime diagnoses.
 

“Rare” effect

Almost the entire study cohort (99%) changed their SSRI treatment over the follow-up period. During this time, of the full study cohort, 2.7% committed violent crimes (21,203 crimes in 5,707,293 person-years).

More men than women were convicted of a violent crime (5.7% vs 1.0%, respectively).

Absolute rates of violent crime were lower in treated versus nontreated periods across all age categories (other than those between 15 and 24 years) when covariates were not taken into account.

However, when hazards during the on- and off-treatment periods were compared and adjusted for covariables, SSRI treatment was associated with a “modest increased” risk of violent crime (HR, 1.10) – particularly in those ages 15-25 years and ages 25–34 years (HR, 1.19 and 1.16, respectively).

Moreover, further analysis stratifying the cohort according to previous violent crime revealed that the elevated risk for violent crime convictions “seemed to be confined to the individuals with previous criminality,” compared to those with no criminal history (HR, 1.13 vs. 1.07).

The within-individual analysis included 2.6% of the overall cohort who experienced SSRI treatment switching as well as ≥1 violent event.

These individuals differed from the overall cohort in that they tended to be younger (close to half were aged 15-24 years compared with one quarter in the overall cohort) and predominantly male (77% vs. 36%, respectively).

When the hazard of violent crime was compared between individuals’ periods on and off medication, there was a significantly increased hazard during treatment in the whole cohort (HR, 1.26), but in particular, in those aged 25-34 years and 35-44 years (HR, 1.35 and 1.15, respectively).

The within-individual HRs remained elevated for up to 12 weeks post discontinuation of the SSRI (HR, 1.37 during the first 28 days; HR, 1.20 during days 29-84). Although women had a significantly elevated on-treatment hazard in the youngest age category, they had a lower incidence of crime across ages.

Treatment with benzodiazepines was associated with a significantly higher hazard of violent crime and treatment with non-SSRI antidepressants was associated with a “modest but nonsignificantly elevated” hazard.

By contrast, treatment with other psychotropic drugs was not associated with elevated risk.
 

Warn patients

Commenting on the study, Eduard Vieta, MD, PhD, professor of psychiatry, Institute of Neuroscience, University of Barcelona, Spain, and author of an accompanying editorial, said it’s still not known if the mediating factor in the increased risk of violent crime was the SSRI or the underlying mental condition that prompted the prescription.

Dr. Vieta, who was not involved with the study, added that the results “raise a note of caution in terms of making a very accurate diagnosis and treatment in patients with a history of conviction, violence, or criminality, and opting ideally for psychosocial therapies whenever possible in this population.”

Also commenting on the study, Michael Thase, MD, professor of psychiatry, University of Pennsylvania, Philadelphia, said the findings are “not easy to brush away or explain away.”

Dr. Thase, who was not involved with the study, continued, “although it is a small finding, it is also a serious problem.”

He suggested the risk should be treated in a similar way to the risk for suicidal thoughts or behaviors.

“Just as you might caution patients [initiating treatment with SSRIs] regarding that risk, you might broaden your counsel to include other types of violent behavior because the same process that provokes the risk of self-harm for a given person may be externalized and provoke harm or violence toward others.”

Ms. Lagerberg added that further research is needed to confirm their findings and “inform whether – and if so, how – clinical practice should change.”

The study was supported by the Swedish Research Council, Horizon 2020 ACTION project, Stockholm County Council, and Thurings Foundation. Ms. Lagerberg has reported no relevant financial relationships. Other author disclosures are listed in the article. Dr. Vieta and coauthors have reported no relevant financial relationships. Dr. Thase has reported consulting with and receiving research funding from many of the companies that manufacture/sell antidepressants.

This article first appeared on Medscape.com.

Selective serotonin reuptake inhibitors (SSRIs) are associated with an increased risk of committing a violent crime, an effect that may linger up to 12 weeks after treatment discontinuation, new research suggests. However, investigators say the finding should be interpreted with caution.

A large population-based study of more than 800,000 individuals showed those taking these antidepressants had an overall 2.7% increased risk of committing a violent crime while on the medications compared with when they were not taking them.

The increased risk persisted up to 12 weeks after discontinuing SSRIs and then returned to pretreatment levels. The risk was highest in younger individuals and those with a history of a prior violent crime.

“Our findings should be interpreted with caution [because] we do not know how far the association between SSRI medication and violent crime reflect causation,” lead author Tyra Lagerberg, MSc, a PhD candidate at Karolinska Institute, Sweden, said in an interview.

“Our findings should not be used as grounds for individuals to go off their [SSRI] medication or for clinicians to withhold medication from those who might benefit from it,” Ms. Lagerberg said.

The study was published online May 29 in European Neuropsychopharmacology.
 

Previous concerns

There has been “apprehension” about a possible association between SSRIs and elevated risk of aggression and violence, especially in young people, but it “remains unclear” if there is a similar risk in middle-aged and older adults, the authors noted. Moreover, it is unclear whether the risk of violence varies with time after initiating and discontinuing SSRI treatment.

To assess how the risk of violent crime might vary by age and time after SSRI treatment initiation and discontinuation, the researchers calculated absolute rates of violent crime per 1000 person-years during on- and off-treatment periods and also conducted within-group analyses.

The cohort, which was derived from several Swedish national registers, included all individuals in Sweden prescribed an SSRI between Jan. 1, 2006, and Dec. 31, 2013 (n = 785,337, 64.2% female) over an average follow-up of 7.3 years.

Some of the covariates used in the analyses included age, recent or previous violent crime, use of non-SSRI medications, sex, family income, education, county of residence, birth country, and lifetime diagnoses.
 

“Rare” effect

Almost the entire study cohort (99%) changed their SSRI treatment over the follow-up period. During this time, of the full study cohort, 2.7% committed violent crimes (21,203 crimes in 5,707,293 person-years).

More men than women were convicted of a violent crime (5.7% vs 1.0%, respectively).

Absolute rates of violent crime were lower in treated versus nontreated periods across all age categories (other than those between 15 and 24 years) when covariates were not taken into account.

However, when hazards during the on- and off-treatment periods were compared and adjusted for covariables, SSRI treatment was associated with a “modest increased” risk of violent crime (HR, 1.10) – particularly in those ages 15-25 years and ages 25–34 years (HR, 1.19 and 1.16, respectively).

Moreover, further analysis stratifying the cohort according to previous violent crime revealed that the elevated risk for violent crime convictions “seemed to be confined to the individuals with previous criminality,” compared to those with no criminal history (HR, 1.13 vs. 1.07).

The within-individual analysis included 2.6% of the overall cohort who experienced SSRI treatment switching as well as ≥1 violent event.

These individuals differed from the overall cohort in that they tended to be younger (close to half were aged 15-24 years compared with one quarter in the overall cohort) and predominantly male (77% vs. 36%, respectively).

When the hazard of violent crime was compared between individuals’ periods on and off medication, there was a significantly increased hazard during treatment in the whole cohort (HR, 1.26), but in particular, in those aged 25-34 years and 35-44 years (HR, 1.35 and 1.15, respectively).

The within-individual HRs remained elevated for up to 12 weeks post discontinuation of the SSRI (HR, 1.37 during the first 28 days; HR, 1.20 during days 29-84). Although women had a significantly elevated on-treatment hazard in the youngest age category, they had a lower incidence of crime across ages.

Treatment with benzodiazepines was associated with a significantly higher hazard of violent crime and treatment with non-SSRI antidepressants was associated with a “modest but nonsignificantly elevated” hazard.

By contrast, treatment with other psychotropic drugs was not associated with elevated risk.
 

Warn patients

Commenting on the study, Eduard Vieta, MD, PhD, professor of psychiatry, Institute of Neuroscience, University of Barcelona, Spain, and author of an accompanying editorial, said it’s still not known if the mediating factor in the increased risk of violent crime was the SSRI or the underlying mental condition that prompted the prescription.

Dr. Vieta, who was not involved with the study, added that the results “raise a note of caution in terms of making a very accurate diagnosis and treatment in patients with a history of conviction, violence, or criminality, and opting ideally for psychosocial therapies whenever possible in this population.”

Also commenting on the study, Michael Thase, MD, professor of psychiatry, University of Pennsylvania, Philadelphia, said the findings are “not easy to brush away or explain away.”

Dr. Thase, who was not involved with the study, continued, “although it is a small finding, it is also a serious problem.”

He suggested the risk should be treated in a similar way to the risk for suicidal thoughts or behaviors.

“Just as you might caution patients [initiating treatment with SSRIs] regarding that risk, you might broaden your counsel to include other types of violent behavior because the same process that provokes the risk of self-harm for a given person may be externalized and provoke harm or violence toward others.”

Ms. Lagerberg added that further research is needed to confirm their findings and “inform whether – and if so, how – clinical practice should change.”

The study was supported by the Swedish Research Council, Horizon 2020 ACTION project, Stockholm County Council, and Thurings Foundation. Ms. Lagerberg has reported no relevant financial relationships. Other author disclosures are listed in the article. Dr. Vieta and coauthors have reported no relevant financial relationships. Dr. Thase has reported consulting with and receiving research funding from many of the companies that manufacture/sell antidepressants.

This article first appeared on Medscape.com.

Two new clinical guidance documents from the American College of Rheumatology provide evidence-based recommendations for managing pediatric rheumatic disease during the COVID-19 pandemic as well as diagnostic and treatment recommendations for multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19 infection.

Although several children’s hospitals have published their treatment protocols for MIS-C since the condition’s initial discovery, the ACR appears to be the first medical organization to review all the most current evidence to issue interim guidance with the expectations that it will change as more data become available.

“It is challenging having to make recommendations not having a lot of scientific evidence, but we still felt we had to use whatever’s out there to the best of our ability and use our experience to put together these recommendations,” Dawn M. Wahezi, MD, chief of pediatric rheumatology at Children’s Hospital at Montefiore and an associate professor of pediatrics at Albert Einstein College of Medicine, New York, said in an interview.

“We wanted to be mindful of the fact that there are things we know and things we don’t know, and we have to be careful about what we’re recommending,” said Dr. Wahezi, a member of the ACR working group that assembled the recommendations for pediatric rheumatic disease management during the pandemic. “We’re recommending the best we can at this moment, but if there are new studies that come out and suggest otherwise, we will definitely have to go back and amend the document.”

The foremost priority of the pediatric rheumatic disease guidance focuses on maintaining control of the disease and avoiding flares that may put children at greater risk of infection. Dr. Wahezi said the ACR has received many calls from patients and clinicians asking whether patients should continue their immunosuppressant medications. Fear of the coronavirus infection, medication shortages, difficulty getting to the pharmacy, uneasiness about going to the clinic or hospital for infusions, and other barriers may have led to gaps in medication.

“We didn’t want people to be too quick to hold patients’ medications just because they were scared of COVID,” Dr. Wahezi said. “If they did have medication stopped for one reason or another and their disease flared, having active disease, regardless of which disease it is, actually puts you at higher risk for infection. By controlling their disease, that would be the way to protect them the most.”

A key takeaway in the guidance on MIS-C, meanwhile, is an emphasis on its rarity lest physicians be too quick to diagnose it and miss another serious condition with overlapping symptoms, explained Lauren Henderson, MD, an attending rheumatologist at Boston Children’s Hospital and assistant professor of pediatrics at Harvard Medical School, Boston. Dr. Henderson participated in the ACR group that wrote the MIS-C guidance.

“The first thing we want to be thoughtful about clinically is to recognize that children in general with the acute infectious phase of SARS-CoV-2 have mild symptoms and generally do well,” Dr. Henderson said. “From what we can tell from all the data, MIS-C is rare. That really needs to be considered when clinicians on the ground are doing the diagnostic evaluation” because of concerns that clinicians “could rush to diagnose and treat patients with MIS-C and miss important diagnoses like malignancies and infections.”

Management of pediatric rheumatic disease during the pandemic

The COVID-19 clinical guidance for managing pediatric rheumatic disease grew from the work of the North American Pediatric Rheumatology Clinical Guidance Task Force, which included seven pediatric rheumatologists, two pediatric infectious disease physicians, one adult rheumatologist, and one pediatric nurse practitioner. The general guidance covers usual preventive measures for reducing risk for COVID-19 infection, the recommendation that children continue to receive recommended vaccines unless contraindicated by medication, and routine in-person visits for ophthalmologic surveillance of those with a history of uveitis or at high risk for chronic uveitis. The guidance also notes the risk of mental health concerns, such as depression and anxiety, related to quarantine and the pandemic.

The top recommendation is initiation or continuation of all medications necessary to control underlying disease, including NSAIDs, hydroxychloroquine, ACE inhibitors/angiotensin II receptor blockers, colchicine, conventional disease-modifying antirheumatic drugs (cDMARDs), biologic DMARDs, and targeted synthetic DMARDs. Even patients who may have had exposure to COVID-19 or who have an asymptomatic COVID-19 infection should continue to take these medications with the exception of ACEi/ARBs.

In those with pediatric rheumatic disease who have a symptomatic COVID-19 infection, “NSAIDs, HCQ, and colchicine may be continued, if necessary, to control underlying disease,” as can interleukin (IL)-1 and IL-6 inhibitors, but “cDMARDs, bDMARDs [except IL-1 and IL-6 inhibitors] and tsDMARDs should be temporarily delayed or withheld,” according to the guidance. Glucocorticoids can be continued at the lowest possible dose to control disease.

“There’s nothing in the literature that suggests people who have rheumatic disease, especially children, and people who are on these medications, really are at increased risk for COVID-19,” Dr. Wahezi said. “That’s why we didn’t want people to be overcautious in stopping medications when the main priority is to control their disease.”

She noted some experts’ speculations that these medications may actually benefit patients with rheumatic disease who develop a COVID-19 infection because the medications keep the immune response in check. “If you allow them to have this dysregulated immune response and have active disease, you’re potentially putting them at greater risk,” Dr. Wahezi said, although she stressed that inadequate evidence exists to support these speculations right now.

Lack of evidence has been the biggest challenge all around with developing this guidance, she said.

“Because this is such an unprecedented situation and because people are so desperate to find treatments both for the illness and to protect those at risk for it, there are lots of people trying to put evidence out there, but it may not be the best-quality evidence,” Dr. Wahezi said.

Insufficient evidence also drove the group’s determination that “SARS-CoV-2 antibody testing is not useful in informing on the history of infection or risk of reinfection,” as the guidance states. Too much variability in the assays exist, Dr. Wahezi said, and, further, it’s unclear what the clinical significance of a positive test would be.

“We didn’t want anyone to feel they had to make clinical decisions based on the results of that antibody testing,” she said. “Even if the test is accurate, we don’t know how to interpret it because it’s so new.”

The guidance also notes that patients with stable disease and previously stable lab markers on stable doses of their medication may be able to extend the interval for medication toxicity lab testing a few months if there is concern about exposure to COVID-19 to get the blood work.

“If you’re just starting a medicine or there’s someone who’s had abnormalities with the medicine in the past or you’re making medication adjustments, you wouldn’t do it in those scenarios, but if there’s someone who’s been on the drug for a long time and are nervous to get [blood] drawn, it’s probably okay to delay it,” Dr. Wahezi said. Lab work for disease activity measures, on the other hand, remain particularly important, especially since telemedicine visits may require clinicians to rely on lab results more than previously.

Management of MIS-C associated with COVID-19

The task force that developed guidance for the new inflammatory condition recently linked to SARS-CoV-2 infections in children included nine pediatric rheumatologists, two adult rheumatologists, two pediatric cardiologists, two pediatric infectious disease specialists, and one pediatric critical care physician.

The guidance includes a figure for the diagnostic pathway in evaluating children suspected of having MIS-C and extensive detail on diagnostic work-up, but the task force intentionally avoided providing a case definition for the condition. Existing case definitions from the Centers for Disease Control and Prevention, World Health Organization, and the United Kingdom’s Royal College of Paediatrics and Child Health differ from one another and are based on unclear evidence, Dr. Henderson noted. “We really don’t have enough data to know the sensitivity and specificity of each parameter, and until that’s available, we didn’t want to add to the confusion,” she said.

The guidance also stresses that MIS-C is a rare complication, so patients suspected of having the condition who do not have “life-threatening manifestations should undergo diagnostic evaluation for MIS-C as well as other possible infectious and noninfectious etiologies before immunomodulatory treatment is initiated,” the guidance states.

Unless a child is in shock or otherwise requires urgent care, physicians should take the time to complete the diagnostic work-up while monitoring the child, Dr. Henderson said. If the child does have MIS-C, the guidance currently recommends intravenous immunoglobulin (IVIG) and/or glucocorticoids to prevent coronary artery aneurysms, the same treatment other institutions have been recommending.

“We don’t have rigorous comparative studies looking at different types of treatments,” Dr. Henderson said, noting that the vast majority of children in the literature received IVIG and/or glucocorticoid treatment. “Often children really responded quite forcefully to those treatments, but we don’t have high-quality data yet to know that this treatment is better than supportive care or another medication.”

Dr. Henderson also stressed the importance of children receiving care at a facility with the necessary expertise to manage MIS-C and receiving long-term follow-up care from a multidisciplinary clinical team that includes a rheumatologist, an infectious disease doctor, a cardiologist, and possibly a hematologist.

“Making sure children are admitted to a hospital that has the resources and are followed by physicians with expertise or understanding of the intricacies of MIS-C is really important,” she said, particularly for children with cardiac involvement. “We don’t know if all the kids presenting with left ventricular dysfunction and shock are at risk for having myocardial fibrosis down the line,” she noted. “There is so much we do not understand and very little data to guide us on what to do, so these children really need to be under the care of a cardiologist and rheumatologist to make sure that their care is tailored to them.”

Although MIS-C shares overlapping symptoms with Kawasaki disease, it’s still unclear how similar or different the two conditions are, Dr. Henderson said.

“We can definitely say that when we look at MIS-C and compare it to historical groups of Kawasaki disease before the pandemic, there are definitely different features in the MIS-C group,” she said. Kawasaki disease generally only affects children under age 5, whereas MIS-C patients run the gamut from age 1-17. Racial demographics are also different, with a higher proportion of black children affected by MIS-C.

It’s possible that the pathophysiology of both conditions will turn out to be similar, particularly given the hypothesis that Kawasaki disease is triggered by infections in genetically predisposed people. However, the severity of symptoms and risk of aneurysms appear greater with MIS-C so far.

“The degree to which these patients are presenting with left ventricular dysfunction and shock is much higher than what we’ve seen previously,” Dr. Henderson said. “Children can have aneurysms even if they don’t meet all the Kawasaki disease features, which makes it feel that this is somehow clinically different from what we’ve seen before. It’s not just the kids who have the rash and the conjunctivitis and the extremity changes and oral changes who have the aneurysms.”

The reason for including both IVIG and glucocorticoids as possible first-line drugs to prevent aneurysms is that some evidence suggests children with MIS-C may have higher levels of IVIG resistance, she said.

Like Dr. Wahezi, Dr. Henderson emphasized the necessarily transient nature of these recommendations.

“These recommendations will almost certainly change based on evolving understanding of MIS-C and the data,” Dr. Henderson said, adding that this new, unique condition highlights the importance of including children in allocating funding for research and in clinical trials.

“Children are not always identical to adults, and it’s really important that we have high-quality data to inform our decisions about how to care for them,” she said.

Dr. Wahezi had no disclosures. Dr. Henderson has consulted for Sobi and Adaptive Technologies. The guidelines did not note other disclosures for members of the ACR groups.

SOURCES: COVID-19 Clinical Guidance for Pediatric Patients with Rheumatic Disease and Clinical Guidance for Pediatric Patients with Multisystem Inflammatory Syndrome in Children (MIS-C) Associated with SARS-CoV-2 and Hyperinflammation in COVID-19

Two new clinical guidance documents from the American College of Rheumatology provide evidence-based recommendations for managing pediatric rheumatic disease during the COVID-19 pandemic as well as diagnostic and treatment recommendations for multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19 infection.

Although several children’s hospitals have published their treatment protocols for MIS-C since the condition’s initial discovery, the ACR appears to be the first medical organization to review all the most current evidence to issue interim guidance with the expectations that it will change as more data become available.

“It is challenging having to make recommendations not having a lot of scientific evidence, but we still felt we had to use whatever’s out there to the best of our ability and use our experience to put together these recommendations,” Dawn M. Wahezi, MD, chief of pediatric rheumatology at Children’s Hospital at Montefiore and an associate professor of pediatrics at Albert Einstein College of Medicine, New York, said in an interview.

“We wanted to be mindful of the fact that there are things we know and things we don’t know, and we have to be careful about what we’re recommending,” said Dr. Wahezi, a member of the ACR working group that assembled the recommendations for pediatric rheumatic disease management during the pandemic. “We’re recommending the best we can at this moment, but if there are new studies that come out and suggest otherwise, we will definitely have to go back and amend the document.”

The foremost priority of the pediatric rheumatic disease guidance focuses on maintaining control of the disease and avoiding flares that may put children at greater risk of infection. Dr. Wahezi said the ACR has received many calls from patients and clinicians asking whether patients should continue their immunosuppressant medications. Fear of the coronavirus infection, medication shortages, difficulty getting to the pharmacy, uneasiness about going to the clinic or hospital for infusions, and other barriers may have led to gaps in medication.

“We didn’t want people to be too quick to hold patients’ medications just because they were scared of COVID,” Dr. Wahezi said. “If they did have medication stopped for one reason or another and their disease flared, having active disease, regardless of which disease it is, actually puts you at higher risk for infection. By controlling their disease, that would be the way to protect them the most.”

A key takeaway in the guidance on MIS-C, meanwhile, is an emphasis on its rarity lest physicians be too quick to diagnose it and miss another serious condition with overlapping symptoms, explained Lauren Henderson, MD, an attending rheumatologist at Boston Children’s Hospital and assistant professor of pediatrics at Harvard Medical School, Boston. Dr. Henderson participated in the ACR group that wrote the MIS-C guidance.

“The first thing we want to be thoughtful about clinically is to recognize that children in general with the acute infectious phase of SARS-CoV-2 have mild symptoms and generally do well,” Dr. Henderson said. “From what we can tell from all the data, MIS-C is rare. That really needs to be considered when clinicians on the ground are doing the diagnostic evaluation” because of concerns that clinicians “could rush to diagnose and treat patients with MIS-C and miss important diagnoses like malignancies and infections.”

Management of pediatric rheumatic disease during the pandemic

The COVID-19 clinical guidance for managing pediatric rheumatic disease grew from the work of the North American Pediatric Rheumatology Clinical Guidance Task Force, which included seven pediatric rheumatologists, two pediatric infectious disease physicians, one adult rheumatologist, and one pediatric nurse practitioner. The general guidance covers usual preventive measures for reducing risk for COVID-19 infection, the recommendation that children continue to receive recommended vaccines unless contraindicated by medication, and routine in-person visits for ophthalmologic surveillance of those with a history of uveitis or at high risk for chronic uveitis. The guidance also notes the risk of mental health concerns, such as depression and anxiety, related to quarantine and the pandemic.

The top recommendation is initiation or continuation of all medications necessary to control underlying disease, including NSAIDs, hydroxychloroquine, ACE inhibitors/angiotensin II receptor blockers, colchicine, conventional disease-modifying antirheumatic drugs (cDMARDs), biologic DMARDs, and targeted synthetic DMARDs. Even patients who may have had exposure to COVID-19 or who have an asymptomatic COVID-19 infection should continue to take these medications with the exception of ACEi/ARBs.

In those with pediatric rheumatic disease who have a symptomatic COVID-19 infection, “NSAIDs, HCQ, and colchicine may be continued, if necessary, to control underlying disease,” as can interleukin (IL)-1 and IL-6 inhibitors, but “cDMARDs, bDMARDs [except IL-1 and IL-6 inhibitors] and tsDMARDs should be temporarily delayed or withheld,” according to the guidance. Glucocorticoids can be continued at the lowest possible dose to control disease.

“There’s nothing in the literature that suggests people who have rheumatic disease, especially children, and people who are on these medications, really are at increased risk for COVID-19,” Dr. Wahezi said. “That’s why we didn’t want people to be overcautious in stopping medications when the main priority is to control their disease.”

She noted some experts’ speculations that these medications may actually benefit patients with rheumatic disease who develop a COVID-19 infection because the medications keep the immune response in check. “If you allow them to have this dysregulated immune response and have active disease, you’re potentially putting them at greater risk,” Dr. Wahezi said, although she stressed that inadequate evidence exists to support these speculations right now.

Lack of evidence has been the biggest challenge all around with developing this guidance, she said.

“Because this is such an unprecedented situation and because people are so desperate to find treatments both for the illness and to protect those at risk for it, there are lots of people trying to put evidence out there, but it may not be the best-quality evidence,” Dr. Wahezi said.

Insufficient evidence also drove the group’s determination that “SARS-CoV-2 antibody testing is not useful in informing on the history of infection or risk of reinfection,” as the guidance states. Too much variability in the assays exist, Dr. Wahezi said, and, further, it’s unclear what the clinical significance of a positive test would be.

“We didn’t want anyone to feel they had to make clinical decisions based on the results of that antibody testing,” she said. “Even if the test is accurate, we don’t know how to interpret it because it’s so new.”

The guidance also notes that patients with stable disease and previously stable lab markers on stable doses of their medication may be able to extend the interval for medication toxicity lab testing a few months if there is concern about exposure to COVID-19 to get the blood work.

“If you’re just starting a medicine or there’s someone who’s had abnormalities with the medicine in the past or you’re making medication adjustments, you wouldn’t do it in those scenarios, but if there’s someone who’s been on the drug for a long time and are nervous to get [blood] drawn, it’s probably okay to delay it,” Dr. Wahezi said. Lab work for disease activity measures, on the other hand, remain particularly important, especially since telemedicine visits may require clinicians to rely on lab results more than previously.

Management of MIS-C associated with COVID-19

The task force that developed guidance for the new inflammatory condition recently linked to SARS-CoV-2 infections in children included nine pediatric rheumatologists, two adult rheumatologists, two pediatric cardiologists, two pediatric infectious disease specialists, and one pediatric critical care physician.

The guidance includes a figure for the diagnostic pathway in evaluating children suspected of having MIS-C and extensive detail on diagnostic work-up, but the task force intentionally avoided providing a case definition for the condition. Existing case definitions from the Centers for Disease Control and Prevention, World Health Organization, and the United Kingdom’s Royal College of Paediatrics and Child Health differ from one another and are based on unclear evidence, Dr. Henderson noted. “We really don’t have enough data to know the sensitivity and specificity of each parameter, and until that’s available, we didn’t want to add to the confusion,” she said.

The guidance also stresses that MIS-C is a rare complication, so patients suspected of having the condition who do not have “life-threatening manifestations should undergo diagnostic evaluation for MIS-C as well as other possible infectious and noninfectious etiologies before immunomodulatory treatment is initiated,” the guidance states.

Unless a child is in shock or otherwise requires urgent care, physicians should take the time to complete the diagnostic work-up while monitoring the child, Dr. Henderson said. If the child does have MIS-C, the guidance currently recommends intravenous immunoglobulin (IVIG) and/or glucocorticoids to prevent coronary artery aneurysms, the same treatment other institutions have been recommending.

“We don’t have rigorous comparative studies looking at different types of treatments,” Dr. Henderson said, noting that the vast majority of children in the literature received IVIG and/or glucocorticoid treatment. “Often children really responded quite forcefully to those treatments, but we don’t have high-quality data yet to know that this treatment is better than supportive care or another medication.”

Dr. Henderson also stressed the importance of children receiving care at a facility with the necessary expertise to manage MIS-C and receiving long-term follow-up care from a multidisciplinary clinical team that includes a rheumatologist, an infectious disease doctor, a cardiologist, and possibly a hematologist.

“Making sure children are admitted to a hospital that has the resources and are followed by physicians with expertise or understanding of the intricacies of MIS-C is really important,” she said, particularly for children with cardiac involvement. “We don’t know if all the kids presenting with left ventricular dysfunction and shock are at risk for having myocardial fibrosis down the line,” she noted. “There is so much we do not understand and very little data to guide us on what to do, so these children really need to be under the care of a cardiologist and rheumatologist to make sure that their care is tailored to them.”

Although MIS-C shares overlapping symptoms with Kawasaki disease, it’s still unclear how similar or different the two conditions are, Dr. Henderson said.

“We can definitely say that when we look at MIS-C and compare it to historical groups of Kawasaki disease before the pandemic, there are definitely different features in the MIS-C group,” she said. Kawasaki disease generally only affects children under age 5, whereas MIS-C patients run the gamut from age 1-17. Racial demographics are also different, with a higher proportion of black children affected by MIS-C.

It’s possible that the pathophysiology of both conditions will turn out to be similar, particularly given the hypothesis that Kawasaki disease is triggered by infections in genetically predisposed people. However, the severity of symptoms and risk of aneurysms appear greater with MIS-C so far.

“The degree to which these patients are presenting with left ventricular dysfunction and shock is much higher than what we’ve seen previously,” Dr. Henderson said. “Children can have aneurysms even if they don’t meet all the Kawasaki disease features, which makes it feel that this is somehow clinically different from what we’ve seen before. It’s not just the kids who have the rash and the conjunctivitis and the extremity changes and oral changes who have the aneurysms.”

The reason for including both IVIG and glucocorticoids as possible first-line drugs to prevent aneurysms is that some evidence suggests children with MIS-C may have higher levels of IVIG resistance, she said.

Like Dr. Wahezi, Dr. Henderson emphasized the necessarily transient nature of these recommendations.

“These recommendations will almost certainly change based on evolving understanding of MIS-C and the data,” Dr. Henderson said, adding that this new, unique condition highlights the importance of including children in allocating funding for research and in clinical trials.

“Children are not always identical to adults, and it’s really important that we have high-quality data to inform our decisions about how to care for them,” she said.

Dr. Wahezi had no disclosures. Dr. Henderson has consulted for Sobi and Adaptive Technologies. The guidelines did not note other disclosures for members of the ACR groups.

SOURCES: COVID-19 Clinical Guidance for Pediatric Patients with Rheumatic Disease and Clinical Guidance for Pediatric Patients with Multisystem Inflammatory Syndrome in Children (MIS-C) Associated with SARS-CoV-2 and Hyperinflammation in COVID-19

Two new clinical guidance documents from the American College of Rheumatology provide evidence-based recommendations for managing pediatric rheumatic disease during the COVID-19 pandemic as well as diagnostic and treatment recommendations for multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19 infection.

Although several children’s hospitals have published their treatment protocols for MIS-C since the condition’s initial discovery, the ACR appears to be the first medical organization to review all the most current evidence to issue interim guidance with the expectations that it will change as more data become available.

“It is challenging having to make recommendations not having a lot of scientific evidence, but we still felt we had to use whatever’s out there to the best of our ability and use our experience to put together these recommendations,” Dawn M. Wahezi, MD, chief of pediatric rheumatology at Children’s Hospital at Montefiore and an associate professor of pediatrics at Albert Einstein College of Medicine, New York, said in an interview.

“We wanted to be mindful of the fact that there are things we know and things we don’t know, and we have to be careful about what we’re recommending,” said Dr. Wahezi, a member of the ACR working group that assembled the recommendations for pediatric rheumatic disease management during the pandemic. “We’re recommending the best we can at this moment, but if there are new studies that come out and suggest otherwise, we will definitely have to go back and amend the document.”

The foremost priority of the pediatric rheumatic disease guidance focuses on maintaining control of the disease and avoiding flares that may put children at greater risk of infection. Dr. Wahezi said the ACR has received many calls from patients and clinicians asking whether patients should continue their immunosuppressant medications. Fear of the coronavirus infection, medication shortages, difficulty getting to the pharmacy, uneasiness about going to the clinic or hospital for infusions, and other barriers may have led to gaps in medication.

“We didn’t want people to be too quick to hold patients’ medications just because they were scared of COVID,” Dr. Wahezi said. “If they did have medication stopped for one reason or another and their disease flared, having active disease, regardless of which disease it is, actually puts you at higher risk for infection. By controlling their disease, that would be the way to protect them the most.”

A key takeaway in the guidance on MIS-C, meanwhile, is an emphasis on its rarity lest physicians be too quick to diagnose it and miss another serious condition with overlapping symptoms, explained Lauren Henderson, MD, an attending rheumatologist at Boston Children’s Hospital and assistant professor of pediatrics at Harvard Medical School, Boston. Dr. Henderson participated in the ACR group that wrote the MIS-C guidance.

“The first thing we want to be thoughtful about clinically is to recognize that children in general with the acute infectious phase of SARS-CoV-2 have mild symptoms and generally do well,” Dr. Henderson said. “From what we can tell from all the data, MIS-C is rare. That really needs to be considered when clinicians on the ground are doing the diagnostic evaluation” because of concerns that clinicians “could rush to diagnose and treat patients with MIS-C and miss important diagnoses like malignancies and infections.”

Management of pediatric rheumatic disease during the pandemic

The COVID-19 clinical guidance for managing pediatric rheumatic disease grew from the work of the North American Pediatric Rheumatology Clinical Guidance Task Force, which included seven pediatric rheumatologists, two pediatric infectious disease physicians, one adult rheumatologist, and one pediatric nurse practitioner. The general guidance covers usual preventive measures for reducing risk for COVID-19 infection, the recommendation that children continue to receive recommended vaccines unless contraindicated by medication, and routine in-person visits for ophthalmologic surveillance of those with a history of uveitis or at high risk for chronic uveitis. The guidance also notes the risk of mental health concerns, such as depression and anxiety, related to quarantine and the pandemic.

The top recommendation is initiation or continuation of all medications necessary to control underlying disease, including NSAIDs, hydroxychloroquine, ACE inhibitors/angiotensin II receptor blockers, colchicine, conventional disease-modifying antirheumatic drugs (cDMARDs), biologic DMARDs, and targeted synthetic DMARDs. Even patients who may have had exposure to COVID-19 or who have an asymptomatic COVID-19 infection should continue to take these medications with the exception of ACEi/ARBs.

In those with pediatric rheumatic disease who have a symptomatic COVID-19 infection, “NSAIDs, HCQ, and colchicine may be continued, if necessary, to control underlying disease,” as can interleukin (IL)-1 and IL-6 inhibitors, but “cDMARDs, bDMARDs [except IL-1 and IL-6 inhibitors] and tsDMARDs should be temporarily delayed or withheld,” according to the guidance. Glucocorticoids can be continued at the lowest possible dose to control disease.

“There’s nothing in the literature that suggests people who have rheumatic disease, especially children, and people who are on these medications, really are at increased risk for COVID-19,” Dr. Wahezi said. “That’s why we didn’t want people to be overcautious in stopping medications when the main priority is to control their disease.”

She noted some experts’ speculations that these medications may actually benefit patients with rheumatic disease who develop a COVID-19 infection because the medications keep the immune response in check. “If you allow them to have this dysregulated immune response and have active disease, you’re potentially putting them at greater risk,” Dr. Wahezi said, although she stressed that inadequate evidence exists to support these speculations right now.

Lack of evidence has been the biggest challenge all around with developing this guidance, she said.

“Because this is such an unprecedented situation and because people are so desperate to find treatments both for the illness and to protect those at risk for it, there are lots of people trying to put evidence out there, but it may not be the best-quality evidence,” Dr. Wahezi said.

Insufficient evidence also drove the group’s determination that “SARS-CoV-2 antibody testing is not useful in informing on the history of infection or risk of reinfection,” as the guidance states. Too much variability in the assays exist, Dr. Wahezi said, and, further, it’s unclear what the clinical significance of a positive test would be.

“We didn’t want anyone to feel they had to make clinical decisions based on the results of that antibody testing,” she said. “Even if the test is accurate, we don’t know how to interpret it because it’s so new.”

The guidance also notes that patients with stable disease and previously stable lab markers on stable doses of their medication may be able to extend the interval for medication toxicity lab testing a few months if there is concern about exposure to COVID-19 to get the blood work.

“If you’re just starting a medicine or there’s someone who’s had abnormalities with the medicine in the past or you’re making medication adjustments, you wouldn’t do it in those scenarios, but if there’s someone who’s been on the drug for a long time and are nervous to get [blood] drawn, it’s probably okay to delay it,” Dr. Wahezi said. Lab work for disease activity measures, on the other hand, remain particularly important, especially since telemedicine visits may require clinicians to rely on lab results more than previously.

Management of MIS-C associated with COVID-19

The task force that developed guidance for the new inflammatory condition recently linked to SARS-CoV-2 infections in children included nine pediatric rheumatologists, two adult rheumatologists, two pediatric cardiologists, two pediatric infectious disease specialists, and one pediatric critical care physician.

The guidance includes a figure for the diagnostic pathway in evaluating children suspected of having MIS-C and extensive detail on diagnostic work-up, but the task force intentionally avoided providing a case definition for the condition. Existing case definitions from the Centers for Disease Control and Prevention, World Health Organization, and the United Kingdom’s Royal College of Paediatrics and Child Health differ from one another and are based on unclear evidence, Dr. Henderson noted. “We really don’t have enough data to know the sensitivity and specificity of each parameter, and until that’s available, we didn’t want to add to the confusion,” she said.

The guidance also stresses that MIS-C is a rare complication, so patients suspected of having the condition who do not have “life-threatening manifestations should undergo diagnostic evaluation for MIS-C as well as other possible infectious and noninfectious etiologies before immunomodulatory treatment is initiated,” the guidance states.

Unless a child is in shock or otherwise requires urgent care, physicians should take the time to complete the diagnostic work-up while monitoring the child, Dr. Henderson said. If the child does have MIS-C, the guidance currently recommends intravenous immunoglobulin (IVIG) and/or glucocorticoids to prevent coronary artery aneurysms, the same treatment other institutions have been recommending.

“We don’t have rigorous comparative studies looking at different types of treatments,” Dr. Henderson said, noting that the vast majority of children in the literature received IVIG and/or glucocorticoid treatment. “Often children really responded quite forcefully to those treatments, but we don’t have high-quality data yet to know that this treatment is better than supportive care or another medication.”

Dr. Henderson also stressed the importance of children receiving care at a facility with the necessary expertise to manage MIS-C and receiving long-term follow-up care from a multidisciplinary clinical team that includes a rheumatologist, an infectious disease doctor, a cardiologist, and possibly a hematologist.

“Making sure children are admitted to a hospital that has the resources and are followed by physicians with expertise or understanding of the intricacies of MIS-C is really important,” she said, particularly for children with cardiac involvement. “We don’t know if all the kids presenting with left ventricular dysfunction and shock are at risk for having myocardial fibrosis down the line,” she noted. “There is so much we do not understand and very little data to guide us on what to do, so these children really need to be under the care of a cardiologist and rheumatologist to make sure that their care is tailored to them.”

Although MIS-C shares overlapping symptoms with Kawasaki disease, it’s still unclear how similar or different the two conditions are, Dr. Henderson said.

“We can definitely say that when we look at MIS-C and compare it to historical groups of Kawasaki disease before the pandemic, there are definitely different features in the MIS-C group,” she said. Kawasaki disease generally only affects children under age 5, whereas MIS-C patients run the gamut from age 1-17. Racial demographics are also different, with a higher proportion of black children affected by MIS-C.

It’s possible that the pathophysiology of both conditions will turn out to be similar, particularly given the hypothesis that Kawasaki disease is triggered by infections in genetically predisposed people. However, the severity of symptoms and risk of aneurysms appear greater with MIS-C so far.

“The degree to which these patients are presenting with left ventricular dysfunction and shock is much higher than what we’ve seen previously,” Dr. Henderson said. “Children can have aneurysms even if they don’t meet all the Kawasaki disease features, which makes it feel that this is somehow clinically different from what we’ve seen before. It’s not just the kids who have the rash and the conjunctivitis and the extremity changes and oral changes who have the aneurysms.”

The reason for including both IVIG and glucocorticoids as possible first-line drugs to prevent aneurysms is that some evidence suggests children with MIS-C may have higher levels of IVIG resistance, she said.

Like Dr. Wahezi, Dr. Henderson emphasized the necessarily transient nature of these recommendations.

“These recommendations will almost certainly change based on evolving understanding of MIS-C and the data,” Dr. Henderson said, adding that this new, unique condition highlights the importance of including children in allocating funding for research and in clinical trials.

“Children are not always identical to adults, and it’s really important that we have high-quality data to inform our decisions about how to care for them,” she said.

Dr. Wahezi had no disclosures. Dr. Henderson has consulted for Sobi and Adaptive Technologies. The guidelines did not note other disclosures for members of the ACR groups.

SOURCES: COVID-19 Clinical Guidance for Pediatric Patients with Rheumatic Disease and Clinical Guidance for Pediatric Patients with Multisystem Inflammatory Syndrome in Children (MIS-C) Associated with SARS-CoV-2 and Hyperinflammation in COVID-19

A team of pulmonologists has synthesized the clinical and imaging characteristics of COVID-19 in children, and has devised recommendations for ordering imaging studies in suspected cases of the infection.

The review also included useful radiographic findings to help in the differential diagnosis of COVID-19 pneumonia from other respiratory infections. Alexandra M. Foust, DO, of Boston Children’s Hospital, and colleagues reported the summary of findings and recommendations in Pediatric Pulmonology.

“Pediatricians face numerous challenges created by increasing reports of severe COVID-19 related findings in affected children,” said Mary Cataletto, MD, of NYU Langone Health in Mineola, N.Y. “[The current review] represents a multinational collaboration to provide up to date information and key imaging findings to guide chest physicians caring for children with pneumonia symptoms during the COVID-19 pandemic.”
 

Clinical presentation in children

In general, pediatric patients infected with the virus show milder symptoms compared with adults, and based on the limited evidence reported to date, the most common clinical symptoms of COVID-19 in children are rhinorrhea and/or nasal congestion, fever and cough with sore throat, fatigue or dyspnea, and diarrhea.

As with other viral pneumonias in children, the laboratory parameters are usually nonspecific; however, while the complete blood count (CBC) is often normal, lymphopenia, thrombocytopenia, and neutropenia have been reported in some cases of pediatric COVID-19, the authors noted.

The current Centers for Disease Control and Prevention (CDC) recommendation for initial diagnosis of SARS-CoV-2 is obtaining a nasopharyngeal swab, followed by reverse transcription polymerase chain reaction (RT-PCR) testing, they explained.
 

Role of imaging in diagnosis

The researchers reported that current recommendations from the American College of Radiology (ACR) do not include chest computed tomography (CT) or chest radiography (CXR) as a upfront test to diagnose pediatric COVID-19, but they may still have a role in clinical monitoring, especially in patients with a moderate to severe disease course.

The potential benefits of utilizing radiologic evaluation, such as establishing a baseline for monitoring disease progression, must be balanced with potential drawbacks, which include radiation exposure, and reduced availability of imaging resources owing to necessary cleaning and air turnover time.
 

Recommendations for ordering imaging studies

Based on the most recent international guidelines for pediatric COVID-19 patient management, the authors developed an algorithm for performing imaging studies in suspected cases of COVID-19 pneumonia.

The purpose of the tool is to support clinical decision-making around the utilization of CXR and CT to evaluate pediatric COVID-19 pneumonia.

“The step by step algorithm addresses the selection, sequence and timing of imaging studies with multiple images illustrating key findings of COVID-19 pneumonia in the pediatric age group,” said Dr. Cataletto. “By synthesizing the available imaging case series and guidelines, this primer provides a useful tool for the practicing pulmonologist,” she explained.
 

Key recommendations: CXR

“For pediatric patients with suspected or known COVID-19 infection with moderate to severe clinical symptoms requiring hospitalization (i.e., hypoxia, moderate or severe dyspnea, signs of sepsis, shock, cardiovascular compromise, altered mentation), CXR is usually indicated to establish an imaging baseline and to assess for an alternative diagnosis,” they recommended.

“Sequential CXRs may be helpful to assess pediatric patients with COVID-19 who demonstrate worsening clinical symptoms or to assess response to supportive therapy,” they wrote.
 

Key recommendations: CT

“Due to the increased radiation sensitivity of pediatric patients, chest CT is not recommended as an initial diagnostic test for pediatric patients with known or suspected COVID-19 pneumonia,” they explained.

The guide also included several considerations around the differential diagnosis of COVID-19 pneumonia from other pediatric lung disorders, including immune-related conditions, infectious etiologies, hematological dyscrasias, and inhalation-related lung injury.

As best practice recommendations for COVID-19 continue to evolve, the availability of practical clinical decision-making tools becomes essential to ensure optimal patient care.

No funding sources or financial disclosures were reported in the manuscript.

SOURCE: Foust AM et al. Pediatr Pulmonol. 2020 May 28. doi: 10.1002/ppul.24870.

A team of pulmonologists has synthesized the clinical and imaging characteristics of COVID-19 in children, and has devised recommendations for ordering imaging studies in suspected cases of the infection.

The review also included useful radiographic findings to help in the differential diagnosis of COVID-19 pneumonia from other respiratory infections. Alexandra M. Foust, DO, of Boston Children’s Hospital, and colleagues reported the summary of findings and recommendations in Pediatric Pulmonology.

“Pediatricians face numerous challenges created by increasing reports of severe COVID-19 related findings in affected children,” said Mary Cataletto, MD, of NYU Langone Health in Mineola, N.Y. “[The current review] represents a multinational collaboration to provide up to date information and key imaging findings to guide chest physicians caring for children with pneumonia symptoms during the COVID-19 pandemic.”
 

Clinical presentation in children

In general, pediatric patients infected with the virus show milder symptoms compared with adults, and based on the limited evidence reported to date, the most common clinical symptoms of COVID-19 in children are rhinorrhea and/or nasal congestion, fever and cough with sore throat, fatigue or dyspnea, and diarrhea.

As with other viral pneumonias in children, the laboratory parameters are usually nonspecific; however, while the complete blood count (CBC) is often normal, lymphopenia, thrombocytopenia, and neutropenia have been reported in some cases of pediatric COVID-19, the authors noted.

The current Centers for Disease Control and Prevention (CDC) recommendation for initial diagnosis of SARS-CoV-2 is obtaining a nasopharyngeal swab, followed by reverse transcription polymerase chain reaction (RT-PCR) testing, they explained.
 

Role of imaging in diagnosis

The researchers reported that current recommendations from the American College of Radiology (ACR) do not include chest computed tomography (CT) or chest radiography (CXR) as a upfront test to diagnose pediatric COVID-19, but they may still have a role in clinical monitoring, especially in patients with a moderate to severe disease course.

The potential benefits of utilizing radiologic evaluation, such as establishing a baseline for monitoring disease progression, must be balanced with potential drawbacks, which include radiation exposure, and reduced availability of imaging resources owing to necessary cleaning and air turnover time.
 

Recommendations for ordering imaging studies

Based on the most recent international guidelines for pediatric COVID-19 patient management, the authors developed an algorithm for performing imaging studies in suspected cases of COVID-19 pneumonia.

The purpose of the tool is to support clinical decision-making around the utilization of CXR and CT to evaluate pediatric COVID-19 pneumonia.

“The step by step algorithm addresses the selection, sequence and timing of imaging studies with multiple images illustrating key findings of COVID-19 pneumonia in the pediatric age group,” said Dr. Cataletto. “By synthesizing the available imaging case series and guidelines, this primer provides a useful tool for the practicing pulmonologist,” she explained.
 

Key recommendations: CXR

“For pediatric patients with suspected or known COVID-19 infection with moderate to severe clinical symptoms requiring hospitalization (i.e., hypoxia, moderate or severe dyspnea, signs of sepsis, shock, cardiovascular compromise, altered mentation), CXR is usually indicated to establish an imaging baseline and to assess for an alternative diagnosis,” they recommended.

“Sequential CXRs may be helpful to assess pediatric patients with COVID-19 who demonstrate worsening clinical symptoms or to assess response to supportive therapy,” they wrote.
 

Key recommendations: CT

“Due to the increased radiation sensitivity of pediatric patients, chest CT is not recommended as an initial diagnostic test for pediatric patients with known or suspected COVID-19 pneumonia,” they explained.

The guide also included several considerations around the differential diagnosis of COVID-19 pneumonia from other pediatric lung disorders, including immune-related conditions, infectious etiologies, hematological dyscrasias, and inhalation-related lung injury.

As best practice recommendations for COVID-19 continue to evolve, the availability of practical clinical decision-making tools becomes essential to ensure optimal patient care.

No funding sources or financial disclosures were reported in the manuscript.

SOURCE: Foust AM et al. Pediatr Pulmonol. 2020 May 28. doi: 10.1002/ppul.24870.

A team of pulmonologists has synthesized the clinical and imaging characteristics of COVID-19 in children, and has devised recommendations for ordering imaging studies in suspected cases of the infection.

The review also included useful radiographic findings to help in the differential diagnosis of COVID-19 pneumonia from other respiratory infections. Alexandra M. Foust, DO, of Boston Children’s Hospital, and colleagues reported the summary of findings and recommendations in Pediatric Pulmonology.

“Pediatricians face numerous challenges created by increasing reports of severe COVID-19 related findings in affected children,” said Mary Cataletto, MD, of NYU Langone Health in Mineola, N.Y. “[The current review] represents a multinational collaboration to provide up to date information and key imaging findings to guide chest physicians caring for children with pneumonia symptoms during the COVID-19 pandemic.”
 

Clinical presentation in children

In general, pediatric patients infected with the virus show milder symptoms compared with adults, and based on the limited evidence reported to date, the most common clinical symptoms of COVID-19 in children are rhinorrhea and/or nasal congestion, fever and cough with sore throat, fatigue or dyspnea, and diarrhea.

As with other viral pneumonias in children, the laboratory parameters are usually nonspecific; however, while the complete blood count (CBC) is often normal, lymphopenia, thrombocytopenia, and neutropenia have been reported in some cases of pediatric COVID-19, the authors noted.

The current Centers for Disease Control and Prevention (CDC) recommendation for initial diagnosis of SARS-CoV-2 is obtaining a nasopharyngeal swab, followed by reverse transcription polymerase chain reaction (RT-PCR) testing, they explained.
 

Role of imaging in diagnosis

The researchers reported that current recommendations from the American College of Radiology (ACR) do not include chest computed tomography (CT) or chest radiography (CXR) as a upfront test to diagnose pediatric COVID-19, but they may still have a role in clinical monitoring, especially in patients with a moderate to severe disease course.

The potential benefits of utilizing radiologic evaluation, such as establishing a baseline for monitoring disease progression, must be balanced with potential drawbacks, which include radiation exposure, and reduced availability of imaging resources owing to necessary cleaning and air turnover time.
 

Recommendations for ordering imaging studies

Based on the most recent international guidelines for pediatric COVID-19 patient management, the authors developed an algorithm for performing imaging studies in suspected cases of COVID-19 pneumonia.

The purpose of the tool is to support clinical decision-making around the utilization of CXR and CT to evaluate pediatric COVID-19 pneumonia.

“The step by step algorithm addresses the selection, sequence and timing of imaging studies with multiple images illustrating key findings of COVID-19 pneumonia in the pediatric age group,” said Dr. Cataletto. “By synthesizing the available imaging case series and guidelines, this primer provides a useful tool for the practicing pulmonologist,” she explained.
 

Key recommendations: CXR

“For pediatric patients with suspected or known COVID-19 infection with moderate to severe clinical symptoms requiring hospitalization (i.e., hypoxia, moderate or severe dyspnea, signs of sepsis, shock, cardiovascular compromise, altered mentation), CXR is usually indicated to establish an imaging baseline and to assess for an alternative diagnosis,” they recommended.

“Sequential CXRs may be helpful to assess pediatric patients with COVID-19 who demonstrate worsening clinical symptoms or to assess response to supportive therapy,” they wrote.
 

Key recommendations: CT

“Due to the increased radiation sensitivity of pediatric patients, chest CT is not recommended as an initial diagnostic test for pediatric patients with known or suspected COVID-19 pneumonia,” they explained.

The guide also included several considerations around the differential diagnosis of COVID-19 pneumonia from other pediatric lung disorders, including immune-related conditions, infectious etiologies, hematological dyscrasias, and inhalation-related lung injury.

As best practice recommendations for COVID-19 continue to evolve, the availability of practical clinical decision-making tools becomes essential to ensure optimal patient care.

No funding sources or financial disclosures were reported in the manuscript.

SOURCE: Foust AM et al. Pediatr Pulmonol. 2020 May 28. doi: 10.1002/ppul.24870.

The desire to feel better is a major driver for patients with first-episode psychosis (FEP) to turn to cannabis, new research shows.

An analysis of more than 1,300 individuals from six European countries showed patients with FEP were four times more likely than their healthy peers to start smoking cannabis in order to make themselves feel better.

The results also revealed that initiating cannabis use to feel better was associated with a more than tripled risk of being a daily user.

These findings could be used to help tailor treatment interventions, as well as offer an opportunity for psychoeducation – particularly as the reasons for starting cannabis appear to influence frequency of use, study investigator Edoardo Spinazzola, MD, Institute of Psychiatry, Psychology, and Neuroscience at King’s College London, said in an interview.

Patients who start smoking cannabis because their friends or family partakes may benefit from therapies that encourage more “assertiveness” and being “socially comfortable without the substance,” Dr. Spinazzola said, noting that it might also be beneficial to identify the specific cause of the psychological discomfort driving cannabis use, such as depression, and specifically treat that issue.

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

Answering the skeptics

Previous studies suggest that cannabis use can increase risk for psychosis up to 290%, with both frequency of use and potency playing a role, the researchers noted.

However, they added that “skeptics” argue the association could be caused by individuals with psychosis using cannabis as a form of self-medication, the comorbid effect of other psychogenic drugs, or a common genetic vulnerability between cannabis use and psychosis.

The reasons for starting cannabis use remain “largely unexplored,” so the researchers examined records from the European network of national schizophrenia networks studying Gene-Environment Interactions (EU-GEI) database, which includes patients with FEP and healthy individuals acting as controls from France, Italy, the Netherlands, Spain, United Kingdom, and Brazil.

The analysis included 1,347 individuals, of whom 446 had a diagnosis of nonaffective psychosis, 89 had bipolar disorder, and 58 had psychotic depression.

Reasons to start smoking cannabis and patterns of use were determined using the modified version of the Cannabis Experiences Questionnaire.

Results showed that participants who started cannabis to feel better were significantly more likely to be younger, have fewer years of education, to be black or of mixed ethnicity, to be single, or to not be living independently than those who started it because their friends or family were using it (P < .001 for all comparisons).

In addition, 68% of the patients with FEP and 85% of the healthy controls started using cannabis because friends or family were using it. In contrast, 18% of those with FEP versus 5% of controls starting using cannabis to feel better; 13% versus 10%, respectively, started using for “other reasons.”

After taking into account gender, age, ethnicity, and study site, the patients with FEP were significantly more likely than their healthy peers to have started using cannabis to feel better (relative risk ratio, 4.67; P < .001).

Starting to smoke cannabis to feel better versus any other reason was associated with an increased frequency of use in both those with and without FEP, with an RRR of 2.9 for using the drug more than once a week (P = .001) and an RRR of 3.13 for daily use (P < .001). However, the association was stronger in the healthy controls than in those with FEP, with an RRR for daily use of 4.45 versus 3.11, respectively.

The investigators also examined whether there was a link between reasons to start smoking and an individual’s polygenic risk score (PRS) for developing schizophrenia.

Multinomial regression indicated that PRS was not associated with starting cannabis to feel better or because friends were using it. However, there was an association between PRS score and starting the drug because family members were using it (RRR, 0.68; P < .05).
 

Complex association

Gabriella Gobbi, MD, PhD, professor in the neurobiological psychiatry unit, department of psychiatry, at McGill University, Montreal, said the data confirm “what we already know about cannabis.”

She noted that one of the “major causes” of young people starting cannabis is the social environment, while the desire to use the drug to feel better is linked to “the fact that cannabis, in a lot of cases, is used as a self-medication” in order to be calmer and as a relief from anxiety.

There is a “very complex” association between using cannabis to feel better and the self-medication seen with cigarette smoking and alcohol in patients with schizophrenia, said Dr. Gobbi, who was not involved with the research.

“When we talk about [patients using] cannabis, alcohol, and cigarettes, actually we’re talking about the same group of people,” she said.

Although “it is true they say that people look to cigarettes, tobacco, and alcohol to feel happier because they are depressed, the risk of psychosis is only for cannabis,” she added. “It is very low for alcohol and tobacco.”

As a result, Dr. Gobbi said she and her colleagues are “very worried” about the consequences for mental health of the legalization of cannabis consumption in Canada in October 2018 with the passing of the Cannabis Act.

Although there are no firm statistics yet, she has observed that since the law was passed, cannabis use has stabilized at a lower level among adolescents. “But now we have another population of people aged 34 and older that consume cannabis,” she said.

Particularly when considering the impact of higher strength cannabis on psychosis risk, Dr. Gobbi believes the increase in consumption in this age group will result in a “more elevated” risk for mental health issues.

Dr. Spinazzola and Dr. Gobbi have reported no relevant financial relationships.

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

The desire to feel better is a major driver for patients with first-episode psychosis (FEP) to turn to cannabis, new research shows.

An analysis of more than 1,300 individuals from six European countries showed patients with FEP were four times more likely than their healthy peers to start smoking cannabis in order to make themselves feel better.

The results also revealed that initiating cannabis use to feel better was associated with a more than tripled risk of being a daily user.

These findings could be used to help tailor treatment interventions, as well as offer an opportunity for psychoeducation – particularly as the reasons for starting cannabis appear to influence frequency of use, study investigator Edoardo Spinazzola, MD, Institute of Psychiatry, Psychology, and Neuroscience at King’s College London, said in an interview.

Patients who start smoking cannabis because their friends or family partakes may benefit from therapies that encourage more “assertiveness” and being “socially comfortable without the substance,” Dr. Spinazzola said, noting that it might also be beneficial to identify the specific cause of the psychological discomfort driving cannabis use, such as depression, and specifically treat that issue.

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

Answering the skeptics

Previous studies suggest that cannabis use can increase risk for psychosis up to 290%, with both frequency of use and potency playing a role, the researchers noted.

However, they added that “skeptics” argue the association could be caused by individuals with psychosis using cannabis as a form of self-medication, the comorbid effect of other psychogenic drugs, or a common genetic vulnerability between cannabis use and psychosis.

The reasons for starting cannabis use remain “largely unexplored,” so the researchers examined records from the European network of national schizophrenia networks studying Gene-Environment Interactions (EU-GEI) database, which includes patients with FEP and healthy individuals acting as controls from France, Italy, the Netherlands, Spain, United Kingdom, and Brazil.

The analysis included 1,347 individuals, of whom 446 had a diagnosis of nonaffective psychosis, 89 had bipolar disorder, and 58 had psychotic depression.

Reasons to start smoking cannabis and patterns of use were determined using the modified version of the Cannabis Experiences Questionnaire.

Results showed that participants who started cannabis to feel better were significantly more likely to be younger, have fewer years of education, to be black or of mixed ethnicity, to be single, or to not be living independently than those who started it because their friends or family were using it (P < .001 for all comparisons).

In addition, 68% of the patients with FEP and 85% of the healthy controls started using cannabis because friends or family were using it. In contrast, 18% of those with FEP versus 5% of controls starting using cannabis to feel better; 13% versus 10%, respectively, started using for “other reasons.”

After taking into account gender, age, ethnicity, and study site, the patients with FEP were significantly more likely than their healthy peers to have started using cannabis to feel better (relative risk ratio, 4.67; P < .001).

Starting to smoke cannabis to feel better versus any other reason was associated with an increased frequency of use in both those with and without FEP, with an RRR of 2.9 for using the drug more than once a week (P = .001) and an RRR of 3.13 for daily use (P < .001). However, the association was stronger in the healthy controls than in those with FEP, with an RRR for daily use of 4.45 versus 3.11, respectively.

The investigators also examined whether there was a link between reasons to start smoking and an individual’s polygenic risk score (PRS) for developing schizophrenia.

Multinomial regression indicated that PRS was not associated with starting cannabis to feel better or because friends were using it. However, there was an association between PRS score and starting the drug because family members were using it (RRR, 0.68; P < .05).
 

Complex association

Gabriella Gobbi, MD, PhD, professor in the neurobiological psychiatry unit, department of psychiatry, at McGill University, Montreal, said the data confirm “what we already know about cannabis.”

She noted that one of the “major causes” of young people starting cannabis is the social environment, while the desire to use the drug to feel better is linked to “the fact that cannabis, in a lot of cases, is used as a self-medication” in order to be calmer and as a relief from anxiety.

There is a “very complex” association between using cannabis to feel better and the self-medication seen with cigarette smoking and alcohol in patients with schizophrenia, said Dr. Gobbi, who was not involved with the research.

“When we talk about [patients using] cannabis, alcohol, and cigarettes, actually we’re talking about the same group of people,” she said.

Although “it is true they say that people look to cigarettes, tobacco, and alcohol to feel happier because they are depressed, the risk of psychosis is only for cannabis,” she added. “It is very low for alcohol and tobacco.”

As a result, Dr. Gobbi said she and her colleagues are “very worried” about the consequences for mental health of the legalization of cannabis consumption in Canada in October 2018 with the passing of the Cannabis Act.

Although there are no firm statistics yet, she has observed that since the law was passed, cannabis use has stabilized at a lower level among adolescents. “But now we have another population of people aged 34 and older that consume cannabis,” she said.

Particularly when considering the impact of higher strength cannabis on psychosis risk, Dr. Gobbi believes the increase in consumption in this age group will result in a “more elevated” risk for mental health issues.

Dr. Spinazzola and Dr. Gobbi have reported no relevant financial relationships.

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

The desire to feel better is a major driver for patients with first-episode psychosis (FEP) to turn to cannabis, new research shows.

An analysis of more than 1,300 individuals from six European countries showed patients with FEP were four times more likely than their healthy peers to start smoking cannabis in order to make themselves feel better.

The results also revealed that initiating cannabis use to feel better was associated with a more than tripled risk of being a daily user.

These findings could be used to help tailor treatment interventions, as well as offer an opportunity for psychoeducation – particularly as the reasons for starting cannabis appear to influence frequency of use, study investigator Edoardo Spinazzola, MD, Institute of Psychiatry, Psychology, and Neuroscience at King’s College London, said in an interview.

Patients who start smoking cannabis because their friends or family partakes may benefit from therapies that encourage more “assertiveness” and being “socially comfortable without the substance,” Dr. Spinazzola said, noting that it might also be beneficial to identify the specific cause of the psychological discomfort driving cannabis use, such as depression, and specifically treat that issue.

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

Answering the skeptics

Previous studies suggest that cannabis use can increase risk for psychosis up to 290%, with both frequency of use and potency playing a role, the researchers noted.

However, they added that “skeptics” argue the association could be caused by individuals with psychosis using cannabis as a form of self-medication, the comorbid effect of other psychogenic drugs, or a common genetic vulnerability between cannabis use and psychosis.

The reasons for starting cannabis use remain “largely unexplored,” so the researchers examined records from the European network of national schizophrenia networks studying Gene-Environment Interactions (EU-GEI) database, which includes patients with FEP and healthy individuals acting as controls from France, Italy, the Netherlands, Spain, United Kingdom, and Brazil.

The analysis included 1,347 individuals, of whom 446 had a diagnosis of nonaffective psychosis, 89 had bipolar disorder, and 58 had psychotic depression.

Reasons to start smoking cannabis and patterns of use were determined using the modified version of the Cannabis Experiences Questionnaire.

Results showed that participants who started cannabis to feel better were significantly more likely to be younger, have fewer years of education, to be black or of mixed ethnicity, to be single, or to not be living independently than those who started it because their friends or family were using it (P < .001 for all comparisons).

In addition, 68% of the patients with FEP and 85% of the healthy controls started using cannabis because friends or family were using it. In contrast, 18% of those with FEP versus 5% of controls starting using cannabis to feel better; 13% versus 10%, respectively, started using for “other reasons.”

After taking into account gender, age, ethnicity, and study site, the patients with FEP were significantly more likely than their healthy peers to have started using cannabis to feel better (relative risk ratio, 4.67; P < .001).

Starting to smoke cannabis to feel better versus any other reason was associated with an increased frequency of use in both those with and without FEP, with an RRR of 2.9 for using the drug more than once a week (P = .001) and an RRR of 3.13 for daily use (P < .001). However, the association was stronger in the healthy controls than in those with FEP, with an RRR for daily use of 4.45 versus 3.11, respectively.

The investigators also examined whether there was a link between reasons to start smoking and an individual’s polygenic risk score (PRS) for developing schizophrenia.

Multinomial regression indicated that PRS was not associated with starting cannabis to feel better or because friends were using it. However, there was an association between PRS score and starting the drug because family members were using it (RRR, 0.68; P < .05).
 

Complex association

Gabriella Gobbi, MD, PhD, professor in the neurobiological psychiatry unit, department of psychiatry, at McGill University, Montreal, said the data confirm “what we already know about cannabis.”

She noted that one of the “major causes” of young people starting cannabis is the social environment, while the desire to use the drug to feel better is linked to “the fact that cannabis, in a lot of cases, is used as a self-medication” in order to be calmer and as a relief from anxiety.

There is a “very complex” association between using cannabis to feel better and the self-medication seen with cigarette smoking and alcohol in patients with schizophrenia, said Dr. Gobbi, who was not involved with the research.

“When we talk about [patients using] cannabis, alcohol, and cigarettes, actually we’re talking about the same group of people,” she said.

Although “it is true they say that people look to cigarettes, tobacco, and alcohol to feel happier because they are depressed, the risk of psychosis is only for cannabis,” she added. “It is very low for alcohol and tobacco.”

As a result, Dr. Gobbi said she and her colleagues are “very worried” about the consequences for mental health of the legalization of cannabis consumption in Canada in October 2018 with the passing of the Cannabis Act.

Although there are no firm statistics yet, she has observed that since the law was passed, cannabis use has stabilized at a lower level among adolescents. “But now we have another population of people aged 34 and older that consume cannabis,” she said.

Particularly when considering the impact of higher strength cannabis on psychosis risk, Dr. Gobbi believes the increase in consumption in this age group will result in a “more elevated” risk for mental health issues.

Dr. Spinazzola and Dr. Gobbi have reported no relevant financial relationships.

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

On the Friday evening after the public execution of George Floyd, we were painfully reminded of the urgency to address the inadequate management of race, racism, and anti-blackness in medical education, residency training, and postgraduate continuing medical education.

The reminder did not originate from the rioting that was occurring in some cities, though we could feel the ground shifting beneath our feet as civic protests that began in U.S. cities spread around the globe. Instead, it occurred during a webinar we were hosting for psychiatry residents focused on techniques for eliminating blind spots in the management of race in clinical psychotherapy supervision. (Dr. Jessica Isom chaired the webinar, Dr. Flavia DeSouza and Dr. Myra Mathis comoderated, and Dr. Ebony Dennis and Dr. Constance E. Dunlap served as discussants.)

Our panel had presented an ambitious agenda that included reviewing how the disavowal of bias, race, racism, and anti-blackness contributes to ineffective psychotherapy, undermines the quality of medical care, and perpetuates mental health disparities. We spent some time exploring how unacknowledged and unexamined conscious and unconscious racial stereotypes affect interpersonal relationships, the psychotherapeutic process, and the supervisory experience. Our presentation included a clinical vignette demonstrating how racism, colorism, and anti-blackness have global impact, influencing the self-esteem, identity formation, and identity consolidation of immigrants as they grapple with the unique form of racism that exists in America. Other clinical vignettes demonstrated blind spots that were retroactively identified though omitted in supervisory discussions. We also discussed alternative interventions and interpretations of the material presented.^1-5

Because 21st-century trainees are generally psychologically astute and committed to social justice, we did two things. First, before the webinar, we provided them access to a prerecorded explanation of object relations theorist Melanie Klein’s paranoid-schizoid and depressive positions concepts, which were applied to theoretically explain the development of race, specifically the defenses used by early colonists that contributed to the development of “whiteness” and “blackness” as social constructs, and their influence on the development of the U.S. psyche. For example, as early colonists attempted to develop new and improved identities distinct from those they had in their homelands, they used enslaved black people (and other vulnerable groups) to “other.” What we mean here by othering is the process of using an other to project one’s badness into in order to relieve the self of uncomfortable aspects and feelings originating within the self. If this other accepts the projection (which is often the case with vulnerable parties), the self recognizes, that is, identifies (locates) the bad they just projected in the other, who is now experienced as a bad-other. This is projection in action. If the other accepts the projection and behaves accordingly, for example, in a manner that reflects badness, this becomes projective identification. Conversely, if the other does not accept these projections, the self (who projects) is left to cope with aspects of the self s/he might not have the capacity to manage. By capacity, we are speaking of the Bionian idea of the ability to experience an extreme emotion while also being able to think. Without the ego strength to cope with bad aspects of the self, the ego either collapses (and is unable to think) or further projection is attempted.^6-8

We have seen this latter dynamic play out repeatedly when police officers fatally shoot black citizens and then claim that they feared for their lives; these same officers have been exonerated by juries by continuing to portray the deceased victims as threatening, dangerous objects not worthy of living. We are also seeing a global movement of black and nonblack people who are in touch with a justified rage that has motivated them to return these projections by collectively protesting, and in some cases, by rioting.
 

Back to the webinar

In anticipating the residents’ curiosity, impatience, and anger about the lack of progress, the second thing we did was to show a segment from the “Black Psychoanalysts Speak” trailer. In the clip played, senior psychoanalyst Kirkland C. Vaughans, PhD, shares: “The issue of race so prompts excessive anxiety that it blocks off our ability to think.”

We showed this clip to validate the trainees’ frustrations about the difficulty the broader establishment has had with addressing this serious, longstanding public health problem. We wanted these young psychiatrists to know that there are psychoanalysts, psychiatrists, psychologists, and social workers who have been committed to this work, even though the contributions of this diverse group have curiously been omitted from education and training curricula.⁹

So, what happened? What was the painful reminder? After the formal panel presentations, a black male psychiatry resident recounted his experience in a clinical supervision meeting that had occurred several days after the murder of George Floyd. In short, a patient had shared his reactions to yet another incident of fatal police use of force and paused to ask how the resident physician, Dr. A., was doing. The question was experienced as sincere concern about the psychiatrist’s mental well-being. The resident was not sure how to answer this question since it was a matter of self-disclosure, which was a reasonable and thoughtful consideration for a seasoned clinician and, certainly, for a novice therapist. The supervisor, Dr. B., seemingly eager to move on, to not think about this, responded to the resident by saying: “Now tell me about the patient.” In other words, what had just been shared by the resident – material that featured a patient’s reaction to another killing of a black man by police and the patient’s expressed concern for his black psychiatrist, and this resident physician appropriately seeking space in supervision to process and receive guidance about how to respond – all of this was considered separate (split off from) and extraneous to the patient’s treatment and the resident’s training. This is a problem. And, unfortunately, this problem or some variation of it is not rare.

Why is this still the state of affairs when we have identified racism as a major health concern and our patients and our trainees are asking for help?
 

Rethinking a metaphor

Despite calls to action over the last 50 years to encourage medicine to effectively address race and racism, deficits remain in didactic education, clinical rotations, and supervisory experiences of trainees learning how to do psychodynamic psychotherapy.^8-10 Earlier that evening, we used the metaphor of a vehicular blind spot to capture what we believe occurs insupervision. Like drivers, supervisors generally have the ability to see. However, there are places (times) and positions (stances) that block their vision (awareness). Racism – whether institutionalized, interpersonally mediated, or internalized – also contributes to this blindness.

As is true of drivers managing a blind spot, what is required is for the drivers – the supervisors – to lean forward or reposition themselves so as to avoid collisions, maintain safety, and continue on course. We use this metaphor because it is understood that any clinician providing psychodynamic supervision to psychiatry residents, regardless of professional discipline, has the requisite skills and training.^10-13

Until May 25, we thought eliminating blind spots would be effective. But, in the aftermath of the police killing of George Floyd, our eyes have been opened.

We are encouraged by the global protests and initial actions to reform law enforcement, but we realize that medicine is in need of reform. Hiding behind the blue wall of silence is an establishment that has looked the other way while black and brown women, men, and children have come to live in fear as a result of the state-sanctioned violence that repeatedly occurs across the nation. Excessive police use of force is a public health issue of crisis magnitude. However, the house of medicine, like many other established structures in society, has colluded with the societal constructs that have supported law enforcement by remaining willfully blind, often neutral, and by refusing to make the necessary adjustments, including connecting the dots between police violence and physical and mental health.

For example, racism has never been listed even in the index of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders.¹⁴ Being the victim of police use of force is not generally regarded as an adverse childhood experience, even though communities that are heavily policed experience harassment by law enforcement on a regular basis. The 12 causes of trauma listed on the website¹⁵ of the National Child Traumatic Stress Network – bullying, community violence, complex trauma, disasters, early childhood trauma, intimate partner violence, medical trauma, physical abuse, refugee trauma, sexual abuse, terrorism and violence, and traumatic grief – do not include maltreatment, abuse, or trauma resulting from interactions with members of law enforcement. Much of the adverse childhood experiences literature focuses on white, upper middle class children and on experiences within the home. When community level experiences, such as discrimination based on race or ethnicity, are included, as in the Philadelphia ACES study,¹⁶ as many as 40% reported ACE scores of greater than 4 for community level exposures.

As psychiatrists, we recognize the psychic underpinnings and parallels between the psychic projections onto black and brown people and the actual bullets pumped into the bodies of black and brown people; there is a lurid propensity to use these others as repositories. Those who have the privilege of being protected by law enforcement and the ability to avoid being used as containers for the psychic projections and bullets of some police officers also have the privilege of compartmentalizing and looking the other way when excessive acts of force – projections and projectiles – are used on other human beings. This partly explains why the injuries and deaths of black and brown people caused by police officers’ excessive use of force have continued even though these unjustified deaths are widely televised and disseminated via various social media platforms.

Prior to the death of George Floyd on May 25, other than the American Public Health Association, the National Medical Association (NMA) was the only major medical organization to issue a call to consider police use of force as a public health issue. In its July 2016 press release, provided in the aftermath of the death of Freddie Gray while in the custody of Baltimore police officers, the NMA summarized the scope of injuries citizens sustain during “the pre-custody (commission of a crime, during a fight, chase, and apprehension, during a siege or hostage situation, or during restraint or submission), custody (soon after being admitted to jail, during interrogation, during incarceration, or legal execution), and post-custody (revenge by police or rival criminals or after reentry into the community)” periods. It is noteworthy that the scope of these injuries is comparable to those encountered in a combat zone.^17,18 According to the NMA:

“Injuries sustained by civilians at the hands of law enforcement include gunshot wounds, skull fractures, cervical spine injuries, facial fractures, broken legs, blunt trauma orbital floor fractures, laryngeal cartilage fractures, shoulder dislocations, cuts and bruises, concussions, hemorrhage, choking (positional or due to upper body holds), abdominal trauma, hemothorax, and pneumothorax. Complications of such injuries include posttraumatic brain swelling, infections following open fractures and lacerations, hydrocephalus due to blood or infection, as well as subdural and epidural hematomas and, in the most severe cases, death.”

In addition, there are multiple emotional and psychiatric sequelae of these injuries for the victims, families, upstanders, bystanders, and those viewing these images via various social media platforms. Increasingly, many are experiencing retraumatization each time a new death is reported. How do we explain that we are turning away from this as physicians and trainers of physicians? Seeing and not seeing – all of the methods used to avert one’s gaze and look the other way (to protect the psyches of nonmarginalized members of society from being disturbed and possibly traumatized) – these key defense mechanisms creep into consulting rooms and become fertile ground for the enactment described above.

Yet, there is reason to believe in change. It’s not simply because we are mental health professionals and that’s what we do. With the posting of position statements issued by major corporations and a growing number of medical organizations, many of us are experiencing a mixture of hope, anger, and sadness. Hope that widespread awareness will continue to tilt the axis of our country in a manner that opens eyes – and hearts – so that real work can be done; and anger and sadness because it has taken 400 years to receive even this level of validation.

In the meantime, we are encouraged by a joint position statement recently issued by the APA and the NMA, the first joint effort by these two medical organizations to partner and advocate for criminal justice reform. We mention this statement because the NMA has been committed to the needs of the black community since its inception in 1895, and the APA has as its mission a commitment to serve “the needs of evolving, diverse, underrepresented, and underserved patient populations” ... and the resources to do so. This is the kind of partnership that could transform words into meaningful action.^19,20

Of course, resident psychiatrist Dr. A. had begun supervision with the discussion of his dyadic experience with his patient, which is set in the context of a global coronavirus pandemic that is disproportionately affecting black and brown people. And, while his peers are marching in protest, he and his fellow trainees deserve our support as they deal with their own psychic pain and prepare to steady themselves. For these psychiatrists will be called to provide care to those who will consult them once they begin to grapple with the experiences and, in some cases, traumas that have compelled them to take action and literally risk their safety and lives while protesting.

That evening, the residents were hungry for methods to fill the gaps in their training and supervision. In some cases, we provided scripts to be taken back to supervision. For example, the following is a potential scripted response for the supervisor in the enactment described above:
 

Resident speaking to supervisor: This is a black patient who, like many others, is affected by the chronic, repeated televised images of black men killed by police. I am also a black man.

I think what I have shared is pertinent to the patient’s care and my experience as a black male psychiatrist who will need to learn how to address this in my patients who are black and for other racialized groups, as well as with whites who might have rarely been cared for by a black man. Can we discuss this?

We also anticipated that some residents would need to exercise their right to request reassignment to another supervisor. And, until we do better at listening, seeing, and deepening our understanding, outside and inside the consulting room and in supervision, more residents might need to steer around those who have the potential to undermine training and adversely affect treatment. But, as a professional medical community in crisis, do we really want to proceed in such an ad hoc fashion?
 

Dr. Dunlap is a psychiatrist and psychoanalyst, and clinical professor of psychiatry and behavioral sciences at George Washington University. She is interested in the management of “difference” – race, gender, ethnicity, and intersectionality – in dyadic relationships and group dynamics; and the impact of racism on interpersonal relationships in institutional structures. Dr. Dunlap practices in Washington and has no disclosures.

Dr. Dennis is a clinical psychologist and psychoanalyst. Her interests are in gender and ethnic diversity, health equity, and supervision and training. Dr. Dennis practices in Washington and has no disclosures.

Dr. DeSouza is a PGY-4 psychiatry resident and public psychiatry fellow in the department of psychiatry at Yale University, New Haven, Conn. Her professional interests include health services development and delivery in low- and middle-income settings, as well as the intersection of mental health and spirituality. She has no disclosures.

Dr. Isom is a staff psychiatrist at the Codman Square Health Center in Dorchester, Mass., and Boston Medical Center. Her interests include racial mental health equity and population health approaches to community psychiatry. She has no disclosures.

Dr. Mathis is an addictions fellow in the department of psychiatry at Yale University and former programwide chief resident at Yale. Her interests include the intersection of racial justice and mental health, health equity, and spirituality. She has no disclosures.

References

1. Mental Health: Culture, Race, and Ethnicity. A Supplement to Mental Health: A Report of the Surgeon General. Rockville, Md.: Substance Abuse and Mental Health Services Administration, 2001.

2. Banaji MR and Greenwald AG. Blindspot: Hidden Biases of Good People. New York: Delacorte Press, 2013.

3. Anekwe ON. Voices in Bioethics. 2014.

4. Soute BJ. The American Psychoanalyst Magazine. 2017 Winter/Spring.

5. Powell DR. J Am Psychoanal Assoc. 2019 Jan 8. doi: 10.1177/000306511881847.

6. Allen TW. The Invention of the White Race. London: Verso, 1994.

7. Klein M. Int J Psychoanal. 1946;27(pt.3-4):99-100.

8. Bion WR. (1962b). Psychoanal Q. 2013 Apr;82(2):301-10.

9. Black Psychoanalysts Speak trailer.

10. Thomas A and Sillen S. Racism and Psychiatry. New York: Brunner/Mazel, 1972.

11. Jones BE et al. Am J Psychiatry. 1970 Dec;127(6):798-803.

12. Sabshin M et al. Am J Psychiatry. 1970 Dec;126(6):787-93.

13. Medlock M et al. Am J Psychiatry. 2017 May 9. doi: 10.1176/appi.ajp-rj.2016.110206.

14. Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). Arlington, Va.: American Psychiatric Association, 2013.

15. “What is Child Trauma?” The National Child Traumatic Stress Network.

16. The Philadelphia Project. Philadelphia ACE Survey.

17. “Addressing law enforcement violence as a public health issue.” Washington: American Public Health Association. 2018 Nov 13. Policy# 20811.

18. National Medical Association position statement on police use of force. NMA 2016.

19. “APA and NMA jointly condemn systemic racism in America.” 2020 Jun 16.

20. APA Strategic Plan. 2015 Mar.

On the Friday evening after the public execution of George Floyd, we were painfully reminded of the urgency to address the inadequate management of race, racism, and anti-blackness in medical education, residency training, and postgraduate continuing medical education.

The reminder did not originate from the rioting that was occurring in some cities, though we could feel the ground shifting beneath our feet as civic protests that began in U.S. cities spread around the globe. Instead, it occurred during a webinar we were hosting for psychiatry residents focused on techniques for eliminating blind spots in the management of race in clinical psychotherapy supervision. (Dr. Jessica Isom chaired the webinar, Dr. Flavia DeSouza and Dr. Myra Mathis comoderated, and Dr. Ebony Dennis and Dr. Constance E. Dunlap served as discussants.)

Our panel had presented an ambitious agenda that included reviewing how the disavowal of bias, race, racism, and anti-blackness contributes to ineffective psychotherapy, undermines the quality of medical care, and perpetuates mental health disparities. We spent some time exploring how unacknowledged and unexamined conscious and unconscious racial stereotypes affect interpersonal relationships, the psychotherapeutic process, and the supervisory experience. Our presentation included a clinical vignette demonstrating how racism, colorism, and anti-blackness have global impact, influencing the self-esteem, identity formation, and identity consolidation of immigrants as they grapple with the unique form of racism that exists in America. Other clinical vignettes demonstrated blind spots that were retroactively identified though omitted in supervisory discussions. We also discussed alternative interventions and interpretations of the material presented.^1-5

Because 21st-century trainees are generally psychologically astute and committed to social justice, we did two things. First, before the webinar, we provided them access to a prerecorded explanation of object relations theorist Melanie Klein’s paranoid-schizoid and depressive positions concepts, which were applied to theoretically explain the development of race, specifically the defenses used by early colonists that contributed to the development of “whiteness” and “blackness” as social constructs, and their influence on the development of the U.S. psyche. For example, as early colonists attempted to develop new and improved identities distinct from those they had in their homelands, they used enslaved black people (and other vulnerable groups) to “other.” What we mean here by othering is the process of using an other to project one’s badness into in order to relieve the self of uncomfortable aspects and feelings originating within the self. If this other accepts the projection (which is often the case with vulnerable parties), the self recognizes, that is, identifies (locates) the bad they just projected in the other, who is now experienced as a bad-other. This is projection in action. If the other accepts the projection and behaves accordingly, for example, in a manner that reflects badness, this becomes projective identification. Conversely, if the other does not accept these projections, the self (who projects) is left to cope with aspects of the self s/he might not have the capacity to manage. By capacity, we are speaking of the Bionian idea of the ability to experience an extreme emotion while also being able to think. Without the ego strength to cope with bad aspects of the self, the ego either collapses (and is unable to think) or further projection is attempted.^6-8

We have seen this latter dynamic play out repeatedly when police officers fatally shoot black citizens and then claim that they feared for their lives; these same officers have been exonerated by juries by continuing to portray the deceased victims as threatening, dangerous objects not worthy of living. We are also seeing a global movement of black and nonblack people who are in touch with a justified rage that has motivated them to return these projections by collectively protesting, and in some cases, by rioting.
 

Back to the webinar

In anticipating the residents’ curiosity, impatience, and anger about the lack of progress, the second thing we did was to show a segment from the “Black Psychoanalysts Speak” trailer. In the clip played, senior psychoanalyst Kirkland C. Vaughans, PhD, shares: “The issue of race so prompts excessive anxiety that it blocks off our ability to think.”

We showed this clip to validate the trainees’ frustrations about the difficulty the broader establishment has had with addressing this serious, longstanding public health problem. We wanted these young psychiatrists to know that there are psychoanalysts, psychiatrists, psychologists, and social workers who have been committed to this work, even though the contributions of this diverse group have curiously been omitted from education and training curricula.⁹

So, what happened? What was the painful reminder? After the formal panel presentations, a black male psychiatry resident recounted his experience in a clinical supervision meeting that had occurred several days after the murder of George Floyd. In short, a patient had shared his reactions to yet another incident of fatal police use of force and paused to ask how the resident physician, Dr. A., was doing. The question was experienced as sincere concern about the psychiatrist’s mental well-being. The resident was not sure how to answer this question since it was a matter of self-disclosure, which was a reasonable and thoughtful consideration for a seasoned clinician and, certainly, for a novice therapist. The supervisor, Dr. B., seemingly eager to move on, to not think about this, responded to the resident by saying: “Now tell me about the patient.” In other words, what had just been shared by the resident – material that featured a patient’s reaction to another killing of a black man by police and the patient’s expressed concern for his black psychiatrist, and this resident physician appropriately seeking space in supervision to process and receive guidance about how to respond – all of this was considered separate (split off from) and extraneous to the patient’s treatment and the resident’s training. This is a problem. And, unfortunately, this problem or some variation of it is not rare.

Why is this still the state of affairs when we have identified racism as a major health concern and our patients and our trainees are asking for help?
 

Rethinking a metaphor

Despite calls to action over the last 50 years to encourage medicine to effectively address race and racism, deficits remain in didactic education, clinical rotations, and supervisory experiences of trainees learning how to do psychodynamic psychotherapy.^8-10 Earlier that evening, we used the metaphor of a vehicular blind spot to capture what we believe occurs insupervision. Like drivers, supervisors generally have the ability to see. However, there are places (times) and positions (stances) that block their vision (awareness). Racism – whether institutionalized, interpersonally mediated, or internalized – also contributes to this blindness.

As is true of drivers managing a blind spot, what is required is for the drivers – the supervisors – to lean forward or reposition themselves so as to avoid collisions, maintain safety, and continue on course. We use this metaphor because it is understood that any clinician providing psychodynamic supervision to psychiatry residents, regardless of professional discipline, has the requisite skills and training.^10-13

Until May 25, we thought eliminating blind spots would be effective. But, in the aftermath of the police killing of George Floyd, our eyes have been opened.

We are encouraged by the global protests and initial actions to reform law enforcement, but we realize that medicine is in need of reform. Hiding behind the blue wall of silence is an establishment that has looked the other way while black and brown women, men, and children have come to live in fear as a result of the state-sanctioned violence that repeatedly occurs across the nation. Excessive police use of force is a public health issue of crisis magnitude. However, the house of medicine, like many other established structures in society, has colluded with the societal constructs that have supported law enforcement by remaining willfully blind, often neutral, and by refusing to make the necessary adjustments, including connecting the dots between police violence and physical and mental health.

For example, racism has never been listed even in the index of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders.¹⁴ Being the victim of police use of force is not generally regarded as an adverse childhood experience, even though communities that are heavily policed experience harassment by law enforcement on a regular basis. The 12 causes of trauma listed on the website¹⁵ of the National Child Traumatic Stress Network – bullying, community violence, complex trauma, disasters, early childhood trauma, intimate partner violence, medical trauma, physical abuse, refugee trauma, sexual abuse, terrorism and violence, and traumatic grief – do not include maltreatment, abuse, or trauma resulting from interactions with members of law enforcement. Much of the adverse childhood experiences literature focuses on white, upper middle class children and on experiences within the home. When community level experiences, such as discrimination based on race or ethnicity, are included, as in the Philadelphia ACES study,¹⁶ as many as 40% reported ACE scores of greater than 4 for community level exposures.

As psychiatrists, we recognize the psychic underpinnings and parallels between the psychic projections onto black and brown people and the actual bullets pumped into the bodies of black and brown people; there is a lurid propensity to use these others as repositories. Those who have the privilege of being protected by law enforcement and the ability to avoid being used as containers for the psychic projections and bullets of some police officers also have the privilege of compartmentalizing and looking the other way when excessive acts of force – projections and projectiles – are used on other human beings. This partly explains why the injuries and deaths of black and brown people caused by police officers’ excessive use of force have continued even though these unjustified deaths are widely televised and disseminated via various social media platforms.

Prior to the death of George Floyd on May 25, other than the American Public Health Association, the National Medical Association (NMA) was the only major medical organization to issue a call to consider police use of force as a public health issue. In its July 2016 press release, provided in the aftermath of the death of Freddie Gray while in the custody of Baltimore police officers, the NMA summarized the scope of injuries citizens sustain during “the pre-custody (commission of a crime, during a fight, chase, and apprehension, during a siege or hostage situation, or during restraint or submission), custody (soon after being admitted to jail, during interrogation, during incarceration, or legal execution), and post-custody (revenge by police or rival criminals or after reentry into the community)” periods. It is noteworthy that the scope of these injuries is comparable to those encountered in a combat zone.^17,18 According to the NMA:

“Injuries sustained by civilians at the hands of law enforcement include gunshot wounds, skull fractures, cervical spine injuries, facial fractures, broken legs, blunt trauma orbital floor fractures, laryngeal cartilage fractures, shoulder dislocations, cuts and bruises, concussions, hemorrhage, choking (positional or due to upper body holds), abdominal trauma, hemothorax, and pneumothorax. Complications of such injuries include posttraumatic brain swelling, infections following open fractures and lacerations, hydrocephalus due to blood or infection, as well as subdural and epidural hematomas and, in the most severe cases, death.”

In addition, there are multiple emotional and psychiatric sequelae of these injuries for the victims, families, upstanders, bystanders, and those viewing these images via various social media platforms. Increasingly, many are experiencing retraumatization each time a new death is reported. How do we explain that we are turning away from this as physicians and trainers of physicians? Seeing and not seeing – all of the methods used to avert one’s gaze and look the other way (to protect the psyches of nonmarginalized members of society from being disturbed and possibly traumatized) – these key defense mechanisms creep into consulting rooms and become fertile ground for the enactment described above.

Yet, there is reason to believe in change. It’s not simply because we are mental health professionals and that’s what we do. With the posting of position statements issued by major corporations and a growing number of medical organizations, many of us are experiencing a mixture of hope, anger, and sadness. Hope that widespread awareness will continue to tilt the axis of our country in a manner that opens eyes – and hearts – so that real work can be done; and anger and sadness because it has taken 400 years to receive even this level of validation.

In the meantime, we are encouraged by a joint position statement recently issued by the APA and the NMA, the first joint effort by these two medical organizations to partner and advocate for criminal justice reform. We mention this statement because the NMA has been committed to the needs of the black community since its inception in 1895, and the APA has as its mission a commitment to serve “the needs of evolving, diverse, underrepresented, and underserved patient populations” ... and the resources to do so. This is the kind of partnership that could transform words into meaningful action.^19,20

Of course, resident psychiatrist Dr. A. had begun supervision with the discussion of his dyadic experience with his patient, which is set in the context of a global coronavirus pandemic that is disproportionately affecting black and brown people. And, while his peers are marching in protest, he and his fellow trainees deserve our support as they deal with their own psychic pain and prepare to steady themselves. For these psychiatrists will be called to provide care to those who will consult them once they begin to grapple with the experiences and, in some cases, traumas that have compelled them to take action and literally risk their safety and lives while protesting.

That evening, the residents were hungry for methods to fill the gaps in their training and supervision. In some cases, we provided scripts to be taken back to supervision. For example, the following is a potential scripted response for the supervisor in the enactment described above:
 

Resident speaking to supervisor: This is a black patient who, like many others, is affected by the chronic, repeated televised images of black men killed by police. I am also a black man.

I think what I have shared is pertinent to the patient’s care and my experience as a black male psychiatrist who will need to learn how to address this in my patients who are black and for other racialized groups, as well as with whites who might have rarely been cared for by a black man. Can we discuss this?

We also anticipated that some residents would need to exercise their right to request reassignment to another supervisor. And, until we do better at listening, seeing, and deepening our understanding, outside and inside the consulting room and in supervision, more residents might need to steer around those who have the potential to undermine training and adversely affect treatment. But, as a professional medical community in crisis, do we really want to proceed in such an ad hoc fashion?
 

Dr. Dunlap is a psychiatrist and psychoanalyst, and clinical professor of psychiatry and behavioral sciences at George Washington University. She is interested in the management of “difference” – race, gender, ethnicity, and intersectionality – in dyadic relationships and group dynamics; and the impact of racism on interpersonal relationships in institutional structures. Dr. Dunlap practices in Washington and has no disclosures.

Dr. Dennis is a clinical psychologist and psychoanalyst. Her interests are in gender and ethnic diversity, health equity, and supervision and training. Dr. Dennis practices in Washington and has no disclosures.

Dr. DeSouza is a PGY-4 psychiatry resident and public psychiatry fellow in the department of psychiatry at Yale University, New Haven, Conn. Her professional interests include health services development and delivery in low- and middle-income settings, as well as the intersection of mental health and spirituality. She has no disclosures.

Dr. Isom is a staff psychiatrist at the Codman Square Health Center in Dorchester, Mass., and Boston Medical Center. Her interests include racial mental health equity and population health approaches to community psychiatry. She has no disclosures.

Dr. Mathis is an addictions fellow in the department of psychiatry at Yale University and former programwide chief resident at Yale. Her interests include the intersection of racial justice and mental health, health equity, and spirituality. She has no disclosures.

References

1. Mental Health: Culture, Race, and Ethnicity. A Supplement to Mental Health: A Report of the Surgeon General. Rockville, Md.: Substance Abuse and Mental Health Services Administration, 2001.

2. Banaji MR and Greenwald AG. Blindspot: Hidden Biases of Good People. New York: Delacorte Press, 2013.

3. Anekwe ON. Voices in Bioethics. 2014.

4. Soute BJ. The American Psychoanalyst Magazine. 2017 Winter/Spring.

5. Powell DR. J Am Psychoanal Assoc. 2019 Jan 8. doi: 10.1177/000306511881847.

6. Allen TW. The Invention of the White Race. London: Verso, 1994.

7. Klein M. Int J Psychoanal. 1946;27(pt.3-4):99-100.

8. Bion WR. (1962b). Psychoanal Q. 2013 Apr;82(2):301-10.

9. Black Psychoanalysts Speak trailer.

10. Thomas A and Sillen S. Racism and Psychiatry. New York: Brunner/Mazel, 1972.

11. Jones BE et al. Am J Psychiatry. 1970 Dec;127(6):798-803.

12. Sabshin M et al. Am J Psychiatry. 1970 Dec;126(6):787-93.

13. Medlock M et al. Am J Psychiatry. 2017 May 9. doi: 10.1176/appi.ajp-rj.2016.110206.

14. Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). Arlington, Va.: American Psychiatric Association, 2013.

15. “What is Child Trauma?” The National Child Traumatic Stress Network.

16. The Philadelphia Project. Philadelphia ACE Survey.

17. “Addressing law enforcement violence as a public health issue.” Washington: American Public Health Association. 2018 Nov 13. Policy# 20811.

18. National Medical Association position statement on police use of force. NMA 2016.

19. “APA and NMA jointly condemn systemic racism in America.” 2020 Jun 16.

20. APA Strategic Plan. 2015 Mar.

On the Friday evening after the public execution of George Floyd, we were painfully reminded of the urgency to address the inadequate management of race, racism, and anti-blackness in medical education, residency training, and postgraduate continuing medical education.

The reminder did not originate from the rioting that was occurring in some cities, though we could feel the ground shifting beneath our feet as civic protests that began in U.S. cities spread around the globe. Instead, it occurred during a webinar we were hosting for psychiatry residents focused on techniques for eliminating blind spots in the management of race in clinical psychotherapy supervision. (Dr. Jessica Isom chaired the webinar, Dr. Flavia DeSouza and Dr. Myra Mathis comoderated, and Dr. Ebony Dennis and Dr. Constance E. Dunlap served as discussants.)

Our panel had presented an ambitious agenda that included reviewing how the disavowal of bias, race, racism, and anti-blackness contributes to ineffective psychotherapy, undermines the quality of medical care, and perpetuates mental health disparities. We spent some time exploring how unacknowledged and unexamined conscious and unconscious racial stereotypes affect interpersonal relationships, the psychotherapeutic process, and the supervisory experience. Our presentation included a clinical vignette demonstrating how racism, colorism, and anti-blackness have global impact, influencing the self-esteem, identity formation, and identity consolidation of immigrants as they grapple with the unique form of racism that exists in America. Other clinical vignettes demonstrated blind spots that were retroactively identified though omitted in supervisory discussions. We also discussed alternative interventions and interpretations of the material presented.^1-5

Because 21st-century trainees are generally psychologically astute and committed to social justice, we did two things. First, before the webinar, we provided them access to a prerecorded explanation of object relations theorist Melanie Klein’s paranoid-schizoid and depressive positions concepts, which were applied to theoretically explain the development of race, specifically the defenses used by early colonists that contributed to the development of “whiteness” and “blackness” as social constructs, and their influence on the development of the U.S. psyche. For example, as early colonists attempted to develop new and improved identities distinct from those they had in their homelands, they used enslaved black people (and other vulnerable groups) to “other.” What we mean here by othering is the process of using an other to project one’s badness into in order to relieve the self of uncomfortable aspects and feelings originating within the self. If this other accepts the projection (which is often the case with vulnerable parties), the self recognizes, that is, identifies (locates) the bad they just projected in the other, who is now experienced as a bad-other. This is projection in action. If the other accepts the projection and behaves accordingly, for example, in a manner that reflects badness, this becomes projective identification. Conversely, if the other does not accept these projections, the self (who projects) is left to cope with aspects of the self s/he might not have the capacity to manage. By capacity, we are speaking of the Bionian idea of the ability to experience an extreme emotion while also being able to think. Without the ego strength to cope with bad aspects of the self, the ego either collapses (and is unable to think) or further projection is attempted.^6-8

We have seen this latter dynamic play out repeatedly when police officers fatally shoot black citizens and then claim that they feared for their lives; these same officers have been exonerated by juries by continuing to portray the deceased victims as threatening, dangerous objects not worthy of living. We are also seeing a global movement of black and nonblack people who are in touch with a justified rage that has motivated them to return these projections by collectively protesting, and in some cases, by rioting.
 

Back to the webinar

In anticipating the residents’ curiosity, impatience, and anger about the lack of progress, the second thing we did was to show a segment from the “Black Psychoanalysts Speak” trailer. In the clip played, senior psychoanalyst Kirkland C. Vaughans, PhD, shares: “The issue of race so prompts excessive anxiety that it blocks off our ability to think.”

We showed this clip to validate the trainees’ frustrations about the difficulty the broader establishment has had with addressing this serious, longstanding public health problem. We wanted these young psychiatrists to know that there are psychoanalysts, psychiatrists, psychologists, and social workers who have been committed to this work, even though the contributions of this diverse group have curiously been omitted from education and training curricula.⁹

So, what happened? What was the painful reminder? After the formal panel presentations, a black male psychiatry resident recounted his experience in a clinical supervision meeting that had occurred several days after the murder of George Floyd. In short, a patient had shared his reactions to yet another incident of fatal police use of force and paused to ask how the resident physician, Dr. A., was doing. The question was experienced as sincere concern about the psychiatrist’s mental well-being. The resident was not sure how to answer this question since it was a matter of self-disclosure, which was a reasonable and thoughtful consideration for a seasoned clinician and, certainly, for a novice therapist. The supervisor, Dr. B., seemingly eager to move on, to not think about this, responded to the resident by saying: “Now tell me about the patient.” In other words, what had just been shared by the resident – material that featured a patient’s reaction to another killing of a black man by police and the patient’s expressed concern for his black psychiatrist, and this resident physician appropriately seeking space in supervision to process and receive guidance about how to respond – all of this was considered separate (split off from) and extraneous to the patient’s treatment and the resident’s training. This is a problem. And, unfortunately, this problem or some variation of it is not rare.

Why is this still the state of affairs when we have identified racism as a major health concern and our patients and our trainees are asking for help?
 

Rethinking a metaphor

Despite calls to action over the last 50 years to encourage medicine to effectively address race and racism, deficits remain in didactic education, clinical rotations, and supervisory experiences of trainees learning how to do psychodynamic psychotherapy.^8-10 Earlier that evening, we used the metaphor of a vehicular blind spot to capture what we believe occurs insupervision. Like drivers, supervisors generally have the ability to see. However, there are places (times) and positions (stances) that block their vision (awareness). Racism – whether institutionalized, interpersonally mediated, or internalized – also contributes to this blindness.

As is true of drivers managing a blind spot, what is required is for the drivers – the supervisors – to lean forward or reposition themselves so as to avoid collisions, maintain safety, and continue on course. We use this metaphor because it is understood that any clinician providing psychodynamic supervision to psychiatry residents, regardless of professional discipline, has the requisite skills and training.^10-13

Until May 25, we thought eliminating blind spots would be effective. But, in the aftermath of the police killing of George Floyd, our eyes have been opened.

We are encouraged by the global protests and initial actions to reform law enforcement, but we realize that medicine is in need of reform. Hiding behind the blue wall of silence is an establishment that has looked the other way while black and brown women, men, and children have come to live in fear as a result of the state-sanctioned violence that repeatedly occurs across the nation. Excessive police use of force is a public health issue of crisis magnitude. However, the house of medicine, like many other established structures in society, has colluded with the societal constructs that have supported law enforcement by remaining willfully blind, often neutral, and by refusing to make the necessary adjustments, including connecting the dots between police violence and physical and mental health.

For example, racism has never been listed even in the index of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders.¹⁴ Being the victim of police use of force is not generally regarded as an adverse childhood experience, even though communities that are heavily policed experience harassment by law enforcement on a regular basis. The 12 causes of trauma listed on the website¹⁵ of the National Child Traumatic Stress Network – bullying, community violence, complex trauma, disasters, early childhood trauma, intimate partner violence, medical trauma, physical abuse, refugee trauma, sexual abuse, terrorism and violence, and traumatic grief – do not include maltreatment, abuse, or trauma resulting from interactions with members of law enforcement. Much of the adverse childhood experiences literature focuses on white, upper middle class children and on experiences within the home. When community level experiences, such as discrimination based on race or ethnicity, are included, as in the Philadelphia ACES study,¹⁶ as many as 40% reported ACE scores of greater than 4 for community level exposures.

As psychiatrists, we recognize the psychic underpinnings and parallels between the psychic projections onto black and brown people and the actual bullets pumped into the bodies of black and brown people; there is a lurid propensity to use these others as repositories. Those who have the privilege of being protected by law enforcement and the ability to avoid being used as containers for the psychic projections and bullets of some police officers also have the privilege of compartmentalizing and looking the other way when excessive acts of force – projections and projectiles – are used on other human beings. This partly explains why the injuries and deaths of black and brown people caused by police officers’ excessive use of force have continued even though these unjustified deaths are widely televised and disseminated via various social media platforms.

Prior to the death of George Floyd on May 25, other than the American Public Health Association, the National Medical Association (NMA) was the only major medical organization to issue a call to consider police use of force as a public health issue. In its July 2016 press release, provided in the aftermath of the death of Freddie Gray while in the custody of Baltimore police officers, the NMA summarized the scope of injuries citizens sustain during “the pre-custody (commission of a crime, during a fight, chase, and apprehension, during a siege or hostage situation, or during restraint or submission), custody (soon after being admitted to jail, during interrogation, during incarceration, or legal execution), and post-custody (revenge by police or rival criminals or after reentry into the community)” periods. It is noteworthy that the scope of these injuries is comparable to those encountered in a combat zone.^17,18 According to the NMA:

“Injuries sustained by civilians at the hands of law enforcement include gunshot wounds, skull fractures, cervical spine injuries, facial fractures, broken legs, blunt trauma orbital floor fractures, laryngeal cartilage fractures, shoulder dislocations, cuts and bruises, concussions, hemorrhage, choking (positional or due to upper body holds), abdominal trauma, hemothorax, and pneumothorax. Complications of such injuries include posttraumatic brain swelling, infections following open fractures and lacerations, hydrocephalus due to blood or infection, as well as subdural and epidural hematomas and, in the most severe cases, death.”

In addition, there are multiple emotional and psychiatric sequelae of these injuries for the victims, families, upstanders, bystanders, and those viewing these images via various social media platforms. Increasingly, many are experiencing retraumatization each time a new death is reported. How do we explain that we are turning away from this as physicians and trainers of physicians? Seeing and not seeing – all of the methods used to avert one’s gaze and look the other way (to protect the psyches of nonmarginalized members of society from being disturbed and possibly traumatized) – these key defense mechanisms creep into consulting rooms and become fertile ground for the enactment described above.

Yet, there is reason to believe in change. It’s not simply because we are mental health professionals and that’s what we do. With the posting of position statements issued by major corporations and a growing number of medical organizations, many of us are experiencing a mixture of hope, anger, and sadness. Hope that widespread awareness will continue to tilt the axis of our country in a manner that opens eyes – and hearts – so that real work can be done; and anger and sadness because it has taken 400 years to receive even this level of validation.

In the meantime, we are encouraged by a joint position statement recently issued by the APA and the NMA, the first joint effort by these two medical organizations to partner and advocate for criminal justice reform. We mention this statement because the NMA has been committed to the needs of the black community since its inception in 1895, and the APA has as its mission a commitment to serve “the needs of evolving, diverse, underrepresented, and underserved patient populations” ... and the resources to do so. This is the kind of partnership that could transform words into meaningful action.^19,20

Of course, resident psychiatrist Dr. A. had begun supervision with the discussion of his dyadic experience with his patient, which is set in the context of a global coronavirus pandemic that is disproportionately affecting black and brown people. And, while his peers are marching in protest, he and his fellow trainees deserve our support as they deal with their own psychic pain and prepare to steady themselves. For these psychiatrists will be called to provide care to those who will consult them once they begin to grapple with the experiences and, in some cases, traumas that have compelled them to take action and literally risk their safety and lives while protesting.

That evening, the residents were hungry for methods to fill the gaps in their training and supervision. In some cases, we provided scripts to be taken back to supervision. For example, the following is a potential scripted response for the supervisor in the enactment described above:
 

Resident speaking to supervisor: This is a black patient who, like many others, is affected by the chronic, repeated televised images of black men killed by police. I am also a black man.

I think what I have shared is pertinent to the patient’s care and my experience as a black male psychiatrist who will need to learn how to address this in my patients who are black and for other racialized groups, as well as with whites who might have rarely been cared for by a black man. Can we discuss this?

We also anticipated that some residents would need to exercise their right to request reassignment to another supervisor. And, until we do better at listening, seeing, and deepening our understanding, outside and inside the consulting room and in supervision, more residents might need to steer around those who have the potential to undermine training and adversely affect treatment. But, as a professional medical community in crisis, do we really want to proceed in such an ad hoc fashion?
 

Dr. Dunlap is a psychiatrist and psychoanalyst, and clinical professor of psychiatry and behavioral sciences at George Washington University. She is interested in the management of “difference” – race, gender, ethnicity, and intersectionality – in dyadic relationships and group dynamics; and the impact of racism on interpersonal relationships in institutional structures. Dr. Dunlap practices in Washington and has no disclosures.

Dr. Dennis is a clinical psychologist and psychoanalyst. Her interests are in gender and ethnic diversity, health equity, and supervision and training. Dr. Dennis practices in Washington and has no disclosures.

Dr. DeSouza is a PGY-4 psychiatry resident and public psychiatry fellow in the department of psychiatry at Yale University, New Haven, Conn. Her professional interests include health services development and delivery in low- and middle-income settings, as well as the intersection of mental health and spirituality. She has no disclosures.

Dr. Isom is a staff psychiatrist at the Codman Square Health Center in Dorchester, Mass., and Boston Medical Center. Her interests include racial mental health equity and population health approaches to community psychiatry. She has no disclosures.

Dr. Mathis is an addictions fellow in the department of psychiatry at Yale University and former programwide chief resident at Yale. Her interests include the intersection of racial justice and mental health, health equity, and spirituality. She has no disclosures.

References

1. Mental Health: Culture, Race, and Ethnicity. A Supplement to Mental Health: A Report of the Surgeon General. Rockville, Md.: Substance Abuse and Mental Health Services Administration, 2001.

2. Banaji MR and Greenwald AG. Blindspot: Hidden Biases of Good People. New York: Delacorte Press, 2013.

3. Anekwe ON. Voices in Bioethics. 2014.

4. Soute BJ. The American Psychoanalyst Magazine. 2017 Winter/Spring.

5. Powell DR. J Am Psychoanal Assoc. 2019 Jan 8. doi: 10.1177/000306511881847.

6. Allen TW. The Invention of the White Race. London: Verso, 1994.

7. Klein M. Int J Psychoanal. 1946;27(pt.3-4):99-100.

8. Bion WR. (1962b). Psychoanal Q. 2013 Apr;82(2):301-10.

9. Black Psychoanalysts Speak trailer.

10. Thomas A and Sillen S. Racism and Psychiatry. New York: Brunner/Mazel, 1972.

11. Jones BE et al. Am J Psychiatry. 1970 Dec;127(6):798-803.

12. Sabshin M et al. Am J Psychiatry. 1970 Dec;126(6):787-93.

13. Medlock M et al. Am J Psychiatry. 2017 May 9. doi: 10.1176/appi.ajp-rj.2016.110206.

14. Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). Arlington, Va.: American Psychiatric Association, 2013.

15. “What is Child Trauma?” The National Child Traumatic Stress Network.

16. The Philadelphia Project. Philadelphia ACE Survey.

17. “Addressing law enforcement violence as a public health issue.” Washington: American Public Health Association. 2018 Nov 13. Policy# 20811.

18. National Medical Association position statement on police use of force. NMA 2016.

19. “APA and NMA jointly condemn systemic racism in America.” 2020 Jun 16.

20. APA Strategic Plan. 2015 Mar.

Prominent female physicians are handing over their social media platforms today to black female physicians as part of a campaign called #ShareTheMicNowMed.

The social media event, which will play out on both Twitter and Instagram, is an offshoot of #ShareTheMicNow, held earlier this month. For that event, more than 90 women, including A-list celebrities like Ellen DeGeneres, Julia Roberts, and Senator Elizabeth Warren, swapped accounts with women of color, such as “I’m Still Here” author Austin Channing Brown, Olympic fencer Ibtihaj Muhammad, and #MeToo founder Tarana Burke.

The physician event will feature 10 teams of two, with one physician handing over her account to her black female counterpart for the day. The takeover will allow the black physician to share her thoughts about the successes and challenges she faces as a woman of color in medicine.

“It was such an honor to be contacted by Arghavan Salles, MD, PhD, to participate in an event that has a goal of connecting like-minded women from various backgrounds to share a diverse perspective with a different audience,” Minnesota family medicine physician Jay-Sheree Allen, MD, told Medscape Medical News. “This event is not only incredibly important but timely.”

Participants say the goal of the takeovers is to amplify the reach and voice of black women in medicine while crossing boundaries and empowering others to do the same. Only about 5% of all active physicians in 2018 identified as Black or African American, according to a report by the Association of American Medical Colleges. And of those, just over a third are female, the report found.

“I think that as we hear those small numbers we often celebrate the success of those people without looking back and understanding where all of the barriers are that are limiting talented black women from entering medicine at every stage,” another campaign participant, Chicago pediatrician Rebekah Fenton, MD, told Medscape Medical News.

Allen says that, amid continuing worldwide protests over racial injustice, prompted by the death of George Floyd while in Minneapolis police custody last month, the online event is very timely and an important way to advocate for black lives and engage in a productive conversation.

Prominent female physicians are handing over their social media platforms today to black female physicians as part of a campaign called #ShareTheMicNowMed.

The social media event, which will play out on both Twitter and Instagram, is an offshoot of #ShareTheMicNow, held earlier this month. For that event, more than 90 women, including A-list celebrities like Ellen DeGeneres, Julia Roberts, and Senator Elizabeth Warren, swapped accounts with women of color, such as “I’m Still Here” author Austin Channing Brown, Olympic fencer Ibtihaj Muhammad, and #MeToo founder Tarana Burke.

The physician event will feature 10 teams of two, with one physician handing over her account to her black female counterpart for the day. The takeover will allow the black physician to share her thoughts about the successes and challenges she faces as a woman of color in medicine.

“It was such an honor to be contacted by Arghavan Salles, MD, PhD, to participate in an event that has a goal of connecting like-minded women from various backgrounds to share a diverse perspective with a different audience,” Minnesota family medicine physician Jay-Sheree Allen, MD, told Medscape Medical News. “This event is not only incredibly important but timely.”

Participants say the goal of the takeovers is to amplify the reach and voice of black women in medicine while crossing boundaries and empowering others to do the same. Only about 5% of all active physicians in 2018 identified as Black or African American, according to a report by the Association of American Medical Colleges. And of those, just over a third are female, the report found.

“I think that as we hear those small numbers we often celebrate the success of those people without looking back and understanding where all of the barriers are that are limiting talented black women from entering medicine at every stage,” another campaign participant, Chicago pediatrician Rebekah Fenton, MD, told Medscape Medical News.

Allen says that, amid continuing worldwide protests over racial injustice, prompted by the death of George Floyd while in Minneapolis police custody last month, the online event is very timely and an important way to advocate for black lives and engage in a productive conversation.

Prominent female physicians are handing over their social media platforms today to black female physicians as part of a campaign called #ShareTheMicNowMed.

The social media event, which will play out on both Twitter and Instagram, is an offshoot of #ShareTheMicNow, held earlier this month. For that event, more than 90 women, including A-list celebrities like Ellen DeGeneres, Julia Roberts, and Senator Elizabeth Warren, swapped accounts with women of color, such as “I’m Still Here” author Austin Channing Brown, Olympic fencer Ibtihaj Muhammad, and #MeToo founder Tarana Burke.

The physician event will feature 10 teams of two, with one physician handing over her account to her black female counterpart for the day. The takeover will allow the black physician to share her thoughts about the successes and challenges she faces as a woman of color in medicine.

“It was such an honor to be contacted by Arghavan Salles, MD, PhD, to participate in an event that has a goal of connecting like-minded women from various backgrounds to share a diverse perspective with a different audience,” Minnesota family medicine physician Jay-Sheree Allen, MD, told Medscape Medical News. “This event is not only incredibly important but timely.”

Participants say the goal of the takeovers is to amplify the reach and voice of black women in medicine while crossing boundaries and empowering others to do the same. Only about 5% of all active physicians in 2018 identified as Black or African American, according to a report by the Association of American Medical Colleges. And of those, just over a third are female, the report found.

“I think that as we hear those small numbers we often celebrate the success of those people without looking back and understanding where all of the barriers are that are limiting talented black women from entering medicine at every stage,” another campaign participant, Chicago pediatrician Rebekah Fenton, MD, told Medscape Medical News.

Allen says that, amid continuing worldwide protests over racial injustice, prompted by the death of George Floyd while in Minneapolis police custody last month, the online event is very timely and an important way to advocate for black lives and engage in a productive conversation.

I was recently interviewed, as a gay psychiatrist treating gay patients who lived through the AIDS epidemic, about my perspectives on living through a COVID pandemic: Were there parallels and contrasts between the two? A month later, listening to patients remotely via teletherapy, I’m experiencing an unsettling similarity to serosorting, a phenomenon that emerged during the AIDS epidemic.

Serosorting is the practice of choosing a sexual partner based on their HIV serostatus. Sorting out who was positive from who was negative allowed people to give themselves permission to have unprotected sex without risk of getting HIV. However, it was not uncommon to make those decisions without really knowing a potential partner’s actual serostatus. In fact, a lot of people serosorted by guessing.

Why not just ask a potential partner, “What’s your serostatus?” Apparently, for some, introducing the subject of HIV was deemed a sexual buzzkill. Instead, assumptions were made based on outer appearances.

Did someone look healthy? Were they well built? Were they overweight, meaning not emaciated from AIDS? If so, they were presumed negative and safe to have risky, unprotected sex with them.

Some imagined age correlated with serostatus. Since anyone older than some arbitrary age – like 30, to pull a number out of a hat – was expected to be more likely to have HIV than someone under 30, they would use that guideline in choosing sexual partners. However, these decisions were made without factual knowledge, like a blood test, but using some internal reasoning process.

Which brings us to what might be called “COVID-sorting.”

Some of my patients believe they had COVID-19, although they’d not been tested to either confirm or disprove that belief. Others had positive COVID-19 antibody tests, which they believe provides immunity. Among that group, some had symptoms, others did not.

Yet regardless of what they actually know or don’t know, patients are making calculations about managing physical distancing using their own internal formulas. They make risk calculations having little to do with actual knowledge of public health precautions on preventing COVID’s spread.

For example, one patient was planning a Memorial Day weekend in a shared Fire Island house with five friends and acquaintances. All six live alone and, as far as he knows, all are physically distancing. Consequently, my patient doesn’t think house-sharing is anything to worry about, even though he doesn’t know how scrupulously others have followed distancing guidelines.

Another patient, recovering at home after being ill with COVID-19, felt safe inviting someone over for sex who had also been ill and recovered. He didn’t think they could infect each other, presuming, not altogether unreasonably, they were both immune.

Finally, there are those who don’t know whether they had COVID-19, but think they did because they experienced influenza-like symptoms. They are giving themselves permission to meet up with others who feel the same.

Yet a Mount Sinai study, which has not yet been peer-reviewed, raises fascinating issues about immunity. The study included 719 people who suspected they had COVID-19 based on some respiratory symptoms. The majority, 62%, had no antibodies. Researchers believe they mistook influenza, another viral infection, or allergies for COVID-19 (medRxiv. 2020 May 5. doi: 10.1101/2020.04.04.2008516).

The study also included 624 people who tested positive for the virus and recovered. All but three developed antibodies. Many assume those who are antibody-positive are now immune. They may be right. However, we don’t know definitively that they are, and if they are, we do not yet know how long immunity may last. Further, as reported in the New York Times, just because you test positive for antibodies, doesn’t mean you have them.

It should be underscored that COVID-sorting is not limited to gay men or psychiatric patients. Central Park, these days, is filled with many unmasked, nonsocially isolating people of all sexual orientations and genders who are making their own questionable decisions. And as many states have begun opening up restrictions on social gatherings, we are seeing an all-too-human psychological mindset with wider implications – rising numbers of cases. As we move forward, all of us will have to decide for ourselves, and not only in sexual situations, how to get on with our lives in a post–COVID-19 era.

Given how much is still unknown, it is likely each of us will come up with our own algorithm of risk assessment. It is likely that the formulas used will not necessarily be based on scientific facts, although that would be ideal. If past epidemic and recent pandemic behaviors are any indicators, people’s actions will reflect some combination of their own needs and desires, their own comfort level with risk-taking, and their relative understanding of complex subjects like virology, immunology, epidemiology, and public health. The challenge faced by public health officials today is to translate complex scientific and medical issues into messages average people can understand.

What exactly can be done? I’m not exactly sure, but I hope that improved education and communication can help. In the first 2 decades of the AIDS epidemic, efforts were made to change and tailor HIV-prevention messages to specific, at-risk demographic groups. Today, public health messages aimed at preventing COVID-19’s spread that resonate with older people can fall on a younger person’s deaf ears. One message size does not fit all. Hopefully, public health officials and government leaders will act on this sooner rather than later.
 

Dr. Drescher, a psychoanalyst, is clinical professor of psychiatry at Columbia University, and training and supervising analyst at the William A. White Institute, both in New York. He also is emeritus editor of the Journal of Gay & Lesbian Mental Health. Dr. Drescher has no other disclosures.

I was recently interviewed, as a gay psychiatrist treating gay patients who lived through the AIDS epidemic, about my perspectives on living through a COVID pandemic: Were there parallels and contrasts between the two? A month later, listening to patients remotely via teletherapy, I’m experiencing an unsettling similarity to serosorting, a phenomenon that emerged during the AIDS epidemic.

Serosorting is the practice of choosing a sexual partner based on their HIV serostatus. Sorting out who was positive from who was negative allowed people to give themselves permission to have unprotected sex without risk of getting HIV. However, it was not uncommon to make those decisions without really knowing a potential partner’s actual serostatus. In fact, a lot of people serosorted by guessing.

Why not just ask a potential partner, “What’s your serostatus?” Apparently, for some, introducing the subject of HIV was deemed a sexual buzzkill. Instead, assumptions were made based on outer appearances.

Did someone look healthy? Were they well built? Were they overweight, meaning not emaciated from AIDS? If so, they were presumed negative and safe to have risky, unprotected sex with them.

Some imagined age correlated with serostatus. Since anyone older than some arbitrary age – like 30, to pull a number out of a hat – was expected to be more likely to have HIV than someone under 30, they would use that guideline in choosing sexual partners. However, these decisions were made without factual knowledge, like a blood test, but using some internal reasoning process.

Which brings us to what might be called “COVID-sorting.”

Some of my patients believe they had COVID-19, although they’d not been tested to either confirm or disprove that belief. Others had positive COVID-19 antibody tests, which they believe provides immunity. Among that group, some had symptoms, others did not.

Yet regardless of what they actually know or don’t know, patients are making calculations about managing physical distancing using their own internal formulas. They make risk calculations having little to do with actual knowledge of public health precautions on preventing COVID’s spread.

For example, one patient was planning a Memorial Day weekend in a shared Fire Island house with five friends and acquaintances. All six live alone and, as far as he knows, all are physically distancing. Consequently, my patient doesn’t think house-sharing is anything to worry about, even though he doesn’t know how scrupulously others have followed distancing guidelines.

Another patient, recovering at home after being ill with COVID-19, felt safe inviting someone over for sex who had also been ill and recovered. He didn’t think they could infect each other, presuming, not altogether unreasonably, they were both immune.

Finally, there are those who don’t know whether they had COVID-19, but think they did because they experienced influenza-like symptoms. They are giving themselves permission to meet up with others who feel the same.

Yet a Mount Sinai study, which has not yet been peer-reviewed, raises fascinating issues about immunity. The study included 719 people who suspected they had COVID-19 based on some respiratory symptoms. The majority, 62%, had no antibodies. Researchers believe they mistook influenza, another viral infection, or allergies for COVID-19 (medRxiv. 2020 May 5. doi: 10.1101/2020.04.04.2008516).

The study also included 624 people who tested positive for the virus and recovered. All but three developed antibodies. Many assume those who are antibody-positive are now immune. They may be right. However, we don’t know definitively that they are, and if they are, we do not yet know how long immunity may last. Further, as reported in the New York Times, just because you test positive for antibodies, doesn’t mean you have them.

It should be underscored that COVID-sorting is not limited to gay men or psychiatric patients. Central Park, these days, is filled with many unmasked, nonsocially isolating people of all sexual orientations and genders who are making their own questionable decisions. And as many states have begun opening up restrictions on social gatherings, we are seeing an all-too-human psychological mindset with wider implications – rising numbers of cases. As we move forward, all of us will have to decide for ourselves, and not only in sexual situations, how to get on with our lives in a post–COVID-19 era.

Given how much is still unknown, it is likely each of us will come up with our own algorithm of risk assessment. It is likely that the formulas used will not necessarily be based on scientific facts, although that would be ideal. If past epidemic and recent pandemic behaviors are any indicators, people’s actions will reflect some combination of their own needs and desires, their own comfort level with risk-taking, and their relative understanding of complex subjects like virology, immunology, epidemiology, and public health. The challenge faced by public health officials today is to translate complex scientific and medical issues into messages average people can understand.

What exactly can be done? I’m not exactly sure, but I hope that improved education and communication can help. In the first 2 decades of the AIDS epidemic, efforts were made to change and tailor HIV-prevention messages to specific, at-risk demographic groups. Today, public health messages aimed at preventing COVID-19’s spread that resonate with older people can fall on a younger person’s deaf ears. One message size does not fit all. Hopefully, public health officials and government leaders will act on this sooner rather than later.
 

Dr. Drescher, a psychoanalyst, is clinical professor of psychiatry at Columbia University, and training and supervising analyst at the William A. White Institute, both in New York. He also is emeritus editor of the Journal of Gay & Lesbian Mental Health. Dr. Drescher has no other disclosures.

I was recently interviewed, as a gay psychiatrist treating gay patients who lived through the AIDS epidemic, about my perspectives on living through a COVID pandemic: Were there parallels and contrasts between the two? A month later, listening to patients remotely via teletherapy, I’m experiencing an unsettling similarity to serosorting, a phenomenon that emerged during the AIDS epidemic.

Serosorting is the practice of choosing a sexual partner based on their HIV serostatus. Sorting out who was positive from who was negative allowed people to give themselves permission to have unprotected sex without risk of getting HIV. However, it was not uncommon to make those decisions without really knowing a potential partner’s actual serostatus. In fact, a lot of people serosorted by guessing.

Why not just ask a potential partner, “What’s your serostatus?” Apparently, for some, introducing the subject of HIV was deemed a sexual buzzkill. Instead, assumptions were made based on outer appearances.

Did someone look healthy? Were they well built? Were they overweight, meaning not emaciated from AIDS? If so, they were presumed negative and safe to have risky, unprotected sex with them.

Some imagined age correlated with serostatus. Since anyone older than some arbitrary age – like 30, to pull a number out of a hat – was expected to be more likely to have HIV than someone under 30, they would use that guideline in choosing sexual partners. However, these decisions were made without factual knowledge, like a blood test, but using some internal reasoning process.

Which brings us to what might be called “COVID-sorting.”

Some of my patients believe they had COVID-19, although they’d not been tested to either confirm or disprove that belief. Others had positive COVID-19 antibody tests, which they believe provides immunity. Among that group, some had symptoms, others did not.

Yet regardless of what they actually know or don’t know, patients are making calculations about managing physical distancing using their own internal formulas. They make risk calculations having little to do with actual knowledge of public health precautions on preventing COVID’s spread.

For example, one patient was planning a Memorial Day weekend in a shared Fire Island house with five friends and acquaintances. All six live alone and, as far as he knows, all are physically distancing. Consequently, my patient doesn’t think house-sharing is anything to worry about, even though he doesn’t know how scrupulously others have followed distancing guidelines.

Another patient, recovering at home after being ill with COVID-19, felt safe inviting someone over for sex who had also been ill and recovered. He didn’t think they could infect each other, presuming, not altogether unreasonably, they were both immune.

Finally, there are those who don’t know whether they had COVID-19, but think they did because they experienced influenza-like symptoms. They are giving themselves permission to meet up with others who feel the same.

Yet a Mount Sinai study, which has not yet been peer-reviewed, raises fascinating issues about immunity. The study included 719 people who suspected they had COVID-19 based on some respiratory symptoms. The majority, 62%, had no antibodies. Researchers believe they mistook influenza, another viral infection, or allergies for COVID-19 (medRxiv. 2020 May 5. doi: 10.1101/2020.04.04.2008516).

The study also included 624 people who tested positive for the virus and recovered. All but three developed antibodies. Many assume those who are antibody-positive are now immune. They may be right. However, we don’t know definitively that they are, and if they are, we do not yet know how long immunity may last. Further, as reported in the New York Times, just because you test positive for antibodies, doesn’t mean you have them.

It should be underscored that COVID-sorting is not limited to gay men or psychiatric patients. Central Park, these days, is filled with many unmasked, nonsocially isolating people of all sexual orientations and genders who are making their own questionable decisions. And as many states have begun opening up restrictions on social gatherings, we are seeing an all-too-human psychological mindset with wider implications – rising numbers of cases. As we move forward, all of us will have to decide for ourselves, and not only in sexual situations, how to get on with our lives in a post–COVID-19 era.

Given how much is still unknown, it is likely each of us will come up with our own algorithm of risk assessment. It is likely that the formulas used will not necessarily be based on scientific facts, although that would be ideal. If past epidemic and recent pandemic behaviors are any indicators, people’s actions will reflect some combination of their own needs and desires, their own comfort level with risk-taking, and their relative understanding of complex subjects like virology, immunology, epidemiology, and public health. The challenge faced by public health officials today is to translate complex scientific and medical issues into messages average people can understand.

What exactly can be done? I’m not exactly sure, but I hope that improved education and communication can help. In the first 2 decades of the AIDS epidemic, efforts were made to change and tailor HIV-prevention messages to specific, at-risk demographic groups. Today, public health messages aimed at preventing COVID-19’s spread that resonate with older people can fall on a younger person’s deaf ears. One message size does not fit all. Hopefully, public health officials and government leaders will act on this sooner rather than later.
 

Dr. Drescher, a psychoanalyst, is clinical professor of psychiatry at Columbia University, and training and supervising analyst at the William A. White Institute, both in New York. He also is emeritus editor of the Journal of Gay & Lesbian Mental Health. Dr. Drescher has no other disclosures.