Clinical Psychiatry News

COVID-19 now. The urban phase of the U.S. pandemic is leveling somewhat, while the rural phase is accelerating – in part because of food processing and handling industries. The pediatric burden has been surprisingly small, with the multisystem inflammatory disease (MIS-c) in children noted in several hundred cases now being seen across the country.

CDC

Next wave? Given ongoing COVID-19 disease, controversy rages about when and how to re-open the country. Regardless how more reopening occurs over the next months, we should expect a next or ongoing COVID-19 wave, particularly given loss of social distancing during social justice protests. A sawtooth disease prevalence pattern is predicted by many experts: a drop in prevalence leading to reopening, leading to scattered prevalence increases and regional if not local restriction tightening, followed by another drop in prevalence. Then “rinse and repeat” until 70% of the population is immune either by disease experience or vaccine-induced immunity, likely sometime in 2021.

Influenza too. A COVID-19 up-cycle is likely during influenza season, although influenza season’s onset could be altered because of whatever social distancing rules are in place in November and December. That said, we need to consider the worst. We have seen what happens if we fail to prepare and then react only after a prevalent respiratory infection has surged into the overall population. Best estimates are that at most 20% of the U.S. population is currently immune to SARS-CoV-2. Given that at least some of that 20% of individuals currently immune to SARS-CoV-2 will lose their neutralizing antibody over the next 4-6 months, we can still expect 70%-80% of the U.S. population to be susceptible to SARS-CoV-2 infection in the fall of 2020.

Pediatric preparedness. As pediatric providers, we have struggled with lower patient loads and dramatic income losses/declines. Many clinics/offices’ attendance remain less than 50% of pre–COVID-19 levels, with necessary furloughs of personnel and spotty office hours. But influenza is coming, and SARS-CoV-2 will not be gone yet. How do we prepare for concurrent influenza and COVID-19?

The annual purchase/administration of influenza vaccine in summer/fall is expensive, time consuming, and logistically difficult even in the best times. Given the loss of income, likely reluctance of patients to come to clinics/offices if COVID-19 is still circulating, and likely need for some form of social distancing during late summer and early fall, how will providers, health departments, and hospitals implement influenza vaccine administration this year?

Minimize double whammy infections. Maximizing influenza vaccine uptake during the COVID-19 pandemic is super important. It is easy to understand why we should maximize influenza protection in SARS-CoV-2 vulnerables (elderly or persons with existing comorbidities). But is it as critical for otherwise healthy children? My answer is yes.

Children are not currently known as SARS-CoV-2 vectors, but children are excellent influenza vectors, shedding higher titers for longer than other age groups. As with SARS-CoV-2, influenza exposure is cumulative, i.e., the more intense and more frequently a person is exposed, the more likely that infection/disease will result. So, the fewer who get and can transmit influenza during the COVID-19 pandemic, the fewer people are likely to get a double whammy of SARS-CoV-2 concurrent or in tandem with influenza. Double whammy infections likely would further increase the medical care burden and return us to March-April crisis mode.

One alarming new question is whether recent influenza could make children vulnerable to SARS-CoV-2 and trigger hospitalizations. A surge in pediatric plus adult COVID-19 disease plus a surge in all-ages influenza disease would likely break the medical care system, at least in some areas.

CDC

Staggering COVID-19 burden. As of June 8, we have had approximately 2 million SARS-CoV-2 cases with 500,000 hospitalizations and 120,000 deaths. Over the past 10 years, total annual U.S. influenza hospitalizations ranged from 180,000 (2011-2012) to 825,000 (2017-2018). The interquartile range for hospitalization length of stay for influenza is 4-6 days¹ vs. 15-23 days² for SARS-CoV-2. One COVID-19 hospitalization uses hospital resources roughly equal to four influenza hospitalizations. To date COVID-19 hospitalizations have used resources equal to an estimated 1.9 million influenza hospitalizations – over twice the worst influenza season in this century – and we are still on the rise. We are likely not even halfway to truly controlling the U.S. pandemic, so expect another 500,000 hospitalizations – equal to another 1.9 million influenza hospitalizations. Further, pneumonia deaths have skyrocketed this year when COVID-19 was superimposed on the last third of influenza season. One hope is that widespread use of antivirals (for example, new antivirals, convalescent plasma, or other interventions) can reduce length of stay by 30% for COVID-19 hospitalizations, yet even with that the numbers remain grim.

Less influenza disease can free up medical resources. Planning ahead could prevent a bad influenza season (for example, up to 850,000 hospitalizations just for influenza). Can we preemptively use vaccine to reduce influenza hospitalizations below 2011-2012 levels – less than 150,000 hospitalizations? Perhaps, if we start by reducing pediatric influenza.

1. Aim to exceed 75% influenza vaccine uptake in your patients.

a. It is ambitious, but if there was ever a year that needed influenza herd immunity, it is 2020-2021.

2. Review practice/group/institution plans for vaccine purchase and ensure adequate personnel to administer vaccine.

3. Plan safe and efficient processes to vaccinate large numbers in August through November.

a. Consider that routine and influenza vaccines can be given concurrently with the annual uptick in school and sports physical examinations.

b. What social distancing and masking rules will be needed?

i. Will patients need to bring their own masks, or will you supply them?

c. What extra supplies and efforts are needed, e.g. hand sanitizer, new signage, 6-foot interval markings on floors or sidewalks, families calling from parking lot to announce their arrivals, etc.?

d. Remember younger patients need two doses before Dec 1, 2020.

e. Be creative, for example, are parking-lot tents for influenza vaccination feasible?

f. Can we partner with other providers to implement influenza vaccine–specific mass clinics?

Ramping up to give seasonal influenza vaccine in 2020 is daunting. But if we do not prepare, it will be even more difficult. Let’s make this the mildest influenza season in memory by vaccinating more than any time in memory – and by doing so, we can hope to blunt medical care burdens despite ongoing COVID-19 disease.
 

Dr. Harrison is professor of pediatrics and pediatric infectious diseases at Children’s Mercy Kansas City (Mo.). Children’s Mercy receives funding from GlaxoSmithKline, Merck, and Pfizer for vaccine research studies on which Dr. Harrison is an investigator. Email him at [email protected].
 

References

1.. HCUP Statistical Brief #253. 2019 Oct.

2. medrxiv. 2020 Apr 10. doi: 10.1101/2020.04.07.20057299.
 

COVID-19 now. The urban phase of the U.S. pandemic is leveling somewhat, while the rural phase is accelerating – in part because of food processing and handling industries. The pediatric burden has been surprisingly small, with the multisystem inflammatory disease (MIS-c) in children noted in several hundred cases now being seen across the country.

CDC

Next wave? Given ongoing COVID-19 disease, controversy rages about when and how to re-open the country. Regardless how more reopening occurs over the next months, we should expect a next or ongoing COVID-19 wave, particularly given loss of social distancing during social justice protests. A sawtooth disease prevalence pattern is predicted by many experts: a drop in prevalence leading to reopening, leading to scattered prevalence increases and regional if not local restriction tightening, followed by another drop in prevalence. Then “rinse and repeat” until 70% of the population is immune either by disease experience or vaccine-induced immunity, likely sometime in 2021.

Influenza too. A COVID-19 up-cycle is likely during influenza season, although influenza season’s onset could be altered because of whatever social distancing rules are in place in November and December. That said, we need to consider the worst. We have seen what happens if we fail to prepare and then react only after a prevalent respiratory infection has surged into the overall population. Best estimates are that at most 20% of the U.S. population is currently immune to SARS-CoV-2. Given that at least some of that 20% of individuals currently immune to SARS-CoV-2 will lose their neutralizing antibody over the next 4-6 months, we can still expect 70%-80% of the U.S. population to be susceptible to SARS-CoV-2 infection in the fall of 2020.

Pediatric preparedness. As pediatric providers, we have struggled with lower patient loads and dramatic income losses/declines. Many clinics/offices’ attendance remain less than 50% of pre–COVID-19 levels, with necessary furloughs of personnel and spotty office hours. But influenza is coming, and SARS-CoV-2 will not be gone yet. How do we prepare for concurrent influenza and COVID-19?

The annual purchase/administration of influenza vaccine in summer/fall is expensive, time consuming, and logistically difficult even in the best times. Given the loss of income, likely reluctance of patients to come to clinics/offices if COVID-19 is still circulating, and likely need for some form of social distancing during late summer and early fall, how will providers, health departments, and hospitals implement influenza vaccine administration this year?

Minimize double whammy infections. Maximizing influenza vaccine uptake during the COVID-19 pandemic is super important. It is easy to understand why we should maximize influenza protection in SARS-CoV-2 vulnerables (elderly or persons with existing comorbidities). But is it as critical for otherwise healthy children? My answer is yes.

Children are not currently known as SARS-CoV-2 vectors, but children are excellent influenza vectors, shedding higher titers for longer than other age groups. As with SARS-CoV-2, influenza exposure is cumulative, i.e., the more intense and more frequently a person is exposed, the more likely that infection/disease will result. So, the fewer who get and can transmit influenza during the COVID-19 pandemic, the fewer people are likely to get a double whammy of SARS-CoV-2 concurrent or in tandem with influenza. Double whammy infections likely would further increase the medical care burden and return us to March-April crisis mode.

One alarming new question is whether recent influenza could make children vulnerable to SARS-CoV-2 and trigger hospitalizations. A surge in pediatric plus adult COVID-19 disease plus a surge in all-ages influenza disease would likely break the medical care system, at least in some areas.

CDC

Staggering COVID-19 burden. As of June 8, we have had approximately 2 million SARS-CoV-2 cases with 500,000 hospitalizations and 120,000 deaths. Over the past 10 years, total annual U.S. influenza hospitalizations ranged from 180,000 (2011-2012) to 825,000 (2017-2018). The interquartile range for hospitalization length of stay for influenza is 4-6 days¹ vs. 15-23 days² for SARS-CoV-2. One COVID-19 hospitalization uses hospital resources roughly equal to four influenza hospitalizations. To date COVID-19 hospitalizations have used resources equal to an estimated 1.9 million influenza hospitalizations – over twice the worst influenza season in this century – and we are still on the rise. We are likely not even halfway to truly controlling the U.S. pandemic, so expect another 500,000 hospitalizations – equal to another 1.9 million influenza hospitalizations. Further, pneumonia deaths have skyrocketed this year when COVID-19 was superimposed on the last third of influenza season. One hope is that widespread use of antivirals (for example, new antivirals, convalescent plasma, or other interventions) can reduce length of stay by 30% for COVID-19 hospitalizations, yet even with that the numbers remain grim.

Less influenza disease can free up medical resources. Planning ahead could prevent a bad influenza season (for example, up to 850,000 hospitalizations just for influenza). Can we preemptively use vaccine to reduce influenza hospitalizations below 2011-2012 levels – less than 150,000 hospitalizations? Perhaps, if we start by reducing pediatric influenza.

1. Aim to exceed 75% influenza vaccine uptake in your patients.

a. It is ambitious, but if there was ever a year that needed influenza herd immunity, it is 2020-2021.

2. Review practice/group/institution plans for vaccine purchase and ensure adequate personnel to administer vaccine.

3. Plan safe and efficient processes to vaccinate large numbers in August through November.

a. Consider that routine and influenza vaccines can be given concurrently with the annual uptick in school and sports physical examinations.

b. What social distancing and masking rules will be needed?

i. Will patients need to bring their own masks, or will you supply them?

c. What extra supplies and efforts are needed, e.g. hand sanitizer, new signage, 6-foot interval markings on floors or sidewalks, families calling from parking lot to announce their arrivals, etc.?

d. Remember younger patients need two doses before Dec 1, 2020.

e. Be creative, for example, are parking-lot tents for influenza vaccination feasible?

f. Can we partner with other providers to implement influenza vaccine–specific mass clinics?

Ramping up to give seasonal influenza vaccine in 2020 is daunting. But if we do not prepare, it will be even more difficult. Let’s make this the mildest influenza season in memory by vaccinating more than any time in memory – and by doing so, we can hope to blunt medical care burdens despite ongoing COVID-19 disease.
 

Dr. Harrison is professor of pediatrics and pediatric infectious diseases at Children’s Mercy Kansas City (Mo.). Children’s Mercy receives funding from GlaxoSmithKline, Merck, and Pfizer for vaccine research studies on which Dr. Harrison is an investigator. Email him at [email protected].
 

References

1.. HCUP Statistical Brief #253. 2019 Oct.

2. medrxiv. 2020 Apr 10. doi: 10.1101/2020.04.07.20057299.
 

COVID-19 now. The urban phase of the U.S. pandemic is leveling somewhat, while the rural phase is accelerating – in part because of food processing and handling industries. The pediatric burden has been surprisingly small, with the multisystem inflammatory disease (MIS-c) in children noted in several hundred cases now being seen across the country.

CDC

Next wave? Given ongoing COVID-19 disease, controversy rages about when and how to re-open the country. Regardless how more reopening occurs over the next months, we should expect a next or ongoing COVID-19 wave, particularly given loss of social distancing during social justice protests. A sawtooth disease prevalence pattern is predicted by many experts: a drop in prevalence leading to reopening, leading to scattered prevalence increases and regional if not local restriction tightening, followed by another drop in prevalence. Then “rinse and repeat” until 70% of the population is immune either by disease experience or vaccine-induced immunity, likely sometime in 2021.

Influenza too. A COVID-19 up-cycle is likely during influenza season, although influenza season’s onset could be altered because of whatever social distancing rules are in place in November and December. That said, we need to consider the worst. We have seen what happens if we fail to prepare and then react only after a prevalent respiratory infection has surged into the overall population. Best estimates are that at most 20% of the U.S. population is currently immune to SARS-CoV-2. Given that at least some of that 20% of individuals currently immune to SARS-CoV-2 will lose their neutralizing antibody over the next 4-6 months, we can still expect 70%-80% of the U.S. population to be susceptible to SARS-CoV-2 infection in the fall of 2020.

Pediatric preparedness. As pediatric providers, we have struggled with lower patient loads and dramatic income losses/declines. Many clinics/offices’ attendance remain less than 50% of pre–COVID-19 levels, with necessary furloughs of personnel and spotty office hours. But influenza is coming, and SARS-CoV-2 will not be gone yet. How do we prepare for concurrent influenza and COVID-19?

The annual purchase/administration of influenza vaccine in summer/fall is expensive, time consuming, and logistically difficult even in the best times. Given the loss of income, likely reluctance of patients to come to clinics/offices if COVID-19 is still circulating, and likely need for some form of social distancing during late summer and early fall, how will providers, health departments, and hospitals implement influenza vaccine administration this year?

Minimize double whammy infections. Maximizing influenza vaccine uptake during the COVID-19 pandemic is super important. It is easy to understand why we should maximize influenza protection in SARS-CoV-2 vulnerables (elderly or persons with existing comorbidities). But is it as critical for otherwise healthy children? My answer is yes.

Children are not currently known as SARS-CoV-2 vectors, but children are excellent influenza vectors, shedding higher titers for longer than other age groups. As with SARS-CoV-2, influenza exposure is cumulative, i.e., the more intense and more frequently a person is exposed, the more likely that infection/disease will result. So, the fewer who get and can transmit influenza during the COVID-19 pandemic, the fewer people are likely to get a double whammy of SARS-CoV-2 concurrent or in tandem with influenza. Double whammy infections likely would further increase the medical care burden and return us to March-April crisis mode.

One alarming new question is whether recent influenza could make children vulnerable to SARS-CoV-2 and trigger hospitalizations. A surge in pediatric plus adult COVID-19 disease plus a surge in all-ages influenza disease would likely break the medical care system, at least in some areas.

CDC

Staggering COVID-19 burden. As of June 8, we have had approximately 2 million SARS-CoV-2 cases with 500,000 hospitalizations and 120,000 deaths. Over the past 10 years, total annual U.S. influenza hospitalizations ranged from 180,000 (2011-2012) to 825,000 (2017-2018). The interquartile range for hospitalization length of stay for influenza is 4-6 days¹ vs. 15-23 days² for SARS-CoV-2. One COVID-19 hospitalization uses hospital resources roughly equal to four influenza hospitalizations. To date COVID-19 hospitalizations have used resources equal to an estimated 1.9 million influenza hospitalizations – over twice the worst influenza season in this century – and we are still on the rise. We are likely not even halfway to truly controlling the U.S. pandemic, so expect another 500,000 hospitalizations – equal to another 1.9 million influenza hospitalizations. Further, pneumonia deaths have skyrocketed this year when COVID-19 was superimposed on the last third of influenza season. One hope is that widespread use of antivirals (for example, new antivirals, convalescent plasma, or other interventions) can reduce length of stay by 30% for COVID-19 hospitalizations, yet even with that the numbers remain grim.

Less influenza disease can free up medical resources. Planning ahead could prevent a bad influenza season (for example, up to 850,000 hospitalizations just for influenza). Can we preemptively use vaccine to reduce influenza hospitalizations below 2011-2012 levels – less than 150,000 hospitalizations? Perhaps, if we start by reducing pediatric influenza.

1. Aim to exceed 75% influenza vaccine uptake in your patients.

a. It is ambitious, but if there was ever a year that needed influenza herd immunity, it is 2020-2021.

2. Review practice/group/institution plans for vaccine purchase and ensure adequate personnel to administer vaccine.

3. Plan safe and efficient processes to vaccinate large numbers in August through November.

a. Consider that routine and influenza vaccines can be given concurrently with the annual uptick in school and sports physical examinations.

b. What social distancing and masking rules will be needed?

i. Will patients need to bring their own masks, or will you supply them?

c. What extra supplies and efforts are needed, e.g. hand sanitizer, new signage, 6-foot interval markings on floors or sidewalks, families calling from parking lot to announce their arrivals, etc.?

d. Remember younger patients need two doses before Dec 1, 2020.

e. Be creative, for example, are parking-lot tents for influenza vaccination feasible?

f. Can we partner with other providers to implement influenza vaccine–specific mass clinics?

Ramping up to give seasonal influenza vaccine in 2020 is daunting. But if we do not prepare, it will be even more difficult. Let’s make this the mildest influenza season in memory by vaccinating more than any time in memory – and by doing so, we can hope to blunt medical care burdens despite ongoing COVID-19 disease.
 

Dr. Harrison is professor of pediatrics and pediatric infectious diseases at Children’s Mercy Kansas City (Mo.). Children’s Mercy receives funding from GlaxoSmithKline, Merck, and Pfizer for vaccine research studies on which Dr. Harrison is an investigator. Email him at [email protected].
 

References

1.. HCUP Statistical Brief #253. 2019 Oct.

2. medrxiv. 2020 Apr 10. doi: 10.1101/2020.04.07.20057299.
 

Although deployment of hospitalists into ICUs during the COVID-19 crisis varies widely, in that sense it reflects the pre-COVID hospital landscape of variable involvement, in which many hospitalists pressed into this role expressed discomfort practicing critical care beyond their scope of training, according to a survey published in the Journal of Hospital Medicine in 2018.¹ “Hospitalists frequently deliver critical care services without adequate training or support, most prevalently in rural hospitals,” the authors concluded.

A Critical Care for the Hospitalist Series of resources and lectures developed by Eric Siegal, MD, a pulmonologist in Milwaukee, Wisc., and David Aymond, MD, a hospitalist in Alexandria, La., is available on the SHM website. They recommend that hospitalists trying to get oriented to working in the ICU start with the online courses on fluid resuscitation, mechanical ventilation, and noninvasive ventilation.

“Ninety-five percent of management of COVID-19 patients is nothing other than practicing sound critical care medicine,” Dr. Siegal said. “If you want to take effective care of sick COVID patients, you need to develop good foundational critical care skills and knowledge. Without them, you’re doing stuff without understand it.”

Dr. Aymond also encourages hospitalists to develop a stronger understanding of key physiological concepts by reviewing the critical care clinical topics compiled at SHM’s website.

References

1. Sweigart JR et al. Characterizing hospitalist practice and perceptions of critical care delivery. J Hosp Med. 2018 Jan;13(1):6-12.

Although deployment of hospitalists into ICUs during the COVID-19 crisis varies widely, in that sense it reflects the pre-COVID hospital landscape of variable involvement, in which many hospitalists pressed into this role expressed discomfort practicing critical care beyond their scope of training, according to a survey published in the Journal of Hospital Medicine in 2018.¹ “Hospitalists frequently deliver critical care services without adequate training or support, most prevalently in rural hospitals,” the authors concluded.

A Critical Care for the Hospitalist Series of resources and lectures developed by Eric Siegal, MD, a pulmonologist in Milwaukee, Wisc., and David Aymond, MD, a hospitalist in Alexandria, La., is available on the SHM website. They recommend that hospitalists trying to get oriented to working in the ICU start with the online courses on fluid resuscitation, mechanical ventilation, and noninvasive ventilation.

“Ninety-five percent of management of COVID-19 patients is nothing other than practicing sound critical care medicine,” Dr. Siegal said. “If you want to take effective care of sick COVID patients, you need to develop good foundational critical care skills and knowledge. Without them, you’re doing stuff without understand it.”

Dr. Aymond also encourages hospitalists to develop a stronger understanding of key physiological concepts by reviewing the critical care clinical topics compiled at SHM’s website.

References

1. Sweigart JR et al. Characterizing hospitalist practice and perceptions of critical care delivery. J Hosp Med. 2018 Jan;13(1):6-12.

Although deployment of hospitalists into ICUs during the COVID-19 crisis varies widely, in that sense it reflects the pre-COVID hospital landscape of variable involvement, in which many hospitalists pressed into this role expressed discomfort practicing critical care beyond their scope of training, according to a survey published in the Journal of Hospital Medicine in 2018.¹ “Hospitalists frequently deliver critical care services without adequate training or support, most prevalently in rural hospitals,” the authors concluded.

A Critical Care for the Hospitalist Series of resources and lectures developed by Eric Siegal, MD, a pulmonologist in Milwaukee, Wisc., and David Aymond, MD, a hospitalist in Alexandria, La., is available on the SHM website. They recommend that hospitalists trying to get oriented to working in the ICU start with the online courses on fluid resuscitation, mechanical ventilation, and noninvasive ventilation.

“Ninety-five percent of management of COVID-19 patients is nothing other than practicing sound critical care medicine,” Dr. Siegal said. “If you want to take effective care of sick COVID patients, you need to develop good foundational critical care skills and knowledge. Without them, you’re doing stuff without understand it.”

Dr. Aymond also encourages hospitalists to develop a stronger understanding of key physiological concepts by reviewing the critical care clinical topics compiled at SHM’s website.

References

1. Sweigart JR et al. Characterizing hospitalist practice and perceptions of critical care delivery. J Hosp Med. 2018 Jan;13(1):6-12.

Race is not something I’ve spent that much time contemplating. I grew up in Elizabeth, N.J., a city of just over 100,000, in the 1970s and attended public schools where people came in all shapes and colors; diversity came with the turf, it wasn’t something anyone needed to strive for.

My high school had more than 4,000 students with roughly even numbers of white, black, and Hispanic students. Armed police patrolled the halls, the thick aroma of weed settled in the stairwells and restrooms, girls brought their babies to school to show them off on half-days, and the “preppies” wore Fair Isle sweaters and played on the tennis team. The school’s campus was brand new and every lab, studio, and athletic amenity was state of the art; at the time, it was the most expensive public high school ever built in America. There were black teachers, librarians, and administrators, and segregation was something we read about in history books. I lived in a world of Technicolor and the Civil Rights movement of the 1960s, while still fresh in the minds of the adults, was something that showed up on black-and-white footage from another time.

My world became both wealthier and whiter when I went to college. There were minority students, but many of the black students at the University of Pennsylvania chose to live in the W.E.B. Du Bois College House.

People are often more comfortable being with others who share their backgrounds and this makes for an interesting conundrum: We all agree that desegregation is a good thing, but not everyone wishes to be told either where to go or not go, and there is an odd unbalance to creating a safe place for black students to be, one that both integrates and separates them from the larger community. Perhaps all our lines get fuzzy – I recall when I was on the Maryland Psychiatric Society Women’s Committee and a male psychiatrist signed up to join us – he was politely told that he could not join, but 20 years later, I’m wondering if it was okay to exclude a man who expressed interest in women’s issues.

In medical school, we were taught to note a patient’s age, race, and marital status, and we might learn that certain illnesses were more prevalent in certain populations, but there was no discussion of racial inequities in health care or anywhere else.

What was really different about the world back then, however, was what we didn’t see and what we didn’t talk about. Social media has opened a world where we can share our pain in the moment and we can band together to speak out against crimes and injustices in every realm. From the MeToo moments, to racially motivated police brutality. Cell phone cameras let us record and publicize these moments so the world can be the judge. George Floyd’s sadistic murder by a police officer, as other officers stood by and watched 8 minutes and 46 seconds of torture, left us all triggered, distressed, angry, sad, and activated. Maybe now we can make real progress on a discussion that began in 1992 with the videotape of Rodney King’s assault, a discussion we’ve had over and over to no avail.

Obviously, I have also been provoked by the events of the past weeks – like many Americans, I’ve paused to wonder how I can help the cause, both personally and as a psychiatrist. I would not normally write about racial topics – as a white woman I can listen, but I don’t feel this pain in the same way as someone who has lived with a lifetime of discrimination and oppression. Dr. Lorenzo Norris and Dr. Brandon Newsome,two black psychiatrists, put out a special edition of the MDEdge Psychcast, “The fallout from George Floyd’s death,” and Dr. Norris noted that two of his white colleagues told him they thought of checking on him, but they didn’t know what to say. Yes, I thought, that’s exactly it, I don’t know what to say and I worry that I might unintentionally say something that would worsen someone else’s pain. Staying silent has always seemed to be the safest option. With this article, I’m moving from a place of comfort.

I started my career with a mix of private practice and community psychiatry. There were things I loved about working in a community clinic: the social aspects of being part of a team, seeing a full range of psychopathology, and treating patients in which the racial and ethnic demographics mirrored that of the community. There were things I didn’t like, however. The pay was low, there were constant institutional requirements that were not relevant to the practice of psychiatry, and my relationship with the patients as their prescriber was much less fulfilling than the relationship I have with those I see for both psychotherapy and medication. Ultimately, the hospital shift to electronic medical records was the final distraction that caused me to leave community work.

Like roughly half of psychiatrists in private practice, I don’t participate with commercial or public insurance plans. Early in my career, I worked in a group setting with billing secretaries, and I did participate with Blue Cross, but even with administrative help, nothing about this was easy, and when I left to do solo practice, I left insurance participation behind. I love the autonomy of my career, I’m proud of the care I am able to give in this setting, and I don’t miss the hassles. But I struggle with the fact that this is not the socially responsible thing to do – the out-of-pocket cost of care is higher and the effort of trying to get reimbursed falls to the patient. It means that most of the patients I see have the means to pay for care, none are impoverished or homeless, and while I work in a city that is 62% black, black patients make up a small percentage of my caseload. I don’t think I am unique in this; I would be shocked if any white private practice psychiatrist who specializes in psychotherapy is serving a racially proportionate population. As we start to embrace the idea that people don’t neatly divide into being racist or not, and that bias affects us all, we must acknowledge that medical practices that don’t support racially balanced access to care are part of the problem.

Amy R. Greensfelder, LMSW, is the executive director of Maryland’s Pro Bono Counseling Project (PBCP), an organization that coordinates mental health professionals in private practice in Maryland to volunteer their services to those with limited resources. PBCP has found that 50% of those seeking services share that they are black or African American, and an additional 5% identify as multiracial. Of all of those seeking care approximately 65% are black, Indigenous, or People of Color (BIPOC), and and 14% are Latino/a/x/Hispanic. She says: “We see the racial composition of our clients as a direct demonstration of who is being left behind in the mental health system as it’s currently set up, as BIPOC individuals are represented to a greater degree in our clients than they are in the general population of Maryland. During our intake interview, we provide an opportunity for clients to share if there are certain characteristics they are looking for in a therapist – often black clients share that they would prefer to be matched with a black therapist or a therapist who has received specific training on working with black clients.”

While 13% of the American population is black, only 4% of physicians, 2% of psychiatrists, and 4% of psychologists are black. In her Psychology Today blog post, “Why African Americans Avoid Psychotherapy,” Monnica T. Williams, PhD, notes: “Apprehension about clashing with the values or worldview of the clinician can cause ambivalence about seeking help, and this may be especially true for the many who believe that mental health treatment was designed by white people for white people.” Dr. Williams notes that black Americans also are less likely to seek care because of increased stigma and fear of judgment, concerns about the treatment process, and fears of being involuntarily hospitalized, cost and lack of insurance, and finally logistical issues with work, transportation, and family responsibilities.

George Floyd’s tragic death has led us to a moment of crisis. It’s my hope that the dialogue is now galvanized to make meaningful changes toward fixing racial inequities. I am part of the problem and these conversations need to include more equitable access to psychiatric care.
 

My thanks to Rachel Donabedian and Gina Henderson for their help with this article.


Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins, both in Baltimore.

Race is not something I’ve spent that much time contemplating. I grew up in Elizabeth, N.J., a city of just over 100,000, in the 1970s and attended public schools where people came in all shapes and colors; diversity came with the turf, it wasn’t something anyone needed to strive for.

My high school had more than 4,000 students with roughly even numbers of white, black, and Hispanic students. Armed police patrolled the halls, the thick aroma of weed settled in the stairwells and restrooms, girls brought their babies to school to show them off on half-days, and the “preppies” wore Fair Isle sweaters and played on the tennis team. The school’s campus was brand new and every lab, studio, and athletic amenity was state of the art; at the time, it was the most expensive public high school ever built in America. There were black teachers, librarians, and administrators, and segregation was something we read about in history books. I lived in a world of Technicolor and the Civil Rights movement of the 1960s, while still fresh in the minds of the adults, was something that showed up on black-and-white footage from another time.

My world became both wealthier and whiter when I went to college. There were minority students, but many of the black students at the University of Pennsylvania chose to live in the W.E.B. Du Bois College House.

People are often more comfortable being with others who share their backgrounds and this makes for an interesting conundrum: We all agree that desegregation is a good thing, but not everyone wishes to be told either where to go or not go, and there is an odd unbalance to creating a safe place for black students to be, one that both integrates and separates them from the larger community. Perhaps all our lines get fuzzy – I recall when I was on the Maryland Psychiatric Society Women’s Committee and a male psychiatrist signed up to join us – he was politely told that he could not join, but 20 years later, I’m wondering if it was okay to exclude a man who expressed interest in women’s issues.

In medical school, we were taught to note a patient’s age, race, and marital status, and we might learn that certain illnesses were more prevalent in certain populations, but there was no discussion of racial inequities in health care or anywhere else.

What was really different about the world back then, however, was what we didn’t see and what we didn’t talk about. Social media has opened a world where we can share our pain in the moment and we can band together to speak out against crimes and injustices in every realm. From the MeToo moments, to racially motivated police brutality. Cell phone cameras let us record and publicize these moments so the world can be the judge. George Floyd’s sadistic murder by a police officer, as other officers stood by and watched 8 minutes and 46 seconds of torture, left us all triggered, distressed, angry, sad, and activated. Maybe now we can make real progress on a discussion that began in 1992 with the videotape of Rodney King’s assault, a discussion we’ve had over and over to no avail.

Obviously, I have also been provoked by the events of the past weeks – like many Americans, I’ve paused to wonder how I can help the cause, both personally and as a psychiatrist. I would not normally write about racial topics – as a white woman I can listen, but I don’t feel this pain in the same way as someone who has lived with a lifetime of discrimination and oppression. Dr. Lorenzo Norris and Dr. Brandon Newsome,two black psychiatrists, put out a special edition of the MDEdge Psychcast, “The fallout from George Floyd’s death,” and Dr. Norris noted that two of his white colleagues told him they thought of checking on him, but they didn’t know what to say. Yes, I thought, that’s exactly it, I don’t know what to say and I worry that I might unintentionally say something that would worsen someone else’s pain. Staying silent has always seemed to be the safest option. With this article, I’m moving from a place of comfort.

I started my career with a mix of private practice and community psychiatry. There were things I loved about working in a community clinic: the social aspects of being part of a team, seeing a full range of psychopathology, and treating patients in which the racial and ethnic demographics mirrored that of the community. There were things I didn’t like, however. The pay was low, there were constant institutional requirements that were not relevant to the practice of psychiatry, and my relationship with the patients as their prescriber was much less fulfilling than the relationship I have with those I see for both psychotherapy and medication. Ultimately, the hospital shift to electronic medical records was the final distraction that caused me to leave community work.

Like roughly half of psychiatrists in private practice, I don’t participate with commercial or public insurance plans. Early in my career, I worked in a group setting with billing secretaries, and I did participate with Blue Cross, but even with administrative help, nothing about this was easy, and when I left to do solo practice, I left insurance participation behind. I love the autonomy of my career, I’m proud of the care I am able to give in this setting, and I don’t miss the hassles. But I struggle with the fact that this is not the socially responsible thing to do – the out-of-pocket cost of care is higher and the effort of trying to get reimbursed falls to the patient. It means that most of the patients I see have the means to pay for care, none are impoverished or homeless, and while I work in a city that is 62% black, black patients make up a small percentage of my caseload. I don’t think I am unique in this; I would be shocked if any white private practice psychiatrist who specializes in psychotherapy is serving a racially proportionate population. As we start to embrace the idea that people don’t neatly divide into being racist or not, and that bias affects us all, we must acknowledge that medical practices that don’t support racially balanced access to care are part of the problem.

Amy R. Greensfelder, LMSW, is the executive director of Maryland’s Pro Bono Counseling Project (PBCP), an organization that coordinates mental health professionals in private practice in Maryland to volunteer their services to those with limited resources. PBCP has found that 50% of those seeking services share that they are black or African American, and an additional 5% identify as multiracial. Of all of those seeking care approximately 65% are black, Indigenous, or People of Color (BIPOC), and and 14% are Latino/a/x/Hispanic. She says: “We see the racial composition of our clients as a direct demonstration of who is being left behind in the mental health system as it’s currently set up, as BIPOC individuals are represented to a greater degree in our clients than they are in the general population of Maryland. During our intake interview, we provide an opportunity for clients to share if there are certain characteristics they are looking for in a therapist – often black clients share that they would prefer to be matched with a black therapist or a therapist who has received specific training on working with black clients.”

While 13% of the American population is black, only 4% of physicians, 2% of psychiatrists, and 4% of psychologists are black. In her Psychology Today blog post, “Why African Americans Avoid Psychotherapy,” Monnica T. Williams, PhD, notes: “Apprehension about clashing with the values or worldview of the clinician can cause ambivalence about seeking help, and this may be especially true for the many who believe that mental health treatment was designed by white people for white people.” Dr. Williams notes that black Americans also are less likely to seek care because of increased stigma and fear of judgment, concerns about the treatment process, and fears of being involuntarily hospitalized, cost and lack of insurance, and finally logistical issues with work, transportation, and family responsibilities.

George Floyd’s tragic death has led us to a moment of crisis. It’s my hope that the dialogue is now galvanized to make meaningful changes toward fixing racial inequities. I am part of the problem and these conversations need to include more equitable access to psychiatric care.
 

My thanks to Rachel Donabedian and Gina Henderson for their help with this article.


Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins, both in Baltimore.

Race is not something I’ve spent that much time contemplating. I grew up in Elizabeth, N.J., a city of just over 100,000, in the 1970s and attended public schools where people came in all shapes and colors; diversity came with the turf, it wasn’t something anyone needed to strive for.

My high school had more than 4,000 students with roughly even numbers of white, black, and Hispanic students. Armed police patrolled the halls, the thick aroma of weed settled in the stairwells and restrooms, girls brought their babies to school to show them off on half-days, and the “preppies” wore Fair Isle sweaters and played on the tennis team. The school’s campus was brand new and every lab, studio, and athletic amenity was state of the art; at the time, it was the most expensive public high school ever built in America. There were black teachers, librarians, and administrators, and segregation was something we read about in history books. I lived in a world of Technicolor and the Civil Rights movement of the 1960s, while still fresh in the minds of the adults, was something that showed up on black-and-white footage from another time.

My world became both wealthier and whiter when I went to college. There were minority students, but many of the black students at the University of Pennsylvania chose to live in the W.E.B. Du Bois College House.

People are often more comfortable being with others who share their backgrounds and this makes for an interesting conundrum: We all agree that desegregation is a good thing, but not everyone wishes to be told either where to go or not go, and there is an odd unbalance to creating a safe place for black students to be, one that both integrates and separates them from the larger community. Perhaps all our lines get fuzzy – I recall when I was on the Maryland Psychiatric Society Women’s Committee and a male psychiatrist signed up to join us – he was politely told that he could not join, but 20 years later, I’m wondering if it was okay to exclude a man who expressed interest in women’s issues.

In medical school, we were taught to note a patient’s age, race, and marital status, and we might learn that certain illnesses were more prevalent in certain populations, but there was no discussion of racial inequities in health care or anywhere else.

What was really different about the world back then, however, was what we didn’t see and what we didn’t talk about. Social media has opened a world where we can share our pain in the moment and we can band together to speak out against crimes and injustices in every realm. From the MeToo moments, to racially motivated police brutality. Cell phone cameras let us record and publicize these moments so the world can be the judge. George Floyd’s sadistic murder by a police officer, as other officers stood by and watched 8 minutes and 46 seconds of torture, left us all triggered, distressed, angry, sad, and activated. Maybe now we can make real progress on a discussion that began in 1992 with the videotape of Rodney King’s assault, a discussion we’ve had over and over to no avail.

Obviously, I have also been provoked by the events of the past weeks – like many Americans, I’ve paused to wonder how I can help the cause, both personally and as a psychiatrist. I would not normally write about racial topics – as a white woman I can listen, but I don’t feel this pain in the same way as someone who has lived with a lifetime of discrimination and oppression. Dr. Lorenzo Norris and Dr. Brandon Newsome,two black psychiatrists, put out a special edition of the MDEdge Psychcast, “The fallout from George Floyd’s death,” and Dr. Norris noted that two of his white colleagues told him they thought of checking on him, but they didn’t know what to say. Yes, I thought, that’s exactly it, I don’t know what to say and I worry that I might unintentionally say something that would worsen someone else’s pain. Staying silent has always seemed to be the safest option. With this article, I’m moving from a place of comfort.

I started my career with a mix of private practice and community psychiatry. There were things I loved about working in a community clinic: the social aspects of being part of a team, seeing a full range of psychopathology, and treating patients in which the racial and ethnic demographics mirrored that of the community. There were things I didn’t like, however. The pay was low, there were constant institutional requirements that were not relevant to the practice of psychiatry, and my relationship with the patients as their prescriber was much less fulfilling than the relationship I have with those I see for both psychotherapy and medication. Ultimately, the hospital shift to electronic medical records was the final distraction that caused me to leave community work.

Like roughly half of psychiatrists in private practice, I don’t participate with commercial or public insurance plans. Early in my career, I worked in a group setting with billing secretaries, and I did participate with Blue Cross, but even with administrative help, nothing about this was easy, and when I left to do solo practice, I left insurance participation behind. I love the autonomy of my career, I’m proud of the care I am able to give in this setting, and I don’t miss the hassles. But I struggle with the fact that this is not the socially responsible thing to do – the out-of-pocket cost of care is higher and the effort of trying to get reimbursed falls to the patient. It means that most of the patients I see have the means to pay for care, none are impoverished or homeless, and while I work in a city that is 62% black, black patients make up a small percentage of my caseload. I don’t think I am unique in this; I would be shocked if any white private practice psychiatrist who specializes in psychotherapy is serving a racially proportionate population. As we start to embrace the idea that people don’t neatly divide into being racist or not, and that bias affects us all, we must acknowledge that medical practices that don’t support racially balanced access to care are part of the problem.

Amy R. Greensfelder, LMSW, is the executive director of Maryland’s Pro Bono Counseling Project (PBCP), an organization that coordinates mental health professionals in private practice in Maryland to volunteer their services to those with limited resources. PBCP has found that 50% of those seeking services share that they are black or African American, and an additional 5% identify as multiracial. Of all of those seeking care approximately 65% are black, Indigenous, or People of Color (BIPOC), and and 14% are Latino/a/x/Hispanic. She says: “We see the racial composition of our clients as a direct demonstration of who is being left behind in the mental health system as it’s currently set up, as BIPOC individuals are represented to a greater degree in our clients than they are in the general population of Maryland. During our intake interview, we provide an opportunity for clients to share if there are certain characteristics they are looking for in a therapist – often black clients share that they would prefer to be matched with a black therapist or a therapist who has received specific training on working with black clients.”

While 13% of the American population is black, only 4% of physicians, 2% of psychiatrists, and 4% of psychologists are black. In her Psychology Today blog post, “Why African Americans Avoid Psychotherapy,” Monnica T. Williams, PhD, notes: “Apprehension about clashing with the values or worldview of the clinician can cause ambivalence about seeking help, and this may be especially true for the many who believe that mental health treatment was designed by white people for white people.” Dr. Williams notes that black Americans also are less likely to seek care because of increased stigma and fear of judgment, concerns about the treatment process, and fears of being involuntarily hospitalized, cost and lack of insurance, and finally logistical issues with work, transportation, and family responsibilities.

George Floyd’s tragic death has led us to a moment of crisis. It’s my hope that the dialogue is now galvanized to make meaningful changes toward fixing racial inequities. I am part of the problem and these conversations need to include more equitable access to psychiatric care.
 

My thanks to Rachel Donabedian and Gina Henderson for their help with this article.


Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins, both in Baltimore.

Psychosocial interventions, particularly cognitive-behavioral therapy (CBT), are associated with enhanced immune system function, new research suggests.

Results of a systematic review and meta-analysis that included 56 randomized controlled trials and more than 4,000 participants showed that over time, psychosocial interventions appeared to augment beneficial immune system function while concurrently decreasing harmful immune system function in comparison with control conditions.

“These associations were most reliable for cognitive-behavioral therapy and multiple or combined interventions and for studies that assessed proinflammatory cytokines or markers, which are key indicators of inflammation in the body,” study investigator George M. Slavich, PhD, said in an interview.

“The analysis helps address the question of which types of psychosocial interventions are most consistently associated with changes in immune system function, under what conditions, and for whom. This knowledge could, in turn, be used to inform research efforts and public policy aimed at using psychosocial interventions to improve immune-related health outcomes,” added Dr. Slavich, director of the Laboratory for Stress Assessment and Research, University of California, Los Angeles.

The study was published online June 3 in JAMA Psychiatry.

Link to serious physical, mental illnesses

There is substantial evidence that the immune system plays a role in a variety of mental and physical health problems. Such problems include anxiety disorders, depression, suicide, schizophrenia, cardiovascular disease, autoimmune disorders, and neurodegenerative diseases. It has been recently suggested that more than half of all deaths worldwide are attributable to inflammation-related conditions.

Although pharmacologic interventions can play a role in addressing inflammation, they are not without drawbacks, most notably, cost and adverse side effects.

The World Health Organization, the National Academy of Medicine, the National Institutes of Health, and other groups have emphasized the importance of addressing global disease burden through psychosocial interventions when possible.

Such recommendations are supported by scientific evidence. Previous research has shown that immune system processes are influenced by a variety of social, neurocognitive, and behavioral factors.

Given such findings, researchers have examined the effects of interventions that reduce stress or bolster psychological resources on immune system function.

However, such research has yielded conflicting findings. Some studies show that psychosocial interventions clearly enhance immunity, whereas others do not.

In addition, questions remain regarding which types of interventions reliably improve immune system function, under what conditions, and for whom.

“Research has shown that psychological factors – such as life stress, negative emotions, and social support – are associated with changes in immune system function,” Dr. Slavich noted.

“In addition, there is growing appreciation that immune system processes involved in inflammation may contribute to peoples’ risk for several major mental and physical health problems, including anxiety disorders, depression, heart disease, and autoimmune and neurodegenerative disorders.”
 

First study of its kind

To shed light on these potential links, the researchers conducted what they believe is the first systematic review and meta-analysis of randomized clinical trials of the effects of psychosocial interventions on immune system outcomes.

As part of the review, Dr. Slavich and colleagues estimated the associations between eight psychosocial interventions and seven markers of immune system function.

The eight psychosocial interventions were behavior therapy, cognitive therapy, CBT, CBT plus additive treatment or mode of delivery, bereavement or supportive therapy, multiple or combined interventions, other psychotherapy, and psychoeducation.

The seven immune outcomes that might be influenced by these interventions are proinflammatory cytokines and markers, anti-inflammatory cytokines, antibodies, immune cell counts, natural killer cell activity, viral load, and other immune outcomes.

The researchers also examined nine potential factors that might moderate the associations between psychosocial interventions and immune system function.

They searched a variety of databases for all relevant randomized controlled trials published through Dec. 31, 2018. Studies were eligible for inclusion if they included a psychosocial intervention and immune outcome, as well as preintervention and postintervention immunologic assessments.

The researchers identified 4,621 studies. Of these studies, 62 were eligible for inclusion; 56, which included 4,060 patients, were included in the final meta-analysis.

Results showed that psychosocial interventions were associated with enhanced immune system function (P < .001). There was relatively low heterogeneity between studies in these effect sizes, which, the investigators said, indicates that the association was relatively consistent across studies and conditions.

The meta-analysis showed that individuals who were assigned to a psychosocial intervention condition demonstrated a 14.7% improvement (95% confidence interval [CI], 5.7%–23.8%) in beneficial immune system function compared with their counterparts who were assigned to a control condition.

Similarly, participants who received psychosocial interventions demonstrated an 18.0% decrease (95% CI, 7.2%–28.8%) in harmful immune system function over time.

A standout

Regarding the effect of the type of intervention on the association, only CBT (31 studies; P < .001) and multiple or combined interventions (seven studies; P = .01) were significantly associated with changes in immune system outcomes.

The analysis also found that interventions that included a group component were more consistently associated with enhanced immune function than were those that did not include a group component. Nevertheless, this difference did not reach statistical significance (P = .06).

Contrary to the researchers’ expectations, the analysis also revealed that intervention length did not moderate the association between psychosocial interventions and immune system function (P = .93).

With respect to the type of immune marker studied, the meta-analysis found that psychosocial interventions had significantly different associations with the various immune markers studied. Of the seven immune outcomes investigated, only proinflammatory cytokine or marker levels (33 studies; P < .001) and immune cell counts (27 studies; P < .001) were significantly associated with the psychosocial interventions examined.

The associations between psychosocial intervention and immune system function persisted for at least 6 months following treatment and were robust across age, sex, and intervention duration.

These results suggest that psychosocial interventions – particularly CBT and multiple or combined psychotherapeutic modalities – may play an important role in improving immune-related health outcomes.

Such interventions may not only be effective, they may also prove to be affordable alternatives to current therapeutic options. The mean length of a CBT intervention in the meta-analysis was 10.4 weeks, which the investigators equated with a total cost of $1,560 per patient.

“By comparison, the cost of using infliximab to reduce inflammation in persons with an autoimmune disorder is approximately $25,000 per patient per year,” they wrote.

“The results suggest the possibility that psychotherapy may be helpful for reducing inflammation and improving immune-related health in certain circumstances,” Dr. Slavich concluded. “However, the studies that we examined differed in terms of their quality, and we did not examine health outcomes in the present investigation.

“Therefore, more research needs to be done to determine how the present findings might be translated into treatment options or public policy.”
 

A path to better health

In an accompanying editorial, Veronika Engert, PhD, Joshua A. Grant, PhD, and Bernhard Strauss, PhD, noted that although infectious disease was once the primary cause of death in society, it has been supplanted by other complex and chronic illnesses, which often do not follow simple cause-and-effect associations.

“Rather,” they wrote, “these illnesses develop from a complex milieu of biological, psychological, and social factors that may also influence the disease progress and its prognosis. Against this backdrop, the meta-analysis by Shields and colleagues is an important confirmation of the biopsychosocial model.”

The editorialists explained that recent psychophysiological, neurobiological, and epigenetic research offers a glimpse into the relationship between psychological and social factors in pathogenesis. Nevertheless, the authors noted that a comprehensive examination of the potential effects of psychosocial interventions on immune parameters in various physical health conditions has been lacking.

“The evidence provided by Shields et al. is exactly what is needed to more fully shift treatment from an illness-centered to a patient-centered approach,” they wrote. “To that end, this meta-analysis may serve as a guide for policy makers aiming to improve immune-associated health.”

The research was supported by a Society in Science–Branco Weiss Fellowship, Brain and Behavior Research, and the National Institutes of Health. Dr. Slavich, Dr. Engert, Dr. Grant, and Dr. Strauss have disclosed no relevant financial relationships.
 

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

Psychosocial interventions, particularly cognitive-behavioral therapy (CBT), are associated with enhanced immune system function, new research suggests.

Results of a systematic review and meta-analysis that included 56 randomized controlled trials and more than 4,000 participants showed that over time, psychosocial interventions appeared to augment beneficial immune system function while concurrently decreasing harmful immune system function in comparison with control conditions.

“These associations were most reliable for cognitive-behavioral therapy and multiple or combined interventions and for studies that assessed proinflammatory cytokines or markers, which are key indicators of inflammation in the body,” study investigator George M. Slavich, PhD, said in an interview.

“The analysis helps address the question of which types of psychosocial interventions are most consistently associated with changes in immune system function, under what conditions, and for whom. This knowledge could, in turn, be used to inform research efforts and public policy aimed at using psychosocial interventions to improve immune-related health outcomes,” added Dr. Slavich, director of the Laboratory for Stress Assessment and Research, University of California, Los Angeles.

The study was published online June 3 in JAMA Psychiatry.

Link to serious physical, mental illnesses

There is substantial evidence that the immune system plays a role in a variety of mental and physical health problems. Such problems include anxiety disorders, depression, suicide, schizophrenia, cardiovascular disease, autoimmune disorders, and neurodegenerative diseases. It has been recently suggested that more than half of all deaths worldwide are attributable to inflammation-related conditions.

Although pharmacologic interventions can play a role in addressing inflammation, they are not without drawbacks, most notably, cost and adverse side effects.

The World Health Organization, the National Academy of Medicine, the National Institutes of Health, and other groups have emphasized the importance of addressing global disease burden through psychosocial interventions when possible.

Such recommendations are supported by scientific evidence. Previous research has shown that immune system processes are influenced by a variety of social, neurocognitive, and behavioral factors.

Given such findings, researchers have examined the effects of interventions that reduce stress or bolster psychological resources on immune system function.

However, such research has yielded conflicting findings. Some studies show that psychosocial interventions clearly enhance immunity, whereas others do not.

In addition, questions remain regarding which types of interventions reliably improve immune system function, under what conditions, and for whom.

“Research has shown that psychological factors – such as life stress, negative emotions, and social support – are associated with changes in immune system function,” Dr. Slavich noted.

“In addition, there is growing appreciation that immune system processes involved in inflammation may contribute to peoples’ risk for several major mental and physical health problems, including anxiety disorders, depression, heart disease, and autoimmune and neurodegenerative disorders.”
 

First study of its kind

To shed light on these potential links, the researchers conducted what they believe is the first systematic review and meta-analysis of randomized clinical trials of the effects of psychosocial interventions on immune system outcomes.

As part of the review, Dr. Slavich and colleagues estimated the associations between eight psychosocial interventions and seven markers of immune system function.

The eight psychosocial interventions were behavior therapy, cognitive therapy, CBT, CBT plus additive treatment or mode of delivery, bereavement or supportive therapy, multiple or combined interventions, other psychotherapy, and psychoeducation.

The seven immune outcomes that might be influenced by these interventions are proinflammatory cytokines and markers, anti-inflammatory cytokines, antibodies, immune cell counts, natural killer cell activity, viral load, and other immune outcomes.

The researchers also examined nine potential factors that might moderate the associations between psychosocial interventions and immune system function.

They searched a variety of databases for all relevant randomized controlled trials published through Dec. 31, 2018. Studies were eligible for inclusion if they included a psychosocial intervention and immune outcome, as well as preintervention and postintervention immunologic assessments.

The researchers identified 4,621 studies. Of these studies, 62 were eligible for inclusion; 56, which included 4,060 patients, were included in the final meta-analysis.

Results showed that psychosocial interventions were associated with enhanced immune system function (P < .001). There was relatively low heterogeneity between studies in these effect sizes, which, the investigators said, indicates that the association was relatively consistent across studies and conditions.

The meta-analysis showed that individuals who were assigned to a psychosocial intervention condition demonstrated a 14.7% improvement (95% confidence interval [CI], 5.7%–23.8%) in beneficial immune system function compared with their counterparts who were assigned to a control condition.

Similarly, participants who received psychosocial interventions demonstrated an 18.0% decrease (95% CI, 7.2%–28.8%) in harmful immune system function over time.

A standout

Regarding the effect of the type of intervention on the association, only CBT (31 studies; P < .001) and multiple or combined interventions (seven studies; P = .01) were significantly associated with changes in immune system outcomes.

The analysis also found that interventions that included a group component were more consistently associated with enhanced immune function than were those that did not include a group component. Nevertheless, this difference did not reach statistical significance (P = .06).

Contrary to the researchers’ expectations, the analysis also revealed that intervention length did not moderate the association between psychosocial interventions and immune system function (P = .93).

With respect to the type of immune marker studied, the meta-analysis found that psychosocial interventions had significantly different associations with the various immune markers studied. Of the seven immune outcomes investigated, only proinflammatory cytokine or marker levels (33 studies; P < .001) and immune cell counts (27 studies; P < .001) were significantly associated with the psychosocial interventions examined.

The associations between psychosocial intervention and immune system function persisted for at least 6 months following treatment and were robust across age, sex, and intervention duration.

These results suggest that psychosocial interventions – particularly CBT and multiple or combined psychotherapeutic modalities – may play an important role in improving immune-related health outcomes.

Such interventions may not only be effective, they may also prove to be affordable alternatives to current therapeutic options. The mean length of a CBT intervention in the meta-analysis was 10.4 weeks, which the investigators equated with a total cost of $1,560 per patient.

“By comparison, the cost of using infliximab to reduce inflammation in persons with an autoimmune disorder is approximately $25,000 per patient per year,” they wrote.

“The results suggest the possibility that psychotherapy may be helpful for reducing inflammation and improving immune-related health in certain circumstances,” Dr. Slavich concluded. “However, the studies that we examined differed in terms of their quality, and we did not examine health outcomes in the present investigation.

“Therefore, more research needs to be done to determine how the present findings might be translated into treatment options or public policy.”
 

A path to better health

In an accompanying editorial, Veronika Engert, PhD, Joshua A. Grant, PhD, and Bernhard Strauss, PhD, noted that although infectious disease was once the primary cause of death in society, it has been supplanted by other complex and chronic illnesses, which often do not follow simple cause-and-effect associations.

“Rather,” they wrote, “these illnesses develop from a complex milieu of biological, psychological, and social factors that may also influence the disease progress and its prognosis. Against this backdrop, the meta-analysis by Shields and colleagues is an important confirmation of the biopsychosocial model.”

The editorialists explained that recent psychophysiological, neurobiological, and epigenetic research offers a glimpse into the relationship between psychological and social factors in pathogenesis. Nevertheless, the authors noted that a comprehensive examination of the potential effects of psychosocial interventions on immune parameters in various physical health conditions has been lacking.

“The evidence provided by Shields et al. is exactly what is needed to more fully shift treatment from an illness-centered to a patient-centered approach,” they wrote. “To that end, this meta-analysis may serve as a guide for policy makers aiming to improve immune-associated health.”

The research was supported by a Society in Science–Branco Weiss Fellowship, Brain and Behavior Research, and the National Institutes of Health. Dr. Slavich, Dr. Engert, Dr. Grant, and Dr. Strauss have disclosed no relevant financial relationships.
 

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

Psychosocial interventions, particularly cognitive-behavioral therapy (CBT), are associated with enhanced immune system function, new research suggests.

Results of a systematic review and meta-analysis that included 56 randomized controlled trials and more than 4,000 participants showed that over time, psychosocial interventions appeared to augment beneficial immune system function while concurrently decreasing harmful immune system function in comparison with control conditions.

“These associations were most reliable for cognitive-behavioral therapy and multiple or combined interventions and for studies that assessed proinflammatory cytokines or markers, which are key indicators of inflammation in the body,” study investigator George M. Slavich, PhD, said in an interview.

“The analysis helps address the question of which types of psychosocial interventions are most consistently associated with changes in immune system function, under what conditions, and for whom. This knowledge could, in turn, be used to inform research efforts and public policy aimed at using psychosocial interventions to improve immune-related health outcomes,” added Dr. Slavich, director of the Laboratory for Stress Assessment and Research, University of California, Los Angeles.

The study was published online June 3 in JAMA Psychiatry.

Link to serious physical, mental illnesses

There is substantial evidence that the immune system plays a role in a variety of mental and physical health problems. Such problems include anxiety disorders, depression, suicide, schizophrenia, cardiovascular disease, autoimmune disorders, and neurodegenerative diseases. It has been recently suggested that more than half of all deaths worldwide are attributable to inflammation-related conditions.

Although pharmacologic interventions can play a role in addressing inflammation, they are not without drawbacks, most notably, cost and adverse side effects.

The World Health Organization, the National Academy of Medicine, the National Institutes of Health, and other groups have emphasized the importance of addressing global disease burden through psychosocial interventions when possible.

Such recommendations are supported by scientific evidence. Previous research has shown that immune system processes are influenced by a variety of social, neurocognitive, and behavioral factors.

Given such findings, researchers have examined the effects of interventions that reduce stress or bolster psychological resources on immune system function.

However, such research has yielded conflicting findings. Some studies show that psychosocial interventions clearly enhance immunity, whereas others do not.

In addition, questions remain regarding which types of interventions reliably improve immune system function, under what conditions, and for whom.

“Research has shown that psychological factors – such as life stress, negative emotions, and social support – are associated with changes in immune system function,” Dr. Slavich noted.

“In addition, there is growing appreciation that immune system processes involved in inflammation may contribute to peoples’ risk for several major mental and physical health problems, including anxiety disorders, depression, heart disease, and autoimmune and neurodegenerative disorders.”
 

First study of its kind

To shed light on these potential links, the researchers conducted what they believe is the first systematic review and meta-analysis of randomized clinical trials of the effects of psychosocial interventions on immune system outcomes.

As part of the review, Dr. Slavich and colleagues estimated the associations between eight psychosocial interventions and seven markers of immune system function.

The eight psychosocial interventions were behavior therapy, cognitive therapy, CBT, CBT plus additive treatment or mode of delivery, bereavement or supportive therapy, multiple or combined interventions, other psychotherapy, and psychoeducation.

The seven immune outcomes that might be influenced by these interventions are proinflammatory cytokines and markers, anti-inflammatory cytokines, antibodies, immune cell counts, natural killer cell activity, viral load, and other immune outcomes.

The researchers also examined nine potential factors that might moderate the associations between psychosocial interventions and immune system function.

They searched a variety of databases for all relevant randomized controlled trials published through Dec. 31, 2018. Studies were eligible for inclusion if they included a psychosocial intervention and immune outcome, as well as preintervention and postintervention immunologic assessments.

The researchers identified 4,621 studies. Of these studies, 62 were eligible for inclusion; 56, which included 4,060 patients, were included in the final meta-analysis.

Results showed that psychosocial interventions were associated with enhanced immune system function (P < .001). There was relatively low heterogeneity between studies in these effect sizes, which, the investigators said, indicates that the association was relatively consistent across studies and conditions.

The meta-analysis showed that individuals who were assigned to a psychosocial intervention condition demonstrated a 14.7% improvement (95% confidence interval [CI], 5.7%–23.8%) in beneficial immune system function compared with their counterparts who were assigned to a control condition.

Similarly, participants who received psychosocial interventions demonstrated an 18.0% decrease (95% CI, 7.2%–28.8%) in harmful immune system function over time.

A standout

Regarding the effect of the type of intervention on the association, only CBT (31 studies; P < .001) and multiple or combined interventions (seven studies; P = .01) were significantly associated with changes in immune system outcomes.

The analysis also found that interventions that included a group component were more consistently associated with enhanced immune function than were those that did not include a group component. Nevertheless, this difference did not reach statistical significance (P = .06).

Contrary to the researchers’ expectations, the analysis also revealed that intervention length did not moderate the association between psychosocial interventions and immune system function (P = .93).

With respect to the type of immune marker studied, the meta-analysis found that psychosocial interventions had significantly different associations with the various immune markers studied. Of the seven immune outcomes investigated, only proinflammatory cytokine or marker levels (33 studies; P < .001) and immune cell counts (27 studies; P < .001) were significantly associated with the psychosocial interventions examined.

The associations between psychosocial intervention and immune system function persisted for at least 6 months following treatment and were robust across age, sex, and intervention duration.

These results suggest that psychosocial interventions – particularly CBT and multiple or combined psychotherapeutic modalities – may play an important role in improving immune-related health outcomes.

Such interventions may not only be effective, they may also prove to be affordable alternatives to current therapeutic options. The mean length of a CBT intervention in the meta-analysis was 10.4 weeks, which the investigators equated with a total cost of $1,560 per patient.

“By comparison, the cost of using infliximab to reduce inflammation in persons with an autoimmune disorder is approximately $25,000 per patient per year,” they wrote.

“The results suggest the possibility that psychotherapy may be helpful for reducing inflammation and improving immune-related health in certain circumstances,” Dr. Slavich concluded. “However, the studies that we examined differed in terms of their quality, and we did not examine health outcomes in the present investigation.

“Therefore, more research needs to be done to determine how the present findings might be translated into treatment options or public policy.”
 

A path to better health

In an accompanying editorial, Veronika Engert, PhD, Joshua A. Grant, PhD, and Bernhard Strauss, PhD, noted that although infectious disease was once the primary cause of death in society, it has been supplanted by other complex and chronic illnesses, which often do not follow simple cause-and-effect associations.

“Rather,” they wrote, “these illnesses develop from a complex milieu of biological, psychological, and social factors that may also influence the disease progress and its prognosis. Against this backdrop, the meta-analysis by Shields and colleagues is an important confirmation of the biopsychosocial model.”

The editorialists explained that recent psychophysiological, neurobiological, and epigenetic research offers a glimpse into the relationship between psychological and social factors in pathogenesis. Nevertheless, the authors noted that a comprehensive examination of the potential effects of psychosocial interventions on immune parameters in various physical health conditions has been lacking.

“The evidence provided by Shields et al. is exactly what is needed to more fully shift treatment from an illness-centered to a patient-centered approach,” they wrote. “To that end, this meta-analysis may serve as a guide for policy makers aiming to improve immune-associated health.”

The research was supported by a Society in Science–Branco Weiss Fellowship, Brain and Behavior Research, and the National Institutes of Health. Dr. Slavich, Dr. Engert, Dr. Grant, and Dr. Strauss have disclosed no relevant financial relationships.
 

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

Optimizing glycemic control “is the key to overall treatment in people with diabetes and COVID-19,” said Antonio Ceriello, MD, during a June 5 webinar sponsored by Harvard Medical School, Boston.

©Tashatuvango/Thinkstockphotos.com

Dr. Ceriello, a research consultant with the Italian Ministry of Health, IRCCS Multi-Medica, Milan, highlighted a recent study that examined the association of blood glucose control and outcomes in COVID-19 patients with preexisting type 2 diabetes.

Among 7,000 cases of COVID-19, type 2 diabetes correlated with a higher death rate. However, those with well-controlled blood glucose (upper limit ≤10 mmol/L) had a survival rate of 98.9%, compared with just 11% among those with poorly controlled blood glucose (upper limit >10 mmol/L), a reduction in risk of 86% (adjusted hazard ratio, 0.14; Cell Metab. 2020 May 1. doi: 10.1016/j.cmet.2020.04.021).

Clinicians should also consider the possible side effects of hypoglycemic agents in the evolution of this disease. This is true of all patients, not just diabetes patients, Dr. Ceriello said. “We have data showing that ... hyperglycemia contributes directly to worsening the prognosis of COVID-19 independent of the presence of diabetes.”

One study found that the glycosylation of ACE-2 played an important role in allowing cellular entry of the virus (Am J Physiol Endocrinol Metab. 2020 Mar 31;318:E736-41). “This is something that could be related to hyperglycemia,” he added.

Another risk factor is thrombosis, a clear contributor to death rates in COVID-19. Research on thrombosis incidence in COVID-19 patients with diabetes reported higher levels of D-dimer levels in people with diabetes, especially among those who couldn’t manage their disease.

Tying all of these factors together, Dr. Ceriello discussed how ACE-2 glycosylation, in combination with other factors in SARS-CoV-2 infection, could lead to hyperglycemia, thrombosis, and subsequently multiorgan damage in diabetes patients.

Other research has associated higher HbA1c levels (mean HbA1c, 7.5%) with higher mortality risk in COVID-19 patients, said another speaker, Linong Ji, MD, director for endocrinology and metabolism at Peking University People’s Hospital, Beijing, and director of Peking University’s Diabetes Center. Proper guidance is key to ensuring early detection of hyperglycemic crisis in people with diabetes, advised Dr. Ji.

Global management of diabetes in SARS-CoV-2 patients is “quite challenging,” given that most patients don’t have their diabetes under control, said host and moderator A. Enrique Caballero, MD, an endocrinologist/investigator in the division of endocrinology, diabetes, and hypertension and division of global health equity at Brigham and Women’s Hospital, Boston. “They are not meeting treatment targets for cholesterol or glucose control. So we’re not managing optimal care. And now on top of this, we have COVID-19.”

Optimizing glycemic control “is the key to overall treatment in people with diabetes and COVID-19,” said Antonio Ceriello, MD, during a June 5 webinar sponsored by Harvard Medical School, Boston.

©Tashatuvango/Thinkstockphotos.com

Dr. Ceriello, a research consultant with the Italian Ministry of Health, IRCCS Multi-Medica, Milan, highlighted a recent study that examined the association of blood glucose control and outcomes in COVID-19 patients with preexisting type 2 diabetes.

Among 7,000 cases of COVID-19, type 2 diabetes correlated with a higher death rate. However, those with well-controlled blood glucose (upper limit ≤10 mmol/L) had a survival rate of 98.9%, compared with just 11% among those with poorly controlled blood glucose (upper limit >10 mmol/L), a reduction in risk of 86% (adjusted hazard ratio, 0.14; Cell Metab. 2020 May 1. doi: 10.1016/j.cmet.2020.04.021).

Clinicians should also consider the possible side effects of hypoglycemic agents in the evolution of this disease. This is true of all patients, not just diabetes patients, Dr. Ceriello said. “We have data showing that ... hyperglycemia contributes directly to worsening the prognosis of COVID-19 independent of the presence of diabetes.”

One study found that the glycosylation of ACE-2 played an important role in allowing cellular entry of the virus (Am J Physiol Endocrinol Metab. 2020 Mar 31;318:E736-41). “This is something that could be related to hyperglycemia,” he added.

Another risk factor is thrombosis, a clear contributor to death rates in COVID-19. Research on thrombosis incidence in COVID-19 patients with diabetes reported higher levels of D-dimer levels in people with diabetes, especially among those who couldn’t manage their disease.

Tying all of these factors together, Dr. Ceriello discussed how ACE-2 glycosylation, in combination with other factors in SARS-CoV-2 infection, could lead to hyperglycemia, thrombosis, and subsequently multiorgan damage in diabetes patients.

Other research has associated higher HbA1c levels (mean HbA1c, 7.5%) with higher mortality risk in COVID-19 patients, said another speaker, Linong Ji, MD, director for endocrinology and metabolism at Peking University People’s Hospital, Beijing, and director of Peking University’s Diabetes Center. Proper guidance is key to ensuring early detection of hyperglycemic crisis in people with diabetes, advised Dr. Ji.

Global management of diabetes in SARS-CoV-2 patients is “quite challenging,” given that most patients don’t have their diabetes under control, said host and moderator A. Enrique Caballero, MD, an endocrinologist/investigator in the division of endocrinology, diabetes, and hypertension and division of global health equity at Brigham and Women’s Hospital, Boston. “They are not meeting treatment targets for cholesterol or glucose control. So we’re not managing optimal care. And now on top of this, we have COVID-19.”

Optimizing glycemic control “is the key to overall treatment in people with diabetes and COVID-19,” said Antonio Ceriello, MD, during a June 5 webinar sponsored by Harvard Medical School, Boston.

©Tashatuvango/Thinkstockphotos.com

Dr. Ceriello, a research consultant with the Italian Ministry of Health, IRCCS Multi-Medica, Milan, highlighted a recent study that examined the association of blood glucose control and outcomes in COVID-19 patients with preexisting type 2 diabetes.

Among 7,000 cases of COVID-19, type 2 diabetes correlated with a higher death rate. However, those with well-controlled blood glucose (upper limit ≤10 mmol/L) had a survival rate of 98.9%, compared with just 11% among those with poorly controlled blood glucose (upper limit >10 mmol/L), a reduction in risk of 86% (adjusted hazard ratio, 0.14; Cell Metab. 2020 May 1. doi: 10.1016/j.cmet.2020.04.021).

Clinicians should also consider the possible side effects of hypoglycemic agents in the evolution of this disease. This is true of all patients, not just diabetes patients, Dr. Ceriello said. “We have data showing that ... hyperglycemia contributes directly to worsening the prognosis of COVID-19 independent of the presence of diabetes.”

One study found that the glycosylation of ACE-2 played an important role in allowing cellular entry of the virus (Am J Physiol Endocrinol Metab. 2020 Mar 31;318:E736-41). “This is something that could be related to hyperglycemia,” he added.

Another risk factor is thrombosis, a clear contributor to death rates in COVID-19. Research on thrombosis incidence in COVID-19 patients with diabetes reported higher levels of D-dimer levels in people with diabetes, especially among those who couldn’t manage their disease.

Tying all of these factors together, Dr. Ceriello discussed how ACE-2 glycosylation, in combination with other factors in SARS-CoV-2 infection, could lead to hyperglycemia, thrombosis, and subsequently multiorgan damage in diabetes patients.

Other research has associated higher HbA1c levels (mean HbA1c, 7.5%) with higher mortality risk in COVID-19 patients, said another speaker, Linong Ji, MD, director for endocrinology and metabolism at Peking University People’s Hospital, Beijing, and director of Peking University’s Diabetes Center. Proper guidance is key to ensuring early detection of hyperglycemic crisis in people with diabetes, advised Dr. Ji.

Global management of diabetes in SARS-CoV-2 patients is “quite challenging,” given that most patients don’t have their diabetes under control, said host and moderator A. Enrique Caballero, MD, an endocrinologist/investigator in the division of endocrinology, diabetes, and hypertension and division of global health equity at Brigham and Women’s Hospital, Boston. “They are not meeting treatment targets for cholesterol or glucose control. So we’re not managing optimal care. And now on top of this, we have COVID-19.”

Secondary respiratory infections appear to be highly prevalent among patients with severe COVID-19, but at this point, most pulmonologists aren’t sure what to make of this understudied phenomenon.

“We really do not understand the implications of secondary infections on outcomes in COVID-19 patients,” David L. Bowton, MD, FCCP, said in an interview. “In most early reports the incidence of secondary infections was much higher in patients dying from COVID-19, compared to survivors, but it isn’t clear whether this indicates that the secondary infection itself led to excess mortality or was more a marker of the severity of the COVID-19 infection.

“Further, details of the diagnostic criteria used, the microbiology, and the appropriateness of treatment of these secondary infections has not generally been included in these reports,” added Dr. Bowton, a pulmonologist and professor emeritus of critical care anesthesiology at Wake Forest University, Winston-Salem, N.C.

One such early retrospective cohort study included 191 COVID-19 patients in Wuhan, China. Of the 54 who died in hospital, half had secondary bacterial lung infections (Lancet. 2020 Mar 28;395[10229]:1054-62). That comes as no surprise to U.S. pulmonologists, who learned back in their training that many deaths during the so-called Spanish influenza epidemic of 1918-1920 were actually caused by secondary pneumonia involving Staphylococcus aureus, commented Daniel L. Ouellette, MD, FCCP, associate director of medical critical care at Henry Ford Hospital, Detroit.

“Critically ill patients are highly susceptible to secondary infections regardless of the cause of the patient’s critical illness,” he noted in an interview. “Recent reports of secondary infections in patients critically ill from COVID-19 are interesting but should be considered in this context. To confirm that COVID-19 patients have a different, or increased, risk of infection at specific sites or from specific agents will require careful study.”

That will be no easy matter given the challenges of obtaining bronchoalveolar lavage samples in mechanically ventilated patients with COVID-19, according to Eric J. Gartman, MD, FCCP, a pulmonologist at Brown University, Providence, R.I., and director of the pulmonary function laboratory at the Providence Veterans Affairs Medical Center.

“Unfortunately, many of the invasive modalities that are typically employed to help diagnose secondary infections in critically ill patients are being severely limited or even prohibited in COVID-19 patients due to infection control measures,” he said. As a result, Dr. Gartman noted, intensivists are often resorting to empiric broad-spectrum antimicrobial therapy in patients with severe COVID-19 and are without ready access to the bacterial cultures which might otherwise permit later treatment de-escalation or retargeting.

Among the myriad areas of uncertainty regarding COVID-19 is the proportion of bacterial coinfections that are hospital acquired. Given the lengthy duration of invasive mechanical ventilation in patients with severe COVID-19 – a mean of 9.1 days in the United Kingdom – the chances of hospital-acquired infection are likely substantial. Moreover, a recent single-center U.K. study involving microbiologic testing in 195 consecutive patients newly hospitalized for COVID-19 reported that community-acquired bacterial infection was uncommon: Just 4% of patients had pneumococcal coinfection at hospital admission, and S. aureus wasn’t detected in anyone (Lancet. 2020;1:362. doi:10.1016/S2666-5247[20]30036-7). French investigators have reported detecting putative invasive pulmonary aspergillosis in nearly one-third of a small series of 27 consecutive mechanically ventilated COVID-19 patients (Lancet Resp Med. 2020; 8[6]:e48-9). Dr. Gartman said the diagnostic testing methods utilized in this and similar reports haven’t been prospectively validated in COVID-19. The testing methods may not indicate invasive Aspergillus infection in this population with a high degree of certainty, since they have previously been performed mainly in patients with hematologic malignancies.

“Although there is nothing definitive regarding this research, as a practicing critical care doctor one should respect these findings and consider this secondary diagnosis if the supporting clinical data is positive, especially given that the mortality risk in this population is high,” he advised.

Dr. Bowton said that he and his fellow intensivists at Wake Forest Baptist Health don’t routinely screen COVID-19 patients for secondary bacterial or fungal infections. And in talking with colleagues around the country, it’s his impression that most have similarly elected not to do so.

“However, our clinical index of suspicion for secondary infections is heightened and, if triggered, will initiate a search for and treatment of these secondary infections,” Dr. Bowton said.
 

[email protected]

Secondary respiratory infections appear to be highly prevalent among patients with severe COVID-19, but at this point, most pulmonologists aren’t sure what to make of this understudied phenomenon.

“We really do not understand the implications of secondary infections on outcomes in COVID-19 patients,” David L. Bowton, MD, FCCP, said in an interview. “In most early reports the incidence of secondary infections was much higher in patients dying from COVID-19, compared to survivors, but it isn’t clear whether this indicates that the secondary infection itself led to excess mortality or was more a marker of the severity of the COVID-19 infection.

“Further, details of the diagnostic criteria used, the microbiology, and the appropriateness of treatment of these secondary infections has not generally been included in these reports,” added Dr. Bowton, a pulmonologist and professor emeritus of critical care anesthesiology at Wake Forest University, Winston-Salem, N.C.

One such early retrospective cohort study included 191 COVID-19 patients in Wuhan, China. Of the 54 who died in hospital, half had secondary bacterial lung infections (Lancet. 2020 Mar 28;395[10229]:1054-62). That comes as no surprise to U.S. pulmonologists, who learned back in their training that many deaths during the so-called Spanish influenza epidemic of 1918-1920 were actually caused by secondary pneumonia involving Staphylococcus aureus, commented Daniel L. Ouellette, MD, FCCP, associate director of medical critical care at Henry Ford Hospital, Detroit.

“Critically ill patients are highly susceptible to secondary infections regardless of the cause of the patient’s critical illness,” he noted in an interview. “Recent reports of secondary infections in patients critically ill from COVID-19 are interesting but should be considered in this context. To confirm that COVID-19 patients have a different, or increased, risk of infection at specific sites or from specific agents will require careful study.”

That will be no easy matter given the challenges of obtaining bronchoalveolar lavage samples in mechanically ventilated patients with COVID-19, according to Eric J. Gartman, MD, FCCP, a pulmonologist at Brown University, Providence, R.I., and director of the pulmonary function laboratory at the Providence Veterans Affairs Medical Center.

“Unfortunately, many of the invasive modalities that are typically employed to help diagnose secondary infections in critically ill patients are being severely limited or even prohibited in COVID-19 patients due to infection control measures,” he said. As a result, Dr. Gartman noted, intensivists are often resorting to empiric broad-spectrum antimicrobial therapy in patients with severe COVID-19 and are without ready access to the bacterial cultures which might otherwise permit later treatment de-escalation or retargeting.

Among the myriad areas of uncertainty regarding COVID-19 is the proportion of bacterial coinfections that are hospital acquired. Given the lengthy duration of invasive mechanical ventilation in patients with severe COVID-19 – a mean of 9.1 days in the United Kingdom – the chances of hospital-acquired infection are likely substantial. Moreover, a recent single-center U.K. study involving microbiologic testing in 195 consecutive patients newly hospitalized for COVID-19 reported that community-acquired bacterial infection was uncommon: Just 4% of patients had pneumococcal coinfection at hospital admission, and S. aureus wasn’t detected in anyone (Lancet. 2020;1:362. doi:10.1016/S2666-5247[20]30036-7). French investigators have reported detecting putative invasive pulmonary aspergillosis in nearly one-third of a small series of 27 consecutive mechanically ventilated COVID-19 patients (Lancet Resp Med. 2020; 8[6]:e48-9). Dr. Gartman said the diagnostic testing methods utilized in this and similar reports haven’t been prospectively validated in COVID-19. The testing methods may not indicate invasive Aspergillus infection in this population with a high degree of certainty, since they have previously been performed mainly in patients with hematologic malignancies.

“Although there is nothing definitive regarding this research, as a practicing critical care doctor one should respect these findings and consider this secondary diagnosis if the supporting clinical data is positive, especially given that the mortality risk in this population is high,” he advised.

Dr. Bowton said that he and his fellow intensivists at Wake Forest Baptist Health don’t routinely screen COVID-19 patients for secondary bacterial or fungal infections. And in talking with colleagues around the country, it’s his impression that most have similarly elected not to do so.

“However, our clinical index of suspicion for secondary infections is heightened and, if triggered, will initiate a search for and treatment of these secondary infections,” Dr. Bowton said.
 

[email protected]

Secondary respiratory infections appear to be highly prevalent among patients with severe COVID-19, but at this point, most pulmonologists aren’t sure what to make of this understudied phenomenon.

“We really do not understand the implications of secondary infections on outcomes in COVID-19 patients,” David L. Bowton, MD, FCCP, said in an interview. “In most early reports the incidence of secondary infections was much higher in patients dying from COVID-19, compared to survivors, but it isn’t clear whether this indicates that the secondary infection itself led to excess mortality or was more a marker of the severity of the COVID-19 infection.

“Further, details of the diagnostic criteria used, the microbiology, and the appropriateness of treatment of these secondary infections has not generally been included in these reports,” added Dr. Bowton, a pulmonologist and professor emeritus of critical care anesthesiology at Wake Forest University, Winston-Salem, N.C.

One such early retrospective cohort study included 191 COVID-19 patients in Wuhan, China. Of the 54 who died in hospital, half had secondary bacterial lung infections (Lancet. 2020 Mar 28;395[10229]:1054-62). That comes as no surprise to U.S. pulmonologists, who learned back in their training that many deaths during the so-called Spanish influenza epidemic of 1918-1920 were actually caused by secondary pneumonia involving Staphylococcus aureus, commented Daniel L. Ouellette, MD, FCCP, associate director of medical critical care at Henry Ford Hospital, Detroit.

“Critically ill patients are highly susceptible to secondary infections regardless of the cause of the patient’s critical illness,” he noted in an interview. “Recent reports of secondary infections in patients critically ill from COVID-19 are interesting but should be considered in this context. To confirm that COVID-19 patients have a different, or increased, risk of infection at specific sites or from specific agents will require careful study.”

That will be no easy matter given the challenges of obtaining bronchoalveolar lavage samples in mechanically ventilated patients with COVID-19, according to Eric J. Gartman, MD, FCCP, a pulmonologist at Brown University, Providence, R.I., and director of the pulmonary function laboratory at the Providence Veterans Affairs Medical Center.

“Unfortunately, many of the invasive modalities that are typically employed to help diagnose secondary infections in critically ill patients are being severely limited or even prohibited in COVID-19 patients due to infection control measures,” he said. As a result, Dr. Gartman noted, intensivists are often resorting to empiric broad-spectrum antimicrobial therapy in patients with severe COVID-19 and are without ready access to the bacterial cultures which might otherwise permit later treatment de-escalation or retargeting.

Among the myriad areas of uncertainty regarding COVID-19 is the proportion of bacterial coinfections that are hospital acquired. Given the lengthy duration of invasive mechanical ventilation in patients with severe COVID-19 – a mean of 9.1 days in the United Kingdom – the chances of hospital-acquired infection are likely substantial. Moreover, a recent single-center U.K. study involving microbiologic testing in 195 consecutive patients newly hospitalized for COVID-19 reported that community-acquired bacterial infection was uncommon: Just 4% of patients had pneumococcal coinfection at hospital admission, and S. aureus wasn’t detected in anyone (Lancet. 2020;1:362. doi:10.1016/S2666-5247[20]30036-7). French investigators have reported detecting putative invasive pulmonary aspergillosis in nearly one-third of a small series of 27 consecutive mechanically ventilated COVID-19 patients (Lancet Resp Med. 2020; 8[6]:e48-9). Dr. Gartman said the diagnostic testing methods utilized in this and similar reports haven’t been prospectively validated in COVID-19. The testing methods may not indicate invasive Aspergillus infection in this population with a high degree of certainty, since they have previously been performed mainly in patients with hematologic malignancies.

“Although there is nothing definitive regarding this research, as a practicing critical care doctor one should respect these findings and consider this secondary diagnosis if the supporting clinical data is positive, especially given that the mortality risk in this population is high,” he advised.

Dr. Bowton said that he and his fellow intensivists at Wake Forest Baptist Health don’t routinely screen COVID-19 patients for secondary bacterial or fungal infections. And in talking with colleagues around the country, it’s his impression that most have similarly elected not to do so.

“However, our clinical index of suspicion for secondary infections is heightened and, if triggered, will initiate a search for and treatment of these secondary infections,” Dr. Bowton said.
 

[email protected]

In its first media briefing on coronavirus in more than 3 months, the Centers for Disease Control and Prevention (CDC) warned that the COVID-19 pandemic is not over, and large gatherings pose a high risk for COVID-19 transmission.

Robert Redfield, MD, Director, CDC, and Jay C. Butler, MD, Deputy Director of Infectious Diseases and COVID-19 Response Incident Manager, CDC, discussed two new sets of CDC guidance on deciding to go out and attending group gatherings.

“We recognize that we’re all getting tired of staying at home; people long for the life that they had back in December, and as we head into the summer months, we know that Americans will be looking forward to reconnecting with family and friends and being able to attend events, and we want that to occur as safely as possible,” Butler said.

“Our recommendations evolved based on new information that becomes available, but it continues to be extremely important that we embrace the recommendations of social distancing, handwashing, and wearing a face covering when we’re in public as some of the key defenses that we have against this virus,” Redfield explained.

“The pandemic is not over and it’s important to recognize that. While COVID-19 is still making headlines everywhere, we know the pandemic hasn’t affected everyone everywhere in the same way,” Butler said.

He noted that it is important to prepare for next fall and winter, when we can expect influenza season to complicate matters. “If anything, we must be overly-prepared for what we might face later this year,” he continued, adding that it is important to get vaccinated against influenza. “[F]lu and COVID-19 could be circulating together as we move into the fall and winter months,” he concluded.

Americans Mostly Following Guidelines

The agency also presented data from an article published online June 12 in Morbidity and Mortality Weekly Report that “underscores the fact that American people have taken mitigation efforts seriously…and it demonstrates our collective spirit in responding to the pandemic,” Butler said.

In it, the researchers describe representative panel surveys conducted among 4042 adults aged 18 years or older in New York City and Los Angeles — the two most populous cities in the United States — and “broadly across the United States” during May 5 to May 12, 2020.

Most respondents supported stay-at-home orders and nonessential business closures (United States, 79.5%; New York City, 86.7%; Los Angeles, 81.5%) and always or often wore cloth face coverings in public (United States, 74.1%; New York City, 89.6%; Los Angeles, 89.8%). Respondents also agreed that nonessential workers should remain at home (United States, 67.3%; New York City, 76.6%; Los Angeles, 69.1%), report Mark É. Czeisler, from Monash University and Austin Health, both in Melbourne, Australia, and colleagues.

There was wide support with public health guidelines: more than 87% of individuals in each area agreed that individuals should keep six feet of distance between themselves and others, and more than 82% in each area said that people should limit gatherings to fewer than 10 individuals.

At the time the survey was conducted, most were against indoor dining at restaurants (United States, 66.6%; New York City, 81.5%; Los Angeles, 71.8%).

Adherence “Widespread,” Survey Finds

Most respondents said they were adhering to COVID-19 mitigation guidance, including self-isolating (United States, 77.3%; New York City, 84.6%; Los Angeles, 83.0%) and “always or often” kept at least six feet between themselves and others (New York City, 85.7%; Los Angeles, 82.6%).

More than 85% of respondents in each of the three cohorts said they always or often avoided groups of 10 or more individuals.

About 90% of respondents said they had been in a public area during the last week, with 74.1% of those saying they always or often covered their face in public; respondents in New York City (89.6%) and Los Angeles (89.8%) had higher percentages of this behavior compared with respondents from the United States overall.

Most respondents felt that restrictions in their state were balanced or too lax (United States, 84.3%; New York City, 89.7%; Los Angeles, 79.7%) and said they would feel unsafe if restrictions were eased nationwide at that time (United States, 74.3%; New York City, 81.5%; Los Angeles, 73.4%). However, some individuals who said they would feel unsafe still wanted community mitigation strategies eased and were willing to accept risks resulting from lifting restrictions (United States, 17.1%; New York City, 12.6%; Los Angeles, 12.7%).

“Reported prevalence of self-isolation and feeling safe if community mitigation strategies were lifted differed significantly by age, employment status, and essential worker status among adults in the U.S. survey cohort,” the authors write.

Reports of self-isolation were highest among persons aged 18 to 24 years (92.3%) and lowest among those aged 45 to 54 years (71.5%). Yet, young adults aged 18 to 24 years (43.1%) were more than twice as likely to say they would feel safe if community mitigation strategies were eased, compared with adults aged 65 years or older (19.2%).

Almost half (47.2%) of employed respondents in the US cohort were essential workers; essential workers were “significantly less likely” to report self-isolating when compared with nonessential workers (63.1% vs 80.6%). Some 37.7% of essential workers said they would feel safe if community mitigation strategies were eased, compared with 23.7% of nonessential workers.

“Respondents who were male, employed, or essential workers were significantly more likely to report having been in public areas in the past week. Among respondents who had been in public areas during the preceding week, significantly higher percentages of women, adults aged ≥ 65 years, retired persons, and those living in urban areas reported wearing cloth face coverings,” the authors explain.

The findings are subject to several limitations, including self-reporting and the fact that some respondents may have known someone who tested positive for COVID-19 or died from it, the authors note. Respondents were not representative of the US population and the findings may not be generalizable.


This article first appeared on Medscape.com.

In its first media briefing on coronavirus in more than 3 months, the Centers for Disease Control and Prevention (CDC) warned that the COVID-19 pandemic is not over, and large gatherings pose a high risk for COVID-19 transmission.

Robert Redfield, MD, Director, CDC, and Jay C. Butler, MD, Deputy Director of Infectious Diseases and COVID-19 Response Incident Manager, CDC, discussed two new sets of CDC guidance on deciding to go out and attending group gatherings.

“We recognize that we’re all getting tired of staying at home; people long for the life that they had back in December, and as we head into the summer months, we know that Americans will be looking forward to reconnecting with family and friends and being able to attend events, and we want that to occur as safely as possible,” Butler said.

“Our recommendations evolved based on new information that becomes available, but it continues to be extremely important that we embrace the recommendations of social distancing, handwashing, and wearing a face covering when we’re in public as some of the key defenses that we have against this virus,” Redfield explained.

“The pandemic is not over and it’s important to recognize that. While COVID-19 is still making headlines everywhere, we know the pandemic hasn’t affected everyone everywhere in the same way,” Butler said.

He noted that it is important to prepare for next fall and winter, when we can expect influenza season to complicate matters. “If anything, we must be overly-prepared for what we might face later this year,” he continued, adding that it is important to get vaccinated against influenza. “[F]lu and COVID-19 could be circulating together as we move into the fall and winter months,” he concluded.

Americans Mostly Following Guidelines

The agency also presented data from an article published online June 12 in Morbidity and Mortality Weekly Report that “underscores the fact that American people have taken mitigation efforts seriously…and it demonstrates our collective spirit in responding to the pandemic,” Butler said.

In it, the researchers describe representative panel surveys conducted among 4042 adults aged 18 years or older in New York City and Los Angeles — the two most populous cities in the United States — and “broadly across the United States” during May 5 to May 12, 2020.

Most respondents supported stay-at-home orders and nonessential business closures (United States, 79.5%; New York City, 86.7%; Los Angeles, 81.5%) and always or often wore cloth face coverings in public (United States, 74.1%; New York City, 89.6%; Los Angeles, 89.8%). Respondents also agreed that nonessential workers should remain at home (United States, 67.3%; New York City, 76.6%; Los Angeles, 69.1%), report Mark É. Czeisler, from Monash University and Austin Health, both in Melbourne, Australia, and colleagues.

There was wide support with public health guidelines: more than 87% of individuals in each area agreed that individuals should keep six feet of distance between themselves and others, and more than 82% in each area said that people should limit gatherings to fewer than 10 individuals.

At the time the survey was conducted, most were against indoor dining at restaurants (United States, 66.6%; New York City, 81.5%; Los Angeles, 71.8%).

Adherence “Widespread,” Survey Finds

Most respondents said they were adhering to COVID-19 mitigation guidance, including self-isolating (United States, 77.3%; New York City, 84.6%; Los Angeles, 83.0%) and “always or often” kept at least six feet between themselves and others (New York City, 85.7%; Los Angeles, 82.6%).

More than 85% of respondents in each of the three cohorts said they always or often avoided groups of 10 or more individuals.

About 90% of respondents said they had been in a public area during the last week, with 74.1% of those saying they always or often covered their face in public; respondents in New York City (89.6%) and Los Angeles (89.8%) had higher percentages of this behavior compared with respondents from the United States overall.

Most respondents felt that restrictions in their state were balanced or too lax (United States, 84.3%; New York City, 89.7%; Los Angeles, 79.7%) and said they would feel unsafe if restrictions were eased nationwide at that time (United States, 74.3%; New York City, 81.5%; Los Angeles, 73.4%). However, some individuals who said they would feel unsafe still wanted community mitigation strategies eased and were willing to accept risks resulting from lifting restrictions (United States, 17.1%; New York City, 12.6%; Los Angeles, 12.7%).

“Reported prevalence of self-isolation and feeling safe if community mitigation strategies were lifted differed significantly by age, employment status, and essential worker status among adults in the U.S. survey cohort,” the authors write.

Reports of self-isolation were highest among persons aged 18 to 24 years (92.3%) and lowest among those aged 45 to 54 years (71.5%). Yet, young adults aged 18 to 24 years (43.1%) were more than twice as likely to say they would feel safe if community mitigation strategies were eased, compared with adults aged 65 years or older (19.2%).

Almost half (47.2%) of employed respondents in the US cohort were essential workers; essential workers were “significantly less likely” to report self-isolating when compared with nonessential workers (63.1% vs 80.6%). Some 37.7% of essential workers said they would feel safe if community mitigation strategies were eased, compared with 23.7% of nonessential workers.

“Respondents who were male, employed, or essential workers were significantly more likely to report having been in public areas in the past week. Among respondents who had been in public areas during the preceding week, significantly higher percentages of women, adults aged ≥ 65 years, retired persons, and those living in urban areas reported wearing cloth face coverings,” the authors explain.

The findings are subject to several limitations, including self-reporting and the fact that some respondents may have known someone who tested positive for COVID-19 or died from it, the authors note. Respondents were not representative of the US population and the findings may not be generalizable.


This article first appeared on Medscape.com.

In its first media briefing on coronavirus in more than 3 months, the Centers for Disease Control and Prevention (CDC) warned that the COVID-19 pandemic is not over, and large gatherings pose a high risk for COVID-19 transmission.

Robert Redfield, MD, Director, CDC, and Jay C. Butler, MD, Deputy Director of Infectious Diseases and COVID-19 Response Incident Manager, CDC, discussed two new sets of CDC guidance on deciding to go out and attending group gatherings.

“We recognize that we’re all getting tired of staying at home; people long for the life that they had back in December, and as we head into the summer months, we know that Americans will be looking forward to reconnecting with family and friends and being able to attend events, and we want that to occur as safely as possible,” Butler said.

“Our recommendations evolved based on new information that becomes available, but it continues to be extremely important that we embrace the recommendations of social distancing, handwashing, and wearing a face covering when we’re in public as some of the key defenses that we have against this virus,” Redfield explained.

“The pandemic is not over and it’s important to recognize that. While COVID-19 is still making headlines everywhere, we know the pandemic hasn’t affected everyone everywhere in the same way,” Butler said.

He noted that it is important to prepare for next fall and winter, when we can expect influenza season to complicate matters. “If anything, we must be overly-prepared for what we might face later this year,” he continued, adding that it is important to get vaccinated against influenza. “[F]lu and COVID-19 could be circulating together as we move into the fall and winter months,” he concluded.

Americans Mostly Following Guidelines

The agency also presented data from an article published online June 12 in Morbidity and Mortality Weekly Report that “underscores the fact that American people have taken mitigation efforts seriously…and it demonstrates our collective spirit in responding to the pandemic,” Butler said.

In it, the researchers describe representative panel surveys conducted among 4042 adults aged 18 years or older in New York City and Los Angeles — the two most populous cities in the United States — and “broadly across the United States” during May 5 to May 12, 2020.

Most respondents supported stay-at-home orders and nonessential business closures (United States, 79.5%; New York City, 86.7%; Los Angeles, 81.5%) and always or often wore cloth face coverings in public (United States, 74.1%; New York City, 89.6%; Los Angeles, 89.8%). Respondents also agreed that nonessential workers should remain at home (United States, 67.3%; New York City, 76.6%; Los Angeles, 69.1%), report Mark É. Czeisler, from Monash University and Austin Health, both in Melbourne, Australia, and colleagues.

There was wide support with public health guidelines: more than 87% of individuals in each area agreed that individuals should keep six feet of distance between themselves and others, and more than 82% in each area said that people should limit gatherings to fewer than 10 individuals.

At the time the survey was conducted, most were against indoor dining at restaurants (United States, 66.6%; New York City, 81.5%; Los Angeles, 71.8%).

Adherence “Widespread,” Survey Finds

Most respondents said they were adhering to COVID-19 mitigation guidance, including self-isolating (United States, 77.3%; New York City, 84.6%; Los Angeles, 83.0%) and “always or often” kept at least six feet between themselves and others (New York City, 85.7%; Los Angeles, 82.6%).

More than 85% of respondents in each of the three cohorts said they always or often avoided groups of 10 or more individuals.

About 90% of respondents said they had been in a public area during the last week, with 74.1% of those saying they always or often covered their face in public; respondents in New York City (89.6%) and Los Angeles (89.8%) had higher percentages of this behavior compared with respondents from the United States overall.

Most respondents felt that restrictions in their state were balanced or too lax (United States, 84.3%; New York City, 89.7%; Los Angeles, 79.7%) and said they would feel unsafe if restrictions were eased nationwide at that time (United States, 74.3%; New York City, 81.5%; Los Angeles, 73.4%). However, some individuals who said they would feel unsafe still wanted community mitigation strategies eased and were willing to accept risks resulting from lifting restrictions (United States, 17.1%; New York City, 12.6%; Los Angeles, 12.7%).

“Reported prevalence of self-isolation and feeling safe if community mitigation strategies were lifted differed significantly by age, employment status, and essential worker status among adults in the U.S. survey cohort,” the authors write.

Reports of self-isolation were highest among persons aged 18 to 24 years (92.3%) and lowest among those aged 45 to 54 years (71.5%). Yet, young adults aged 18 to 24 years (43.1%) were more than twice as likely to say they would feel safe if community mitigation strategies were eased, compared with adults aged 65 years or older (19.2%).

Almost half (47.2%) of employed respondents in the US cohort were essential workers; essential workers were “significantly less likely” to report self-isolating when compared with nonessential workers (63.1% vs 80.6%). Some 37.7% of essential workers said they would feel safe if community mitigation strategies were eased, compared with 23.7% of nonessential workers.

“Respondents who were male, employed, or essential workers were significantly more likely to report having been in public areas in the past week. Among respondents who had been in public areas during the preceding week, significantly higher percentages of women, adults aged ≥ 65 years, retired persons, and those living in urban areas reported wearing cloth face coverings,” the authors explain.

The findings are subject to several limitations, including self-reporting and the fact that some respondents may have known someone who tested positive for COVID-19 or died from it, the authors note. Respondents were not representative of the US population and the findings may not be generalizable.


This article first appeared on Medscape.com.

New preliminary data from the T1D Exchange suggest that, although hyperglycemia and diabetic ketoacidosis (DKA) are common in people with type 1 diabetes who develop COVID-19, many are still able to manage the illness at home and overall mortality is relatively low.

The new findings – the first US data on individuals with type 1 diabetes and COVID-19 – were published online June 5 in Diabetes Care by Osagie A. Ebekozien, MD, vice president, quality improvement and population health at the T1D Exchange, and colleagues.

Two UK studies are the only prior ones to previously examine the topic.

The newly published study includes data as of May 5 on 64 individuals from a total of 64 US sites, including 15 T1D Exchange member clinics and an additional 49 endocrinology clinics from around the country. Since the paper was submitted, there are now 220 patients from 68 sites. Another publication with a more detailed analysis of risk factors and adjustment for confounders is planned for later this year.

Some of the findings from the preliminary data have shifted, but many aspects remain consistent, Ebekozien told Medscape Medical News.

“One thing still very true, even with the unpublished findings, is the influence of A1c and glycemic management. ...With higher A1c levels, we’re seeing more COVID-19 hospitalizations and worse outcomes,” he said.

And as has been generally reported for COVID-19, high body mass index was a major risk factor in the preliminary dataset – and remains so.

There were two deaths in the preliminary report, both individuals with comorbidities in addition to type 1 diabetes, Ebekozien said. There have been a few more deaths in the larger dataset, but the mortality rate remains relatively low.

Interestingly, females predominate in both cohorts. That may be a reporting phenomenon, another factor that is being analyzed.

Hyperglycemia Remains a Major Risk Factor

The study is specifically being conducted by the T1D Exchange’s Quality Improvement Collaborative, which Ebekozien heads.

Data were obtained for 33 patients with type 1 diabetes who tested positive for COVID-19, and another 31 who were classified as “COVID-19–like” because they had symptoms consistent with COVID-19, as identified by the Centers for Disease Control and Prevention, but hadn’t been tested for the virus.

For all 64 patients, the mean age was 20.9 years and two thirds (65.6%) were aged 18 or younger. A higher proportion of the COVID-19–like patients were pediatric than the confirmed cases. The larger dataset includes more adult patients, Ebekozien told Medscape Medical News.

Overall, 60.9% of patients were female. Nearly half were white, a quarter Hispanic, and 18.8% black. More confirmed COVID-19 cases were black compared with suspected cases (30.3% vs 6.5%).

Median A1c for the overall group (including suspected COVID-19 cases) was 8.0%, but it was 8.5% among confirmed cases. Overall, six patients (9.8%) presented with new-onset type 1 diabetes after they developed COVID-19.

Hyperglycemia was present in half (32) of patients overall. DKA occurred in 19 people (30.2%): 15 of the confirmed COVID-19 cases (45.5%) versus just 4 (13.3%) of the COVID-19–like cases. Nausea was reported in 30.2% of patients overall.

Other symptoms were typical of COVID-19, including fever (41.3%), dry cough (38.1%), and shortness of breath (27.0%). Loss of taste and smell was less common, at just 9.5% overall.

Obesity was present in 39.7% of patients overall, with similar proportions in the confirmed and suspected COVID-19 groups. Hypertension and/or cardiovascular disease were present in 14.3% of patients overall, and the rate was similar between the two subgroups.

One of the two patients who died was a 79-year-old man who had hypertension and a prior stroke in addition to type 1 diabetes. The other was a 19-year-old woman with a history of asthma who developed a pulmonary embolism during the onset of COVID-19. Neither had DKA.

Even in Type 1 Diabetes, COVID-19 Can Be Managed at Home

Overall, 34.9% of patients were able to manage COVID-19 entirely at home, with 27.3% of the confirmed and 43.3% of the suspected cases able to do so.

At the other extreme, 22.2% of patients overall were admitted to the intensive care unit; 30.3% of the confirmed versus 13.3% of suspected cases.

Including the small proportion of patients sent home after being seen in emergency or urgent care, overall roughly half were not admitted to hospital.

“Interestingly, even in this preliminary study, half were managed at home via telemedicine with an endocrinologist and infectious disease specialist. ... I think it continues to be a case-by-case clinical decision between the patient and their provider,” Ebekozien said.

“But, we’re seeing a good number of patients who are managed at home and the symptoms resolve in a week or two, and the illness runs its course, and they don’t have to even be seen,” he added.

The research team is also collecting data on barriers to remote care, including challenges with telemedicine and how frontline providers are navigating them.

“Those are all things that our future paper will be able to shed more light on,” he explained.

Endocrinologists around the country are invited to report cases of COVID-19 in patients with type 1 diabetes to the T1D Exchange by emailing [email protected].

And in fact, Ebekozien also requested that clinicians with a large type 1 diabetes population also report if they’ve had no COVID-19 cases.

“Even if they haven’t had a case, that’s very useful information for us to know. One of the things we want to calculate down the line is the incidence ratio. Not all participating sites have had a case.”

Endocrinologists from all the participating sites have formed a dedicated community that meets regularly via webinars to share information, he noted. “It’s been a very selfless effort to work collaboratively as a community to quickly answer critical questions.”

The Helmsley Charitable Trust funds the T1D Exchange Quality Improvement Collaborative. The T1D Exchange received financial support for this study from Abbott Diabetes, Dexcom, JDRF, Insulet Corporation, Lilly, Medtronic, and Tandem Diabetes Care. No other relevant financial relationships were reported.
 

This article first appeared on Medscape.com.

New preliminary data from the T1D Exchange suggest that, although hyperglycemia and diabetic ketoacidosis (DKA) are common in people with type 1 diabetes who develop COVID-19, many are still able to manage the illness at home and overall mortality is relatively low.

The new findings – the first US data on individuals with type 1 diabetes and COVID-19 – were published online June 5 in Diabetes Care by Osagie A. Ebekozien, MD, vice president, quality improvement and population health at the T1D Exchange, and colleagues.

Two UK studies are the only prior ones to previously examine the topic.

The newly published study includes data as of May 5 on 64 individuals from a total of 64 US sites, including 15 T1D Exchange member clinics and an additional 49 endocrinology clinics from around the country. Since the paper was submitted, there are now 220 patients from 68 sites. Another publication with a more detailed analysis of risk factors and adjustment for confounders is planned for later this year.

Some of the findings from the preliminary data have shifted, but many aspects remain consistent, Ebekozien told Medscape Medical News.

“One thing still very true, even with the unpublished findings, is the influence of A1c and glycemic management. ...With higher A1c levels, we’re seeing more COVID-19 hospitalizations and worse outcomes,” he said.

And as has been generally reported for COVID-19, high body mass index was a major risk factor in the preliminary dataset – and remains so.

There were two deaths in the preliminary report, both individuals with comorbidities in addition to type 1 diabetes, Ebekozien said. There have been a few more deaths in the larger dataset, but the mortality rate remains relatively low.

Interestingly, females predominate in both cohorts. That may be a reporting phenomenon, another factor that is being analyzed.

Hyperglycemia Remains a Major Risk Factor

The study is specifically being conducted by the T1D Exchange’s Quality Improvement Collaborative, which Ebekozien heads.

Data were obtained for 33 patients with type 1 diabetes who tested positive for COVID-19, and another 31 who were classified as “COVID-19–like” because they had symptoms consistent with COVID-19, as identified by the Centers for Disease Control and Prevention, but hadn’t been tested for the virus.

For all 64 patients, the mean age was 20.9 years and two thirds (65.6%) were aged 18 or younger. A higher proportion of the COVID-19–like patients were pediatric than the confirmed cases. The larger dataset includes more adult patients, Ebekozien told Medscape Medical News.

Overall, 60.9% of patients were female. Nearly half were white, a quarter Hispanic, and 18.8% black. More confirmed COVID-19 cases were black compared with suspected cases (30.3% vs 6.5%).

Median A1c for the overall group (including suspected COVID-19 cases) was 8.0%, but it was 8.5% among confirmed cases. Overall, six patients (9.8%) presented with new-onset type 1 diabetes after they developed COVID-19.

Hyperglycemia was present in half (32) of patients overall. DKA occurred in 19 people (30.2%): 15 of the confirmed COVID-19 cases (45.5%) versus just 4 (13.3%) of the COVID-19–like cases. Nausea was reported in 30.2% of patients overall.

Other symptoms were typical of COVID-19, including fever (41.3%), dry cough (38.1%), and shortness of breath (27.0%). Loss of taste and smell was less common, at just 9.5% overall.

Obesity was present in 39.7% of patients overall, with similar proportions in the confirmed and suspected COVID-19 groups. Hypertension and/or cardiovascular disease were present in 14.3% of patients overall, and the rate was similar between the two subgroups.

One of the two patients who died was a 79-year-old man who had hypertension and a prior stroke in addition to type 1 diabetes. The other was a 19-year-old woman with a history of asthma who developed a pulmonary embolism during the onset of COVID-19. Neither had DKA.

Even in Type 1 Diabetes, COVID-19 Can Be Managed at Home

Overall, 34.9% of patients were able to manage COVID-19 entirely at home, with 27.3% of the confirmed and 43.3% of the suspected cases able to do so.

At the other extreme, 22.2% of patients overall were admitted to the intensive care unit; 30.3% of the confirmed versus 13.3% of suspected cases.

Including the small proportion of patients sent home after being seen in emergency or urgent care, overall roughly half were not admitted to hospital.

“Interestingly, even in this preliminary study, half were managed at home via telemedicine with an endocrinologist and infectious disease specialist. ... I think it continues to be a case-by-case clinical decision between the patient and their provider,” Ebekozien said.

“But, we’re seeing a good number of patients who are managed at home and the symptoms resolve in a week or two, and the illness runs its course, and they don’t have to even be seen,” he added.

The research team is also collecting data on barriers to remote care, including challenges with telemedicine and how frontline providers are navigating them.

“Those are all things that our future paper will be able to shed more light on,” he explained.

Endocrinologists around the country are invited to report cases of COVID-19 in patients with type 1 diabetes to the T1D Exchange by emailing [email protected].

And in fact, Ebekozien also requested that clinicians with a large type 1 diabetes population also report if they’ve had no COVID-19 cases.

“Even if they haven’t had a case, that’s very useful information for us to know. One of the things we want to calculate down the line is the incidence ratio. Not all participating sites have had a case.”

Endocrinologists from all the participating sites have formed a dedicated community that meets regularly via webinars to share information, he noted. “It’s been a very selfless effort to work collaboratively as a community to quickly answer critical questions.”

The Helmsley Charitable Trust funds the T1D Exchange Quality Improvement Collaborative. The T1D Exchange received financial support for this study from Abbott Diabetes, Dexcom, JDRF, Insulet Corporation, Lilly, Medtronic, and Tandem Diabetes Care. No other relevant financial relationships were reported.
 

This article first appeared on Medscape.com.

New preliminary data from the T1D Exchange suggest that, although hyperglycemia and diabetic ketoacidosis (DKA) are common in people with type 1 diabetes who develop COVID-19, many are still able to manage the illness at home and overall mortality is relatively low.

The new findings – the first US data on individuals with type 1 diabetes and COVID-19 – were published online June 5 in Diabetes Care by Osagie A. Ebekozien, MD, vice president, quality improvement and population health at the T1D Exchange, and colleagues.

Two UK studies are the only prior ones to previously examine the topic.

The newly published study includes data as of May 5 on 64 individuals from a total of 64 US sites, including 15 T1D Exchange member clinics and an additional 49 endocrinology clinics from around the country. Since the paper was submitted, there are now 220 patients from 68 sites. Another publication with a more detailed analysis of risk factors and adjustment for confounders is planned for later this year.

Some of the findings from the preliminary data have shifted, but many aspects remain consistent, Ebekozien told Medscape Medical News.

“One thing still very true, even with the unpublished findings, is the influence of A1c and glycemic management. ...With higher A1c levels, we’re seeing more COVID-19 hospitalizations and worse outcomes,” he said.

And as has been generally reported for COVID-19, high body mass index was a major risk factor in the preliminary dataset – and remains so.

There were two deaths in the preliminary report, both individuals with comorbidities in addition to type 1 diabetes, Ebekozien said. There have been a few more deaths in the larger dataset, but the mortality rate remains relatively low.

Interestingly, females predominate in both cohorts. That may be a reporting phenomenon, another factor that is being analyzed.

Hyperglycemia Remains a Major Risk Factor

The study is specifically being conducted by the T1D Exchange’s Quality Improvement Collaborative, which Ebekozien heads.

Data were obtained for 33 patients with type 1 diabetes who tested positive for COVID-19, and another 31 who were classified as “COVID-19–like” because they had symptoms consistent with COVID-19, as identified by the Centers for Disease Control and Prevention, but hadn’t been tested for the virus.

For all 64 patients, the mean age was 20.9 years and two thirds (65.6%) were aged 18 or younger. A higher proportion of the COVID-19–like patients were pediatric than the confirmed cases. The larger dataset includes more adult patients, Ebekozien told Medscape Medical News.

Overall, 60.9% of patients were female. Nearly half were white, a quarter Hispanic, and 18.8% black. More confirmed COVID-19 cases were black compared with suspected cases (30.3% vs 6.5%).

Median A1c for the overall group (including suspected COVID-19 cases) was 8.0%, but it was 8.5% among confirmed cases. Overall, six patients (9.8%) presented with new-onset type 1 diabetes after they developed COVID-19.

Hyperglycemia was present in half (32) of patients overall. DKA occurred in 19 people (30.2%): 15 of the confirmed COVID-19 cases (45.5%) versus just 4 (13.3%) of the COVID-19–like cases. Nausea was reported in 30.2% of patients overall.

Other symptoms were typical of COVID-19, including fever (41.3%), dry cough (38.1%), and shortness of breath (27.0%). Loss of taste and smell was less common, at just 9.5% overall.

Obesity was present in 39.7% of patients overall, with similar proportions in the confirmed and suspected COVID-19 groups. Hypertension and/or cardiovascular disease were present in 14.3% of patients overall, and the rate was similar between the two subgroups.

One of the two patients who died was a 79-year-old man who had hypertension and a prior stroke in addition to type 1 diabetes. The other was a 19-year-old woman with a history of asthma who developed a pulmonary embolism during the onset of COVID-19. Neither had DKA.

Even in Type 1 Diabetes, COVID-19 Can Be Managed at Home

Overall, 34.9% of patients were able to manage COVID-19 entirely at home, with 27.3% of the confirmed and 43.3% of the suspected cases able to do so.

At the other extreme, 22.2% of patients overall were admitted to the intensive care unit; 30.3% of the confirmed versus 13.3% of suspected cases.

Including the small proportion of patients sent home after being seen in emergency or urgent care, overall roughly half were not admitted to hospital.

“Interestingly, even in this preliminary study, half were managed at home via telemedicine with an endocrinologist and infectious disease specialist. ... I think it continues to be a case-by-case clinical decision between the patient and their provider,” Ebekozien said.

“But, we’re seeing a good number of patients who are managed at home and the symptoms resolve in a week or two, and the illness runs its course, and they don’t have to even be seen,” he added.

The research team is also collecting data on barriers to remote care, including challenges with telemedicine and how frontline providers are navigating them.

“Those are all things that our future paper will be able to shed more light on,” he explained.

Endocrinologists around the country are invited to report cases of COVID-19 in patients with type 1 diabetes to the T1D Exchange by emailing [email protected].

And in fact, Ebekozien also requested that clinicians with a large type 1 diabetes population also report if they’ve had no COVID-19 cases.

“Even if they haven’t had a case, that’s very useful information for us to know. One of the things we want to calculate down the line is the incidence ratio. Not all participating sites have had a case.”

Endocrinologists from all the participating sites have formed a dedicated community that meets regularly via webinars to share information, he noted. “It’s been a very selfless effort to work collaboratively as a community to quickly answer critical questions.”

The Helmsley Charitable Trust funds the T1D Exchange Quality Improvement Collaborative. The T1D Exchange received financial support for this study from Abbott Diabetes, Dexcom, JDRF, Insulet Corporation, Lilly, Medtronic, and Tandem Diabetes Care. No other relevant financial relationships were reported.
 

This article first appeared on Medscape.com.

On first glance, the age-adjusted rate of suicide for Asian and Pacific Islander populations living in the United States looks comparatively low.

Over the past 2 decades in the United States, for example, the overall rate increased by 35%, from, 10.5 to 14.2 per 100,000 individuals. That compares with a rate of 7.0 per 100,000 among Asian and Pacific Islander communities.¹

However, because of the aggregate nature (national suicide mortality data combine people of Asian, Native Hawaiian, and other Pacific Islander descent into a single group) in which these data are reported, a significant amount of salient information on subgroups of Asian Americans is lost.² There is a growing body of research on the mental health of Asian Americans, but the dearth of information and research on suicide in South Asians is striking.³ In fact, a review of literature finds fewer than 10 articles on the topic that have been published in peer-reviewed journals in the last decade. It is important for mental health professionals to understand the unique cultural characteristics of South Asians living in the United States to provide effective, culturally sensitive care.
 

Diverse group

There are 3.4 million individuals of South Asian descent in the United States. Geographically, South Asians may have familial and cultural/historical roots in Bangladesh, Bhutan, India, Maldives, Nepal, and Pakistan.⁴ They enjoy a rich diversity in terms of cultural and religious beliefs, language, socioeconomic status, modes of acculturation, and immigration patterns. Asian Indians are the largest group of South Asians in the United States. They are highly educated, with a larger proportion of them pursuing an undergraduate and/or graduate level education than the general population. The median household income of Asian Indians is also higher than the national average.⁵

In general, suicide, like all mental health issues, is a stigmatized and taboo topic in the South Asian community.⁶ Also, South Asian Americans are hesitant to seek mental health care because of a perceived inability of Western health care professionals to understand their cultural views. Extrapolation from data on South Asians in the United Kingdom, aggregate statistics for Asian Americans and Pacific Islanders, and studies on South Asians in the United States highlight two South Asian subgroups that are particularly vulnerable to suicide. These are young adults (aged 18-24 years) and women.⁷

Suicide is the second-leading cause of death for young Asian American men in the United States. Rates of lifetime suicidal ideation and attempts are higher among younger Asian Americans (aged 18-24 years) than among older Asian American adults. Young Asian American adults have been found to have higher levels of suicidal ideation than their white counterparts.^8,9 Acculturation or assimilating into a different culture, familial violence as a child, hopelessness or a thought pattern with a pessimistic outlook, depression, and childhood sexual abuse have all been found to be positively correlated with suicidal ideation and attempted suicide in South Asian Americans. One study that conducted0 in-group analysis on undergraduate university students of South Asian descent living in New York found higher levels of hopelessness and depression in Asian Indians relative to Bangladeshi or Pakistani Americans.¹⁰

In addition, higher levels of suicidal ideation are reported in Asian Indians relative to Bangladeshi or Pakistani Americans. These results resemble findings from similar studies in the United Kingdom. A posited reason for these findings is a difference in religious beliefs. Pakistani and Bangladeshi Americans are predominantly Muslim, have stronger moral beliefs against suicide, and consider it a sin as defined by Islamic beliefs. Asian Indians, in contrast, are majority Hindu and believe in reincarnation – a context that might make suicide seem more permissible.¹¹

South Asian women are particularly vulnerable to domestic violence, childhood sexual abuse, intimate partner violence, and/or familial violence. Cultural gender norms, traditional norms, and patriarchal ideology in the South Asian community make quantifying the level of childhood sexual abuse and familial violence a challenge. Furthermore, culturally, South Asian women are often considered subordinate relative to men, and discussion around family violence and childhood sexual abuse is avoided. Studies from the United Kingdom find a lack of knowledge around, disclosure of, and fear of reporting childhood sexual abuse in South Asian women. A study of a sample of representative South Asian American women found that 25.2% had experienced some form of childhood sexual abuse.¹²

Research also suggests that South Asians in the United States have some of the highest rates of intimate partner violence. Another study in the United States found that two out of five South Asian women have experienced physical and/or sexual intimate partner violence. This is much higher than the rate found in representative general U.S. population samples.

Literature suggests that exposure to these factors increases womens’ risk for suicidal ideation and attempted suicide. In the United Kingdom, research on South Asian women (aged 18-24 years) has found rates of attempted suicide to be three times higher than those of their white counterparts. Research from the United Kingdom and the United States suggests that younger married South Asian women are exposed to emotional and/or physical abuse from their spouse or in-laws, which is often a mediating factor in their increased risk for suicide.

Attempts to address suicide in the South Asian American community have to be multifaceted. An ideal approach would consist of educating, and connecting with, the community through ethnic media and trusted community sources, such as primary care doctors, caregivers, and social workers. In line with established American Psychological Association guidelines on caring for individuals of immigrant origin, health care professionals should document the patient’s number of generations in the country, number of years in the country, language fluency, family and community support, educational level, social status changes related to immigration, intimate relationships with people of different backgrounds, and stress related to acculturation. Special attention should be paid to South Asian women. Health care professionals should screen South Asian women for past and current intimate partner violence, provide culturally appropriate intimate partner violence resources, and be prepared to refer them to legal counseling services. Also, South Asian women should be screened for a history of exposure to familial violence and childhood sexual abuse.¹

To adequately serve this population, there is a need to build capacity in the provision of culturally appropriate mental health services. Access to mental health care professionals through settings such as shelters for abused women, South Asian community–based organizations, youth centers, college counseling, and senior centers would encourage individuals to seek care without the threat of being stigmatized.
 

References

1. Hedegaard H et al. Suicide mortality in the United States, 1999–2017. NCHS Data Brief, No. 330. 2018 Nov.

2. Ahmad-Stout DJ and Nath SR. J College Stud Psychother. 2013 Jan 10;27(1):43-61.

3. Li H and Keshavan M. Asian J Psychiatry. 2011;4(1):1.

4. Nagaraj NC et al. J Immigr Minor Health. 2019 Oct;21(5):978-1003.

5. Nagaraj NC et al. J Comm Health. 2018;43(3):543-51.

6. Cao KO. Generations. 2014;30(4):82-5.

7. Hurwitz EJ et al. J Immigr Minor Health. 2006;8(3):251-61.

8. Polanco-Roman L et al. Cultur Divers Ethnic Minor Psychol. 2019 Dec 23. doi: 10.1037/cpd0000313.

9. Erausquin JT et al. J Youth Adolesc. 2019 Sep;48(9):1796-1805.

10. Lane R et al. Asian Am J Psychol. 2016;7(2):120-8.

11. Nath SR et al. Asian Am J Psychol. 2018;9(4):334-343.

12. Robertson HA et al. J Immigr Minor Health. 2016 Jul 31;18(4):921-7.
 

Mr. Kaleka is a medical student in the class of 2021 at Central Michigan University (CMU) College of Medicine, Mt. Pleasant. He has no disclosures. Mr. Kaleka would like to thank his mentor, Furhut Janssen, DO, for her continued guidance and support in research on mental health in immigrant populations.

On first glance, the age-adjusted rate of suicide for Asian and Pacific Islander populations living in the United States looks comparatively low.

Over the past 2 decades in the United States, for example, the overall rate increased by 35%, from, 10.5 to 14.2 per 100,000 individuals. That compares with a rate of 7.0 per 100,000 among Asian and Pacific Islander communities.¹

However, because of the aggregate nature (national suicide mortality data combine people of Asian, Native Hawaiian, and other Pacific Islander descent into a single group) in which these data are reported, a significant amount of salient information on subgroups of Asian Americans is lost.² There is a growing body of research on the mental health of Asian Americans, but the dearth of information and research on suicide in South Asians is striking.³ In fact, a review of literature finds fewer than 10 articles on the topic that have been published in peer-reviewed journals in the last decade. It is important for mental health professionals to understand the unique cultural characteristics of South Asians living in the United States to provide effective, culturally sensitive care.
 

Diverse group

There are 3.4 million individuals of South Asian descent in the United States. Geographically, South Asians may have familial and cultural/historical roots in Bangladesh, Bhutan, India, Maldives, Nepal, and Pakistan.⁴ They enjoy a rich diversity in terms of cultural and religious beliefs, language, socioeconomic status, modes of acculturation, and immigration patterns. Asian Indians are the largest group of South Asians in the United States. They are highly educated, with a larger proportion of them pursuing an undergraduate and/or graduate level education than the general population. The median household income of Asian Indians is also higher than the national average.⁵

In general, suicide, like all mental health issues, is a stigmatized and taboo topic in the South Asian community.⁶ Also, South Asian Americans are hesitant to seek mental health care because of a perceived inability of Western health care professionals to understand their cultural views. Extrapolation from data on South Asians in the United Kingdom, aggregate statistics for Asian Americans and Pacific Islanders, and studies on South Asians in the United States highlight two South Asian subgroups that are particularly vulnerable to suicide. These are young adults (aged 18-24 years) and women.⁷

Suicide is the second-leading cause of death for young Asian American men in the United States. Rates of lifetime suicidal ideation and attempts are higher among younger Asian Americans (aged 18-24 years) than among older Asian American adults. Young Asian American adults have been found to have higher levels of suicidal ideation than their white counterparts.^8,9 Acculturation or assimilating into a different culture, familial violence as a child, hopelessness or a thought pattern with a pessimistic outlook, depression, and childhood sexual abuse have all been found to be positively correlated with suicidal ideation and attempted suicide in South Asian Americans. One study that conducted0 in-group analysis on undergraduate university students of South Asian descent living in New York found higher levels of hopelessness and depression in Asian Indians relative to Bangladeshi or Pakistani Americans.¹⁰

In addition, higher levels of suicidal ideation are reported in Asian Indians relative to Bangladeshi or Pakistani Americans. These results resemble findings from similar studies in the United Kingdom. A posited reason for these findings is a difference in religious beliefs. Pakistani and Bangladeshi Americans are predominantly Muslim, have stronger moral beliefs against suicide, and consider it a sin as defined by Islamic beliefs. Asian Indians, in contrast, are majority Hindu and believe in reincarnation – a context that might make suicide seem more permissible.¹¹

South Asian women are particularly vulnerable to domestic violence, childhood sexual abuse, intimate partner violence, and/or familial violence. Cultural gender norms, traditional norms, and patriarchal ideology in the South Asian community make quantifying the level of childhood sexual abuse and familial violence a challenge. Furthermore, culturally, South Asian women are often considered subordinate relative to men, and discussion around family violence and childhood sexual abuse is avoided. Studies from the United Kingdom find a lack of knowledge around, disclosure of, and fear of reporting childhood sexual abuse in South Asian women. A study of a sample of representative South Asian American women found that 25.2% had experienced some form of childhood sexual abuse.¹²

Research also suggests that South Asians in the United States have some of the highest rates of intimate partner violence. Another study in the United States found that two out of five South Asian women have experienced physical and/or sexual intimate partner violence. This is much higher than the rate found in representative general U.S. population samples.

Literature suggests that exposure to these factors increases womens’ risk for suicidal ideation and attempted suicide. In the United Kingdom, research on South Asian women (aged 18-24 years) has found rates of attempted suicide to be three times higher than those of their white counterparts. Research from the United Kingdom and the United States suggests that younger married South Asian women are exposed to emotional and/or physical abuse from their spouse or in-laws, which is often a mediating factor in their increased risk for suicide.

Attempts to address suicide in the South Asian American community have to be multifaceted. An ideal approach would consist of educating, and connecting with, the community through ethnic media and trusted community sources, such as primary care doctors, caregivers, and social workers. In line with established American Psychological Association guidelines on caring for individuals of immigrant origin, health care professionals should document the patient’s number of generations in the country, number of years in the country, language fluency, family and community support, educational level, social status changes related to immigration, intimate relationships with people of different backgrounds, and stress related to acculturation. Special attention should be paid to South Asian women. Health care professionals should screen South Asian women for past and current intimate partner violence, provide culturally appropriate intimate partner violence resources, and be prepared to refer them to legal counseling services. Also, South Asian women should be screened for a history of exposure to familial violence and childhood sexual abuse.¹

To adequately serve this population, there is a need to build capacity in the provision of culturally appropriate mental health services. Access to mental health care professionals through settings such as shelters for abused women, South Asian community–based organizations, youth centers, college counseling, and senior centers would encourage individuals to seek care without the threat of being stigmatized.
 

References

1. Hedegaard H et al. Suicide mortality in the United States, 1999–2017. NCHS Data Brief, No. 330. 2018 Nov.

2. Ahmad-Stout DJ and Nath SR. J College Stud Psychother. 2013 Jan 10;27(1):43-61.

3. Li H and Keshavan M. Asian J Psychiatry. 2011;4(1):1.

4. Nagaraj NC et al. J Immigr Minor Health. 2019 Oct;21(5):978-1003.

5. Nagaraj NC et al. J Comm Health. 2018;43(3):543-51.

6. Cao KO. Generations. 2014;30(4):82-5.

7. Hurwitz EJ et al. J Immigr Minor Health. 2006;8(3):251-61.

8. Polanco-Roman L et al. Cultur Divers Ethnic Minor Psychol. 2019 Dec 23. doi: 10.1037/cpd0000313.

9. Erausquin JT et al. J Youth Adolesc. 2019 Sep;48(9):1796-1805.

10. Lane R et al. Asian Am J Psychol. 2016;7(2):120-8.

11. Nath SR et al. Asian Am J Psychol. 2018;9(4):334-343.

12. Robertson HA et al. J Immigr Minor Health. 2016 Jul 31;18(4):921-7.
 

Mr. Kaleka is a medical student in the class of 2021 at Central Michigan University (CMU) College of Medicine, Mt. Pleasant. He has no disclosures. Mr. Kaleka would like to thank his mentor, Furhut Janssen, DO, for her continued guidance and support in research on mental health in immigrant populations.

On first glance, the age-adjusted rate of suicide for Asian and Pacific Islander populations living in the United States looks comparatively low.

Over the past 2 decades in the United States, for example, the overall rate increased by 35%, from, 10.5 to 14.2 per 100,000 individuals. That compares with a rate of 7.0 per 100,000 among Asian and Pacific Islander communities.¹

However, because of the aggregate nature (national suicide mortality data combine people of Asian, Native Hawaiian, and other Pacific Islander descent into a single group) in which these data are reported, a significant amount of salient information on subgroups of Asian Americans is lost.² There is a growing body of research on the mental health of Asian Americans, but the dearth of information and research on suicide in South Asians is striking.³ In fact, a review of literature finds fewer than 10 articles on the topic that have been published in peer-reviewed journals in the last decade. It is important for mental health professionals to understand the unique cultural characteristics of South Asians living in the United States to provide effective, culturally sensitive care.
 

Diverse group

There are 3.4 million individuals of South Asian descent in the United States. Geographically, South Asians may have familial and cultural/historical roots in Bangladesh, Bhutan, India, Maldives, Nepal, and Pakistan.⁴ They enjoy a rich diversity in terms of cultural and religious beliefs, language, socioeconomic status, modes of acculturation, and immigration patterns. Asian Indians are the largest group of South Asians in the United States. They are highly educated, with a larger proportion of them pursuing an undergraduate and/or graduate level education than the general population. The median household income of Asian Indians is also higher than the national average.⁵

In general, suicide, like all mental health issues, is a stigmatized and taboo topic in the South Asian community.⁶ Also, South Asian Americans are hesitant to seek mental health care because of a perceived inability of Western health care professionals to understand their cultural views. Extrapolation from data on South Asians in the United Kingdom, aggregate statistics for Asian Americans and Pacific Islanders, and studies on South Asians in the United States highlight two South Asian subgroups that are particularly vulnerable to suicide. These are young adults (aged 18-24 years) and women.⁷

Suicide is the second-leading cause of death for young Asian American men in the United States. Rates of lifetime suicidal ideation and attempts are higher among younger Asian Americans (aged 18-24 years) than among older Asian American adults. Young Asian American adults have been found to have higher levels of suicidal ideation than their white counterparts.^8,9 Acculturation or assimilating into a different culture, familial violence as a child, hopelessness or a thought pattern with a pessimistic outlook, depression, and childhood sexual abuse have all been found to be positively correlated with suicidal ideation and attempted suicide in South Asian Americans. One study that conducted0 in-group analysis on undergraduate university students of South Asian descent living in New York found higher levels of hopelessness and depression in Asian Indians relative to Bangladeshi or Pakistani Americans.¹⁰

In addition, higher levels of suicidal ideation are reported in Asian Indians relative to Bangladeshi or Pakistani Americans. These results resemble findings from similar studies in the United Kingdom. A posited reason for these findings is a difference in religious beliefs. Pakistani and Bangladeshi Americans are predominantly Muslim, have stronger moral beliefs against suicide, and consider it a sin as defined by Islamic beliefs. Asian Indians, in contrast, are majority Hindu and believe in reincarnation – a context that might make suicide seem more permissible.¹¹

South Asian women are particularly vulnerable to domestic violence, childhood sexual abuse, intimate partner violence, and/or familial violence. Cultural gender norms, traditional norms, and patriarchal ideology in the South Asian community make quantifying the level of childhood sexual abuse and familial violence a challenge. Furthermore, culturally, South Asian women are often considered subordinate relative to men, and discussion around family violence and childhood sexual abuse is avoided. Studies from the United Kingdom find a lack of knowledge around, disclosure of, and fear of reporting childhood sexual abuse in South Asian women. A study of a sample of representative South Asian American women found that 25.2% had experienced some form of childhood sexual abuse.¹²

Research also suggests that South Asians in the United States have some of the highest rates of intimate partner violence. Another study in the United States found that two out of five South Asian women have experienced physical and/or sexual intimate partner violence. This is much higher than the rate found in representative general U.S. population samples.

Literature suggests that exposure to these factors increases womens’ risk for suicidal ideation and attempted suicide. In the United Kingdom, research on South Asian women (aged 18-24 years) has found rates of attempted suicide to be three times higher than those of their white counterparts. Research from the United Kingdom and the United States suggests that younger married South Asian women are exposed to emotional and/or physical abuse from their spouse or in-laws, which is often a mediating factor in their increased risk for suicide.

Attempts to address suicide in the South Asian American community have to be multifaceted. An ideal approach would consist of educating, and connecting with, the community through ethnic media and trusted community sources, such as primary care doctors, caregivers, and social workers. In line with established American Psychological Association guidelines on caring for individuals of immigrant origin, health care professionals should document the patient’s number of generations in the country, number of years in the country, language fluency, family and community support, educational level, social status changes related to immigration, intimate relationships with people of different backgrounds, and stress related to acculturation. Special attention should be paid to South Asian women. Health care professionals should screen South Asian women for past and current intimate partner violence, provide culturally appropriate intimate partner violence resources, and be prepared to refer them to legal counseling services. Also, South Asian women should be screened for a history of exposure to familial violence and childhood sexual abuse.¹

To adequately serve this population, there is a need to build capacity in the provision of culturally appropriate mental health services. Access to mental health care professionals through settings such as shelters for abused women, South Asian community–based organizations, youth centers, college counseling, and senior centers would encourage individuals to seek care without the threat of being stigmatized.
 

References

1. Hedegaard H et al. Suicide mortality in the United States, 1999–2017. NCHS Data Brief, No. 330. 2018 Nov.

2. Ahmad-Stout DJ and Nath SR. J College Stud Psychother. 2013 Jan 10;27(1):43-61.

3. Li H and Keshavan M. Asian J Psychiatry. 2011;4(1):1.

4. Nagaraj NC et al. J Immigr Minor Health. 2019 Oct;21(5):978-1003.

5. Nagaraj NC et al. J Comm Health. 2018;43(3):543-51.

6. Cao KO. Generations. 2014;30(4):82-5.

7. Hurwitz EJ et al. J Immigr Minor Health. 2006;8(3):251-61.

8. Polanco-Roman L et al. Cultur Divers Ethnic Minor Psychol. 2019 Dec 23. doi: 10.1037/cpd0000313.

9. Erausquin JT et al. J Youth Adolesc. 2019 Sep;48(9):1796-1805.

10. Lane R et al. Asian Am J Psychol. 2016;7(2):120-8.

11. Nath SR et al. Asian Am J Psychol. 2018;9(4):334-343.

12. Robertson HA et al. J Immigr Minor Health. 2016 Jul 31;18(4):921-7.
 

Mr. Kaleka is a medical student in the class of 2021 at Central Michigan University (CMU) College of Medicine, Mt. Pleasant. He has no disclosures. Mr. Kaleka would like to thank his mentor, Furhut Janssen, DO, for her continued guidance and support in research on mental health in immigrant populations.

Amid clouds of choking tear gas, booming flash-bang grenades and other “riot control agents,” volunteer medics plunged into street protests over the past weeks to help the injured – sometimes rushing to the front lines as soon as their hospital shifts ended.

Known as “street medics,” these unorthodox teams of nursing students, veterinarians, doctors, trauma surgeons, security guards, ski patrollers, nurses, wilderness EMTs, and off-the-clock ambulance workers poured water – not milk – into the eyes of tear-gassed protesters. They stanched bleeding wounds and plucked disoriented teenagers from clouds of gas, entering dangerous corners where on-duty emergency health responders may fear to go.

Many are medical professionals who see parallels between the front lines of COVID-19, where they confront stark racial imbalances among those stricken by the coronavirus, and what they see as racialized police brutality.

So donning cloth masks to protect against the virus – plus helmets, makeshift shields and other gear to guard against rubber bullets, projectiles and tear gas – the volunteer medics organized themselves into a web of first responders to care for people on the streets. They showed up early, set up first-aid stations, established transportation networks and covered their arms, helmets and backpacks with crosses made of red duct tape, to signify that they were medics. Some stayed late into the night past curfews until every protester had left.

Iris Butler, a 21-year-old certified nursing assistant who works in a nursing home, decided to offer her skills after seeing a man injured by a rubber bullet on her first night at the Denver protests. She showed up as a medic every night thereafter. She didn’t see it as a choice.

“I am working full time and basically being at the protest after getting straight off of work,” said Butler, who is black. That’s tiring, she added, but so is being a black woman in America.

After going out as a medic on her own, she soon met other volunteers. Together they used text-message chains to organize their efforts. One night, she responded to a man who had been shot with a rubber bullet in the chest; she said his torso had turned blue and purple from the impact. She also provided aid after a shooting near the protest left someone in critical condition.

“It’s hard, but bills need to be paid and justice needs to be served,” she said.

The street medic movement traces its roots, in part, to the 1960s protests, as well as the American Indian Movement and the Black Panther Party. Denver Action Medic Network offers a 20-hour training course that prepares them to treat patients in conflicts with police and large crowds; a four-hour session is offered to medical professionals as “bridge” training.

Since the coronavirus pandemic began, the Denver Action Medic Network has added new training guidelines: Don’t go to protests if sick or in contact with those who are infected; wear a mask; give people lots of space and use hand sanitizer. Jordan Garcia, a 39-year-old medic for over 20 years who works with the network of veteran street medics, said they also warn medics about the increased risk of transmission because of protesters coughing from tear gas, and urge them to get tested for the virus after the protests.

The number of volunteer medics swelled after George Floyd’s May 25 killing in Minneapolis. In Denver alone, at least 40 people reached out to the Denver Action Medic Network for training.

On June 3, Dr. Rupa Marya, an associate professor of medicine at the University of California,San Francisco, and the co-founder of the Do No Harm Coalition, which runs street medic training in the Bay Area, hosted a national webinar attended by over 3,000 medical professionals to provide the bridge training to be a street medic. In her online bio, Marya describes the coalition as “an organization of over 450 health workers committed to structural change” in addressing health problems.

“When we see suffering, that’s where we go,” Marya said. “And right now that suffering is happening on the streets.”

In the recent Denver protests, street medics responded to major head, face and eye injuries among protesters from what are sometimes described as “kinetic impact projectiles” or “less-than-lethal” bullets shot at protesters, along with tear-gas and flash-bang stun grenade canisters that either hit them or exploded in their faces.

Garcia, who by day works for an immigrant rights nonprofit, said that these weapons are not designed to be shot directly at people.

“We’re seeing police use these less-lethal weapons in lethal ways, and that is pretty upsetting,” Garcia said about the recent protests.

Denver police Chief Paul Pazen promised to make changes, including banning chokeholds and requiring SWAT teams to turn on their body cameras. Last week, a federal judge also issued a temporary injunction to stop Denver police from using tear gas and other less-than-lethal weapons in response to a class action lawsuit, in which a medic stated he was shot multiple times by police with pepper balls while treating patients. (Last week in North Carolina police were recorded destroying medic stations.)

Denver street medic Kevin Connell, a 30-year-old emergency room nurse, said he was hit with pepper balls in the back of his medic vest – which was clearly marked by red crosses – while treating a patient. He showed up to the Denver protests every night he did not have to work, he said, wearing a Kevlar medic vest, protective goggles and a homemade gas mask fashioned from a water bottle. As a member of the Denver Action Medic Network, Connell also served at the Standing Rock protests in North Dakota in a dispute over the building of the Dakota Access Pipeline.

“I mean, as bad as it sounds, it was only tear gas, pepper balls and rubber bullets that were being fired on us,” Connell said of his recent experience in Denver. “When I was at Standing Rock, they were using high-powered water hoses even when it was, like, freezing cold. … So I think the police here had a little bit more restraint.”

Still, first-time street medic Aj Mossman, a 31-year-old Denver emergency medical technician studying for nursing school, was shocked to be tear-gassed and struck in the back of the leg with a flash grenade while treating a protester on May 30. Mossman still has a large leg bruise.

The following night, Mossman, who uses the pronoun they, brought more protective gear, but said they are still having difficulty processing what felt like a war zone.

“I thought I understood what my black friends went through. I thought I understood what the black community went through,” said Mossman, who is white. “But I had absolutely no idea how violent the police were and how little they cared about who they hurt.”

For Butler, serving as a medic with others from various walks of life was inspiring. “They’re also out there to protect black and brown bodies. And that’s amazing,” she said. “That’s just a beautiful sight.”

This article originally appeared on Kaiser Health News, which is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

Amid clouds of choking tear gas, booming flash-bang grenades and other “riot control agents,” volunteer medics plunged into street protests over the past weeks to help the injured – sometimes rushing to the front lines as soon as their hospital shifts ended.

Known as “street medics,” these unorthodox teams of nursing students, veterinarians, doctors, trauma surgeons, security guards, ski patrollers, nurses, wilderness EMTs, and off-the-clock ambulance workers poured water – not milk – into the eyes of tear-gassed protesters. They stanched bleeding wounds and plucked disoriented teenagers from clouds of gas, entering dangerous corners where on-duty emergency health responders may fear to go.

Many are medical professionals who see parallels between the front lines of COVID-19, where they confront stark racial imbalances among those stricken by the coronavirus, and what they see as racialized police brutality.

So donning cloth masks to protect against the virus – plus helmets, makeshift shields and other gear to guard against rubber bullets, projectiles and tear gas – the volunteer medics organized themselves into a web of first responders to care for people on the streets. They showed up early, set up first-aid stations, established transportation networks and covered their arms, helmets and backpacks with crosses made of red duct tape, to signify that they were medics. Some stayed late into the night past curfews until every protester had left.

Iris Butler, a 21-year-old certified nursing assistant who works in a nursing home, decided to offer her skills after seeing a man injured by a rubber bullet on her first night at the Denver protests. She showed up as a medic every night thereafter. She didn’t see it as a choice.

“I am working full time and basically being at the protest after getting straight off of work,” said Butler, who is black. That’s tiring, she added, but so is being a black woman in America.

After going out as a medic on her own, she soon met other volunteers. Together they used text-message chains to organize their efforts. One night, she responded to a man who had been shot with a rubber bullet in the chest; she said his torso had turned blue and purple from the impact. She also provided aid after a shooting near the protest left someone in critical condition.

“It’s hard, but bills need to be paid and justice needs to be served,” she said.

The street medic movement traces its roots, in part, to the 1960s protests, as well as the American Indian Movement and the Black Panther Party. Denver Action Medic Network offers a 20-hour training course that prepares them to treat patients in conflicts with police and large crowds; a four-hour session is offered to medical professionals as “bridge” training.

Since the coronavirus pandemic began, the Denver Action Medic Network has added new training guidelines: Don’t go to protests if sick or in contact with those who are infected; wear a mask; give people lots of space and use hand sanitizer. Jordan Garcia, a 39-year-old medic for over 20 years who works with the network of veteran street medics, said they also warn medics about the increased risk of transmission because of protesters coughing from tear gas, and urge them to get tested for the virus after the protests.

The number of volunteer medics swelled after George Floyd’s May 25 killing in Minneapolis. In Denver alone, at least 40 people reached out to the Denver Action Medic Network for training.

On June 3, Dr. Rupa Marya, an associate professor of medicine at the University of California,San Francisco, and the co-founder of the Do No Harm Coalition, which runs street medic training in the Bay Area, hosted a national webinar attended by over 3,000 medical professionals to provide the bridge training to be a street medic. In her online bio, Marya describes the coalition as “an organization of over 450 health workers committed to structural change” in addressing health problems.

“When we see suffering, that’s where we go,” Marya said. “And right now that suffering is happening on the streets.”

In the recent Denver protests, street medics responded to major head, face and eye injuries among protesters from what are sometimes described as “kinetic impact projectiles” or “less-than-lethal” bullets shot at protesters, along with tear-gas and flash-bang stun grenade canisters that either hit them or exploded in their faces.

Garcia, who by day works for an immigrant rights nonprofit, said that these weapons are not designed to be shot directly at people.

“We’re seeing police use these less-lethal weapons in lethal ways, and that is pretty upsetting,” Garcia said about the recent protests.

Denver police Chief Paul Pazen promised to make changes, including banning chokeholds and requiring SWAT teams to turn on their body cameras. Last week, a federal judge also issued a temporary injunction to stop Denver police from using tear gas and other less-than-lethal weapons in response to a class action lawsuit, in which a medic stated he was shot multiple times by police with pepper balls while treating patients. (Last week in North Carolina police were recorded destroying medic stations.)

Denver street medic Kevin Connell, a 30-year-old emergency room nurse, said he was hit with pepper balls in the back of his medic vest – which was clearly marked by red crosses – while treating a patient. He showed up to the Denver protests every night he did not have to work, he said, wearing a Kevlar medic vest, protective goggles and a homemade gas mask fashioned from a water bottle. As a member of the Denver Action Medic Network, Connell also served at the Standing Rock protests in North Dakota in a dispute over the building of the Dakota Access Pipeline.

“I mean, as bad as it sounds, it was only tear gas, pepper balls and rubber bullets that were being fired on us,” Connell said of his recent experience in Denver. “When I was at Standing Rock, they were using high-powered water hoses even when it was, like, freezing cold. … So I think the police here had a little bit more restraint.”

Still, first-time street medic Aj Mossman, a 31-year-old Denver emergency medical technician studying for nursing school, was shocked to be tear-gassed and struck in the back of the leg with a flash grenade while treating a protester on May 30. Mossman still has a large leg bruise.

The following night, Mossman, who uses the pronoun they, brought more protective gear, but said they are still having difficulty processing what felt like a war zone.

“I thought I understood what my black friends went through. I thought I understood what the black community went through,” said Mossman, who is white. “But I had absolutely no idea how violent the police were and how little they cared about who they hurt.”

For Butler, serving as a medic with others from various walks of life was inspiring. “They’re also out there to protect black and brown bodies. And that’s amazing,” she said. “That’s just a beautiful sight.”

This article originally appeared on Kaiser Health News, which is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

Amid clouds of choking tear gas, booming flash-bang grenades and other “riot control agents,” volunteer medics plunged into street protests over the past weeks to help the injured – sometimes rushing to the front lines as soon as their hospital shifts ended.

Known as “street medics,” these unorthodox teams of nursing students, veterinarians, doctors, trauma surgeons, security guards, ski patrollers, nurses, wilderness EMTs, and off-the-clock ambulance workers poured water – not milk – into the eyes of tear-gassed protesters. They stanched bleeding wounds and plucked disoriented teenagers from clouds of gas, entering dangerous corners where on-duty emergency health responders may fear to go.

Many are medical professionals who see parallels between the front lines of COVID-19, where they confront stark racial imbalances among those stricken by the coronavirus, and what they see as racialized police brutality.

So donning cloth masks to protect against the virus – plus helmets, makeshift shields and other gear to guard against rubber bullets, projectiles and tear gas – the volunteer medics organized themselves into a web of first responders to care for people on the streets. They showed up early, set up first-aid stations, established transportation networks and covered their arms, helmets and backpacks with crosses made of red duct tape, to signify that they were medics. Some stayed late into the night past curfews until every protester had left.

Iris Butler, a 21-year-old certified nursing assistant who works in a nursing home, decided to offer her skills after seeing a man injured by a rubber bullet on her first night at the Denver protests. She showed up as a medic every night thereafter. She didn’t see it as a choice.

“I am working full time and basically being at the protest after getting straight off of work,” said Butler, who is black. That’s tiring, she added, but so is being a black woman in America.

After going out as a medic on her own, she soon met other volunteers. Together they used text-message chains to organize their efforts. One night, she responded to a man who had been shot with a rubber bullet in the chest; she said his torso had turned blue and purple from the impact. She also provided aid after a shooting near the protest left someone in critical condition.

“It’s hard, but bills need to be paid and justice needs to be served,” she said.

The street medic movement traces its roots, in part, to the 1960s protests, as well as the American Indian Movement and the Black Panther Party. Denver Action Medic Network offers a 20-hour training course that prepares them to treat patients in conflicts with police and large crowds; a four-hour session is offered to medical professionals as “bridge” training.

Since the coronavirus pandemic began, the Denver Action Medic Network has added new training guidelines: Don’t go to protests if sick or in contact with those who are infected; wear a mask; give people lots of space and use hand sanitizer. Jordan Garcia, a 39-year-old medic for over 20 years who works with the network of veteran street medics, said they also warn medics about the increased risk of transmission because of protesters coughing from tear gas, and urge them to get tested for the virus after the protests.

The number of volunteer medics swelled after George Floyd’s May 25 killing in Minneapolis. In Denver alone, at least 40 people reached out to the Denver Action Medic Network for training.

On June 3, Dr. Rupa Marya, an associate professor of medicine at the University of California,San Francisco, and the co-founder of the Do No Harm Coalition, which runs street medic training in the Bay Area, hosted a national webinar attended by over 3,000 medical professionals to provide the bridge training to be a street medic. In her online bio, Marya describes the coalition as “an organization of over 450 health workers committed to structural change” in addressing health problems.

“When we see suffering, that’s where we go,” Marya said. “And right now that suffering is happening on the streets.”

In the recent Denver protests, street medics responded to major head, face and eye injuries among protesters from what are sometimes described as “kinetic impact projectiles” or “less-than-lethal” bullets shot at protesters, along with tear-gas and flash-bang stun grenade canisters that either hit them or exploded in their faces.

Garcia, who by day works for an immigrant rights nonprofit, said that these weapons are not designed to be shot directly at people.

“We’re seeing police use these less-lethal weapons in lethal ways, and that is pretty upsetting,” Garcia said about the recent protests.

Denver police Chief Paul Pazen promised to make changes, including banning chokeholds and requiring SWAT teams to turn on their body cameras. Last week, a federal judge also issued a temporary injunction to stop Denver police from using tear gas and other less-than-lethal weapons in response to a class action lawsuit, in which a medic stated he was shot multiple times by police with pepper balls while treating patients. (Last week in North Carolina police were recorded destroying medic stations.)

Denver street medic Kevin Connell, a 30-year-old emergency room nurse, said he was hit with pepper balls in the back of his medic vest – which was clearly marked by red crosses – while treating a patient. He showed up to the Denver protests every night he did not have to work, he said, wearing a Kevlar medic vest, protective goggles and a homemade gas mask fashioned from a water bottle. As a member of the Denver Action Medic Network, Connell also served at the Standing Rock protests in North Dakota in a dispute over the building of the Dakota Access Pipeline.

“I mean, as bad as it sounds, it was only tear gas, pepper balls and rubber bullets that were being fired on us,” Connell said of his recent experience in Denver. “When I was at Standing Rock, they were using high-powered water hoses even when it was, like, freezing cold. … So I think the police here had a little bit more restraint.”

Still, first-time street medic Aj Mossman, a 31-year-old Denver emergency medical technician studying for nursing school, was shocked to be tear-gassed and struck in the back of the leg with a flash grenade while treating a protester on May 30. Mossman still has a large leg bruise.

The following night, Mossman, who uses the pronoun they, brought more protective gear, but said they are still having difficulty processing what felt like a war zone.

“I thought I understood what my black friends went through. I thought I understood what the black community went through,” said Mossman, who is white. “But I had absolutely no idea how violent the police were and how little they cared about who they hurt.”

For Butler, serving as a medic with others from various walks of life was inspiring. “They’re also out there to protect black and brown bodies. And that’s amazing,” she said. “That’s just a beautiful sight.”

This article originally appeared on Kaiser Health News, which is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.