Opinion

Although it is not glamorous, snail mucus is a popular ingredient in skin care products. Its use dates back to ancient Greece, where Hippocrates reportedly applied crushed snails to treat skin inflammations.¹ The modern consideration of using snail secretions in skin care arose serendipitously in the 1990s when Chilean farmers observed accelerated healing of their skin lesions without scarring after handling snails.¹

valentinrussanov/E+

Today, snail mucin is among the increasingly wide array of bioactive ingredients undergoing scientific validation and inclusion in the burgeoning Korean cosmeceutical market.^2,3 In fact, a variety of Korean cosmeceuticals incorporate the mucus derived from Achatina fulica (African giant land snail) and Cryptomphalus (Helix) aspersa (common brown garden snail) based on their demonstrated antimicrobial and skin regenerative activity.^1,3,4 The antioxidant properties also attributed to snail mucus are thought to originate in constituents such as glycosaminoglycans, as well as growth factors, and may justify the use of these ingredients in novel cosmeceuticals.⁵ The focus of this discussion is recent research into the novel use of this animal-derived product for dermatologic purposes.
 

Antioxidant activity, skin rejuvenation, and wound healing

In 2008, Brieva et al. reported on a screen for natural products yielding a molecular basis for the secretions of the mollusk Cryptomphalus aspersa, which displays skin-regenerative activity. Specifically, they found that the secretion exerts antioxidant superoxide dismutase and glutathione S-transferase, and spurred fibroblast proliferation and extracellular matrix assembly while regulating metalloproteinase function. The researchers concluded that such activities may support wound regeneration.⁵

Four years later, Cruz et al. found that secretions of C. aspersa promote in vitro cell proliferation and migration by localizing beta-catenin to the nuclei of human fibroblasts and keratinocytes, augment phosphorylated focal adhesion kinase, and thereby enhance cell survival. The investigators concluded that snail secretions may therefore impart regenerative and wound healing activity.3,6

Antimicrobial properties

In 2015, Pitt et al. investigated the antimicrobial properties of the mucus of the brown garden snail C. or H. aspersa, which had a reputation for exhibiting skin regeneration capabilities. Their results revealed that snail mucus displayed a strong antibacterial effect against multiple strains of Pseudomonas aeruginosa and a weak effect against Staphylococcus aureus.⁴

Indications for the use of snail mucin

Radiation-induced dermatitis and burns represented the first indication for the initial use of snail mucin as a cutaneous therapy.⁷ Experimental and clinical studies have since been performed to assess its applicability to treat acute radiation dermatitis, atopic dermatitis, partial-thickness burns, and photoaging.^8-11

A 2017 in vitro investigation by Ellijimi et al. revealed that snail mucin displayed antimelanogenic and antitumoral activity against human melanoma cells, suggesting another possible application of this product.¹²

Human studies on photoaging

In a 2009 study by Tsoutsos et al. of an open, moist burn management protocol in deep partial-thickness facial burns, a cream containing H. aspersa secretions was identified to be an effective treatment option. For 14 days or until full epithelialization, 27 adult patients were treated with snail extract cream twice daily. Comparisons were made to 16 patients treated with moist exposure burn ointment. Visual analog scale pain scores were significantly lower in the group that received the H. aspersa cream, compared with the moist exposure burn group. The researchers concluded that the H. aspersa cream is a safe, effective, and natural option for treating partial-thickness burns in adults that acts by facilitating debris removal and accelerating reepithelialization.¹⁰

Also that year, Tribo-Boixareu et al. treated 15 patients with chronic photodamage with secretions of C. aspersa over a 3-month period, yielding significant amelioration in the clinical and histologic markers of photoaging.¹¹

Four years later, a double-blind, split-face, randomized, controlled clinical study conducted by Fabi et al. over 12 weeks demonstrated that the topical application of an antiphotoaging formulation containing C. aspersa mucus diminished periocular and fine facial rhytides and enhanced skin texture within 8 weeks of treatment initiation.⁷

Snail eggs and photoaging

In 2015, Espada et al. determined in vitro that an extract derived from C. aspersa eggs could reorganize the cytoskeleton of keratinocytes and fibroblasts, as well as trigger the synthesis of the extracellular proteins collagen and fibronectin. They also found that gene expression declined in age-related genes including p53 and b-Gal. The researchers concluded that C. aspersa egg extract has the potential to reduce the signs of photoaging.^3,13

Antiaging cosmeceuticals

In a 2017 assessment of the antiaging and skin-whitening activity of the nine most popular ingredients in the South Korean skin care product market, Quay et al. considered industry profit data from Euromonitor and conducted a comprehensive literature search. They identified licorice, niacinamide, green tea, soy, beta-glucan, snail mucus, ginkgo biloba, ginseng, and pomegranate as the nine most popular ingredients, with the first four associated with the most supportive data. They found a paucity of cogent evidence on the use of the other ingredients in antiaging and skin-whitening formulations.¹⁴

Conclusion

The use of snail mucin to treat skin dates back at least to the time of Hippocrates. Recent research suggests reasons for optimism, and further investigation, as this ingredient appears to have potential across various cutaneous conditions. As is often the case, though, much more research is necessary to ascertain what enduring benefits may be derived from the use of snail mucin. Nevertheless, this product has been available on the market for the last 20 years and is associated with anecdotal reports of efficacy.

Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014), and a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC. Write to her at [email protected]. She has no relevant disclosures.

References

1. Liu L et al. Snails and skin care – an uncovered combination. JAMA Dermatol. 2017 Jul 1;153(7):650.

2. Nguyen JK et al. J Cosmet Dermatol. 2020 Feb 26. doi: 10.1111/jocd.13344.

3. Juhász ML et al. J Cosmet Dermatol. 2018;17(3):305-12.

4. Pitt SJ et al. Br J Biomed Sci. 2015;72(4):174-81.

5. Brieva A et al. Skin Pharmacol Physiol. 2008;21(1):15-22.

6. Cruz MC et al. Int J Cosmet Sci. 2012 Apr;34(2):183-9.

7. Fabi SG et al. J Drugs Dermatol. 2013; Apr;12(4):453-7.

8. Ledo E et al. Radioproteccion. 1999;23(7):34-8.

9. Oh M-Jet al. J Korean Med Ophthalmol Otolaryngol Dermatol. 2010; Dec,23(3):138-53.

10. Tsoutsos D et al. J Dermatolog Treat. 2009;20(4):219-22.

11. Tribo-Boixareu MJ et al. Cosmet Dermatol. 2009;22(5):247-52.

12. Ellijimi C et al. Biomed Pharmacother. 2018 May;101:871-80.

13. Espada J et al. Int J Cosmet Sci. 2015 Feb;37(1):41-55.

14. Quay ER et al. J Drugs Dermatol. 2017 Apr 1;16(4):358-63.
 

Although it is not glamorous, snail mucus is a popular ingredient in skin care products. Its use dates back to ancient Greece, where Hippocrates reportedly applied crushed snails to treat skin inflammations.¹ The modern consideration of using snail secretions in skin care arose serendipitously in the 1990s when Chilean farmers observed accelerated healing of their skin lesions without scarring after handling snails.¹

valentinrussanov/E+

Today, snail mucin is among the increasingly wide array of bioactive ingredients undergoing scientific validation and inclusion in the burgeoning Korean cosmeceutical market.^2,3 In fact, a variety of Korean cosmeceuticals incorporate the mucus derived from Achatina fulica (African giant land snail) and Cryptomphalus (Helix) aspersa (common brown garden snail) based on their demonstrated antimicrobial and skin regenerative activity.^1,3,4 The antioxidant properties also attributed to snail mucus are thought to originate in constituents such as glycosaminoglycans, as well as growth factors, and may justify the use of these ingredients in novel cosmeceuticals.⁵ The focus of this discussion is recent research into the novel use of this animal-derived product for dermatologic purposes.
 

Antioxidant activity, skin rejuvenation, and wound healing

In 2008, Brieva et al. reported on a screen for natural products yielding a molecular basis for the secretions of the mollusk Cryptomphalus aspersa, which displays skin-regenerative activity. Specifically, they found that the secretion exerts antioxidant superoxide dismutase and glutathione S-transferase, and spurred fibroblast proliferation and extracellular matrix assembly while regulating metalloproteinase function. The researchers concluded that such activities may support wound regeneration.⁵

Four years later, Cruz et al. found that secretions of C. aspersa promote in vitro cell proliferation and migration by localizing beta-catenin to the nuclei of human fibroblasts and keratinocytes, augment phosphorylated focal adhesion kinase, and thereby enhance cell survival. The investigators concluded that snail secretions may therefore impart regenerative and wound healing activity.3,6

Antimicrobial properties

In 2015, Pitt et al. investigated the antimicrobial properties of the mucus of the brown garden snail C. or H. aspersa, which had a reputation for exhibiting skin regeneration capabilities. Their results revealed that snail mucus displayed a strong antibacterial effect against multiple strains of Pseudomonas aeruginosa and a weak effect against Staphylococcus aureus.⁴

Indications for the use of snail mucin

Radiation-induced dermatitis and burns represented the first indication for the initial use of snail mucin as a cutaneous therapy.⁷ Experimental and clinical studies have since been performed to assess its applicability to treat acute radiation dermatitis, atopic dermatitis, partial-thickness burns, and photoaging.^8-11

A 2017 in vitro investigation by Ellijimi et al. revealed that snail mucin displayed antimelanogenic and antitumoral activity against human melanoma cells, suggesting another possible application of this product.¹²

Human studies on photoaging

In a 2009 study by Tsoutsos et al. of an open, moist burn management protocol in deep partial-thickness facial burns, a cream containing H. aspersa secretions was identified to be an effective treatment option. For 14 days or until full epithelialization, 27 adult patients were treated with snail extract cream twice daily. Comparisons were made to 16 patients treated with moist exposure burn ointment. Visual analog scale pain scores were significantly lower in the group that received the H. aspersa cream, compared with the moist exposure burn group. The researchers concluded that the H. aspersa cream is a safe, effective, and natural option for treating partial-thickness burns in adults that acts by facilitating debris removal and accelerating reepithelialization.¹⁰

Also that year, Tribo-Boixareu et al. treated 15 patients with chronic photodamage with secretions of C. aspersa over a 3-month period, yielding significant amelioration in the clinical and histologic markers of photoaging.¹¹

Four years later, a double-blind, split-face, randomized, controlled clinical study conducted by Fabi et al. over 12 weeks demonstrated that the topical application of an antiphotoaging formulation containing C. aspersa mucus diminished periocular and fine facial rhytides and enhanced skin texture within 8 weeks of treatment initiation.⁷

Snail eggs and photoaging

In 2015, Espada et al. determined in vitro that an extract derived from C. aspersa eggs could reorganize the cytoskeleton of keratinocytes and fibroblasts, as well as trigger the synthesis of the extracellular proteins collagen and fibronectin. They also found that gene expression declined in age-related genes including p53 and b-Gal. The researchers concluded that C. aspersa egg extract has the potential to reduce the signs of photoaging.^3,13

Antiaging cosmeceuticals

In a 2017 assessment of the antiaging and skin-whitening activity of the nine most popular ingredients in the South Korean skin care product market, Quay et al. considered industry profit data from Euromonitor and conducted a comprehensive literature search. They identified licorice, niacinamide, green tea, soy, beta-glucan, snail mucus, ginkgo biloba, ginseng, and pomegranate as the nine most popular ingredients, with the first four associated with the most supportive data. They found a paucity of cogent evidence on the use of the other ingredients in antiaging and skin-whitening formulations.¹⁴

Conclusion

The use of snail mucin to treat skin dates back at least to the time of Hippocrates. Recent research suggests reasons for optimism, and further investigation, as this ingredient appears to have potential across various cutaneous conditions. As is often the case, though, much more research is necessary to ascertain what enduring benefits may be derived from the use of snail mucin. Nevertheless, this product has been available on the market for the last 20 years and is associated with anecdotal reports of efficacy.

Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014), and a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC. Write to her at [email protected]. She has no relevant disclosures.

References

1. Liu L et al. Snails and skin care – an uncovered combination. JAMA Dermatol. 2017 Jul 1;153(7):650.

2. Nguyen JK et al. J Cosmet Dermatol. 2020 Feb 26. doi: 10.1111/jocd.13344.

3. Juhász ML et al. J Cosmet Dermatol. 2018;17(3):305-12.

4. Pitt SJ et al. Br J Biomed Sci. 2015;72(4):174-81.

5. Brieva A et al. Skin Pharmacol Physiol. 2008;21(1):15-22.

6. Cruz MC et al. Int J Cosmet Sci. 2012 Apr;34(2):183-9.

7. Fabi SG et al. J Drugs Dermatol. 2013; Apr;12(4):453-7.

8. Ledo E et al. Radioproteccion. 1999;23(7):34-8.

9. Oh M-Jet al. J Korean Med Ophthalmol Otolaryngol Dermatol. 2010; Dec,23(3):138-53.

10. Tsoutsos D et al. J Dermatolog Treat. 2009;20(4):219-22.

11. Tribo-Boixareu MJ et al. Cosmet Dermatol. 2009;22(5):247-52.

12. Ellijimi C et al. Biomed Pharmacother. 2018 May;101:871-80.

13. Espada J et al. Int J Cosmet Sci. 2015 Feb;37(1):41-55.

14. Quay ER et al. J Drugs Dermatol. 2017 Apr 1;16(4):358-63.
 

Although it is not glamorous, snail mucus is a popular ingredient in skin care products. Its use dates back to ancient Greece, where Hippocrates reportedly applied crushed snails to treat skin inflammations.¹ The modern consideration of using snail secretions in skin care arose serendipitously in the 1990s when Chilean farmers observed accelerated healing of their skin lesions without scarring after handling snails.¹

valentinrussanov/E+

Today, snail mucin is among the increasingly wide array of bioactive ingredients undergoing scientific validation and inclusion in the burgeoning Korean cosmeceutical market.^2,3 In fact, a variety of Korean cosmeceuticals incorporate the mucus derived from Achatina fulica (African giant land snail) and Cryptomphalus (Helix) aspersa (common brown garden snail) based on their demonstrated antimicrobial and skin regenerative activity.^1,3,4 The antioxidant properties also attributed to snail mucus are thought to originate in constituents such as glycosaminoglycans, as well as growth factors, and may justify the use of these ingredients in novel cosmeceuticals.⁵ The focus of this discussion is recent research into the novel use of this animal-derived product for dermatologic purposes.
 

Antioxidant activity, skin rejuvenation, and wound healing

In 2008, Brieva et al. reported on a screen for natural products yielding a molecular basis for the secretions of the mollusk Cryptomphalus aspersa, which displays skin-regenerative activity. Specifically, they found that the secretion exerts antioxidant superoxide dismutase and glutathione S-transferase, and spurred fibroblast proliferation and extracellular matrix assembly while regulating metalloproteinase function. The researchers concluded that such activities may support wound regeneration.⁵

Four years later, Cruz et al. found that secretions of C. aspersa promote in vitro cell proliferation and migration by localizing beta-catenin to the nuclei of human fibroblasts and keratinocytes, augment phosphorylated focal adhesion kinase, and thereby enhance cell survival. The investigators concluded that snail secretions may therefore impart regenerative and wound healing activity.3,6

Antimicrobial properties

In 2015, Pitt et al. investigated the antimicrobial properties of the mucus of the brown garden snail C. or H. aspersa, which had a reputation for exhibiting skin regeneration capabilities. Their results revealed that snail mucus displayed a strong antibacterial effect against multiple strains of Pseudomonas aeruginosa and a weak effect against Staphylococcus aureus.⁴

Indications for the use of snail mucin

Radiation-induced dermatitis and burns represented the first indication for the initial use of snail mucin as a cutaneous therapy.⁷ Experimental and clinical studies have since been performed to assess its applicability to treat acute radiation dermatitis, atopic dermatitis, partial-thickness burns, and photoaging.^8-11

A 2017 in vitro investigation by Ellijimi et al. revealed that snail mucin displayed antimelanogenic and antitumoral activity against human melanoma cells, suggesting another possible application of this product.¹²

Human studies on photoaging

In a 2009 study by Tsoutsos et al. of an open, moist burn management protocol in deep partial-thickness facial burns, a cream containing H. aspersa secretions was identified to be an effective treatment option. For 14 days or until full epithelialization, 27 adult patients were treated with snail extract cream twice daily. Comparisons were made to 16 patients treated with moist exposure burn ointment. Visual analog scale pain scores were significantly lower in the group that received the H. aspersa cream, compared with the moist exposure burn group. The researchers concluded that the H. aspersa cream is a safe, effective, and natural option for treating partial-thickness burns in adults that acts by facilitating debris removal and accelerating reepithelialization.¹⁰

Also that year, Tribo-Boixareu et al. treated 15 patients with chronic photodamage with secretions of C. aspersa over a 3-month period, yielding significant amelioration in the clinical and histologic markers of photoaging.¹¹

Four years later, a double-blind, split-face, randomized, controlled clinical study conducted by Fabi et al. over 12 weeks demonstrated that the topical application of an antiphotoaging formulation containing C. aspersa mucus diminished periocular and fine facial rhytides and enhanced skin texture within 8 weeks of treatment initiation.⁷

Snail eggs and photoaging

In 2015, Espada et al. determined in vitro that an extract derived from C. aspersa eggs could reorganize the cytoskeleton of keratinocytes and fibroblasts, as well as trigger the synthesis of the extracellular proteins collagen and fibronectin. They also found that gene expression declined in age-related genes including p53 and b-Gal. The researchers concluded that C. aspersa egg extract has the potential to reduce the signs of photoaging.^3,13

Antiaging cosmeceuticals

In a 2017 assessment of the antiaging and skin-whitening activity of the nine most popular ingredients in the South Korean skin care product market, Quay et al. considered industry profit data from Euromonitor and conducted a comprehensive literature search. They identified licorice, niacinamide, green tea, soy, beta-glucan, snail mucus, ginkgo biloba, ginseng, and pomegranate as the nine most popular ingredients, with the first four associated with the most supportive data. They found a paucity of cogent evidence on the use of the other ingredients in antiaging and skin-whitening formulations.¹⁴

Conclusion

The use of snail mucin to treat skin dates back at least to the time of Hippocrates. Recent research suggests reasons for optimism, and further investigation, as this ingredient appears to have potential across various cutaneous conditions. As is often the case, though, much more research is necessary to ascertain what enduring benefits may be derived from the use of snail mucin. Nevertheless, this product has been available on the market for the last 20 years and is associated with anecdotal reports of efficacy.

Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014), and a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC. Write to her at [email protected]. She has no relevant disclosures.

References

1. Liu L et al. Snails and skin care – an uncovered combination. JAMA Dermatol. 2017 Jul 1;153(7):650.

2. Nguyen JK et al. J Cosmet Dermatol. 2020 Feb 26. doi: 10.1111/jocd.13344.

3. Juhász ML et al. J Cosmet Dermatol. 2018;17(3):305-12.

4. Pitt SJ et al. Br J Biomed Sci. 2015;72(4):174-81.

5. Brieva A et al. Skin Pharmacol Physiol. 2008;21(1):15-22.

6. Cruz MC et al. Int J Cosmet Sci. 2012 Apr;34(2):183-9.

7. Fabi SG et al. J Drugs Dermatol. 2013; Apr;12(4):453-7.

8. Ledo E et al. Radioproteccion. 1999;23(7):34-8.

9. Oh M-Jet al. J Korean Med Ophthalmol Otolaryngol Dermatol. 2010; Dec,23(3):138-53.

10. Tsoutsos D et al. J Dermatolog Treat. 2009;20(4):219-22.

11. Tribo-Boixareu MJ et al. Cosmet Dermatol. 2009;22(5):247-52.

12. Ellijimi C et al. Biomed Pharmacother. 2018 May;101:871-80.

13. Espada J et al. Int J Cosmet Sci. 2015 Feb;37(1):41-55.

14. Quay ER et al. J Drugs Dermatol. 2017 Apr 1;16(4):358-63.
 

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.

Case:

A 37-year-old woman presents with severe emaciation (body mass index, 9.4 kg/m²) because of chronic severe avoidant/restrictive food intake disorder. She had asked for parenteral nutrition (PN) for several years, whenever her providers pushed her to accept nutrition support, as she had experienced extreme distress because of presumed gastroparesis with enteral feeds or any time she tried to eat. All of her many physicians refused the request for PN on the basis that her intestine was believed to be functioning and her symptoms were functional, so they insisted on tube feeding. The medical team was angered by the request for PN, and very concerned that providing it would support her belief that she could not eat, which they likened to a delusion. They opined that refusal of appropriate therapy (enteral nutrition) did not constitute an indication for inappropriate therapy (PN). They also deemed her to have capacity, so her refusal of tube feeding was honored. She continued to deteriorate, and because of her inability to travel, along with financial and insurance-related issues, was unable to seek alternative care providers. The family provided access to highly credible external consultants, and begged that her providers initiate PN as a life-saving measure. Both were declined. She was taken by her family to the emergency department when she began to have difficulty ambulating and increasing confusion. In recognition of the severity of her starvation, she was to be admitted to the critical care unit. With minimal monitoring while awaiting transfer from the emergency department overnight, she developed severe hypoglycemia and sustained cardiac arrest. Although spontaneous circulation was resumed, she sustained anoxic brain injury, and died after removal of life-sustaining treatment.

Ethical considerations

This case illustrates how the practice of caring for certain patients may come with deep unconscious determinants and conflicts of expectation – the duty to treat can be unclear in cases of refractory eating disorders. Multiple clinical teams were angry at the patient and her family for requesting PN and refused external input.

Although other eating disorders have received more attention, there is little research specific to avoidant/restrictive food intake disorder. There is some consensus that someone at a very low weight because of anorexia nervosa cannot, by definition, have decisional capacity with regard to feeding. Certainly, reviews cite cognitive dysfunction as a common finding, far worse during starvation, in patients with anorexia nervosa,^1,2 and nourishment over objection has been advised.³ Further, it is known that gastric dysfunction occurs with some frequency in the presence of starvation in patients with eating disorders.⁴ Moreover, the potential risks of PN should be contextualized and compared with the certainty of death in someone this starved. Finally, if the patient’s refusal to eat or be tube fed were a delusion, which is by definition “fixed,” refusing to provide PN, and allowing further starvation, would not be expected to have benefit in resolution of the delusion.

Issues related to nourishment can be highly emotive – from “starving to death” on the one hand and “force feeding” on the other. Delivery of adequate nutrition and hydration is considered a basic human right, and must be offered as part of basic care. At the same time, we have observed that the request for nutrition support creates severe moral distress and anger among clinicians treating patients with eating disorders or with fatal illness. Does a delusion preclude feeding, even if by less than ideal means? How should a physician react to feeding treatments they deem excessive or unnecessary? Does a treating team have a duty to consider input from specialists with expertise specific to the patient when such conflict occurs between the patient/family and the treating team? Speculation exists that onset of anorexia nervosa may be linked to a postinfectious condition – a post–viral disease brain reprogramming.^5,6 Would an organic explanation change our attitude toward patients with eating disorders?
 

Medicine’s emotive harms

Clinicians hold more negative attitudes toward certain patients – our implicit bias. It has been suggested that nice patients may be preferred by clinicians and therefore receive more humanistic care.⁷ Clinicians hold more negative attitudes toward patients with eating disorders than toward other patients. Cases of starvation caused by eating disorders are often seen by clinicians as a form of deviance, which provokes a visceral reaction of anger and frustration. These reactions have been associated with patients’ lack of improvement and personality pathology and with clinicians’ stigmatizing beliefs and inexperience.⁸ One could argue that this type of unconscious partiality may be worse than intentional harm.

Families and patients often request a treatment as a way to exert their agency. We clinicians may experience ethical dissonance as a result, whether because of ego or because the desired treatment is less favorable (for example, parenteral vs. enteral nutrition). Should maintaining clinical obstinance overrule patient and family autonomy, particularly in the face of the availability of life-saving intervention, even if less desirable than other standard treatments?

Should the physicians have better considered the relative risk of PN? What is the true potential harm? Would it benefit the patient or family? While PN’s benefit is usually life prolongation, it is not without risk of infection, potential mucosal atrophy of the unused gut, hepatic dysfunction, high cost, and an increased complexity of care. However, the incidence of blood stream infections in hospitalized patients receiving PN is only 1 episode for every 100 patient-days of treatment.⁹ On the other hand, weight regain is a significant determinant of success for treating eating disorders.¹⁰ Does the small risk of line-related sepsis, unlikely to be fatal, outweigh the certainty of death from starvation? What is the source of providers’ anger toward such patients? Even when providers feel any hope of improved outcome to be unreasonable, does refusal to provide nourishment, even if less than ideally, improve the likelihood the family will “come to grips” with the situation? Is there an obligation to consider our contribution to the emotional harm to the family because of our refusal, especially if coupled with anger?
 

Duty of life-saving care

Treating a competent patient without consent is unlawful. Autonomy is the dominant ethical principle, and a mentally competent person has the right to refuse consent to medical treatment for any reason, even when that decision may lead to death. Authors urge that patient lives should not be intentionally shortened, including the withholding of life-prolonging medical treatments or interventions.^11,12 Although starvation can compromise capacity, whether patients with severe starvation have truly lost their mental competence and right to self-determination is debated.¹³ Do physicians have a duty to provide nutrition support by whatever route a patient will accept as a life-saving measure or at least until nutritional stability and improved mental status can be attained?

Next steps

Despite potential concerns clinicians may have over the risks and disadvantages of PN, reeducation of clinician emotional responses toward providing it is needed. As illustrated by this case study, there are likely situations, not fitting the norm, when PN is warranted as a life-saving measure. An awareness of implicit bias we may experience is paramount in all situations. Case-by-case multidisciplinary evaluations are warranted based on guidelines from professional organizations,¹⁴ alongside core ethical principles, when considering nutrition support.

References

1. Guillaume S et al. Psychol Med. 2015 Dec;45(16):3377-91.

2. Katzman DK et al. Semin Clin Neuropsychiatry. 2001 Apr;6(2):146-52.

3. Elzakkers IF et al. Int J Eat Disord. 2014 Dec;47(8):845-52.

4. Robinson PH et al. Gut. 1988 Apr;29(4):458-64.

5. Breithaupt L et al. JAMA Psychiatry. 2019 Apr 24;76(8):800-9.

6. Sokol MS. J Child Adolesc Psychopharmacol. 2000;10(2):133-45.

7. Detsky AS, Baerlocher MO. JAMA. 2011 Jul;306(1):94-5.

8. Thompson-Brenner H et al. Psychiatr Serv. 2012 Jan;63(1):73-8.

9. Fonseca G et al. JPEN J Parenter Enteral Nutr. 2018 Jan;42(1):171-5.

10. National Collaborating Centre for Mental Health. In: Eating disorders: Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. Leicester, United Kingdom: British Psychological Society, 2004.

11. Keown J. Leg Stud. 2000 Mar;20(1):66-84.

12. Sayers GM et al. Postgrad Med J. 2006 Feb;82(964):79-83.

13. Miller I. BioSocieties. 2017;12:89-108.

14. A.S.P.E.N. Ethics Position Paper Task Force; Barrocas A et al. Nutr Clin Pract. 2010 Dec;25(6):672-9.
 

Dr. Anderson (@dochitect) is a clinical fellow in geriatric medicine at the University of California, San Francisco; Dr. Seres (@davidseres1) is an associate professor of medicine in the Institute of Human Nutrition, director of medical nutrition, and associate clinical ethicist at Columbia University Irving Medical Center, New York. They have no funding sources to declare and no conflicts of interest.

Case:

A 37-year-old woman presents with severe emaciation (body mass index, 9.4 kg/m²) because of chronic severe avoidant/restrictive food intake disorder. She had asked for parenteral nutrition (PN) for several years, whenever her providers pushed her to accept nutrition support, as she had experienced extreme distress because of presumed gastroparesis with enteral feeds or any time she tried to eat. All of her many physicians refused the request for PN on the basis that her intestine was believed to be functioning and her symptoms were functional, so they insisted on tube feeding. The medical team was angered by the request for PN, and very concerned that providing it would support her belief that she could not eat, which they likened to a delusion. They opined that refusal of appropriate therapy (enteral nutrition) did not constitute an indication for inappropriate therapy (PN). They also deemed her to have capacity, so her refusal of tube feeding was honored. She continued to deteriorate, and because of her inability to travel, along with financial and insurance-related issues, was unable to seek alternative care providers. The family provided access to highly credible external consultants, and begged that her providers initiate PN as a life-saving measure. Both were declined. She was taken by her family to the emergency department when she began to have difficulty ambulating and increasing confusion. In recognition of the severity of her starvation, she was to be admitted to the critical care unit. With minimal monitoring while awaiting transfer from the emergency department overnight, she developed severe hypoglycemia and sustained cardiac arrest. Although spontaneous circulation was resumed, she sustained anoxic brain injury, and died after removal of life-sustaining treatment.

Ethical considerations

This case illustrates how the practice of caring for certain patients may come with deep unconscious determinants and conflicts of expectation – the duty to treat can be unclear in cases of refractory eating disorders. Multiple clinical teams were angry at the patient and her family for requesting PN and refused external input.

Although other eating disorders have received more attention, there is little research specific to avoidant/restrictive food intake disorder. There is some consensus that someone at a very low weight because of anorexia nervosa cannot, by definition, have decisional capacity with regard to feeding. Certainly, reviews cite cognitive dysfunction as a common finding, far worse during starvation, in patients with anorexia nervosa,^1,2 and nourishment over objection has been advised.³ Further, it is known that gastric dysfunction occurs with some frequency in the presence of starvation in patients with eating disorders.⁴ Moreover, the potential risks of PN should be contextualized and compared with the certainty of death in someone this starved. Finally, if the patient’s refusal to eat or be tube fed were a delusion, which is by definition “fixed,” refusing to provide PN, and allowing further starvation, would not be expected to have benefit in resolution of the delusion.

Issues related to nourishment can be highly emotive – from “starving to death” on the one hand and “force feeding” on the other. Delivery of adequate nutrition and hydration is considered a basic human right, and must be offered as part of basic care. At the same time, we have observed that the request for nutrition support creates severe moral distress and anger among clinicians treating patients with eating disorders or with fatal illness. Does a delusion preclude feeding, even if by less than ideal means? How should a physician react to feeding treatments they deem excessive or unnecessary? Does a treating team have a duty to consider input from specialists with expertise specific to the patient when such conflict occurs between the patient/family and the treating team? Speculation exists that onset of anorexia nervosa may be linked to a postinfectious condition – a post–viral disease brain reprogramming.^5,6 Would an organic explanation change our attitude toward patients with eating disorders?
 

Medicine’s emotive harms

Clinicians hold more negative attitudes toward certain patients – our implicit bias. It has been suggested that nice patients may be preferred by clinicians and therefore receive more humanistic care.⁷ Clinicians hold more negative attitudes toward patients with eating disorders than toward other patients. Cases of starvation caused by eating disorders are often seen by clinicians as a form of deviance, which provokes a visceral reaction of anger and frustration. These reactions have been associated with patients’ lack of improvement and personality pathology and with clinicians’ stigmatizing beliefs and inexperience.⁸ One could argue that this type of unconscious partiality may be worse than intentional harm.

Families and patients often request a treatment as a way to exert their agency. We clinicians may experience ethical dissonance as a result, whether because of ego or because the desired treatment is less favorable (for example, parenteral vs. enteral nutrition). Should maintaining clinical obstinance overrule patient and family autonomy, particularly in the face of the availability of life-saving intervention, even if less desirable than other standard treatments?

Should the physicians have better considered the relative risk of PN? What is the true potential harm? Would it benefit the patient or family? While PN’s benefit is usually life prolongation, it is not without risk of infection, potential mucosal atrophy of the unused gut, hepatic dysfunction, high cost, and an increased complexity of care. However, the incidence of blood stream infections in hospitalized patients receiving PN is only 1 episode for every 100 patient-days of treatment.⁹ On the other hand, weight regain is a significant determinant of success for treating eating disorders.¹⁰ Does the small risk of line-related sepsis, unlikely to be fatal, outweigh the certainty of death from starvation? What is the source of providers’ anger toward such patients? Even when providers feel any hope of improved outcome to be unreasonable, does refusal to provide nourishment, even if less than ideally, improve the likelihood the family will “come to grips” with the situation? Is there an obligation to consider our contribution to the emotional harm to the family because of our refusal, especially if coupled with anger?
 

Duty of life-saving care

Treating a competent patient without consent is unlawful. Autonomy is the dominant ethical principle, and a mentally competent person has the right to refuse consent to medical treatment for any reason, even when that decision may lead to death. Authors urge that patient lives should not be intentionally shortened, including the withholding of life-prolonging medical treatments or interventions.^11,12 Although starvation can compromise capacity, whether patients with severe starvation have truly lost their mental competence and right to self-determination is debated.¹³ Do physicians have a duty to provide nutrition support by whatever route a patient will accept as a life-saving measure or at least until nutritional stability and improved mental status can be attained?

Next steps

Despite potential concerns clinicians may have over the risks and disadvantages of PN, reeducation of clinician emotional responses toward providing it is needed. As illustrated by this case study, there are likely situations, not fitting the norm, when PN is warranted as a life-saving measure. An awareness of implicit bias we may experience is paramount in all situations. Case-by-case multidisciplinary evaluations are warranted based on guidelines from professional organizations,¹⁴ alongside core ethical principles, when considering nutrition support.

References

1. Guillaume S et al. Psychol Med. 2015 Dec;45(16):3377-91.

2. Katzman DK et al. Semin Clin Neuropsychiatry. 2001 Apr;6(2):146-52.

3. Elzakkers IF et al. Int J Eat Disord. 2014 Dec;47(8):845-52.

4. Robinson PH et al. Gut. 1988 Apr;29(4):458-64.

5. Breithaupt L et al. JAMA Psychiatry. 2019 Apr 24;76(8):800-9.

6. Sokol MS. J Child Adolesc Psychopharmacol. 2000;10(2):133-45.

7. Detsky AS, Baerlocher MO. JAMA. 2011 Jul;306(1):94-5.

8. Thompson-Brenner H et al. Psychiatr Serv. 2012 Jan;63(1):73-8.

9. Fonseca G et al. JPEN J Parenter Enteral Nutr. 2018 Jan;42(1):171-5.

10. National Collaborating Centre for Mental Health. In: Eating disorders: Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. Leicester, United Kingdom: British Psychological Society, 2004.

11. Keown J. Leg Stud. 2000 Mar;20(1):66-84.

12. Sayers GM et al. Postgrad Med J. 2006 Feb;82(964):79-83.

13. Miller I. BioSocieties. 2017;12:89-108.

14. A.S.P.E.N. Ethics Position Paper Task Force; Barrocas A et al. Nutr Clin Pract. 2010 Dec;25(6):672-9.
 

Dr. Anderson (@dochitect) is a clinical fellow in geriatric medicine at the University of California, San Francisco; Dr. Seres (@davidseres1) is an associate professor of medicine in the Institute of Human Nutrition, director of medical nutrition, and associate clinical ethicist at Columbia University Irving Medical Center, New York. They have no funding sources to declare and no conflicts of interest.

Case:

A 37-year-old woman presents with severe emaciation (body mass index, 9.4 kg/m²) because of chronic severe avoidant/restrictive food intake disorder. She had asked for parenteral nutrition (PN) for several years, whenever her providers pushed her to accept nutrition support, as she had experienced extreme distress because of presumed gastroparesis with enteral feeds or any time she tried to eat. All of her many physicians refused the request for PN on the basis that her intestine was believed to be functioning and her symptoms were functional, so they insisted on tube feeding. The medical team was angered by the request for PN, and very concerned that providing it would support her belief that she could not eat, which they likened to a delusion. They opined that refusal of appropriate therapy (enteral nutrition) did not constitute an indication for inappropriate therapy (PN). They also deemed her to have capacity, so her refusal of tube feeding was honored. She continued to deteriorate, and because of her inability to travel, along with financial and insurance-related issues, was unable to seek alternative care providers. The family provided access to highly credible external consultants, and begged that her providers initiate PN as a life-saving measure. Both were declined. She was taken by her family to the emergency department when she began to have difficulty ambulating and increasing confusion. In recognition of the severity of her starvation, she was to be admitted to the critical care unit. With minimal monitoring while awaiting transfer from the emergency department overnight, she developed severe hypoglycemia and sustained cardiac arrest. Although spontaneous circulation was resumed, she sustained anoxic brain injury, and died after removal of life-sustaining treatment.

Ethical considerations

This case illustrates how the practice of caring for certain patients may come with deep unconscious determinants and conflicts of expectation – the duty to treat can be unclear in cases of refractory eating disorders. Multiple clinical teams were angry at the patient and her family for requesting PN and refused external input.

Although other eating disorders have received more attention, there is little research specific to avoidant/restrictive food intake disorder. There is some consensus that someone at a very low weight because of anorexia nervosa cannot, by definition, have decisional capacity with regard to feeding. Certainly, reviews cite cognitive dysfunction as a common finding, far worse during starvation, in patients with anorexia nervosa,^1,2 and nourishment over objection has been advised.³ Further, it is known that gastric dysfunction occurs with some frequency in the presence of starvation in patients with eating disorders.⁴ Moreover, the potential risks of PN should be contextualized and compared with the certainty of death in someone this starved. Finally, if the patient’s refusal to eat or be tube fed were a delusion, which is by definition “fixed,” refusing to provide PN, and allowing further starvation, would not be expected to have benefit in resolution of the delusion.

Issues related to nourishment can be highly emotive – from “starving to death” on the one hand and “force feeding” on the other. Delivery of adequate nutrition and hydration is considered a basic human right, and must be offered as part of basic care. At the same time, we have observed that the request for nutrition support creates severe moral distress and anger among clinicians treating patients with eating disorders or with fatal illness. Does a delusion preclude feeding, even if by less than ideal means? How should a physician react to feeding treatments they deem excessive or unnecessary? Does a treating team have a duty to consider input from specialists with expertise specific to the patient when such conflict occurs between the patient/family and the treating team? Speculation exists that onset of anorexia nervosa may be linked to a postinfectious condition – a post–viral disease brain reprogramming.^5,6 Would an organic explanation change our attitude toward patients with eating disorders?
 

Medicine’s emotive harms

Clinicians hold more negative attitudes toward certain patients – our implicit bias. It has been suggested that nice patients may be preferred by clinicians and therefore receive more humanistic care.⁷ Clinicians hold more negative attitudes toward patients with eating disorders than toward other patients. Cases of starvation caused by eating disorders are often seen by clinicians as a form of deviance, which provokes a visceral reaction of anger and frustration. These reactions have been associated with patients’ lack of improvement and personality pathology and with clinicians’ stigmatizing beliefs and inexperience.⁸ One could argue that this type of unconscious partiality may be worse than intentional harm.

Families and patients often request a treatment as a way to exert their agency. We clinicians may experience ethical dissonance as a result, whether because of ego or because the desired treatment is less favorable (for example, parenteral vs. enteral nutrition). Should maintaining clinical obstinance overrule patient and family autonomy, particularly in the face of the availability of life-saving intervention, even if less desirable than other standard treatments?

Should the physicians have better considered the relative risk of PN? What is the true potential harm? Would it benefit the patient or family? While PN’s benefit is usually life prolongation, it is not without risk of infection, potential mucosal atrophy of the unused gut, hepatic dysfunction, high cost, and an increased complexity of care. However, the incidence of blood stream infections in hospitalized patients receiving PN is only 1 episode for every 100 patient-days of treatment.⁹ On the other hand, weight regain is a significant determinant of success for treating eating disorders.¹⁰ Does the small risk of line-related sepsis, unlikely to be fatal, outweigh the certainty of death from starvation? What is the source of providers’ anger toward such patients? Even when providers feel any hope of improved outcome to be unreasonable, does refusal to provide nourishment, even if less than ideally, improve the likelihood the family will “come to grips” with the situation? Is there an obligation to consider our contribution to the emotional harm to the family because of our refusal, especially if coupled with anger?
 

Duty of life-saving care

Treating a competent patient without consent is unlawful. Autonomy is the dominant ethical principle, and a mentally competent person has the right to refuse consent to medical treatment for any reason, even when that decision may lead to death. Authors urge that patient lives should not be intentionally shortened, including the withholding of life-prolonging medical treatments or interventions.^11,12 Although starvation can compromise capacity, whether patients with severe starvation have truly lost their mental competence and right to self-determination is debated.¹³ Do physicians have a duty to provide nutrition support by whatever route a patient will accept as a life-saving measure or at least until nutritional stability and improved mental status can be attained?

Next steps

Despite potential concerns clinicians may have over the risks and disadvantages of PN, reeducation of clinician emotional responses toward providing it is needed. As illustrated by this case study, there are likely situations, not fitting the norm, when PN is warranted as a life-saving measure. An awareness of implicit bias we may experience is paramount in all situations. Case-by-case multidisciplinary evaluations are warranted based on guidelines from professional organizations,¹⁴ alongside core ethical principles, when considering nutrition support.

References

1. Guillaume S et al. Psychol Med. 2015 Dec;45(16):3377-91.

2. Katzman DK et al. Semin Clin Neuropsychiatry. 2001 Apr;6(2):146-52.

3. Elzakkers IF et al. Int J Eat Disord. 2014 Dec;47(8):845-52.

4. Robinson PH et al. Gut. 1988 Apr;29(4):458-64.

5. Breithaupt L et al. JAMA Psychiatry. 2019 Apr 24;76(8):800-9.

6. Sokol MS. J Child Adolesc Psychopharmacol. 2000;10(2):133-45.

7. Detsky AS, Baerlocher MO. JAMA. 2011 Jul;306(1):94-5.

8. Thompson-Brenner H et al. Psychiatr Serv. 2012 Jan;63(1):73-8.

9. Fonseca G et al. JPEN J Parenter Enteral Nutr. 2018 Jan;42(1):171-5.

10. National Collaborating Centre for Mental Health. In: Eating disorders: Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. Leicester, United Kingdom: British Psychological Society, 2004.

11. Keown J. Leg Stud. 2000 Mar;20(1):66-84.

12. Sayers GM et al. Postgrad Med J. 2006 Feb;82(964):79-83.

13. Miller I. BioSocieties. 2017;12:89-108.

14. A.S.P.E.N. Ethics Position Paper Task Force; Barrocas A et al. Nutr Clin Pract. 2010 Dec;25(6):672-9.
 

Dr. Anderson (@dochitect) is a clinical fellow in geriatric medicine at the University of California, San Francisco; Dr. Seres (@davidseres1) is an associate professor of medicine in the Institute of Human Nutrition, director of medical nutrition, and associate clinical ethicist at Columbia University Irving Medical Center, New York. They have no funding sources to declare and no conflicts of interest.

On April 16, the White House released federal guidelines for reopening American businesses – followed 3 days later by specific recommendations from the Centers for Medicare and Medicaid Services for health care practices in areas with a low incidence of COVID-19. Since then, a slew of resources and guidelines have emerged to help you safely reopen your medical practice.

Depending on where you live, you may have already reopened (or even never closed), or you may be awaiting the relaxation of restrictions in your state. (As I write this on June 10, the stay-at-home order in my state, New Jersey, is being rescinded.)

The big question, of course, is whether patients can be convinced that it is safe to leave their homes and come to your office. The answer may depend on how well you time your reopening and adhere to the appropriate federal, state, and independent guidelines.

The federal guidelines have three sections: criteria, which outline conditions each region or state should satisfy before reopening; preparedness, which lists how states should prepare for reopening; and phase guidelines, which detail responsibilities of individuals and employers during distinct reopening phases.

You should pay the most attention to the “criteria” section. The key question to ask: “Has my state or region satisfied the basic criteria for reopening?”

Those criteria are as follows:

• Symptoms reported within a 14-day period should be on a downward trajectory.
• Cases documented (or positive tests as a percentage of total tests) within a 14-day period should also be on a downward trajectory.
• Hospitals should be treating all patients without crisis care. They should also have a robust testing program in place for at-risk health care workers.

If your area meets these criteria, you can proceed to the CMS recommendations. They cover general advice related to personal protective equipment (PPE), workforce availability, facility considerations, sanitation protocols, supplies, and testing capacity.

The key takeaway: As long as your area has the resources to quickly respond to a surge of COVID-19 cases, you can start offering care to non-COVID patients. Keep seeing patients via telehealth as often as possible, and prioritize surgical/procedural care and high-complexity chronic disease management before moving on to preventive and cosmetic services.

The American Medical Association has issued its own checklist of criteria for reopening your practice to supplement the federal guidelines. Highlights include the following:

• Sit down with a calendar and pick an expected reopening day. Ideally, this should include a “soft reopening.” Make a plan to stock necessary PPE and write down plans for cleaning and staffing if an employee or patient is diagnosed with COVID-19 after visiting your office.
• Take a stepwise approach so you can identify challenges early and address them. It’s important to figure out which visits can continue via telehealth, and begin with just a few in-person visits each day. Plan out a schedule and clearly communicate it to patients, clinicians, and staff.
• Patient safety is your top concern. Encourage patients to visit without companions whenever possible, and of course, all individuals who visit the office should wear a cloth face covering.
• Screen employees for fevers and other symptoms of COVID-19; remember that those records are subject to HIPAA rules and must be kept confidential. Minimize contact between employees as much as possible.
• Do your best to screen patients before in-person visits, to verify they don’t have symptoms of COVID-19. Consider creating a script that office staff can use to contact patients 24 hours before they come in. Use this as a chance to ask about symptoms, and explain any reopening logistics they should know about.
• Contact your malpractice insurance carrier to discuss whether you need to make any changes to your coverage.

This would also be a great time to review your confidentiality, privacy, and data security protocols. COVID-19 presents new challenges for data privacy – for example, if you must inform coworkers or patients that they have come into contact with someone who tested positive. Make a plan that follows HIPAA guidelines during COVID-19. Also, make sure you have a plan for handling issues like paid sick leave or reporting COVID-19 cases to your local health department.

Another useful resource is the Medical Group Management Association’s COVID-19 Medical Practice Reopening Checklist. You can use it to confirm that you are addressing all the important items, and that you haven’t missed anything.

As for me, I am advising patients who are reluctant to seek treatment that many medical problems pose more risk than COVID-19, faster treatment means better outcomes, and because we maintain strict disinfection protocols, they are far less likely to be infected with COVID-19 in my office than, say, at a grocery store.
 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].

On April 16, the White House released federal guidelines for reopening American businesses – followed 3 days later by specific recommendations from the Centers for Medicare and Medicaid Services for health care practices in areas with a low incidence of COVID-19. Since then, a slew of resources and guidelines have emerged to help you safely reopen your medical practice.

Depending on where you live, you may have already reopened (or even never closed), or you may be awaiting the relaxation of restrictions in your state. (As I write this on June 10, the stay-at-home order in my state, New Jersey, is being rescinded.)

The big question, of course, is whether patients can be convinced that it is safe to leave their homes and come to your office. The answer may depend on how well you time your reopening and adhere to the appropriate federal, state, and independent guidelines.

The federal guidelines have three sections: criteria, which outline conditions each region or state should satisfy before reopening; preparedness, which lists how states should prepare for reopening; and phase guidelines, which detail responsibilities of individuals and employers during distinct reopening phases.

You should pay the most attention to the “criteria” section. The key question to ask: “Has my state or region satisfied the basic criteria for reopening?”

Those criteria are as follows:

• Symptoms reported within a 14-day period should be on a downward trajectory.
• Cases documented (or positive tests as a percentage of total tests) within a 14-day period should also be on a downward trajectory.
• Hospitals should be treating all patients without crisis care. They should also have a robust testing program in place for at-risk health care workers.

If your area meets these criteria, you can proceed to the CMS recommendations. They cover general advice related to personal protective equipment (PPE), workforce availability, facility considerations, sanitation protocols, supplies, and testing capacity.

The key takeaway: As long as your area has the resources to quickly respond to a surge of COVID-19 cases, you can start offering care to non-COVID patients. Keep seeing patients via telehealth as often as possible, and prioritize surgical/procedural care and high-complexity chronic disease management before moving on to preventive and cosmetic services.

The American Medical Association has issued its own checklist of criteria for reopening your practice to supplement the federal guidelines. Highlights include the following:

• Sit down with a calendar and pick an expected reopening day. Ideally, this should include a “soft reopening.” Make a plan to stock necessary PPE and write down plans for cleaning and staffing if an employee or patient is diagnosed with COVID-19 after visiting your office.
• Take a stepwise approach so you can identify challenges early and address them. It’s important to figure out which visits can continue via telehealth, and begin with just a few in-person visits each day. Plan out a schedule and clearly communicate it to patients, clinicians, and staff.
• Patient safety is your top concern. Encourage patients to visit without companions whenever possible, and of course, all individuals who visit the office should wear a cloth face covering.
• Screen employees for fevers and other symptoms of COVID-19; remember that those records are subject to HIPAA rules and must be kept confidential. Minimize contact between employees as much as possible.
• Do your best to screen patients before in-person visits, to verify they don’t have symptoms of COVID-19. Consider creating a script that office staff can use to contact patients 24 hours before they come in. Use this as a chance to ask about symptoms, and explain any reopening logistics they should know about.
• Contact your malpractice insurance carrier to discuss whether you need to make any changes to your coverage.

This would also be a great time to review your confidentiality, privacy, and data security protocols. COVID-19 presents new challenges for data privacy – for example, if you must inform coworkers or patients that they have come into contact with someone who tested positive. Make a plan that follows HIPAA guidelines during COVID-19. Also, make sure you have a plan for handling issues like paid sick leave or reporting COVID-19 cases to your local health department.

Another useful resource is the Medical Group Management Association’s COVID-19 Medical Practice Reopening Checklist. You can use it to confirm that you are addressing all the important items, and that you haven’t missed anything.

As for me, I am advising patients who are reluctant to seek treatment that many medical problems pose more risk than COVID-19, faster treatment means better outcomes, and because we maintain strict disinfection protocols, they are far less likely to be infected with COVID-19 in my office than, say, at a grocery store.
 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].

On April 16, the White House released federal guidelines for reopening American businesses – followed 3 days later by specific recommendations from the Centers for Medicare and Medicaid Services for health care practices in areas with a low incidence of COVID-19. Since then, a slew of resources and guidelines have emerged to help you safely reopen your medical practice.

Depending on where you live, you may have already reopened (or even never closed), or you may be awaiting the relaxation of restrictions in your state. (As I write this on June 10, the stay-at-home order in my state, New Jersey, is being rescinded.)

The big question, of course, is whether patients can be convinced that it is safe to leave their homes and come to your office. The answer may depend on how well you time your reopening and adhere to the appropriate federal, state, and independent guidelines.

The federal guidelines have three sections: criteria, which outline conditions each region or state should satisfy before reopening; preparedness, which lists how states should prepare for reopening; and phase guidelines, which detail responsibilities of individuals and employers during distinct reopening phases.

You should pay the most attention to the “criteria” section. The key question to ask: “Has my state or region satisfied the basic criteria for reopening?”

Those criteria are as follows:

• Symptoms reported within a 14-day period should be on a downward trajectory.
• Cases documented (or positive tests as a percentage of total tests) within a 14-day period should also be on a downward trajectory.
• Hospitals should be treating all patients without crisis care. They should also have a robust testing program in place for at-risk health care workers.

If your area meets these criteria, you can proceed to the CMS recommendations. They cover general advice related to personal protective equipment (PPE), workforce availability, facility considerations, sanitation protocols, supplies, and testing capacity.

The key takeaway: As long as your area has the resources to quickly respond to a surge of COVID-19 cases, you can start offering care to non-COVID patients. Keep seeing patients via telehealth as often as possible, and prioritize surgical/procedural care and high-complexity chronic disease management before moving on to preventive and cosmetic services.

The American Medical Association has issued its own checklist of criteria for reopening your practice to supplement the federal guidelines. Highlights include the following:

• Sit down with a calendar and pick an expected reopening day. Ideally, this should include a “soft reopening.” Make a plan to stock necessary PPE and write down plans for cleaning and staffing if an employee or patient is diagnosed with COVID-19 after visiting your office.
• Take a stepwise approach so you can identify challenges early and address them. It’s important to figure out which visits can continue via telehealth, and begin with just a few in-person visits each day. Plan out a schedule and clearly communicate it to patients, clinicians, and staff.
• Patient safety is your top concern. Encourage patients to visit without companions whenever possible, and of course, all individuals who visit the office should wear a cloth face covering.
• Screen employees for fevers and other symptoms of COVID-19; remember that those records are subject to HIPAA rules and must be kept confidential. Minimize contact between employees as much as possible.
• Do your best to screen patients before in-person visits, to verify they don’t have symptoms of COVID-19. Consider creating a script that office staff can use to contact patients 24 hours before they come in. Use this as a chance to ask about symptoms, and explain any reopening logistics they should know about.
• Contact your malpractice insurance carrier to discuss whether you need to make any changes to your coverage.

This would also be a great time to review your confidentiality, privacy, and data security protocols. COVID-19 presents new challenges for data privacy – for example, if you must inform coworkers or patients that they have come into contact with someone who tested positive. Make a plan that follows HIPAA guidelines during COVID-19. Also, make sure you have a plan for handling issues like paid sick leave or reporting COVID-19 cases to your local health department.

Another useful resource is the Medical Group Management Association’s COVID-19 Medical Practice Reopening Checklist. You can use it to confirm that you are addressing all the important items, and that you haven’t missed anything.

As for me, I am advising patients who are reluctant to seek treatment that many medical problems pose more risk than COVID-19, faster treatment means better outcomes, and because we maintain strict disinfection protocols, they are far less likely to be infected with COVID-19 in my office than, say, at a grocery store.
 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].

“Hey there – just checking on you and letting you know I’m thinking of you."

"I know words don't suffice right now. You are in my thoughts."

"If there's any way that I can be of support or if there's something you need, just let me know."

The texts and emails have come in waves. Pinging into my already distracted headspace when, like them, I’m supposed to be focused on a Zoom or WebEx department meeting. These somber reminders underscore what I have known for years but struggled to describe with each new “justice for” hashtag accompanying the name of the latest unarmed black person to die. This is grief.

With every headline in prior years, as black Americans we have usually found solace in our collective fellowship of suffering. Social media timelines become flooded with our own amen choirs and outrage along with words of comfort and inspiration. We remind ourselves of the prior atrocities survived by our people. And like them, we vow to rally; clinging to one other and praying to make it to shore. Though intermittently joined by a smattering of allies, our suffering has mostly been a private, repetitive mourning.
 

The two pandemics

The year 2020 ushered in a new decade along with the novel SARS-CoV2 (COVID-19) global pandemic. In addition to the thousands of lives that have been lost in the United States alone, COVID-19 brought with it a disruption of life in ways never seen by most generations. Schools and businesses were closed to mitigate spread. Mandatory shelter-in-place orders coupled with physical distancing recommendations limited human interactions and canceled everything from hospital visitations to graduations, intergenerational family gatherings, conferences, and weddings. As the data expanded, it quickly became apparent that minorities, particularly black Americans, shouldered a disproportionate burden of COVID-19. Known health disparities were amplified.

While caring for our patients as black physicians in the time of coronavirus, silently we mourned again. The connection and trust once found through racial concordance was now masked figuratively and literally by personal protective equipment (PPE). We ignored the sting of intimations that the staggering numbers of African Americans hospitalized and dying from COVID-19 could be explained by lack of discipline or, worse, genetic differences by race. Years of disenfranchisement and missed economic opportunities forced large numbers of our patients and loved ones out on the front lines to do essential jobs – but without the celebratory cheers or fanfare enjoyed by others. Frantic phone calls from family and acquaintances interrupted our quiet drives home from emotionally grueling shifts in the hospital – each conversation serving as our personal evidence of COVID-19 and her ruthless ravage of the black community. Add to this trying to serve as cultural bridges between the complexities of medical distrust and patient advocacy along with wrestling with our own vulnerability as potential COVID-19 patients, these have been overwhelming times to say the least.

Then came the acute decompensation of the chronic racism we’d always known in the form of three recent killings of more unarmed African Americans. On March 13, 2020, 26-year-old Breonna Taylor was shot after police forcibly entered her home after midnight on a “no knock” warrant. The story was buried in the news of COVID-19 – but we knew. Later we’d learn that 26-year-old Ahmaud Arbery was shot and killed by armed neighbors while running through a Brunswick, Georgia, neighborhood. His death on Feb. 23, 2020, initially yielded no criminal charges. Then, on May 25, 2020, George Floyd, a 46-year-old father arrested for suspected use of a counterfeit $20 bill, died after a law enforcement official kneeled with his full body weight upon Floyd’s neck for more than 8 minutes. The deaths of Arbery and Floyd were captured by cell phone cameras which, aided by social media, quickly reached the eyes of the entire world.

At first, it seemed plausible that this would be like it always has been. A black mother would stand before a podium filled with multiple microphones crying out in anguish. She would be flanked by community leaders and attorneys demanding justice. Hashtags would be formed. Our people would stand up or kneel down in solidarity – holding fast to our historic resilience. Evanescent allies would appear with signs on lawns and held high over heads. A few weeks would pass by and things would go back to normal. Black people would be left with what always remains: heads bowed and praying at dinner tables petitioning a higher power for protection followed by reaffirmations of what, if anything, could be done to keep our own mamas away from that podium. We’ve learned to treat the grief of racism as endemic to us alone, knowing that it has been a pandemic all along.
 

Dr. Manning is a professor of medicine and the associate vice chair of diversity, equity, and inclusion at Emory University in Atlanta, where she also is a hospitalist at Grady Memorial Hospital. To read the full version of this article, visit the Journal of Hospital Medicine, where it first appeared (doi: 10.12788/jhm.3481).

“Hey there – just checking on you and letting you know I’m thinking of you."

"I know words don't suffice right now. You are in my thoughts."

"If there's any way that I can be of support or if there's something you need, just let me know."

The texts and emails have come in waves. Pinging into my already distracted headspace when, like them, I’m supposed to be focused on a Zoom or WebEx department meeting. These somber reminders underscore what I have known for years but struggled to describe with each new “justice for” hashtag accompanying the name of the latest unarmed black person to die. This is grief.

With every headline in prior years, as black Americans we have usually found solace in our collective fellowship of suffering. Social media timelines become flooded with our own amen choirs and outrage along with words of comfort and inspiration. We remind ourselves of the prior atrocities survived by our people. And like them, we vow to rally; clinging to one other and praying to make it to shore. Though intermittently joined by a smattering of allies, our suffering has mostly been a private, repetitive mourning.
 

The two pandemics

The year 2020 ushered in a new decade along with the novel SARS-CoV2 (COVID-19) global pandemic. In addition to the thousands of lives that have been lost in the United States alone, COVID-19 brought with it a disruption of life in ways never seen by most generations. Schools and businesses were closed to mitigate spread. Mandatory shelter-in-place orders coupled with physical distancing recommendations limited human interactions and canceled everything from hospital visitations to graduations, intergenerational family gatherings, conferences, and weddings. As the data expanded, it quickly became apparent that minorities, particularly black Americans, shouldered a disproportionate burden of COVID-19. Known health disparities were amplified.

While caring for our patients as black physicians in the time of coronavirus, silently we mourned again. The connection and trust once found through racial concordance was now masked figuratively and literally by personal protective equipment (PPE). We ignored the sting of intimations that the staggering numbers of African Americans hospitalized and dying from COVID-19 could be explained by lack of discipline or, worse, genetic differences by race. Years of disenfranchisement and missed economic opportunities forced large numbers of our patients and loved ones out on the front lines to do essential jobs – but without the celebratory cheers or fanfare enjoyed by others. Frantic phone calls from family and acquaintances interrupted our quiet drives home from emotionally grueling shifts in the hospital – each conversation serving as our personal evidence of COVID-19 and her ruthless ravage of the black community. Add to this trying to serve as cultural bridges between the complexities of medical distrust and patient advocacy along with wrestling with our own vulnerability as potential COVID-19 patients, these have been overwhelming times to say the least.

Then came the acute decompensation of the chronic racism we’d always known in the form of three recent killings of more unarmed African Americans. On March 13, 2020, 26-year-old Breonna Taylor was shot after police forcibly entered her home after midnight on a “no knock” warrant. The story was buried in the news of COVID-19 – but we knew. Later we’d learn that 26-year-old Ahmaud Arbery was shot and killed by armed neighbors while running through a Brunswick, Georgia, neighborhood. His death on Feb. 23, 2020, initially yielded no criminal charges. Then, on May 25, 2020, George Floyd, a 46-year-old father arrested for suspected use of a counterfeit $20 bill, died after a law enforcement official kneeled with his full body weight upon Floyd’s neck for more than 8 minutes. The deaths of Arbery and Floyd were captured by cell phone cameras which, aided by social media, quickly reached the eyes of the entire world.

At first, it seemed plausible that this would be like it always has been. A black mother would stand before a podium filled with multiple microphones crying out in anguish. She would be flanked by community leaders and attorneys demanding justice. Hashtags would be formed. Our people would stand up or kneel down in solidarity – holding fast to our historic resilience. Evanescent allies would appear with signs on lawns and held high over heads. A few weeks would pass by and things would go back to normal. Black people would be left with what always remains: heads bowed and praying at dinner tables petitioning a higher power for protection followed by reaffirmations of what, if anything, could be done to keep our own mamas away from that podium. We’ve learned to treat the grief of racism as endemic to us alone, knowing that it has been a pandemic all along.
 

Dr. Manning is a professor of medicine and the associate vice chair of diversity, equity, and inclusion at Emory University in Atlanta, where she also is a hospitalist at Grady Memorial Hospital. To read the full version of this article, visit the Journal of Hospital Medicine, where it first appeared (doi: 10.12788/jhm.3481).

“Hey there – just checking on you and letting you know I’m thinking of you."

"I know words don't suffice right now. You are in my thoughts."

"If there's any way that I can be of support or if there's something you need, just let me know."

The texts and emails have come in waves. Pinging into my already distracted headspace when, like them, I’m supposed to be focused on a Zoom or WebEx department meeting. These somber reminders underscore what I have known for years but struggled to describe with each new “justice for” hashtag accompanying the name of the latest unarmed black person to die. This is grief.

With every headline in prior years, as black Americans we have usually found solace in our collective fellowship of suffering. Social media timelines become flooded with our own amen choirs and outrage along with words of comfort and inspiration. We remind ourselves of the prior atrocities survived by our people. And like them, we vow to rally; clinging to one other and praying to make it to shore. Though intermittently joined by a smattering of allies, our suffering has mostly been a private, repetitive mourning.
 

The two pandemics

The year 2020 ushered in a new decade along with the novel SARS-CoV2 (COVID-19) global pandemic. In addition to the thousands of lives that have been lost in the United States alone, COVID-19 brought with it a disruption of life in ways never seen by most generations. Schools and businesses were closed to mitigate spread. Mandatory shelter-in-place orders coupled with physical distancing recommendations limited human interactions and canceled everything from hospital visitations to graduations, intergenerational family gatherings, conferences, and weddings. As the data expanded, it quickly became apparent that minorities, particularly black Americans, shouldered a disproportionate burden of COVID-19. Known health disparities were amplified.

While caring for our patients as black physicians in the time of coronavirus, silently we mourned again. The connection and trust once found through racial concordance was now masked figuratively and literally by personal protective equipment (PPE). We ignored the sting of intimations that the staggering numbers of African Americans hospitalized and dying from COVID-19 could be explained by lack of discipline or, worse, genetic differences by race. Years of disenfranchisement and missed economic opportunities forced large numbers of our patients and loved ones out on the front lines to do essential jobs – but without the celebratory cheers or fanfare enjoyed by others. Frantic phone calls from family and acquaintances interrupted our quiet drives home from emotionally grueling shifts in the hospital – each conversation serving as our personal evidence of COVID-19 and her ruthless ravage of the black community. Add to this trying to serve as cultural bridges between the complexities of medical distrust and patient advocacy along with wrestling with our own vulnerability as potential COVID-19 patients, these have been overwhelming times to say the least.

Then came the acute decompensation of the chronic racism we’d always known in the form of three recent killings of more unarmed African Americans. On March 13, 2020, 26-year-old Breonna Taylor was shot after police forcibly entered her home after midnight on a “no knock” warrant. The story was buried in the news of COVID-19 – but we knew. Later we’d learn that 26-year-old Ahmaud Arbery was shot and killed by armed neighbors while running through a Brunswick, Georgia, neighborhood. His death on Feb. 23, 2020, initially yielded no criminal charges. Then, on May 25, 2020, George Floyd, a 46-year-old father arrested for suspected use of a counterfeit $20 bill, died after a law enforcement official kneeled with his full body weight upon Floyd’s neck for more than 8 minutes. The deaths of Arbery and Floyd were captured by cell phone cameras which, aided by social media, quickly reached the eyes of the entire world.

At first, it seemed plausible that this would be like it always has been. A black mother would stand before a podium filled with multiple microphones crying out in anguish. She would be flanked by community leaders and attorneys demanding justice. Hashtags would be formed. Our people would stand up or kneel down in solidarity – holding fast to our historic resilience. Evanescent allies would appear with signs on lawns and held high over heads. A few weeks would pass by and things would go back to normal. Black people would be left with what always remains: heads bowed and praying at dinner tables petitioning a higher power for protection followed by reaffirmations of what, if anything, could be done to keep our own mamas away from that podium. We’ve learned to treat the grief of racism as endemic to us alone, knowing that it has been a pandemic all along.
 

Dr. Manning is a professor of medicine and the associate vice chair of diversity, equity, and inclusion at Emory University in Atlanta, where she also is a hospitalist at Grady Memorial Hospital. To read the full version of this article, visit the Journal of Hospital Medicine, where it first appeared (doi: 10.12788/jhm.3481).

Acting as an expert witness in a legal matter can be a nice way to compliment your practice. However, it is important to understand the role of experts, as well as their duties and obligations. Expert witnesses are called to testify on the basis of their specialized knowledge, not necessarily their direct knowledge of events and issues in the case.

Medical experts often play an important role in the evaluation, development, and preparation of a case long before it ever goes to trial. In some states, to even file a medical malpractice complaint a plaintiff is required to have the case evaluated by an expert and obtain a written report outlining why the plaintiff has a reasonable and meritorious cause for filing such an action.

There are different types of expert witness testimony. Experts can give opinion testimony as a physician who provided treatment to the plaintiff and whose conduct is not at issue. The second type of expert witness is a retained or controlled expert witness. This is a person giving opinion testimony after being retained by a lawyer on behalf of one of the parties to the lawsuit.

Before you give deposition or trial testimony, your opinions must be disclosed in writing and provided to the other parties in the case. In federal court, this is governed by Federal Rule of Civil Procedure 26. If the case is pending in state court, your written opinions are governed by local court rules. In both cases, the written opinions should be thorough and complete because you will not be allowed to testify to new opinions at the time of trial but will generally be allowed to expand upon those disclosed in writing at your deposition trial.

In order for a jury to hear your opinions at trial, your opinions must be reliable. In federal court, expert testimony is governed by Federal Rule of Evidence 702, which states:

A witness who is qualified as an expert by knowledge, skill, experience, training, or education may testify in the form of an opinion or otherwise if:

a) the expert’s scientific, technical, or other specialized knowledge will help the trier of fact to understand the evidence or to determine a fact in issue;

b) the testimony is based on sufficient facts or data;

c) the testimony is the product of reliable principles and methods; and

d) the expert has reliably applied the principles and methods to the facts of the case.

This means, that if a fact or evidence at issue involves scientific, technical, or specialized knowledge that is outside the scope of an ordinary layman’s experience, or involves complex issues challenging a layman’s comprehension, expert testimony is required. The scientific evidence must not just be relevant but also reliable. Expert opinions will be scrutinized to see if they are based on scientific testing or review of scientific data rather than just assumptions or speculation. Additionally, the experts must be qualified by their knowledge, skill, experience, training, or education. Given these parameters, it should come as no surprise that expert trial testimony is required for all medical malpractice cases.

Some states follow the “new or novel rule” which dictates that expert testimony is only admissible if the methodology or scientific principal on which the opinion is based is sufficiently established to have gained general acceptance in the particular field in which it belongs. This means that the evidence must be generally accepted as reliable in the relevant scientific community. New or novel techniques will be placed under the scrutiny of this standard. Courts will look at papers, books, journals, and case law to make a determination as to the reliability and general acceptance. Failure to meet the requisite standards may render a physician ineligible to testify.

Mr. Mills is an equity partner at Cunningham, Meyer & Vedrine PC in Chicago. Ms. Lindbert is a partner at Cunningham, Meyer & Vedrine PC. Both focus their practices on defending doctors and hospitals in medical malpractice actions.

Acting as an expert witness in a legal matter can be a nice way to compliment your practice. However, it is important to understand the role of experts, as well as their duties and obligations. Expert witnesses are called to testify on the basis of their specialized knowledge, not necessarily their direct knowledge of events and issues in the case.

Medical experts often play an important role in the evaluation, development, and preparation of a case long before it ever goes to trial. In some states, to even file a medical malpractice complaint a plaintiff is required to have the case evaluated by an expert and obtain a written report outlining why the plaintiff has a reasonable and meritorious cause for filing such an action.

There are different types of expert witness testimony. Experts can give opinion testimony as a physician who provided treatment to the plaintiff and whose conduct is not at issue. The second type of expert witness is a retained or controlled expert witness. This is a person giving opinion testimony after being retained by a lawyer on behalf of one of the parties to the lawsuit.

Before you give deposition or trial testimony, your opinions must be disclosed in writing and provided to the other parties in the case. In federal court, this is governed by Federal Rule of Civil Procedure 26. If the case is pending in state court, your written opinions are governed by local court rules. In both cases, the written opinions should be thorough and complete because you will not be allowed to testify to new opinions at the time of trial but will generally be allowed to expand upon those disclosed in writing at your deposition trial.

In order for a jury to hear your opinions at trial, your opinions must be reliable. In federal court, expert testimony is governed by Federal Rule of Evidence 702, which states:

A witness who is qualified as an expert by knowledge, skill, experience, training, or education may testify in the form of an opinion or otherwise if:

a) the expert’s scientific, technical, or other specialized knowledge will help the trier of fact to understand the evidence or to determine a fact in issue;

b) the testimony is based on sufficient facts or data;

c) the testimony is the product of reliable principles and methods; and

d) the expert has reliably applied the principles and methods to the facts of the case.

This means, that if a fact or evidence at issue involves scientific, technical, or specialized knowledge that is outside the scope of an ordinary layman’s experience, or involves complex issues challenging a layman’s comprehension, expert testimony is required. The scientific evidence must not just be relevant but also reliable. Expert opinions will be scrutinized to see if they are based on scientific testing or review of scientific data rather than just assumptions or speculation. Additionally, the experts must be qualified by their knowledge, skill, experience, training, or education. Given these parameters, it should come as no surprise that expert trial testimony is required for all medical malpractice cases.

Some states follow the “new or novel rule” which dictates that expert testimony is only admissible if the methodology or scientific principal on which the opinion is based is sufficiently established to have gained general acceptance in the particular field in which it belongs. This means that the evidence must be generally accepted as reliable in the relevant scientific community. New or novel techniques will be placed under the scrutiny of this standard. Courts will look at papers, books, journals, and case law to make a determination as to the reliability and general acceptance. Failure to meet the requisite standards may render a physician ineligible to testify.

Mr. Mills is an equity partner at Cunningham, Meyer & Vedrine PC in Chicago. Ms. Lindbert is a partner at Cunningham, Meyer & Vedrine PC. Both focus their practices on defending doctors and hospitals in medical malpractice actions.

Acting as an expert witness in a legal matter can be a nice way to compliment your practice. However, it is important to understand the role of experts, as well as their duties and obligations. Expert witnesses are called to testify on the basis of their specialized knowledge, not necessarily their direct knowledge of events and issues in the case.

Medical experts often play an important role in the evaluation, development, and preparation of a case long before it ever goes to trial. In some states, to even file a medical malpractice complaint a plaintiff is required to have the case evaluated by an expert and obtain a written report outlining why the plaintiff has a reasonable and meritorious cause for filing such an action.

There are different types of expert witness testimony. Experts can give opinion testimony as a physician who provided treatment to the plaintiff and whose conduct is not at issue. The second type of expert witness is a retained or controlled expert witness. This is a person giving opinion testimony after being retained by a lawyer on behalf of one of the parties to the lawsuit.

Before you give deposition or trial testimony, your opinions must be disclosed in writing and provided to the other parties in the case. In federal court, this is governed by Federal Rule of Civil Procedure 26. If the case is pending in state court, your written opinions are governed by local court rules. In both cases, the written opinions should be thorough and complete because you will not be allowed to testify to new opinions at the time of trial but will generally be allowed to expand upon those disclosed in writing at your deposition trial.

In order for a jury to hear your opinions at trial, your opinions must be reliable. In federal court, expert testimony is governed by Federal Rule of Evidence 702, which states:

A witness who is qualified as an expert by knowledge, skill, experience, training, or education may testify in the form of an opinion or otherwise if:

a) the expert’s scientific, technical, or other specialized knowledge will help the trier of fact to understand the evidence or to determine a fact in issue;

b) the testimony is based on sufficient facts or data;

c) the testimony is the product of reliable principles and methods; and

d) the expert has reliably applied the principles and methods to the facts of the case.

This means, that if a fact or evidence at issue involves scientific, technical, or specialized knowledge that is outside the scope of an ordinary layman’s experience, or involves complex issues challenging a layman’s comprehension, expert testimony is required. The scientific evidence must not just be relevant but also reliable. Expert opinions will be scrutinized to see if they are based on scientific testing or review of scientific data rather than just assumptions or speculation. Additionally, the experts must be qualified by their knowledge, skill, experience, training, or education. Given these parameters, it should come as no surprise that expert trial testimony is required for all medical malpractice cases.

Some states follow the “new or novel rule” which dictates that expert testimony is only admissible if the methodology or scientific principal on which the opinion is based is sufficiently established to have gained general acceptance in the particular field in which it belongs. This means that the evidence must be generally accepted as reliable in the relevant scientific community. New or novel techniques will be placed under the scrutiny of this standard. Courts will look at papers, books, journals, and case law to make a determination as to the reliability and general acceptance. Failure to meet the requisite standards may render a physician ineligible to testify.

Mr. Mills is an equity partner at Cunningham, Meyer & Vedrine PC in Chicago. Ms. Lindbert is a partner at Cunningham, Meyer & Vedrine PC. Both focus their practices on defending doctors and hospitals in medical malpractice actions.

Grandma Exie used to tell a story about her grandmother on her father’s side, who lived in northeastern Arkansas. Towards the end of the Civil War, Northern and Southern troops were expected to “live off the land,” and both sides had torn through her poor dirt farm and carried off all the livestock and crops. The only thing they didn’t take was her bull mastiff, who was a pretty fair hunting and guard dog. Starving, she had no other option than to pack up and head east for Tennessee, where her husband was stationed with Joseph Hooker’s army. Many thousands of destitute women and children, most of whom were related to one of the troops, followed the army, where some of the army’s rations could be shared with them.

She headed out on foot and all went well until day 3 or so, when a panther attacked them, but she, armed with a branch, and her loyal dog were able to drive it off. The panther followed them for 3 days while she hid in a tree at night with her dog at the foot of a tree. Eventually, the panther gave up and she made it to Tennessee to safety.

Grandma Exie said her grandmother had “grit” and used this story whenever any of us would complain about how hard times were or how we were mistreated.

It is time for all of us to buck up and show a little grit in the face of a viral pandemic and social unrest. The answers are not easy or clear, but our health care system and our nation have faced much greater challenges. The 1918 flu pandemic was much more devastating, killing millions worldwide, and recall, 620,000 died in the Civil War, more than all other American wars combined. There is a deep seam of grit and resilience in Americans. We don’t always get it right immediately, but we usually do in the end.

The protests are justifiable outrage over police brutality, fueled by a high unemployment rate, both of which are a cause for frustration. The looting and destruction appears to be opportunistic thievery and some organized vandalization in my opinion. Most of the damage caused by riots and looting is not covered by insurance, and this will be a death blow to many small businesses already facing major financial setbacks as customers have stayed home for months and laying off staff has become necessary.

As for the impact on our practices, most physicians have been lucky and not been looted or burned out. Most of us have resumed practice, at least in a limited fashion, wearing masks; keeping the waiting room mostly empty; using social distancing and hand, air, and surface disinfection. In most of the country, the disease incidence has become lower, and the risk of not seeing the doctor is now greater than catching COVID-19.

So show grit, be careful, be vigilant, and practice your profession. Support your local small businesses, particularly if they have been the victims of senseless violence. We will work our way through these times.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. He had no disclosures related to this column. Write to him at [email protected].

Grandma Exie used to tell a story about her grandmother on her father’s side, who lived in northeastern Arkansas. Towards the end of the Civil War, Northern and Southern troops were expected to “live off the land,” and both sides had torn through her poor dirt farm and carried off all the livestock and crops. The only thing they didn’t take was her bull mastiff, who was a pretty fair hunting and guard dog. Starving, she had no other option than to pack up and head east for Tennessee, where her husband was stationed with Joseph Hooker’s army. Many thousands of destitute women and children, most of whom were related to one of the troops, followed the army, where some of the army’s rations could be shared with them.

She headed out on foot and all went well until day 3 or so, when a panther attacked them, but she, armed with a branch, and her loyal dog were able to drive it off. The panther followed them for 3 days while she hid in a tree at night with her dog at the foot of a tree. Eventually, the panther gave up and she made it to Tennessee to safety.

Grandma Exie said her grandmother had “grit” and used this story whenever any of us would complain about how hard times were or how we were mistreated.

It is time for all of us to buck up and show a little grit in the face of a viral pandemic and social unrest. The answers are not easy or clear, but our health care system and our nation have faced much greater challenges. The 1918 flu pandemic was much more devastating, killing millions worldwide, and recall, 620,000 died in the Civil War, more than all other American wars combined. There is a deep seam of grit and resilience in Americans. We don’t always get it right immediately, but we usually do in the end.

The protests are justifiable outrage over police brutality, fueled by a high unemployment rate, both of which are a cause for frustration. The looting and destruction appears to be opportunistic thievery and some organized vandalization in my opinion. Most of the damage caused by riots and looting is not covered by insurance, and this will be a death blow to many small businesses already facing major financial setbacks as customers have stayed home for months and laying off staff has become necessary.

As for the impact on our practices, most physicians have been lucky and not been looted or burned out. Most of us have resumed practice, at least in a limited fashion, wearing masks; keeping the waiting room mostly empty; using social distancing and hand, air, and surface disinfection. In most of the country, the disease incidence has become lower, and the risk of not seeing the doctor is now greater than catching COVID-19.

So show grit, be careful, be vigilant, and practice your profession. Support your local small businesses, particularly if they have been the victims of senseless violence. We will work our way through these times.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. He had no disclosures related to this column. Write to him at [email protected].

Grandma Exie used to tell a story about her grandmother on her father’s side, who lived in northeastern Arkansas. Towards the end of the Civil War, Northern and Southern troops were expected to “live off the land,” and both sides had torn through her poor dirt farm and carried off all the livestock and crops. The only thing they didn’t take was her bull mastiff, who was a pretty fair hunting and guard dog. Starving, she had no other option than to pack up and head east for Tennessee, where her husband was stationed with Joseph Hooker’s army. Many thousands of destitute women and children, most of whom were related to one of the troops, followed the army, where some of the army’s rations could be shared with them.

She headed out on foot and all went well until day 3 or so, when a panther attacked them, but she, armed with a branch, and her loyal dog were able to drive it off. The panther followed them for 3 days while she hid in a tree at night with her dog at the foot of a tree. Eventually, the panther gave up and she made it to Tennessee to safety.

Grandma Exie said her grandmother had “grit” and used this story whenever any of us would complain about how hard times were or how we were mistreated.

It is time for all of us to buck up and show a little grit in the face of a viral pandemic and social unrest. The answers are not easy or clear, but our health care system and our nation have faced much greater challenges. The 1918 flu pandemic was much more devastating, killing millions worldwide, and recall, 620,000 died in the Civil War, more than all other American wars combined. There is a deep seam of grit and resilience in Americans. We don’t always get it right immediately, but we usually do in the end.

The protests are justifiable outrage over police brutality, fueled by a high unemployment rate, both of which are a cause for frustration. The looting and destruction appears to be opportunistic thievery and some organized vandalization in my opinion. Most of the damage caused by riots and looting is not covered by insurance, and this will be a death blow to many small businesses already facing major financial setbacks as customers have stayed home for months and laying off staff has become necessary.

As for the impact on our practices, most physicians have been lucky and not been looted or burned out. Most of us have resumed practice, at least in a limited fashion, wearing masks; keeping the waiting room mostly empty; using social distancing and hand, air, and surface disinfection. In most of the country, the disease incidence has become lower, and the risk of not seeing the doctor is now greater than catching COVID-19.

So show grit, be careful, be vigilant, and practice your profession. Support your local small businesses, particularly if they have been the victims of senseless violence. We will work our way through these times.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. He had no disclosures related to this column. Write to him at [email protected].

Melissa R. Arbuckle, MD: Hi. I’m Dr. Melissa Arbuckle, vice chair for education and training in the Department of Psychiatry at Columbia University. I’m reporting on behalf of Medscape and our Columbia Psychiatry partnership. Today we’ll be discussing biomarkers with Dr. Jeffrey Lieberman. Welcome.

Jeffrey A. Lieberman, MD: Thanks, Melissa. Great to be here to talk about a subject that is near and dear to my heart.



Dr. Arbuckle: Dr. Lieberman is chair of the Department of Psychiatry at Columbia and is also director of the New York State Psychiatric Institute. Tell us about biomarkers and psychiatry, Dr Lieberman.

Dr. Lieberman: It would be nice if we had some! But first let me tell you what a biomarker is and what it would do for us. A biomarker is a biologic measure, a biologic feature, whether it’s blood pressure, pulse rate, an analyte in blood or cerebrospinal fluid, or a feature of an MRI or PET scan image of the brain that has diagnostic, prognostic, or theragnostic significance. A biomarker identifies an individual with symptoms of a specific disorder, indicates that they have this disorder, and can suggest a particular prognosis – less severe, more severe – or specify which treatment a person would likely respond to. For the entire history of our discipline, as long as physicians have studied mental illness, we have not had a diagnostic test for it. It’s a clinical diagnosis.

All illnesses in medicine began with clinical diagnosis: seizure disorder, epilepsy, was falling sickness; congestive heart failure was dropsy; for diabetes you tasted the urine to see if it was sweet or watery. But when we began to measure glucose and hemoglobin A1c, or when we developed the electrocardiogram to measure heart rhythms, and the electroencephalogram to measure brain activity, those were diagnostic tests based on biomarkers. We just don’t have them yet in psychiatry. The day we do have our first diagnostic tests, courtesy of a validated biomarker, will be a real milestone in the history of our profession.



Dr. Arbuckle: How far off might that be for psychiatry?

Dr. Lieberman: I’ve been in this profession for more than 30 years, and I’ve been saying for a while that it is coming soon. But we’re still waiting. Let me just add a cautionary note. Ever since psychiatry became scientifically minded and used scientific methodology and technology to understand the underpinnings of mental illness, there’s been an effort to identify biomarkers. It began in the 1960s with a series of false leads. There was something called the pink spot, as well as other metabolites, which were indicators on chromatographs linked to schizophrenia. This turned out to be wrong.

There was also the dexamethasone suppression test, to identify people who hypersecreted cortisol, which was believed to be diagnostic of depression. That turned out to be inadequate also.

There was the identification of genes beginning in the late 1980s. But the specific genes that indicated manic depressive illness and schizophrenia were not replicated. And now we know that the genetics of these disorders is polygenic and very complex.

So we cannot overpromise. I don’t want to say exactly when, but I will say that this is an area of intense research. There are a variety of different technologies that could yield this holy grail of diagnostic measures, including imaging measures such as MRI, PET, and nuclear medicine imaging, the use of genetics to create a polygenic risk score, and serologic analyses of blood to develop a panel of measures that may predict a specific condition or specific subtype of a condition.

It’s very likely, though, that we’ll not have a single pathognomonic test. I suspect that we’ll have several measures that, in combination, will be diagnostic or prognostic, in the same way that with cancer you have nomograms that give a prognosis. Or in the case of cardiovascular disease, where you have a lipid panel that takes into account a variety of lipid analytes to give you a risk score. I do believe that certainly within my professional lifetime, and hopefully sooner rather than later, we will see a diagnostic test.



Dr. Arbuckle: Given the different tests that did not pan out, what guidance can we offer clinicians as data come out and new potential biomarkers hit the media? How can we sift through what may or may not hold real promise?

Dr. Lieberman: I can tell practicing clinicians what not to do. Do not do what some of the charlatans in our field do. There are self-promoting psychiatrists out there who use SPECT scans to get a picture of the brain that is little more than pseudo color phrenology, and then they tell patients, “See this? This indicates that you have (this condition or that condition).” You can’t do that. Nothing we have now has that kind of validity or specificity.

However, even though a standard workup for an illness like schizophrenia does not require specific diagnostic tests, other than to rule out other conditions, imaging procedures can be useful additional information. For example, if you have an individual who presents with symptoms that meet criteria for schizophrenia and you obtain an MRI to rule out other possibilities, and the patient turns out to have dilated lateral ventricles or specific reductions in the size or distortions in the shape of certain temporal cortical structures, particularly in the hippocampus, that adds substance to your clinical diagnosis. So those kinds of things are useful. Similarly, with genetic testing, some institutions are now doing exome sequencing or whole genome sequencing that can provide a risk score. It adds something beyond a family history. These are not diagnostic, but they can add to your understanding.

Finally, with respect to schizophrenia and MRI in particular, if it does show structural abnormalities that are among the ones that have been reported for schizophrenia, this can be informative prognostically; such an individual may have a greater likelihood of having a chronic course with progression of the illness. And if that were my patient, I would be thinking that greater effort needs to be taken to ensure that the patient remains on treatment and does not suffer relapse.



Dr. Arbuckle: How do we prepare our trainees for a future of psychiatry with more biomarkers?

Dr. Lieberman: In medical school and postgraduate training, apart from understanding the method of diagnosis and the criteria for diagnoses, it’s important to understand the ancillary measures that are used in clinical medicine: blood testing, electrophysiologic measures, imaging procedures, neurocognitive testing, etc. This is a standard in terms of general medical training.

In terms of then applying it to mental illness and psychiatry, it’s a matter of knowing that these will be relevant at some point, staying apprised of the research literature that is generating data that pertain to the use of these measures for diagnostic, prognostic, or treatment-specific purposes, and then gauging how useful these will be. Right now, these measures are not required for diagnosis. They’re not validated sufficiently so that third-party payers will uniformly reimburse for them, but at some point they will be. Even before that time occurs, there are some measures that can be informative and enhance confidence in the diagnosis or add information about treatment response and outcome.



Dr. Arbuckle: We’re hearing about biotypes and how biotypes may not map to our current diagnostic systems. What are your thoughts about that?

Dr. Lieberman: You know, psychiatry has always been kind of the stepchild of medicine. And related to that, the Diagnostic and Statistical Manual of Mental Disorders (DSM) is the punching bag of the critics of psychiatry and the purported reason it hasn’t progressed faster. Sitting here at Columbia, the home of Robert Spitzer, who was the pioneer of the modern method of nosology that we still use in the DSM, it’s disappointing that we continue to lob tomatoes at this system, which is the best. It took psychiatry out of what was a dark age of clinical methodology and put it on solid scientific footing. That was in the late 1970s with [the development of] DSM-III.

And as much as we would like to have further progress, which would allow for not using a list of criteria in a menu-driven fashion to establish diagnoses, we’d like to have it be like a glucose tolerance test or an angiogram.

We’d like to do that, but we can’t yet. So there’s this aspirational desire to have something better, and this is permeating and motivating a lot of the research, which is good. But to claim that these don’t map to the current DSM and therefore invalidate the DSM-defined diagnoses is wrong and self-defeating. If the biotypes were validated, we would be using them. So if they don’t map to the current DSM diagnosis, is the diagnosis wrong or are the biotypes wrong? I believe it’s wishful thinking; individuals are trying to project their desires onto clinical practice, and it’s not desirable to do that. If there was anything that was an improvement on the DSM, it would have been incorporated into our practice.

The question about the limitations of DSM and the improved methods of neuroscientifically informed diagnostic systems was an issue that brought me into a confrontation with our former director of the National Institute of Mental Health (NIMH) in 2013.

After 5 years of the DSM task force laboring to revise the fifth edition of the DSM, as it was about to be launched, our former director, Tom Insel, disavowed it and proposed as a preferable alternative the research domains criteria (RDoC) system that was in development at the NIMH, which I believe epitomized this kind of sour grapes at what psychiatry didn’t have – an aspiration to have a more neuroscientifically informed diagnostic system. And as soon as he made the statement publicly, he had to walk it back because the RDoC system or any other system was not ready for prime time. It would have been a catastrophe if it would have been the one that informed clinical psychiatry. There was nothing that was superior to the DSM to be used at the time. This shows how frustration sometimes impels people to make rash statements.

We’re on the right track. Our field is progressing enormously, and one has to remember that everything that’s relevant in terms of being scientifically based and validated through empirical research in clinical psychiatry and mental illness has happened since the last half of the 20th century.

It is a very short period of time. We’ve made tremendous progress, and we’re continuing to make progress toward the milestone we’re all hoping for, where we have diagnostic tests. But we shouldn’t shortchange ourselves or underestimate the progress we have made in the meantime.
 

Dr. Arbuckle: This has been a great conversation. Signing off for Medscape and Columbia Psychiatry. Thank you.

Dr. Lieberman is chairman of the Department of Psychiatry at Columbia University. He is a former president of the American Psychiatric Association. Dr. Arbuckle is vice chair for education and director of resident education in the Department of Psychiatry at Columbia University. She is particularly interested in the role of medical education in translating research into the practice of psychiatry.

This article first appeared on Medscape.com.

Melissa R. Arbuckle, MD: Hi. I’m Dr. Melissa Arbuckle, vice chair for education and training in the Department of Psychiatry at Columbia University. I’m reporting on behalf of Medscape and our Columbia Psychiatry partnership. Today we’ll be discussing biomarkers with Dr. Jeffrey Lieberman. Welcome.

Jeffrey A. Lieberman, MD: Thanks, Melissa. Great to be here to talk about a subject that is near and dear to my heart.



Dr. Arbuckle: Dr. Lieberman is chair of the Department of Psychiatry at Columbia and is also director of the New York State Psychiatric Institute. Tell us about biomarkers and psychiatry, Dr Lieberman.

Dr. Lieberman: It would be nice if we had some! But first let me tell you what a biomarker is and what it would do for us. A biomarker is a biologic measure, a biologic feature, whether it’s blood pressure, pulse rate, an analyte in blood or cerebrospinal fluid, or a feature of an MRI or PET scan image of the brain that has diagnostic, prognostic, or theragnostic significance. A biomarker identifies an individual with symptoms of a specific disorder, indicates that they have this disorder, and can suggest a particular prognosis – less severe, more severe – or specify which treatment a person would likely respond to. For the entire history of our discipline, as long as physicians have studied mental illness, we have not had a diagnostic test for it. It’s a clinical diagnosis.

All illnesses in medicine began with clinical diagnosis: seizure disorder, epilepsy, was falling sickness; congestive heart failure was dropsy; for diabetes you tasted the urine to see if it was sweet or watery. But when we began to measure glucose and hemoglobin A1c, or when we developed the electrocardiogram to measure heart rhythms, and the electroencephalogram to measure brain activity, those were diagnostic tests based on biomarkers. We just don’t have them yet in psychiatry. The day we do have our first diagnostic tests, courtesy of a validated biomarker, will be a real milestone in the history of our profession.



Dr. Arbuckle: How far off might that be for psychiatry?

Dr. Lieberman: I’ve been in this profession for more than 30 years, and I’ve been saying for a while that it is coming soon. But we’re still waiting. Let me just add a cautionary note. Ever since psychiatry became scientifically minded and used scientific methodology and technology to understand the underpinnings of mental illness, there’s been an effort to identify biomarkers. It began in the 1960s with a series of false leads. There was something called the pink spot, as well as other metabolites, which were indicators on chromatographs linked to schizophrenia. This turned out to be wrong.

There was also the dexamethasone suppression test, to identify people who hypersecreted cortisol, which was believed to be diagnostic of depression. That turned out to be inadequate also.

There was the identification of genes beginning in the late 1980s. But the specific genes that indicated manic depressive illness and schizophrenia were not replicated. And now we know that the genetics of these disorders is polygenic and very complex.

So we cannot overpromise. I don’t want to say exactly when, but I will say that this is an area of intense research. There are a variety of different technologies that could yield this holy grail of diagnostic measures, including imaging measures such as MRI, PET, and nuclear medicine imaging, the use of genetics to create a polygenic risk score, and serologic analyses of blood to develop a panel of measures that may predict a specific condition or specific subtype of a condition.

It’s very likely, though, that we’ll not have a single pathognomonic test. I suspect that we’ll have several measures that, in combination, will be diagnostic or prognostic, in the same way that with cancer you have nomograms that give a prognosis. Or in the case of cardiovascular disease, where you have a lipid panel that takes into account a variety of lipid analytes to give you a risk score. I do believe that certainly within my professional lifetime, and hopefully sooner rather than later, we will see a diagnostic test.



Dr. Arbuckle: Given the different tests that did not pan out, what guidance can we offer clinicians as data come out and new potential biomarkers hit the media? How can we sift through what may or may not hold real promise?

Dr. Lieberman: I can tell practicing clinicians what not to do. Do not do what some of the charlatans in our field do. There are self-promoting psychiatrists out there who use SPECT scans to get a picture of the brain that is little more than pseudo color phrenology, and then they tell patients, “See this? This indicates that you have (this condition or that condition).” You can’t do that. Nothing we have now has that kind of validity or specificity.

However, even though a standard workup for an illness like schizophrenia does not require specific diagnostic tests, other than to rule out other conditions, imaging procedures can be useful additional information. For example, if you have an individual who presents with symptoms that meet criteria for schizophrenia and you obtain an MRI to rule out other possibilities, and the patient turns out to have dilated lateral ventricles or specific reductions in the size or distortions in the shape of certain temporal cortical structures, particularly in the hippocampus, that adds substance to your clinical diagnosis. So those kinds of things are useful. Similarly, with genetic testing, some institutions are now doing exome sequencing or whole genome sequencing that can provide a risk score. It adds something beyond a family history. These are not diagnostic, but they can add to your understanding.

Finally, with respect to schizophrenia and MRI in particular, if it does show structural abnormalities that are among the ones that have been reported for schizophrenia, this can be informative prognostically; such an individual may have a greater likelihood of having a chronic course with progression of the illness. And if that were my patient, I would be thinking that greater effort needs to be taken to ensure that the patient remains on treatment and does not suffer relapse.



Dr. Arbuckle: How do we prepare our trainees for a future of psychiatry with more biomarkers?

Dr. Lieberman: In medical school and postgraduate training, apart from understanding the method of diagnosis and the criteria for diagnoses, it’s important to understand the ancillary measures that are used in clinical medicine: blood testing, electrophysiologic measures, imaging procedures, neurocognitive testing, etc. This is a standard in terms of general medical training.

In terms of then applying it to mental illness and psychiatry, it’s a matter of knowing that these will be relevant at some point, staying apprised of the research literature that is generating data that pertain to the use of these measures for diagnostic, prognostic, or treatment-specific purposes, and then gauging how useful these will be. Right now, these measures are not required for diagnosis. They’re not validated sufficiently so that third-party payers will uniformly reimburse for them, but at some point they will be. Even before that time occurs, there are some measures that can be informative and enhance confidence in the diagnosis or add information about treatment response and outcome.



Dr. Arbuckle: We’re hearing about biotypes and how biotypes may not map to our current diagnostic systems. What are your thoughts about that?

Dr. Lieberman: You know, psychiatry has always been kind of the stepchild of medicine. And related to that, the Diagnostic and Statistical Manual of Mental Disorders (DSM) is the punching bag of the critics of psychiatry and the purported reason it hasn’t progressed faster. Sitting here at Columbia, the home of Robert Spitzer, who was the pioneer of the modern method of nosology that we still use in the DSM, it’s disappointing that we continue to lob tomatoes at this system, which is the best. It took psychiatry out of what was a dark age of clinical methodology and put it on solid scientific footing. That was in the late 1970s with [the development of] DSM-III.

And as much as we would like to have further progress, which would allow for not using a list of criteria in a menu-driven fashion to establish diagnoses, we’d like to have it be like a glucose tolerance test or an angiogram.

We’d like to do that, but we can’t yet. So there’s this aspirational desire to have something better, and this is permeating and motivating a lot of the research, which is good. But to claim that these don’t map to the current DSM and therefore invalidate the DSM-defined diagnoses is wrong and self-defeating. If the biotypes were validated, we would be using them. So if they don’t map to the current DSM diagnosis, is the diagnosis wrong or are the biotypes wrong? I believe it’s wishful thinking; individuals are trying to project their desires onto clinical practice, and it’s not desirable to do that. If there was anything that was an improvement on the DSM, it would have been incorporated into our practice.

The question about the limitations of DSM and the improved methods of neuroscientifically informed diagnostic systems was an issue that brought me into a confrontation with our former director of the National Institute of Mental Health (NIMH) in 2013.

After 5 years of the DSM task force laboring to revise the fifth edition of the DSM, as it was about to be launched, our former director, Tom Insel, disavowed it and proposed as a preferable alternative the research domains criteria (RDoC) system that was in development at the NIMH, which I believe epitomized this kind of sour grapes at what psychiatry didn’t have – an aspiration to have a more neuroscientifically informed diagnostic system. And as soon as he made the statement publicly, he had to walk it back because the RDoC system or any other system was not ready for prime time. It would have been a catastrophe if it would have been the one that informed clinical psychiatry. There was nothing that was superior to the DSM to be used at the time. This shows how frustration sometimes impels people to make rash statements.

We’re on the right track. Our field is progressing enormously, and one has to remember that everything that’s relevant in terms of being scientifically based and validated through empirical research in clinical psychiatry and mental illness has happened since the last half of the 20th century.

It is a very short period of time. We’ve made tremendous progress, and we’re continuing to make progress toward the milestone we’re all hoping for, where we have diagnostic tests. But we shouldn’t shortchange ourselves or underestimate the progress we have made in the meantime.
 

Dr. Arbuckle: This has been a great conversation. Signing off for Medscape and Columbia Psychiatry. Thank you.

Dr. Lieberman is chairman of the Department of Psychiatry at Columbia University. He is a former president of the American Psychiatric Association. Dr. Arbuckle is vice chair for education and director of resident education in the Department of Psychiatry at Columbia University. She is particularly interested in the role of medical education in translating research into the practice of psychiatry.

This article first appeared on Medscape.com.

Melissa R. Arbuckle, MD: Hi. I’m Dr. Melissa Arbuckle, vice chair for education and training in the Department of Psychiatry at Columbia University. I’m reporting on behalf of Medscape and our Columbia Psychiatry partnership. Today we’ll be discussing biomarkers with Dr. Jeffrey Lieberman. Welcome.

Jeffrey A. Lieberman, MD: Thanks, Melissa. Great to be here to talk about a subject that is near and dear to my heart.



Dr. Arbuckle: Dr. Lieberman is chair of the Department of Psychiatry at Columbia and is also director of the New York State Psychiatric Institute. Tell us about biomarkers and psychiatry, Dr Lieberman.

Dr. Lieberman: It would be nice if we had some! But first let me tell you what a biomarker is and what it would do for us. A biomarker is a biologic measure, a biologic feature, whether it’s blood pressure, pulse rate, an analyte in blood or cerebrospinal fluid, or a feature of an MRI or PET scan image of the brain that has diagnostic, prognostic, or theragnostic significance. A biomarker identifies an individual with symptoms of a specific disorder, indicates that they have this disorder, and can suggest a particular prognosis – less severe, more severe – or specify which treatment a person would likely respond to. For the entire history of our discipline, as long as physicians have studied mental illness, we have not had a diagnostic test for it. It’s a clinical diagnosis.

All illnesses in medicine began with clinical diagnosis: seizure disorder, epilepsy, was falling sickness; congestive heart failure was dropsy; for diabetes you tasted the urine to see if it was sweet or watery. But when we began to measure glucose and hemoglobin A1c, or when we developed the electrocardiogram to measure heart rhythms, and the electroencephalogram to measure brain activity, those were diagnostic tests based on biomarkers. We just don’t have them yet in psychiatry. The day we do have our first diagnostic tests, courtesy of a validated biomarker, will be a real milestone in the history of our profession.



Dr. Arbuckle: How far off might that be for psychiatry?

Dr. Lieberman: I’ve been in this profession for more than 30 years, and I’ve been saying for a while that it is coming soon. But we’re still waiting. Let me just add a cautionary note. Ever since psychiatry became scientifically minded and used scientific methodology and technology to understand the underpinnings of mental illness, there’s been an effort to identify biomarkers. It began in the 1960s with a series of false leads. There was something called the pink spot, as well as other metabolites, which were indicators on chromatographs linked to schizophrenia. This turned out to be wrong.

There was also the dexamethasone suppression test, to identify people who hypersecreted cortisol, which was believed to be diagnostic of depression. That turned out to be inadequate also.

There was the identification of genes beginning in the late 1980s. But the specific genes that indicated manic depressive illness and schizophrenia were not replicated. And now we know that the genetics of these disorders is polygenic and very complex.

So we cannot overpromise. I don’t want to say exactly when, but I will say that this is an area of intense research. There are a variety of different technologies that could yield this holy grail of diagnostic measures, including imaging measures such as MRI, PET, and nuclear medicine imaging, the use of genetics to create a polygenic risk score, and serologic analyses of blood to develop a panel of measures that may predict a specific condition or specific subtype of a condition.

It’s very likely, though, that we’ll not have a single pathognomonic test. I suspect that we’ll have several measures that, in combination, will be diagnostic or prognostic, in the same way that with cancer you have nomograms that give a prognosis. Or in the case of cardiovascular disease, where you have a lipid panel that takes into account a variety of lipid analytes to give you a risk score. I do believe that certainly within my professional lifetime, and hopefully sooner rather than later, we will see a diagnostic test.



Dr. Arbuckle: Given the different tests that did not pan out, what guidance can we offer clinicians as data come out and new potential biomarkers hit the media? How can we sift through what may or may not hold real promise?

Dr. Lieberman: I can tell practicing clinicians what not to do. Do not do what some of the charlatans in our field do. There are self-promoting psychiatrists out there who use SPECT scans to get a picture of the brain that is little more than pseudo color phrenology, and then they tell patients, “See this? This indicates that you have (this condition or that condition).” You can’t do that. Nothing we have now has that kind of validity or specificity.

However, even though a standard workup for an illness like schizophrenia does not require specific diagnostic tests, other than to rule out other conditions, imaging procedures can be useful additional information. For example, if you have an individual who presents with symptoms that meet criteria for schizophrenia and you obtain an MRI to rule out other possibilities, and the patient turns out to have dilated lateral ventricles or specific reductions in the size or distortions in the shape of certain temporal cortical structures, particularly in the hippocampus, that adds substance to your clinical diagnosis. So those kinds of things are useful. Similarly, with genetic testing, some institutions are now doing exome sequencing or whole genome sequencing that can provide a risk score. It adds something beyond a family history. These are not diagnostic, but they can add to your understanding.

Finally, with respect to schizophrenia and MRI in particular, if it does show structural abnormalities that are among the ones that have been reported for schizophrenia, this can be informative prognostically; such an individual may have a greater likelihood of having a chronic course with progression of the illness. And if that were my patient, I would be thinking that greater effort needs to be taken to ensure that the patient remains on treatment and does not suffer relapse.



Dr. Arbuckle: How do we prepare our trainees for a future of psychiatry with more biomarkers?

Dr. Lieberman: In medical school and postgraduate training, apart from understanding the method of diagnosis and the criteria for diagnoses, it’s important to understand the ancillary measures that are used in clinical medicine: blood testing, electrophysiologic measures, imaging procedures, neurocognitive testing, etc. This is a standard in terms of general medical training.

In terms of then applying it to mental illness and psychiatry, it’s a matter of knowing that these will be relevant at some point, staying apprised of the research literature that is generating data that pertain to the use of these measures for diagnostic, prognostic, or treatment-specific purposes, and then gauging how useful these will be. Right now, these measures are not required for diagnosis. They’re not validated sufficiently so that third-party payers will uniformly reimburse for them, but at some point they will be. Even before that time occurs, there are some measures that can be informative and enhance confidence in the diagnosis or add information about treatment response and outcome.



Dr. Arbuckle: We’re hearing about biotypes and how biotypes may not map to our current diagnostic systems. What are your thoughts about that?

Dr. Lieberman: You know, psychiatry has always been kind of the stepchild of medicine. And related to that, the Diagnostic and Statistical Manual of Mental Disorders (DSM) is the punching bag of the critics of psychiatry and the purported reason it hasn’t progressed faster. Sitting here at Columbia, the home of Robert Spitzer, who was the pioneer of the modern method of nosology that we still use in the DSM, it’s disappointing that we continue to lob tomatoes at this system, which is the best. It took psychiatry out of what was a dark age of clinical methodology and put it on solid scientific footing. That was in the late 1970s with [the development of] DSM-III.

And as much as we would like to have further progress, which would allow for not using a list of criteria in a menu-driven fashion to establish diagnoses, we’d like to have it be like a glucose tolerance test or an angiogram.

We’d like to do that, but we can’t yet. So there’s this aspirational desire to have something better, and this is permeating and motivating a lot of the research, which is good. But to claim that these don’t map to the current DSM and therefore invalidate the DSM-defined diagnoses is wrong and self-defeating. If the biotypes were validated, we would be using them. So if they don’t map to the current DSM diagnosis, is the diagnosis wrong or are the biotypes wrong? I believe it’s wishful thinking; individuals are trying to project their desires onto clinical practice, and it’s not desirable to do that. If there was anything that was an improvement on the DSM, it would have been incorporated into our practice.

The question about the limitations of DSM and the improved methods of neuroscientifically informed diagnostic systems was an issue that brought me into a confrontation with our former director of the National Institute of Mental Health (NIMH) in 2013.

After 5 years of the DSM task force laboring to revise the fifth edition of the DSM, as it was about to be launched, our former director, Tom Insel, disavowed it and proposed as a preferable alternative the research domains criteria (RDoC) system that was in development at the NIMH, which I believe epitomized this kind of sour grapes at what psychiatry didn’t have – an aspiration to have a more neuroscientifically informed diagnostic system. And as soon as he made the statement publicly, he had to walk it back because the RDoC system or any other system was not ready for prime time. It would have been a catastrophe if it would have been the one that informed clinical psychiatry. There was nothing that was superior to the DSM to be used at the time. This shows how frustration sometimes impels people to make rash statements.

We’re on the right track. Our field is progressing enormously, and one has to remember that everything that’s relevant in terms of being scientifically based and validated through empirical research in clinical psychiatry and mental illness has happened since the last half of the 20th century.

It is a very short period of time. We’ve made tremendous progress, and we’re continuing to make progress toward the milestone we’re all hoping for, where we have diagnostic tests. But we shouldn’t shortchange ourselves or underestimate the progress we have made in the meantime.
 

Dr. Arbuckle: This has been a great conversation. Signing off for Medscape and Columbia Psychiatry. Thank you.

Dr. Lieberman is chairman of the Department of Psychiatry at Columbia University. He is a former president of the American Psychiatric Association. Dr. Arbuckle is vice chair for education and director of resident education in the Department of Psychiatry at Columbia University. She is particularly interested in the role of medical education in translating research into the practice of psychiatry.

This article first appeared on Medscape.com.

Food insecurity is not knowing how you will get your next meal. This pandemic has led to a lot of it, especially as a result of massive unemployment. Now imagine being in that situation with a food-allergic child. It would be frightening.

There is always a level of anxiety for parents of food-allergic children, but the Food and Drug Administration–mandated labeling of food allergens has helped to allay some of those concerns. Shopping can feel safer, even if it’s not foolproof.

Now, that fear for the safety of food-allergic children is going to be compounded by the FDA’s latest announcement, made at the behest of the food industry.

Disruptions in the food supply chain caused by the COVID-19 pandemic have created some problems for the food industry. The industry sought – and received – relief from the FDA; they are now allowing some ingredient substitutions without mandating a change in labeling. These changes were made without opportunity for public comment, according to the FDA, because of the exigency of the situation. Furthermore, the changes may stay in effect for an indeterminate period of time after the pandemic is deemed under control.

Labeling of gluten and the major eight allergens (peanuts, tree nuts, milk, eggs, soy, wheat, fish, and crustacean shellfish) cannot change under the new guidelines. The FDA also advised “consideration” of major food allergens recognized in other countries (sesame, celery, lupin, buckwheat, molluscan shellfish, and mustard). Of these, lupin is known to cross-react with peanut, and sesame seed allergy is increasingly prevalent. In fact, the FDA has considered adding it to the list of major allergens.

Meanwhile, according to this temporary FDA policy, substitutions should be limited to no more than 2% of the weight of the final product unless it is a variety of the same ingredient. The example provided is substitution of one type of mushroom for another, but even that could be an issue for the rare patient. And what if this is misinterpreted – as will surely happen somewhere – and one seed is substituted for another?

A friend of mine is a pediatrician and mother of a child who is allergic to sesame, peanuts, tree nuts, and garbanzo beans. Naturally, she had grave concerns about these changes. She also wondered what the liability would be for the food manufacturing company in the current situation despite the FDA notice, which seems like a valid point. It is worth noting that, at the very top of this FDA notice, are the words “contains nonbinding recommendations,” so manufacturers may want to think twice about how they approach this. A minority of companies have pledged to relabel foods if necessary. Meanwhile, without any alert in advance, it is now up to patients and their physicians to sort out the attendant risks.

The FDA should have advised or mandated that food manufacturers give notice to online and physical retailers of ingredient changes. A simple sign in front of a display or alert online would be a very reasonable solution and pose no burden to those involved. It should be self-evident that mistakes always happen, especially under duress, and that the loosening of these regulations will have unintended consequences. To the severe problem of food insecurity, we can add one more concern for the parents of allergic children: food-allergen insecurity.

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

Food insecurity is not knowing how you will get your next meal. This pandemic has led to a lot of it, especially as a result of massive unemployment. Now imagine being in that situation with a food-allergic child. It would be frightening.

There is always a level of anxiety for parents of food-allergic children, but the Food and Drug Administration–mandated labeling of food allergens has helped to allay some of those concerns. Shopping can feel safer, even if it’s not foolproof.

Now, that fear for the safety of food-allergic children is going to be compounded by the FDA’s latest announcement, made at the behest of the food industry.

Disruptions in the food supply chain caused by the COVID-19 pandemic have created some problems for the food industry. The industry sought – and received – relief from the FDA; they are now allowing some ingredient substitutions without mandating a change in labeling. These changes were made without opportunity for public comment, according to the FDA, because of the exigency of the situation. Furthermore, the changes may stay in effect for an indeterminate period of time after the pandemic is deemed under control.

Labeling of gluten and the major eight allergens (peanuts, tree nuts, milk, eggs, soy, wheat, fish, and crustacean shellfish) cannot change under the new guidelines. The FDA also advised “consideration” of major food allergens recognized in other countries (sesame, celery, lupin, buckwheat, molluscan shellfish, and mustard). Of these, lupin is known to cross-react with peanut, and sesame seed allergy is increasingly prevalent. In fact, the FDA has considered adding it to the list of major allergens.

Meanwhile, according to this temporary FDA policy, substitutions should be limited to no more than 2% of the weight of the final product unless it is a variety of the same ingredient. The example provided is substitution of one type of mushroom for another, but even that could be an issue for the rare patient. And what if this is misinterpreted – as will surely happen somewhere – and one seed is substituted for another?

A friend of mine is a pediatrician and mother of a child who is allergic to sesame, peanuts, tree nuts, and garbanzo beans. Naturally, she had grave concerns about these changes. She also wondered what the liability would be for the food manufacturing company in the current situation despite the FDA notice, which seems like a valid point. It is worth noting that, at the very top of this FDA notice, are the words “contains nonbinding recommendations,” so manufacturers may want to think twice about how they approach this. A minority of companies have pledged to relabel foods if necessary. Meanwhile, without any alert in advance, it is now up to patients and their physicians to sort out the attendant risks.

The FDA should have advised or mandated that food manufacturers give notice to online and physical retailers of ingredient changes. A simple sign in front of a display or alert online would be a very reasonable solution and pose no burden to those involved. It should be self-evident that mistakes always happen, especially under duress, and that the loosening of these regulations will have unintended consequences. To the severe problem of food insecurity, we can add one more concern for the parents of allergic children: food-allergen insecurity.

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

Food insecurity is not knowing how you will get your next meal. This pandemic has led to a lot of it, especially as a result of massive unemployment. Now imagine being in that situation with a food-allergic child. It would be frightening.

There is always a level of anxiety for parents of food-allergic children, but the Food and Drug Administration–mandated labeling of food allergens has helped to allay some of those concerns. Shopping can feel safer, even if it’s not foolproof.

Now, that fear for the safety of food-allergic children is going to be compounded by the FDA’s latest announcement, made at the behest of the food industry.

Disruptions in the food supply chain caused by the COVID-19 pandemic have created some problems for the food industry. The industry sought – and received – relief from the FDA; they are now allowing some ingredient substitutions without mandating a change in labeling. These changes were made without opportunity for public comment, according to the FDA, because of the exigency of the situation. Furthermore, the changes may stay in effect for an indeterminate period of time after the pandemic is deemed under control.

Labeling of gluten and the major eight allergens (peanuts, tree nuts, milk, eggs, soy, wheat, fish, and crustacean shellfish) cannot change under the new guidelines. The FDA also advised “consideration” of major food allergens recognized in other countries (sesame, celery, lupin, buckwheat, molluscan shellfish, and mustard). Of these, lupin is known to cross-react with peanut, and sesame seed allergy is increasingly prevalent. In fact, the FDA has considered adding it to the list of major allergens.

Meanwhile, according to this temporary FDA policy, substitutions should be limited to no more than 2% of the weight of the final product unless it is a variety of the same ingredient. The example provided is substitution of one type of mushroom for another, but even that could be an issue for the rare patient. And what if this is misinterpreted – as will surely happen somewhere – and one seed is substituted for another?

A friend of mine is a pediatrician and mother of a child who is allergic to sesame, peanuts, tree nuts, and garbanzo beans. Naturally, she had grave concerns about these changes. She also wondered what the liability would be for the food manufacturing company in the current situation despite the FDA notice, which seems like a valid point. It is worth noting that, at the very top of this FDA notice, are the words “contains nonbinding recommendations,” so manufacturers may want to think twice about how they approach this. A minority of companies have pledged to relabel foods if necessary. Meanwhile, without any alert in advance, it is now up to patients and their physicians to sort out the attendant risks.

The FDA should have advised or mandated that food manufacturers give notice to online and physical retailers of ingredient changes. A simple sign in front of a display or alert online would be a very reasonable solution and pose no burden to those involved. It should be self-evident that mistakes always happen, especially under duress, and that the loosening of these regulations will have unintended consequences. To the severe problem of food insecurity, we can add one more concern for the parents of allergic children: food-allergen insecurity.

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

I am writing this commentary to bring to readers’ attention a medical and ethical complexity related to human sitters for presumably suicidal, COVID-19–positive hospitalized patients.

To shape and bundle the ethics issues addressed here into a single question, I offer the following: Should policies and practices requiring that patients in presumed need of a sitter because of assessed suicidality change when the patient is COVID-19–positive? Although the analysis might be similar when a sitter is monitoring a Patient Under Investigation (PUI), here I focus only on COVID-19–positive patients. Similarly, there are other reasons for sitters, of course, such as to prevent elopement, or, if a patient is in restraints, to prevent the patient from pulling out lines or tubes. Again, discussion of some of these ethical complications is beyond the scope of this piece. Just considering the matter of potential suicidality and sitters is complex enough. And so, to start, I sought out existing sources for guidance.

In looking for such sources, I first turned to the Centers for Medicare and Medicaid Services before COVID-19. CMS has required that there be a sitter for a patient who is suicidal and that the sitter remain in the room so that the sitter can intervene expeditiously if the patient tries to hurt himself or herself. There has been no change in this guidance since the COVID-19 pandemic in the United States. To the best of my knowledge, there is no substantive guidance for protecting sitters from contagion other than PPE. Given this, it begs the question: Shouldn’t the CMS guidance be changed to allow for hospitals to study different approaches to contagion reduction for sitters?

In my hospital, I already have begun discussing the potential risks of harm and potential benefits to our suicidal patients of having a sitter directly outside the patient’s room. I also have considered whether to have one sitter watching several room cameras at once, commonly referred to as “telehealth strategies.”

To be sure, sitting for hours in the room of a COVID-19–positive patient is onerous. The sitter is required to be in full PPE (N-95 mask, gown, and gloves), which is hot and uncomfortable. Current practice is resource intensive in other ways. It requires changing out the sitter every 2 hours, which uses substantial amounts of PPE and multiple sitters.

Regardless, however, there are really no data upon which to base any sound ethics judgment about what should or should not be tried. We just have no information on how to attempt to balance potential risks and prospects for the benefit of whom and when. And, given that good clinical ethics always begin with the facts, I write this piece to see whether readers have thought about these issues before – and whether any of clinicians have started collecting the valuable data needed to begin making sound ethical judgments about how to care for our presumably suicidal COVID-19–positive patients and the sitters who watch over them.
 

Dr. Ritchie is chair of psychiatry at Medstar Washington Hospital Center and professor of psychiatry at Georgetown University, Washington. She has no disclosures and can be reached at [email protected].

This column is an outcome of a discussion that occurred during Psych/Ethics rounds on June 5, and does not represent any official statements of Medstar Washington Hospital Center or any entity of the MedStar Corp. Dr. Ritchie would like to thank Evan G. DeRenzo, PhD, of the John J. Lynch Center for Ethics, for her thoughtful review of a previous draft of this commentary.

I am writing this commentary to bring to readers’ attention a medical and ethical complexity related to human sitters for presumably suicidal, COVID-19–positive hospitalized patients.

To shape and bundle the ethics issues addressed here into a single question, I offer the following: Should policies and practices requiring that patients in presumed need of a sitter because of assessed suicidality change when the patient is COVID-19–positive? Although the analysis might be similar when a sitter is monitoring a Patient Under Investigation (PUI), here I focus only on COVID-19–positive patients. Similarly, there are other reasons for sitters, of course, such as to prevent elopement, or, if a patient is in restraints, to prevent the patient from pulling out lines or tubes. Again, discussion of some of these ethical complications is beyond the scope of this piece. Just considering the matter of potential suicidality and sitters is complex enough. And so, to start, I sought out existing sources for guidance.

In looking for such sources, I first turned to the Centers for Medicare and Medicaid Services before COVID-19. CMS has required that there be a sitter for a patient who is suicidal and that the sitter remain in the room so that the sitter can intervene expeditiously if the patient tries to hurt himself or herself. There has been no change in this guidance since the COVID-19 pandemic in the United States. To the best of my knowledge, there is no substantive guidance for protecting sitters from contagion other than PPE. Given this, it begs the question: Shouldn’t the CMS guidance be changed to allow for hospitals to study different approaches to contagion reduction for sitters?

In my hospital, I already have begun discussing the potential risks of harm and potential benefits to our suicidal patients of having a sitter directly outside the patient’s room. I also have considered whether to have one sitter watching several room cameras at once, commonly referred to as “telehealth strategies.”

To be sure, sitting for hours in the room of a COVID-19–positive patient is onerous. The sitter is required to be in full PPE (N-95 mask, gown, and gloves), which is hot and uncomfortable. Current practice is resource intensive in other ways. It requires changing out the sitter every 2 hours, which uses substantial amounts of PPE and multiple sitters.

Regardless, however, there are really no data upon which to base any sound ethics judgment about what should or should not be tried. We just have no information on how to attempt to balance potential risks and prospects for the benefit of whom and when. And, given that good clinical ethics always begin with the facts, I write this piece to see whether readers have thought about these issues before – and whether any of clinicians have started collecting the valuable data needed to begin making sound ethical judgments about how to care for our presumably suicidal COVID-19–positive patients and the sitters who watch over them.
 

Dr. Ritchie is chair of psychiatry at Medstar Washington Hospital Center and professor of psychiatry at Georgetown University, Washington. She has no disclosures and can be reached at [email protected].

This column is an outcome of a discussion that occurred during Psych/Ethics rounds on June 5, and does not represent any official statements of Medstar Washington Hospital Center or any entity of the MedStar Corp. Dr. Ritchie would like to thank Evan G. DeRenzo, PhD, of the John J. Lynch Center for Ethics, for her thoughtful review of a previous draft of this commentary.

I am writing this commentary to bring to readers’ attention a medical and ethical complexity related to human sitters for presumably suicidal, COVID-19–positive hospitalized patients.

To shape and bundle the ethics issues addressed here into a single question, I offer the following: Should policies and practices requiring that patients in presumed need of a sitter because of assessed suicidality change when the patient is COVID-19–positive? Although the analysis might be similar when a sitter is monitoring a Patient Under Investigation (PUI), here I focus only on COVID-19–positive patients. Similarly, there are other reasons for sitters, of course, such as to prevent elopement, or, if a patient is in restraints, to prevent the patient from pulling out lines or tubes. Again, discussion of some of these ethical complications is beyond the scope of this piece. Just considering the matter of potential suicidality and sitters is complex enough. And so, to start, I sought out existing sources for guidance.

In looking for such sources, I first turned to the Centers for Medicare and Medicaid Services before COVID-19. CMS has required that there be a sitter for a patient who is suicidal and that the sitter remain in the room so that the sitter can intervene expeditiously if the patient tries to hurt himself or herself. There has been no change in this guidance since the COVID-19 pandemic in the United States. To the best of my knowledge, there is no substantive guidance for protecting sitters from contagion other than PPE. Given this, it begs the question: Shouldn’t the CMS guidance be changed to allow for hospitals to study different approaches to contagion reduction for sitters?

In my hospital, I already have begun discussing the potential risks of harm and potential benefits to our suicidal patients of having a sitter directly outside the patient’s room. I also have considered whether to have one sitter watching several room cameras at once, commonly referred to as “telehealth strategies.”

To be sure, sitting for hours in the room of a COVID-19–positive patient is onerous. The sitter is required to be in full PPE (N-95 mask, gown, and gloves), which is hot and uncomfortable. Current practice is resource intensive in other ways. It requires changing out the sitter every 2 hours, which uses substantial amounts of PPE and multiple sitters.

Regardless, however, there are really no data upon which to base any sound ethics judgment about what should or should not be tried. We just have no information on how to attempt to balance potential risks and prospects for the benefit of whom and when. And, given that good clinical ethics always begin with the facts, I write this piece to see whether readers have thought about these issues before – and whether any of clinicians have started collecting the valuable data needed to begin making sound ethical judgments about how to care for our presumably suicidal COVID-19–positive patients and the sitters who watch over them.
 

Dr. Ritchie is chair of psychiatry at Medstar Washington Hospital Center and professor of psychiatry at Georgetown University, Washington. She has no disclosures and can be reached at [email protected].

This column is an outcome of a discussion that occurred during Psych/Ethics rounds on June 5, and does not represent any official statements of Medstar Washington Hospital Center or any entity of the MedStar Corp. Dr. Ritchie would like to thank Evan G. DeRenzo, PhD, of the John J. Lynch Center for Ethics, for her thoughtful review of a previous draft of this commentary.